Implementation of primary palliative care interventions across six sub-Saharan African countries: understanding contextual determinants and lessons learnt

OBJECTIVE: To synthesise five purposively selected service-level primary palliative care interventions in six sub-Saharan African countries to identify the contextual barriers and facilitators and the implementation strategies employed to address them. SETTING: Primary palliative care studies that have taken place in sub-Saharan Africa in the last 5 years. DESIGN: We used an implementation-focused formative evaluation design involving semi-structured interviews with every site lead (n=7) supplemented by a review of study-related documentation. Data were analysed using framework analysis underpinned by the relevant constructs of the Consolidated Framework for Implementation Research. PARTICIPANTS: Site leads from each of the five studies were interviewed. RESULTS: Facilitators to implementing primary palliative care interventions included the following: (1) the relative advantage compared with standard care (ie, person-centred approach, expansion to those with non-cancer conditions), (2) primary care worker champions within sites, (3) broad sustained engagement with policymakers, managers, healthcare workers, patients and families and (4) availability of linked healthcare records. Barriers included the following: (1) inconsistent staffing and training needs for the diverse workforce, (2) fragmented referral pathways, (3) inconsistent national and local policies and (4) physical infrastructural limitations. CONCLUSION: Context-specific facilitators, barriers and recommendations should be considered to bolster the implementation process of future primary palliative care interventions. Advocacy is needed to ensure adequate investments in the design, equipping and staffing of primary healthcare in sub-Saharan Africa to properly support patients and their families.