# Barriers to and enablers of availability and integration of palliative care into routine services at Charlotte Maxeke Johannesburg Academic Hospital, South Africa

## TL;DR

This study explores the challenges and opportunities for integrating palliative care into routine hospital services at a South African hospital.

## Contribution

The study identifies specific barriers and enablers to palliative care integration using a structured implementation research framework.

## Key findings

- Positive individual characteristics and adequate training support palliative care availability.
- Budget allocation and management support are critical for service integration.
- Poor planning and reliance on donor funds hinder implementation.

## Abstract

The prevalence of chronic diseases among the South African population is increasing. The incidence of cancers is high and expected to double by 2030 while the HIV burden is disproportionately high. These are indicators of the need for palliative care services in the South African health system. While some palliative care service exists, there are challenges with availability and integration into routine services nationally. In Gauteng Province, CMJAH is one of two quaternary hospitals that provide palliative care services. We sought to find the barriers and enablers for the availability and integration of palliative care into routine services at CMJAH.

We used an exploratory qualitative research approach. Study sites were the internal medicine, surgical, and medical oncology departments, the palliative care unit, and the administration block at CMJAH. We interviewed four groups of personnel: the management of the four departments, previous and current staff in the palliative care unit, and hospital management staff. A hybrid of inductive and deductive coding was conducted, and the final codebook was developed using all the domains and selected constructs of the Consolidated Framework for Implementation Research (CFIR).

Barriers and enablers were categorised according to the domains of the CFIR. We found that individual characteristics such as knowledge and awareness of palliative care, adequate training, and positive attitude towards palliative care encourage the availability of services at a hospital. The availability of a budget for palliative care, a conducive environment for service provision, and management buy-in are also key determinants for palliative care. Poor planning, lack of implementation of the national policy framework and strategy for palliative care, and over-reliance on external donor funds are some of the hinderances for availability and integration of palliative care at a public hospital.

Despite the importance of palliative care, implementation is a challenge at CMJAH. The availability of a palliative care budget from relevant Government departments, and inclusion of some roles (navigators, spiritual chaplains) in the personnel structure for the Health Department are some of the ways through which availability and integration of the service can be improved across public hospitals in South Africa.