Who will pay for the palliative care promised in South Africa’s next policy?
Motlalentoa Motsoane is CEO of the Association of Palliative Care Centres. (Photo: Supplied)As South Africa is piecing together a new policy document on palliative care services for people with life-limiting and life-threatening illness, Motlalentoa Motsoane argues that making people’s lives better will depend on details like accurate costing, sufficient funding, and effective referral systems.
South Africa’s National Policy Framework and Strategy on Palliative Care, which ran from 2017 to 2022, recognised that care must begin at diagnosis. A study conducted in Cape Town found that at least some palliative care-related indicators improved after the adoption of the policy, although substantial challenges remain.
We define palliative care as, “… the physical, psychological, social and spiritual care provided by an inter-disciplinary team of experts to anyone with a life-threatening illness and their loved ones. Care is offered from the point of diagnosis and extends to bereavement support if needed.”
With goals for referrals, provincial planning, training and funding, a key pillar of the 2017-2022 policy was the intention to integrate palliative care services into the public healthcare system. The idea was that each province would develop a plan to implement the policy.
As Spotlight reported previously, in the expired national policy document, Health Minister Dr Aaron Motsoaledi noted that palliative care as a health service module has not been determined and therefore adequate funding has not been allocated for the delivery of care. “The cost of palliative care services has not been determined both for district health services and primary health care within district health services and at hospital level. Currently there is no costing model in place,” the document reads.
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The document also acknowledges that while service providers get some funding from government, it is not nearly enough. “Many of these organizations are largely reliant on donor-funding, making them particularly vulnerable to changes in donor patterns,” it stated.
In 2024, Dr Sibongiseni Dhlomo, the Deputy Minister of Health at the time, acknowledged that the funding goal had not yet been met.
In May 2025, the National Department of Health brought practitioners and other stakeholders together to review the framework and contribute to its successor. As work continues on the proposed 2026–2030 strategy, we need to ask whether people are referred in time, and whether the services receiving them have the staff and resources to provide care.
For us at the Association of Palliative Care Centres (APCC), the revision is an opportunity to cost the work needed to make referrals and care possible, especially beyond hospital walls.
Dr Lindsay Farrant, Dr Colleen Cox and Liz Gwyther recently wrote in Daily Maverick about poor understanding of palliative care and the shortage of people trained to provide it. Better awareness and training are essential. They also need to lead to a service clinicians can refer to and patients can use.
Clearing up the referral pathway
A referral starts with a clinician recognising that a patient needs more support. Then someone has to find a local service, contact its team and pass on the clinical information. The patient may need reassurance that palliative care can be added while treatment continues. If support is to happen at home, the team needs time and transport. A policy instruction to “integrate palliative care” leaves those arrangements to the people doing the work unless the plan sets out how they will be supported.
For a Wits University study conducted at Chris Hani Baragwanath Academic Hospital, researchers reviewed 459 cancer patient records from August 2021 to July 2022. It counted a referral within 90 days of diagnosis as timely. Only 63 patients, or 13.7%, were referred within this 90-day cut-off. While it is obvious that one hospital cannot tell us the national referral rate, the study findings show why the revised framework needs to specify who is responsible for referring patients and how it will identify delays.
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A cross-sectional descriptive study carried out in the Cape Metro District looked more broadly at what happened as palliative care was integrated into district healthcare services between 2019 and 2021. More health professionals received training, intermediate care capacity increased, and morphine use rose in some subdistricts. The researchers also found that integration into primary care remained partial and varied considerably across the district. While the study period included the height of the Covid-19 pandemic, which affected services, the differences between subdistricts still offer something useful for the revised framework – referral and prescribing practices need people responsible for putting them in place and keeping them working.
The costs factor
The costing cannot stop at a national total. Provinces will need to work out how many people to train, what support those staff require, and who will manage referrals between facilities and community providers. Home visits take staff time and transport. Pain relief depends on access to medicines and clinicians confident in prescribing them. Yet the nurses who deliver most of this care, often alone in patients’ homes, cannot prescribe morphine: regulations dating from 1984 limit nurse prescribing to Schedule 4 medicines, and the Medicines Act route for authorising specially trained nurses to prescribe stronger painkillers has yet to be put to use.
These things have to appear in local plans and budgets if health workers are expected to provide them.
Community providers belong in those plans. APCC members provide more than 90% of their care in people’s homes. Their nurses, social workers and carers see what families are managing between appointments and can stay involved as patients move between home, clinic and hospital. The public system can draw on that experience, provided it recognises the staff and funding required to sustain it.
What to do
Recognising that palliative care can begin at diagnosis does not mean every patient needs a specialist team immediately. Clinicians need to know when additional support would help and how to reach it. That route will differ between a rural clinic, a district hospital and a city practice, but in each setting, someone must take responsibility for making the connection.
For patients referred to a palliative care organisation, that connection needs more than a name and a phone number. Health departments and providers should agree what care is available locally, what clinical information moves with the patient and how home visits will be paid for. Those agreements must reflect what each provider can realistically take on. The APCC’s standards and accreditation programme can help establish expectations for quality; it cannot pay for visits that a government care pathway depends on.
Provinces also need to know what happens after a referral. Training figures alone cannot show whether a patient reached a service in time, or whether care continued after discharge. Recording referrals and follow-up at district level would help managers find where people lose contact with care. The Cape Metro study found substantial differences between subdistricts; a provincial total would obscure them.
As we marked World Hospice and Palliative Care Day on 10 October, the policy revision gives us a chance to address what the first framework could not deliver consistently. APCC’s Imagine If campaign shares accounts of what palliative care can do when people reach it. Behind each account sits work that can be planned: referrals, staff, transport, medicines and relationships between providers.
That work belongs in the plan and the budget. A patient will know the policy has made a difference when their clinician can find a team, and that team can reach them.
*Motlalentoa Motsoane is CEO of the Association of Palliative Care Centres.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.