In Malawi, a large proportion of women with cervical cancer arrive at the hospital with already advanced cancer, requiring palliative care management. Some women do not respond well to the available curative treatments—which are limited in the country—or can no longer afford them. As their condition worsens, another obstacle arises: the more care patients need, the less able they are to reach a health facility. Since 2022, Doctors Without Borders teams have been working with the Ministry of Health to bring palliative care closer to patients, even in the most remote villages.
Managing intense pain
Jean Gama is sitting on a mat in front of her small red-brick house. She is surrounded by two members of the MSF team, with whom she is talking. From time to time, they laugh together. Jean is well acquainted with the team that regularly provides her with palliative care. “They give me medicine and explain how to take it,” says Jean, who is 76 years old. “When I tell them I’m having a bad reaction to certain medications, they stop giving them to me and only give me the ones I tolerate well.”
It took the medical team nearly two hours that day to travel from Blantyre, the country’s commercial capital to Jean’s home in a small rural community in the Mulanje district. “Before we arrive, we ask the patient about the main problems she’s facing,” explains Christopher Chalunda, an MSF palliative care nurse. “When we arrive, we try to create a friendly atmosphere, joke around a bit, and make sure the patient is comfortably settled.”
Jean first received curative treatment before joining the palliative care program at Queen Elizabeth Central Hospital in Blantyre. “Palliative care aims to improve the quality of life and preserve the dignity of patients with incurable illnesses or who are at the end of life,” explains Dr. Camille Desforges, palliative care coordinator at the MSF headquarter, who previously worked in Malawi. “We manage both the symptoms caused by the disease and those resulting from treatment, but we also focus on providing psychological and social support.”
In the case of cervical cancer, one of the first challenges faced by MSF teams and the Ministry of Health—with whom they collaborate closely—is pain management. In the case of cervical cancer, pain is one of the most distressing symptoms. “I was in terrible pain,” Jean recalls. “Now I feel much better. I’m able to cook again, for example.” As the pain subsides, other concerns are taking centre stage in her daily life. During this visit from the MSF teams, Jean is more worried about the bad condition of her house than about her illness.
“Malawi is unique in that it has long had access to morphine, an essential medication for pain management,” explains Camille. “The key issue was to establish a system that would allow patients to receive it right up until their final moments.” Home visits and the decentralisation of palliative care—by strengthening care at health centres closest to patients’ homes—were designed to meet this need. Camille emphasises this is a common concern in palliative care: “We know that when the disease is very advanced, patients will be confined to their homes, unable to travel. It is imperative that we equip ourselves to support them until that moment.”
Aida Malosi lives alone with her daughter in the village of Lirangwe, located about 30 kilometres from Blantyre. She is 66 years old and, like Jean, lives in a small house with a corrugated-iron roof. Her husband left her shortly after she was diagnosed with cervical cancer in 2022—a situation that is very common in Malawi, and a known phenomenon in case of serious illness in women outside of Malawi as well. A few weeks after her diagnosis, she was admitted to palliative care. “Before I started treatment, I couldn’t even eat,” she explains. “I spent several months in bed. I couldn’t take care of my personal hygiene anymore; my family had to help me.” Aida is helped daily by her daughter Rose, one of her six children.
At each visit, the MSF medical team assesses the patients’ condition. “We monitor their vital signs, assess their pain, and examine their symptoms,” explains MSF nurse Christopher. “We usually visit the patient once a month. If she is very weak, we see her again after a week. If she is at the end of her life, we see her again two or three days after the first visit.” Aida has been receiving a monthly visit for several months now, which spares her an extremely complicated and costly trip to hospital in the city.
Ultimately, these women can spend their final days at home, in a familiar environment within their community. They can go through this stage with less suffering and greater dignity, while maintaining their social connection
Shifting the centre of care as close as possible to patients
Long before the launch of MSF’s oncology project in Malawi, the country had a well-developed – yet incomplete and not fully-functional, palliative care system; a legacy of the HIV/AIDS epidemic that severely affected the country beginning in the 1990s.
“We realised that this system, managed by the Ministry of Health needed support in certain areas,” says palliative care coordinator Camille. “Patients were given monthly appointments, but some did not return. Some facilities struggled to function due to a lack of sufficient resources. By identifying the gaps to reconnect the patients to care, we built on the existing system, worked with the Ministry of Health, and we gradually stopped losing track of patients.”
One of the keys to improving this system of care as close as possible to patients was the mentoring provided by MSF to the health centers workers. In consultation with the Ministry of Health, one of the objectives of the MSF program became strengthening the existing teams by training them in pain management, the use of morphine, home follow-up, and medical, social and psychological support of patients.
“This program also involved training our teams to become mentors themselves. Then, each MSF palliative care nurse mentored about 15 healthcare workers from the Ministry of Health, accompanying them every month for over a year. We did this site by site, district by district,” explains Osman Assam, Palliative Care supervisor of MSF in Malawi. “Even today, this support continues through guidance and regular visits by the teams.” Today, 46 health centres across the 11 districts that make up the greater southern region of Malawi have already benefited from this mentoring program.
The MSF program also provided practical support to the ministry’s teams: fuel for home visits, phone credit, essential medications, and assistance with procurement procedures. This model, around precise and specific components of patient care and implemented in complementarity with the Ministry of Health, is particularly relevant and replicable in a context of drastic cuts to international humanitarian and development funding.
Aida, in Lirangwe village, is now benefiting from this decentralisation of care. “Because of my wounds, I had great difficulty walking,” she recalls. “When the health workers [at Queen Elizabeth Central Hospital] saw that I was in pain, they told me to stay home and that they would come see me.” Her daughter Rose, who was present during the MSF team visit, echoes her words: “To get to the hospital, my mother sometimes had to leave the house at four in the morning. First, she had to ride a motorcycle to the main road, then find a bus to Blantyre. With her wounds and pain, this trip could take several hours and was becoming increasingly difficult.”
The need for financial support
The expansion of home visits has also enabled MSF and the Ministry of Health teams to better consider the social realities within which patients live. During their visits, they encounter women who are alone or, conversely, supported by others; homes that are sometimes dilapidated or dangerous; and financial situations that are often complicated because illness and fatigue prevent the women from working.
“When you only see the patient in an outpatient clinic, you miss a lot,” explains Christopher. “If a patient tells us at the hospital, ‘I went to bed on an empty stomach,’ we can’t really understand the situation because we’ve never seen her home.” When we visit them, we see how the patient gets to the hospital, how she interacts with her loved ones, and just how much she’s really struggling. Some are even victims of discrimination within their families or communities.”
Many patients, who receive care both at a health clinic and at the hospital, were no longer able to get there due to a lack of transportation. Poverty is an additional barrier to accessing care, even though it is free. In response, MSF has set up a financial assistance program for patients—a component that was not initially prioritised in the program.
Lucy Mchoma, a 60-year-old patient who lives in the Thyolo district south of Blantyre, takes between two and three hours by minibus to reach hospital. “The cost of transportation is a problem,” she worries. “If this assistance stops, I wonder what will happen next. If I’m called to come to the hospital, will I still be able to afford the trip?” Lucy was diagnosed with cervical cancer in 2022 and is supported solely by her sister, who accompanies her to medical appointments. She is divorced and receives no support from either her daughter or her son.
