Improving palliative care access in rural Malawi: insights from a mixed-methods exploration of structural and social determinants

Abstract Introduction Globally, an estimated 56.8 million people require palliative care each year, with half in their final year of life. However, access appears to be scarce in the most impoverished settings, like rural sub-Saharan Africa. Africa is expected to experience a sharp rise in severe health-related suffering, underscoring the need to increase access to palliative care. Methods A convergent parallel mixed-methods design was conducted to assess factors affecting palliative care access and utilisation in rural Malawi. Interviews using a question guide were conducted with patients, caregivers, and service providers to examine experiences in palliative care access and service utilisation, and the analysis used thematic content analysis. Electronic medical data were extracted, de-identified, and analysed using STATA software version 18.0 from nine palliative care implementing facilities using descriptive statistics. Results Electronic medical records were analysed with 204 patients enrolled in the program. The mean age was 58.6 years, and 47% (n = 96) were aged 65+. Females predominated, comprising 65% (n = 132) of the enrollees. 72% (n = 139) of the patients lived more than five kilometres from the nearest clinic. Analysis of forty-four key informants’ interviews highlighted the importance of health system and facility management, structural and contextual determinants of healthcare access, and community-based care and household health determinants, which play a central role in program management and coordination, community health worker (CHW) engagement, and availability of essential supplies plays a central role in service accessibility and utilisation. Conclusion The findings from the study highlight the importance of addressing social determinants of health, supporting community-based health workers, and strengthening local leadership to improve palliative care access. Provider support and locally adapted strategies can facilitate the delivery of palliative care services in hard-to-reach settings. While these insights are drawn from a single district and may not be broadly generalizable, they provide context-specific guidance for program managers and policymakers aiming to enhance palliative care access and utilisation in similar low-resource settings.