Preparedness of African Palliative Care Services to Respond to the COVID-19 Pandemic: A Rapid Assessment.

CONTEXT: Palliative care is an essential component of the coronavirus disease 2019 (COVID-19) pandemic response but is overlooked in national and international preparedness plans. The preparedness and capacity of African palliative care services to respond to COVID-19 is unknown.
OBJECTIVES: To evaluate the preparedness and capacity of African palliative care services to respond to the COVID-19 pandemic.
METHODS: We developed, piloted, and conducted a cross-sectional online survey guided by the 2005 International Health Regulations. It was electronically mailed to the 166 African Palliative Care Association's members and partners. Descriptive analyses were conducted.
RESULTS: About 83 participants from 21 countries completed the survey. Most services had at least one procedure for the case management of COVID-19 or another infectious disease (63%). Respondents reported concerns over accessing running water, soap, and disinfectant products (43%, 42%, and 59%, respectively) and security concerns for themselves or their staff (52%). Two in five services (41%) did not have any or make available additional personal protective equipment. Most services (80%) reported having the capacity to use technology instead of face-to-face appointment, and half (52%) reported having palliative care protocols for symptom management and psychological support that could be shared with nonspecialist staff in other health care settings.
CONCLUSION: Our survey suggests that African palliative care services could support the wider health system's response to the COVID-19 pandemic with greater resources such as basic infection control materials. It identified specific and systemic weaknesses impeding their preparedness to respond to outbreaks. The findings call for urgent measures to ensure staff and patient safety.

Key Message

This study is the first to assess the preparedness of African palliative care services to respond to coronavirus disease 2019 and future outbreaks. The findings call for more resources to implement existing procedures. Urgent measures to ensure infection control and a safe provision of services are needed, especially in the community.

Introduction

Risk factors for severe illness and mortality in coronavirus disease 2019 (COVID-19) include being elderly, the presence of pre-existing health problems, and multimorbidities.1, 2, 3 Race and ethnicity are also associated with higher incidence and poor prognosis., On the African continent, prevalent comorbidities such as HIV and tuberculosis pose a higher risk of mortality for patients with COVID-19. Patients with moderate to severe forms of the disease and distressing symptoms such as breathlessness may require intensive care, which is poorly available within weak health systems.,

Case management of COVID-19 must include palliative care to relieve suffering, improve outcomes, and save costs., This is especially true in resource-limited settings, where palliative care teams are supporting complex decision making for patients with severe COVID-19. Early evidence of needs among COVID-19 patients referred to palliative care include distressing physical symptoms, such as fever, breathlessness, fatigue, and cough;, spiritual or existential distress caused by the threat to survival; and psychological distress among patients and families associated with clinical uncertainty.

Palliative care is an essential health service within Universal Health Coverage goals. However, serious health-related suffering because of neglect of palliative care in global health disproportionately affects African countries.12, 13, 14 The 2005 International Health Regulations (IHR) requires countries to develop and implement preparedness and response plans in case of public health threats of international concern. In a pandemic, the need for palliative care is amplified but has been overlooked in preparedness and response plans to public health emergencies and humanitarian crises., This results in a failure to protect highly vulnerable populations from unnecessary suffering. Prior evidence shows palliative care's key role in pandemics to integrate protocols for symptom management, train nonspecialists, support triage, and provide psychosocial and bereavement care.

A 2020 World Health Organization (WHO) assessment of COVID-19 readiness showed moderate preparedness for 62% of the 34 participating African countries. As with other preparedness assessments, palliative care was not included. An appraisal of COVID-19 case management guidelines in Africa found that only eight countries had identifiable palliative care components.

Palliative care services are well placed to support health systems in caring for patients and families facing clinical uncertainty, assist complex decision making, and avoid unnecessary suffering. However, there is limited evidence of their preparedness to respond to a pandemic. This study aimed to evaluate the preparedness and capacity of palliative care services in Africa to respond to the COVID-19 pandemic.

Methods

We developed, piloted, and conducted a cross-sectional online survey, using the 2005 IHRs and online survey methodological guidelines.,

Participants

Eligible participants were palliative care services in any African country, including inpatient or outpatient hospice, community-based, or hospital-based care. We used nonprobabilistic sampling to recruit representatives of palliative care services part of the African Palliative Care Association's (APCA) members or nonmember partners. APCA is a pan-African nonprofit organization promoting and delivering culturally appropriate palliative care with 166 members and partners in 48 of the 52 African countries. An invitation electronic mail with a link to the online survey was sent out via APCA.

Data Collection

The survey questionnaire was originally designed by researchers from Italy and U.K. for an assessment of the Italian palliative care situation early in the epidemic. It was adapted for the African context with APCA and further developed to include existing international recommendations and evidence for generic preparedness to response to infectious disease outbreak or pandemic,25, 26, 27, 28, 29, 30, 31, 32 and recommendations for palliative care response and roles in epidemics and pandemics., The questionnaire addresses 1) service characteristics; 2) current COVID-19 situation; 3) written procedures; 4) measures in place for infection control; 5) communication and coordination; 6) resources; 7) perceived effects on staff and 8) risks; and 9) potential support to offer to the wider health system. Questions in Section 1 were single and multiple choice; in Sections 3–6 and 8 and 9, single, multiple choice, and open-ended questions; and Sections 7 and 8 also included 1–10 Likert scales. The full questionnaire is provided in Appendix I.

The questionnaire was uploaded on the Smart Survey™ platform where only one response per computer was permitted to avoid duplicate responses. If Internet connectivity issues made online completion difficult, potential participants were given an option to complete the survey using a Word™ questionnaire or by phone with E. N. These data would be entered onto the online platform, and the paper version stored securely at the office of the APCA .

Data collection was conducted from April 17, 2020 to May 1, 2020. Reminders to complete the survey were sent out twice during the two-week period of data collection.

Data Analysis

Data were imported from the survey platform into Excel and subsequently into Stata® (Version 16, StataCorp LLC). Only fully complete questionnaires were included in the analysis, as incomplete questionnaires contained more than 60% of missing data. Descriptive analysis was conducted. Categorical data were described using frequency and percentage; continuous variables were described by median and interquartile range (IQR). Open-ended questions were thematically analyzed. Dominant themes from the analysis of the open-ended questions are reported.

Results

Of 166 palliative care services invited to participate, 122 completed the survey at least partially (participation rate: 73%). We excluded 39 because of missing data and conducted analysis on data from 83 respondents in 21 countries (completion rate for those invited to participate: 50%). Of these, four questionnaires were completed using a Word version. None chose to participate by telephone.

Table 1 presents the characteristics of participating services. Most were nonprofit charity or public services, and half were hospital-based services. These services provided care for a median of 500 patients per year (IQR 200–2500).

Table 1

Description of the 83 Participants

	n (%)
Country
Kenya	18 (22)
South Africa	14 (17)
Tanzania	9 (11)
Nigeria	7 (8)
Uganda	7 (8)
Malawi	6 (7)
Ethiopia	3 (4)
Mozambique	2 (2)
Sierra Leone	2 (2)
Sudan	2 (2)
Togo	2 (2)
Zimbabwe	2 (2)
Othera	9 (10)
Type of service
Public or governmental	25 (30)
Private	2 (2)
Nonprofit charity	32 (39)
Mixedb	13 (16)
Missing	11 (13)
Type of service
Hospital-basedc	42 (51)
Nonhospital-basedd	39 (47)
Missing	2 (2)
Services having beds	33 (40)
Beds in hospital	13 (39)
Inpatient beds (not within hospital)	8 (24)
Inpatient and/or hospital beds	7 (21)
Outpatient beds	4 (12)
Missing	1 (3)
Respondent's current role(s)
Doctor	17 (20)
Nurse	12 (14)
Psychosocial professional	1 (1)
Manager or responsible of the service	25 (30)
Manager or responsible of the service and doctor, nurse, or psychosocial professionale	21 (25)
Otherf	7 (8)

Other: Burundi, Democratic Republic of the Congo, Republic of the Congo, Cote d'Ivoire, Eswatini, The Gambia, Liberia, Mauritius, and Zambia (n = 1).

Public and private (n = 2); public and nonprofit charity (n = 1); private and nonprofit charity (n = 6); and public, private, and nonprofit charity (n = 4).

Details: Within hospital (n = 12); within hospital and within community (n = 10); within hospital, within community, inpatient, and outpatient (n = 9); within hospital and outpatient (n = 5); within hospital, inpatient, and outpatient (n = 3); within hospital, within community, and inpatient (n = 2); within hospital and inpatient (n = 1).

Details: Within community, outpatient (n = 15); within community (n = 9); outpatient (n = 7); inpatient and outpatient (n = 3); within community, inpatient, and outpatient (n = 3); inpatient (n = 1); within community and inpatient (n = 1).

Doctor and manager (n = 7), nurse and manager (n = 10), and psychosocial professional and manager (n = 1).

Other: Clinical officer, health officer/palliative care trainer, palliative care clinical officer, pharmacist, project officer, rehabilitation technician-palliative care provider, and ward attendant.

COVID-19 Situation in the Service, Perceived Effects, and Risks for Staff

A third of services reported having at least one probable, suspected, or confirmed case of COVID-19 with a median of 4.5 overall cases (IQR 2–10·5). Half of cases concerned a patient, with the remaining cases among patients' relatives or service staff (details in Appendix II).

Appendix II

Description of the COVID-19 Situation for Palliative Care Services Reporting Suspected, Probable, or Confirmed Cases (N = 31)

	n (%)
Type of cases reported
Confirmed	5 (16.13)
Probable	1 (3.23)
Suspected	20 (64.52)
Confirmed and suspected	4 (12.90)
Confirmed, suspected, and probable	1 (3.23)
Cases reported amonga
Patientb	10 (32.26)
Relative	3 (9.68)
Patient and relative	2 (6.45)
Physicianc	3 (9.68)
Patient and physician	1 (3.23)
Patient and nurse	1 (3.23)
Physician and nurse	1 (3.23)
Patient, physician, and nurse	2 (6.45)
Missing	8 (25.81)
Location of the cases identified
In the service	1 (3.23)
Another service of the hospital where the palliative care is located	4 (12.90)
Other locationd	4 (12.90)
Missing (not specified)	22 (70.97)

COVID-19 = coronavirus disease 2019.

Multiple selection was allowed.

One also reported additional cases as cleaners.

One also reported an additional case of a nonmedical staff.

Community and emergency cases.

Respondents perceived high levels of anxiety and worry among service staff regarding the effects of COVID-19 (Table 2). Staff were perceived to be highly anxious about being infected themselves (on a 1–10 Likert scale, median 9; IQR 8–10) and worried about potential issues for their interaction with the community if the service is known to manage a potential COVID-19 case (on a 1–10 Likert scale, median 8; IQR 7–10). About one-third reported a perceived increase in staff absenteeism.

Table 2

Perceived Effects on Staff and Potential Risks in the Upcoming Week (N = 83)

	Median (IQR)a
Perceived effects on work staff
Staff anxious about the need to care for their children who may not be at schoolb	8 (6–9)
Staff anxious about the need to care for their own relativesb	7 (5–9)
Staff anxious about getting infected themselves	9 (8–10)
Worried regarding potential issues for your interaction with the community if your service is known to manage a potential COVID-19 casec	8 (7–10)
Perception of the risks in the coming week
Staff are at risk of being infected by COVID-19b	7 (5–9)
Service is at risk of closing because of an infection in the servicec	5 (2–9)

IQR = interquartile range; COVID-19 = coronavirus disease 2019.

On a scale from 1 to 10.

One missing data.

Two missing data.

Half of respondents reported security concerns for themselves or their staff. These included socioeconomic concerns, such as loss of employment and livelihood and fear of civil unrest related to the lockdown enforcement (e.g., curfew and police involvement in enforcement and staff's exposure to infection at work, in their home communities, or during their commute to work).

Policies and Mitigation in Place

Table 3 describes the procedures and policies in place as well as their modifications in relation to COVID-19 case management. Three in five services had a case definition for COVID-19 (59%) and at least one written procedure for COVID-19 case management or for another infectious disease such as tuberculosis, HIV, or Ebola. Four in five services had at least one written service procedure specific to COVID-19. Most palliative care services had modified at least one existing policy or procedure, mostly regarding visitors or relatives.

Table 3

Written Procedures, Policies, and Recommendations in Place

	Yes	No	Unsure/Do Not Know	Missing
	n (%)
Case definition for confirmed, probable, and suspected COVID-19 cases	49 (59)	25 (30)	8 (10)	1 (1)
A written procedure for what to do in case of COVID-19 case among the following
Patients	58 (70)	17 (20)	3 (4)	5 (6)
Relatives and visitors	55 (66)	16 (19)	6 (7)	6 (7)
Health care professional staff member	56 (67)	17 (20)	5 (6)	5 (6)
Volunteers and medical staff	49 (59)	23 (28)	4 (5)	7 (8)
Staff and volunteers going in the community (N = 46)	27 (59)	13 (28)	3 (7)	3 (7)
A written procedure for what to do in case of other infectious diseases among the following
Patients	54 (65)	11 (13)	2 (2)	16 (19)
Relatives and visitors	43 (52)	19 (23)	2 (2)	19 (23)
Health care professional staff member	54 (65)	13 (16)	1 (1)	15 (18)
Volunteers and medical staff	42 (51)	21 (25)	4 (5)	16 (19)
Staff and volunteers going in the community (N = 46)	26 (57)	11 (24)	2 (4)	7 (15)
Policies or procedures modified as a measure to avoid contagion
Policy for visitors/relatives (number of visitors, hours, etc.)	65 (78)	14 (17)	4 (5)	0 (0)
Policy for operator protection (PPE)	59 (71)	19 (23)	5 (6)	0 (0)
Policy for patients' admission	46 (55)	27 (33)	8 (10)	2 (2)
Volunteer support policy	46 (55)	26 (31)	10 (13)	1 (1)
Policy regarding care of the relatives after the patient's death	42 (51)	32 (39)	8 (10)	1 (1)
Procedure to support health care providers to manage stress	37 (45)	37 (45)	0 (0)	3 (4)
Recommendations if you or someone in your household becomes ill with COVID-19 symptoms	57 (69)	19 (23)	6 (7)	1 (1)
Cleaning staff included in information sharing and training regarding managing COVID-19	48 (58)	25 (30)	7 (8)	3 (4)

COVID-19 = coronavirus disease 2019; PPE = personal protective equipment.

With respect to staff support and training, less than half of respondents reported having a procedure to support health care providers to manage stress. One in five did not provide recommendations for situations of staff member (or someone in their household) becoming ill with COVID-19. Forty-one respondents gave comments on procedures for staff stress, and most of these included having a staff support program available, counseling (59%), or discussions in team meetings (17%).

Two in five reported that not all health care providers have been trained in handling highly infectious conditions, such as COVID. Of the 51 services reporting such training, half had been trained before the pandemic and half in response to COVID-19. Three in five palliative care services declared that cleaning staff were included in information sharing and training regarding managing COVID-19.

All but one service had put in place at least one measure to avoid contagion in their service. Additional handwashing facilities were introduced in the vast majority of services (82%). However, two in five services did not have any or make available additional personal protective equipment (PPE) for clinical staff (41%) and cleaning staff (45%). Fifty-seven respondents provided details on the PPE available and revealed that the PPE is not always complete. They mainly reported having access to masks (61%) and gloves (49%). Of 28 services having inpatient or managing patients in hospital beds, 19 reported having identified an isolation room for COVID-19 cases (68%).

Communication, Information, and Coordination

Table 4 presents the mechanisms in place to receive information if there is a confirmed case or a suspected case in the service or surrounding community. Respondents stated that they would receive information from the local hospital or health center, the facility or the hospital, the COVID-19 task team or the rapid response team, and/or the Ministry or Department of Health. The head of nursing or palliative care, person in charge, or project manager and/or hospital or facility management or health services coordinator were identified as recipients of this information. One in four respondents reported either no designated focal point identified in the service as responsible for collecting and sharing up-to-date information or being unsure of who that person is.

Table 4

Communication Mechanisms in Place to Receive Information if There Is a Confirmed or Suspected Case in the Service or in the Locality

	n (%)
Institutions or person who would inform the servicea
Local hospital or health center	16 (19)
Facility or hospital	14 (17)
COVID-19 task team/rapid response team	13 (16)
Ministry or Department of Health	12 (14)
Staff doing screening or exchanges on social media between staff	9 (11)
Community and volunteers in the community	9 (11)
National Center for Diseases Control/National Hygiene Institute	5 (6)
Media	4 (5)
Local authority or committee	4 (5)
None reported	3 (4)
Otherb	3 (4)
Missing	5 (6)
Person who would be informed in the servicea
Head of nursing or palliative care, person in charge or project manager	40 (48)
Hospital or facility management or health services coordinator	28 (34)
All staff/team	9 (11)
Medical staff	7 (8)
None reported in the facility or hospital	6 (7)
COVID-19 response team in the hospital or facility	2 (2)
Otherc	2 (2)
Missing	5 (6)
Communication system(s) that will be used to receive information
Mobile phone available 24/7	66 (80)
Telephone (in the service)	39 (47)
E-mail	32 (39)
WhatsApp/Viber group	47 (57)
None reported	4 (5)
Otherd	12 (14)
Designated focal point person identified in the service responsible for collecting and sharing up-to-date information
Yes	60 (72)
No	15 (18)
Unsure	6 (7)
Missing	2 (2)

COVID-19 = coronavirus disease 2019.

Data obtained from the analysis of open text questions.

Other: Central laboratory; public health team; Medical Research Institute.

Other: Nonmedical staff or volunteers.

Other: Text messages/SMS (n = 3); word of mouth (n = 2); in person; using the peer system; where mass communications are done; administration; Facebook messenger; media; verbal; referral forms; and written documents.

Communication reliant on mobile phones could be used to disseminate COVID-19 or other urgent information with staff, patients, visitors, or relatives. The most reported means to share information with staff were WhatsApp/Viber (71%) and phone calls (65%) as well as phone calls with patients (71%) and relatives or visitors (76%). About one in five services reported having no communication means for sharing information with patients (18%) or relatives (19%). Other means included face-to-face communications, posters, or noticeboards in the facility or the hospital, and radio or other media. Respondents identified a lack of mobile phones or airtime to communicate with patients.

Table 5 describes the information systems available to palliative care services for contact tracing and investigation. Almost all services had up-to-date lists of staff and patients and records of patients' symptoms and outcomes. Most of the information systems were paper based. However, half did not have up-to-date lists of relatives who have visited and did not record their visit dates.

Table 5

Information Systems Available

	Paper-Based Registry	Electronic Record	None	Othera
	n (%)
Up-to-date contact list of
All staff working in or for the service	64 (77)	43 (52)	3 (4)	1 (1)
All patients who attended or have attended the hospice or service	69 (83)	32 (39)	5 (6)	1 (1)
All relatives who visited or have visited the service	34 (41)	12 (14)	40 (48)	3 (4)
Patients visited in the community (N = 46)	35 (76)	22 (48)	3 (6·52)	0 (0)
System collecting information about
Patients' symptoms	71 (86)	19 (23)	5 (6)	2 (2)
Patients' outcomes	68 (82)	20 (24)	9 (11)	2 (2)
Treatment given	69 (83)	19 (23)	7 (8)	2 (2)
Dates of patients' visits or stay	68 (82)	24 (29)	5 (6)	2 (2)
Dates of relatives' visits	35 (42)	10 (12)	36 (43)	2 (2)

Of seven respondents who replied other: visit register; register; patient files and interdisciplinary minutes and inpatient record book; four missing.

Table 6 describes the concerns regarding access to basic resources for infection control and highlight respondents' concerns over essentials like accessing running water, soap, and disinfectant products for the service and community.

Table 6

Concerns About Access to Infection Control Resources in the Service or Surrounding Community

	Facility, n (%)			Surrounding Community, n (%)
	Yes	No	Missing	Yes	No	Missing
Running water	36 (43)	46 (55)	1 (1)	49 (59)	25 (30)	9 (11)
Soap	35 (42)	47 (57)	1 (1)	47 (57)	23 (28)	13 (16)
Hand sanitizers (with 60% alcohol)	40 (48)	42 (51)	1 (1)	53 (64)	23 (28)	7 (8)
Electricity	39 (47)	42 (51)	2 (2)	51 (61)	22 (27)	10 (12)
Thermometers (contactless, Thermoflash-type)	48 (58)	34 (41)	1 (1)	50 (60)	27 (33)	6 (7)
Disinfectant products	49 (59)	33 (40)	1 (1)	48 (58)	27 (33)	8 (10)
Othera	20 (24)	12 (14)	51 (61)	16 (19)	15 (18)	52 (63)

Analyzed using 16 open-ended questions of 23 respondents who replied other: lack of PPE (n = 10); lack of supplies for consumables and medicines as well as appropriate infrastructure to manage referrals (n = 1); appropriate infrastructure to allow of patient isolation (n = 1); unsafe waste disposal practices for infectious waste in communities (n = 1); lack of hygiene material in the community and for medical waste (n = 2); financial concerns (n = 2); and dependence on Department of Health (n = 1).

A third of respondents reported not having, or not being sure of having, adequate material and facilities to dispose of highly infectious waste within the service (28% and 8%, respectively), especially in the community (61% and 15%, respectively, for the 46 services delivering community care). Most services had up-to-date inventories of medicines and medical supplies (72%) and of protective materials for staff, patients, and visitors (57%).

Most services (80%) reported having capacity to use technology instead of face-to-face appointments to provide remote care; 76% could use phone calls. Half of the services knew how to access additional staff in case of emergency, lockdown, or quarantine (47%); three-fifth how to access medicines and other medical supplies (63%); and less than half of the 50 services providing inpatient or hospital-based services knew how to access food (42%).

Fifty-four services had education material available (65%). Of these, most services were available for the surrounding community (70%), and almost all services displayed posters where staff, patients, and visitors can see them (94%).

Palliative Care Support to COVID-19 Management

Half of services reported having palliative care protocols for symptom management and psychological support that could be shared with nonspecialist staff in other health care facilities (Table 7). Of these 43 services, all but three had the capacity to train nonspecialists in using these protocols. Three in four services reported having plans to support other health care services in the triage of patients in case of COVID-19 outbreak. Twelve respondents specified these plans, which included support in screenings, advanced care planning with newly admitted hospital patients, care of the dying, and beds supply because of service closure.

Table 7

Potential Means for Palliative Care Services to Offer Support to the Wider Health System

	n (%)
Palliative care protocols for symptom management and psychological support that could be shared with nonspecialist staff and/or COVID-19 response teams in other health care facilities	43 (52)
If yes, capacity to train nonspecialist in using these protocols	40 (93)
Plans to support other health care services in the triage of patients in case of COVID-19 outbreak	60 (72)

COVID-19 = coronavirus disease 2019.

Half of the services (52%) reported having a plan to redeploy health care providers, volunteers, or resources outside inpatient settings, in case of outbreak. Forty-four respondents reported limitations in their ability to share expertise. They included mostly financial concerns related to the lack of funding and cost of communication as well as a lack of resources for training (including human resources).

Discussion

Palliative care services on the African continent have put in place several measures to prepare and respond to COVID-19 but are limited by a lack of resources and the wider context within which they operate. The participating services had adapted their policies and procedures. They reported existing data collection and communication systems and had the capacity to use technology to provide care remotely, mostly relying on mobile phones that could help prevent the spread of COVID-19. Those with existing symptoms management and psychosocial support protocols are ready to train nonspecialists in using them. The sharing of these skills is essential to meet potential population level of palliative care needs. Yet, their capacity to support the preparedness and response to an outbreak has some limitations. Our study reveals high level of staff anxiety and a lack of training, material, and facilities to handle highly infectious diseases, especially in the community. The findings demonstrate that the context surrounding the provision of palliative care, such as concerns over security and the lack of running water and soap in the facility and community, may limit the safe implementation of policies and epidemic control measures. These limitations represent barriers to further supporting the national responses to COVID-19 and other outbreaks.

The serious concerns we identified over access to water, sanitation, and hygiene concurs with existing evidence. This exposes a lack of basic infrastructure preventing palliative care team to work safely and confirms wider gaps in the health systems, which are likely to persist beyond the COVID-19 pandemic. Most African countries have reported community transmissions, whereas public health preventive measures including restricted movements would most likely result into a surge in the use of primary and community-based care. Urgent measures must be taken to ensure infection control and safety in the community and could be based on the already existing expertise in the provision of community-based palliative care for drug-resistant tuberculosis patients and their families.

Our study highlights staff safety and security concerns. Like in Italian palliative care services, respondents reported an increase in absenteeism and a high level of anxiety among the staff, which may be explained by the lack of protective equipment, and procedures and resources to support staff stress. This may also relate to potential risk of violence in the community as a result of poverty and lockdown enforcement., Further research on the effects of epidemics and pandemics on palliative care staff health, safety, and security is needed.

We assessed preparedness and capacity in light of the recommendations of Etkind et al. for African palliative care services to support the COVID-19 response by sharing palliative care clinical protocols, training nonspecialists in their use, and using mobile phones to provide remote care. M-health offers great potential to expand access to palliative care in sub-Saharan Africa. However, not all patients and relatives have mobile phones as some respondents highlighted. The shifting of resources in the community and redeployment of staff may need to be considered carefully considering the security and availability of basic resources to ensure infection control.

The findings highlight the importance of palliative care services beyond hands-on care, which should be integrated to strengthen the wider health system response. The common use of outcome measures among African palliative care services to improve patient care may be used to enable health care professionals across the health system to assess and monitor patient and family symptoms and concerns. Although palliative care services have expertise and protocols to build capacity among colleagues across the health system, they lack the resources to deliver this crucial contribution of palliative care during public health emergencies.

To the best of our knowledge, this study is the first to provide a comprehensive assessment of the preparedness and capacity of palliative care services to respond to a pandemic in palliative care services, using the WHO IHRs. Although our sample may not be representative as there is no comprehensive list of all palliative care services in the continent, using the network of APCA offered a unique and heterogeneous sample that enabled us to integrating the inputs from remote services in 21 countries. Our sample includes mostly English-speaking African countries as time restraints prevented us from translating it, although it includes three French-speaking (Democratic Republic of the Congo, Republic of the Congo, and Côte d'Ivoire) and one Portuguese-speaking countries (Mozambique), respondents from Kenya (22%) and South Africa (17%) represented two-fifths (38%) of our sample, which may be because these are the countries with the second and third highest number of hospices and palliative care services in Africa. The use of the SmartSurvey platform has enabled a fast and user-friendly data collection while preventing multiple completion from a single computer. Although we piloted the survey, the choice of coding generated missing data, and it took longer to complete than estimated (median of 40 minutes in practice rather than 15 minutes estimated). The length of the questionnaire may also explain why 39 respondents only completed the survey partially. We excluded these records because they completed a maximum of two questions after describing their COVID-19 situation (Section 2 of the questionnaire of nine sections). We felt that including these records would carry a high number of unnecessary missing data in the sections that actually described their preparedness and capacity to respond. Participation relied almost solely on Internet completion, even if alternative means were provided.

This study provides much-needed evidence on the preparedness and capacity of African palliative care services to respond to COVID-19 and future outbreaks. With adequate resources, they could ensure the safe provision of care and support health systems' pandemic response and IHR implementation.,, Our findings support calls to include palliative care in preparedness and response plans,,16, 17, 18 and WHO should incorporate palliative care into its evaluation of countries' preparedness. Beyond the current pandemic, the service-level responses and contextual challenges identified for delivering essential palliative care must be addressed to integrate palliative care into the broader health system and reach Universal Health Coverage goals.

	Procedure Specific to COVID-19	Procedure for Infectious Diseases in General or to Another Specific Highly Infectious Disease (e.g., Influenza, Ebola, Tuberculosis, etc.)Please Specify for Which Disease(s): _______
Patients	□ Yes □ No □ Do not know	□ Yes □ No □ Do not know
Relatives and visitors	□ Yes □ No □ Do not know	□ Yes □ No □ Do not know
Health care professional staff member	□ Yes □ No □ Do not know	□ Yes □ No □ Do not know
Volunteers and medical staff	□ Yes □ No □ Do not know	□ Yes □ No □ Do not know
Staff and volunteers going in the community	□ Yes □ No □ Do not know	□ Yes □ No □ Do not know
Other please specify _______	□ Yes □ No □ Do not know	□ Yes □ No □ Do not know

1. Policy for visitors/relatives (number of visitors, hours etc.)	□ Yes □ No □ Not Sure □ N/A
2. Policy for operator protection (PPE)	□ Yes □ No □ Not sure □ N/A
3. Policy for patients' admission to the hospice	□ Yes □ No □ Not sure □ N/A
4. Volunteer support policy	□ Yes □ No □ Not sure □ N/A
5. Policy regarding care of the relatives after the patient's death	□ Yes □ No □ Not sure □ N/A
6. Other policy modified, please specify	__________________

N/A = not applicable; PPE, personal protective equipment.

• All staff working in or for the hospice or service (medical, administrative, cleaning staff, etc.?)	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other _____
• All patients who attended or have attended the hospice or service	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other _____
• All relatives who visited or have visited the hospice or service	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other _____
• Patients visited in the community	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other _____

•Patients' symptoms	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other ____
•Patients' outcomes	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other ____
•Treatment given	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other ____
•Dates of patients' visits or stay	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other ____
•Dates of relatives' visits	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other ____

	In Your Hospice or Service?	In the Surrounding Community?
Running water	□ Yes □ No	□ Yes □ No
Soap	□ Yes □ No	□ Yes □ No
Hand sanitizers (with 60% alcohol)	□ Yes □ No	□ Yes □ No
Electricity	□ Yes □ No	□ Yes □ No
Thermometers (contactless, thermoflash type)	□ Yes □ No	□ Yes □ No
Accessing disinfectant products to continue providing care safely	□ Yes □ No	□ Yes □ No
Other, please specify _________	□ Yes □ No	□ Yes □ No

Health care providers	□ Yes □ No □ Do not know □ N/A
Volunteers	□ Yes □ No □ Do not know □ N/A
Resources (material and supplies)	□ Yes □ No □ Do not know □ N/A