For the families who care for a loved one with a life-threatening illness, the promise of palliative care is deeply personal: someone to manage the pain, someone to explain what comes next, someone to help at home between hospital visits. Whether that promise becomes real in South Africa may soon depend on decisions being made now, as the country drafts a successor to its National Policy Framework and Strategy on Palliative Care, which ran from 2017 to 2022. Writing in a recent opinion piece, Motlalentoa Motsoane, CEO of the Association of Palliative Care Centres (APCC), argues that the new policy will only change lives if it confronts three unglamorous details: accurate costing, sufficient funding, and working referral systems.
The first framework recognised something important, that palliative care, defined as the physical, psychological, social and spiritual care provided by an interdisciplinary team to anyone with a life-threatening illness and their loved ones, must begin at diagnosis and extend, if needed, to bereavement support. Its central pillar was the intention to integrate these services into the public healthcare system, with each province developing its own implementation plan covering referrals, provincial planning, training and funding.
What it did not settle was the money. In the expired 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 delivering 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. It also acknowledged that service providers receive some government funding, but not nearly enough, leaving many organisations largely reliant on donor funding and particularly vulnerable to shifts in donor patterns. In 2024, then Deputy Minister of Health Dr Sibongiseni Dhlomo conceded that the funding goal had not been met.
The consequences of that gap show up in patient records. A Wits University study at Chris Hani Baragwanath Academic Hospital reviewed 459 cancer patient records from August 2021 to July 2022, counting a referral within 90 days of diagnosis as timely. Only 63 patients, or 13.7%, made that cut-off. One hospital cannot speak for the country, but the finding illustrates why the revised framework must specify who is responsible for referring patients and how delays will be identified.
A referral, as Motsoane describes it, is a chain of human tasks: a clinician must recognise that a patient needs more support, someone must find a local service and pass on clinical information, the patient may need reassurance that palliative care can continue alongside treatment, and if support is to happen at home, the team needs time and transport. A policy instruction to “integrate palliative care” leaves all of that to the people doing the work unless the plan says how they will be supported.
Evidence from the Cape Metro District, where a cross-sectional study tracked integration into district healthcare services between 2019 and 2021, points the same way. More health professionals were trained, intermediate care capacity increased, and morphine use rose in some subdistricts, yet integration into primary care remained partial and varied considerably across the district. Even accounting for the disruption of the Covid-19 pandemic during the study period, the lesson for the revised framework is clear: referral and prescribing practices need people responsible for making them work. An earlier Cape Town study found that at least some palliative care-related indicators improved after the adoption of the first policy, though substantial challenges remain.
Costing, Motsoane argues, cannot stop at a national total. Provinces must 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 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 never been used.
Community providers belong in those plans too. APCC members provide more than 90% of their care in people’s homes, and their nurses, social workers and carers see what families manage between appointments. The public system can draw on that experience, provided it recognises the staff and funding needed to sustain it. The APCC’s standards and accreditation programme can help set expectations for quality, Motsoane notes, but it cannot pay for home visits that a government care pathway depends on.
Meanwhile, in May 2025, the National Department of Health brought practitioners and stakeholders together to review the framework and shape its proposed 2026 to 2030 successor. Dr Lindsay Farrant, Dr Colleen Cox and Liz Gwyther have written elsewhere about poor understanding of palliative care and the shortage of trained providers, arguing that better awareness and training must lead to a service clinicians can refer to and patients can use. As the revision continues, Motsoane suggests recording referrals and follow-up at district level so managers can find where people lose contact with care, since a provincial total would obscure the differences the Cape Metro study found.
Marking World Hospice and Palliative Care Day on 10 October, Motsoane frames the revision as a chance to address what the first framework could not deliver consistently. The APCC’s Imagine If campaign shares accounts of what palliative care can do when people reach it, and behind each account sits work that can be planned: referrals, staff, transport, medicines and relationships between providers. The full argument, published by Spotlight, is available at https://www.spotlightnsp.co.za/2026/10/22/who-will-pay-for-the-palliative-care-promised-in-south-africas-next-policy/. The measure of success, in the end, is simple: a patient will know the policy has made a difference when their clinician can find a team, and that team can reach them.