Introduction and aims There is an urgent need to develop serviceable models of palliative care. A case study evaluation of eight palliative care programmes in Kenya and Malawi was undertaken to define the current models, understand their context, identify challenges and explore transferable lessons.

Methods A desk based review was conducted on the health environment and systems. Eight sites were visited and interviews held with staff, community and local health leaders.

Results Models of palliative care fell into three categories – specialist, district hospital, and rural health clinic/community level. Staffing levels and the type of work undertaken were influenced by the model, but lack of support systems meant that all models ended up delivering a mix of services. All consistently emphasised pain relief, symptom management and comprehensive care, but differed in their integration into mainstream services, and ability to understand and actively respond to dynamic patient need. This was influenced by staff knowledge, and level of clarity on staff roles. Questions arising in terms of the models of care include ‘who shapes the work?’, ‘who delivers the work?’, ‘who plans the working day?’, ‘who defines what palliative care is?’, ‘who manages changing patient needs? and ‘is the model patient or professional centred? ‘Challenges include the diversity of diseases and need, limited referral options, the tendency to ‘be everything for everyone’, and the speed of scaling up of services.

Conclusion Stand alone models of palliative care have evolved, but many are trying to deliver beyond capacity. When developing a programme, questions on defining the role of palliative care, who and how work is delivered, and support networks need to be asked.