Indian Journal of Community Medicine

LETTER TO EDITOR
Year
: 2018  |  Volume : 43  |  Issue : 4  |  Page : 320--321

The importance of integrating palliative care in Universal Health Coverage discourse in India


GS Adithyan, Abhijith Jose 
 Department of Health and Family Welfare, Consultant, National Health Mission, Chennai, Tamil Nadu, India

Correspondence Address:
Dr. G S Adithyan
National Health Mission, Chennai, Tamil Nadu
India




How to cite this article:
Adithyan G S, Jose A. The importance of integrating palliative care in Universal Health Coverage discourse in India.Indian J Community Med 2018;43:320-321


How to cite this URL:
Adithyan G S, Jose A. The importance of integrating palliative care in Universal Health Coverage discourse in India. Indian J Community Med [serial online] 2018 [cited 2019 Dec 15 ];43:320-321
Available from: http://www.ijcm.org.in/text.asp?2018/43/4/320/248196


Full Text



Sir,

Ideally, Universal Health Coverage (UHC) is designed to provide full spectrum of health services which include health promotion, prevention and treatment, rehabilitation, and palliative care irrespective of economic or gender status.[1] Palliative care is defined as an approach that improves the quality of life of patients and their families facing problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.[2]

Globally, palliative care got included in the definition of UHC as a component in 2012 and palliative care resolution was adopted at the World Health Assembly in 2014 which calls on governments to “integrate palliative care services in the continuum of care, across all levels, with emphasis on primary care, community- and home-based care, and universal coverage schemes.”[3]

The myths and misconceptions

Most of the UHC models restricts in providing a minimum package of health services and see it in the paradigm of medical care and not as a comprehensive primary health-care approach. Even in the basket of services provided under UHC, palliative care is the service which is often neglected even though it can be delivered at an affordable cost compared to any other set of health services. With regards to palliative care, it is also seen in the paradigm of medicine and usually get confined to cancer care and end of life care, even though many other diseases of all age groups come under its ambit.

In the western world, the traditional social support system has given way to a formal, rigid, and expensive medical system. This western perspective has culminated in the formation of a specialized branch called Palliative Medicine which clearly failed to extend to domains of social and financial aspects of the patient.[4] This practice gets followed in many countries including India. The concept of “social care” which is the cornerstone of palliative care always gets diluted in this scenario, and the institutionalized medical approach has failed to reach the majority of those in need of palliative care. Palliative medicine should only be seen as a part of palliative care but should not be equated to palliative care since it includes all levels of care.[5]

Community-based palliative care approach

The community-based model is generally patient-centric, takes into account cultural value systems and reduces the expenses associated with accessing health facility for follow-up visits and unnecessary investigations and treatments thus making it cost-effective and apt for any low- and middle-income country settings to follow.[6]

Kerala was the first state in the country to formulate a palliative care policy in the year 2008 with home-based care as its cornerstone. The program works in a highly decentralized manner where local self-governments have taken the ownership of the program and volunteers are given a prominent place in service delivery, mainly in providing psychosocial care. Hence, being a resource constraint country, India should also focus more on adopting a community-based palliative care model which is financially sustainable and socially viable.

Importance of integrating palliative care in universal health coverage discourse in India

In India, all the existing UHC models operationalized across various states focus on a limited range of issues such as maternal and child health issues, family planning, and certain national health programs and palliative care services is never seen in the range of services. The recent Global Burden of Disease Report for India also clearly shows the change in epidemiological transition happening in the country and how the morbidity and mortality pattern are changing.[7] Palliative care is not often available, accessible, and affordable to the needy in the country even though the people in need for the services are huge.

Since equity is considered as the central theme of UHC, palliative care services must be made an integral component of UHC models as it will mainly increase the quality of life and mitigate the sufferings of the poor and vulnerable, mostly patients at the end of life and reduces their financial burden.[8]

There is no primary validated database in India to understand the palliative care needs of the people in the country. As per Kumar (2013), among the 9.8 million deaths happening in India every year, around 60% of them are in need of any palliative care services. However, only a meagre 2% of them receive any kind of palliative care. It is also a stark reality that among all the palliative care programs that exist in the country, 90% are available in the small State of Kerala, which accounts for nearly 3% of the country's population.[9] Hence, there is a clear demand-supply mismatch in the provision of palliative care services in the country.

Recently, the Government of India has introduced the idea of transforming Health Sub-Centres and Primary Health Centers into Health and Wellness Centers (HWCs) to expand the reach, coverage, and package of primary health care by placing a Mid-Level Health Provider (MLHP) who will be trained in public health and primary care. The HWCs are envisaged to provide a comprehensive set of 12 services which includes basic palliative care and geriatric care. As of now, the concept of government is to institutionalize the role of an MLHP. However, it should be noted that while including palliative care as part of the HWC concept, the approach needs to be community oriented as it is the only realistic model for achieving significant coverage of care for the most needy. The proposed model for the organization of palliative care service delivery at the HWC is represented in [Table 1].{Table 1}

Palliative care is not a novel concept as far as Indian traditions are concerned. We have had an inbuilt social structure that respected and cared for the well-being of the aged and chronically ill patients. It is lost in the passage of times, though. We only have to rediscover it and assimilate it into our psyche.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Universal Health Coverage Fact Sheet. Geneva: World Health Organization; c 2017. Available from: http://www.who.int/mediacentre/factsheets/fs395/en/. [Last accessed on 2017 Sep 20].
2World Health Organization Definition of Palliative Care. Geneva: World Health Organization; c 2017. Available from: http://www.who.int/cancer/palliative/definition/en. [Last accessed on 2017 Sep 20].
3World Health Organization's Certified. World Health Assembly. Strengthening of Palliative Care as a Component of Comprehensive Care Throughout the Life Course. [WHA67.19, 2014]; c2017. Available from: http://www.apps.who.int/medicinedocs/documents/s21454en/s21454en.pdf. [Last accessed on 2017 Oct 05].
4Stjernsward J. Community participation in palliative care. Indian J Palliat Care 2005;11:111.
5Connor SR, Bermedo MC, editors. Global Atlas of Palliative Care at the End of Life. Worldwide Palliative Care Alliance; 2014. Available from: http://www.thewhpca.org/resources/global-atlas-on-end-of-life-care. [Last accessed on 2017 Oct 01].
6Knaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Jiang Kwete X, et al. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: The lancet commission report. Lancet 2018;391:1391-454.
7Indian Council of Medical Research, the Public Health Foundation of India, Institute for Health Metrics and Evaluation. India: Health of the Nation's States – The India State-Level Disease Burden Initiative; c2016. Available from: http://www.icmr.nic.in/publications/India_Health_of_the_Nation's_States_Report_2017.pdf. [Last accessed on 2018 Jan 18].
8Morris C. Universal Health Coverage and Palliative Care: Do not Leave Those Suffering Behind. Worldwide Hospice Palliative Care Alliance; December, 2014. Available from: http://www.thewhpca.org/resources/item/uhc-and-palliativecare. [Last accessed on 2017 Oct 03].
9Kumar S. Models of delivering palliative and end-of-life care in India. Current opinion in supportive and palliative care 2013;7:216-22.