This year World Hospice and Palliative Care Day on October 14th is focusing on palliative care as part of ‘Universal Health Coverage.’ Our immediate response to this might be: “what on earth does that mean”? Or “does that not risk losing the message about the importance of palliative care, because there are so many other pressing health needs worldwide”? Or “Is Universal Health Coverage not just a pipe dream”?
Well, a few years ago it was not unusual to hear people say “Palliative care in low-income settings, is that a priority with so many other pressing health needs”? However, through persistent advocacy of health development agencies such as EMMS International, demonstration of the impact that palliative care can have on people’s lives (even in settings where material resources are in short supply), championing of global palliative care by major health journals such as the BMJ, and Human Rights Watch and others defining pain control as being a basic human right, palliative care has been placed firmly on the health map for all settings, worldwide.
The Declaration on Palliative Care made at the World Health Assembly in Geneva in May 2014 formalised these developments and committed signatory countries and the WHO to making sure palliative care was incorporated into basic healthcare service provision. The challenge however comes in defining what universal palliative care should look like. What is possible and appropriate in Scotland may not be possible or appropriate in Nepal. What is appropriate in India might not be in Malawi. Each context needs to define how palliative care can be most successfully delivered.
In Nepal, we face a growing epidemic of chronic illness as life expectancy increases through the control of infectious disease, improved nutrition and the reduction in maternal and child mortality. Managing chronic illness needs a different approach to managing acute conditions. Chronic disease management includes prevention of the drivers of chronic disease (smoking, unhealthy diet, obesity etc.), accurate diagnosis, proper evidence based treatment, excellent follow up and, indeed, provision of palliative care for those with advanced and life limiting illness. To achieve this requires health systems which can provide good continuity of care and health care professionals who have good communication skills and who know how to approach complex health problems.
Nepal’s health services are finding it difficult to cope with provision of health care at this level. In a recent survey, funded by EMMS International, in areas of rural Nepal severely affected by the 2015 earthquake, we found high levels of chronic illness. Many people suffered chronic breathlessness and weakness, much of it without a formal diagnosis and few of the sufferers were receiving ongoing chronic disease management. Our conclusion was that introducing palliative care on its own was neither feasible nor desirable. People need the whole spectrum of care, from health education, the possibility of early diagnosis, ongoing management and palliative care. This is why palliative care needs to be embedded in Universal Health Coverage – or UHC.
The Nobel Prize winning economist, Amartya Sen, argues that Universal Healthcare is ‘an affordable dream.’ It can be relatively low tech, can draw on locally available resources and personnel and as well as improving a population’s life expectancy and quality of life, it can have huge economic benefits.
Nepal is fortunate in having a well-developed system for training GPs; doctors highly skilled in providing rural health in district hospitals, including maternal and child health and chronic disease management. WHO has identified that to make UHC a reality, it needs to be primary care led, using the skills of GPs such as we have in Nepal. Providing training in palliative care is becoming part of the core curriculum for GPs in at least one medical school in Nepal.
We believe that palliative care can take a lead in the development of appropriate UHC for chronic disease management. Continuity of care, excellent communication skills and complex problem solving – core skills in palliative care - are also fundamental to achieve excellence in the spectrum of UHC in chronic illness.
So we believe that the focus on palliative care as part of UHC for this year’s World Hospice and Palliative Care Day is an exceptional opportunity to promote palliative care – not as a ‘Cinderella specialty’ peripheral to the world’s real health problems – but as a vital ingredient for achieving health for all in the 21st Century.
Dr Daniel Munday works with EMMS International's partner International Nepal Fellowship. He has been leading their work in developing palliative care through engaging with policymakers, training healthcare workers and gathering evidence on the need for improved palliative care services.