What are the main barriers to palliative care development?

Palliative care development follows a public health model developed by the WHO that emphasizes policy, education, medication availability, and implementation. There are many barriers to achieving each of these components.

Policy

Without policies that support the provision of palliative care it is quite difficult for any palliative care to develop. In some countries there is no government support whatsoever for palliative care. In others, such as Romania and Zimbabwe, charitable palliative care services have developed. But even in these cases permission to operate has to be granted. Policy is therefore seen as the fundamental component, because without it other changes cannot be introduced.

Types of policies needed include:

• laws that acknowledge and define that palliative care is part of the health-care
system;
• national standards defining how palliative care programs must operate;
• clinical guidelines for the delivery of palliative care services;
• establishment of palliative care as a recognized medical specialty/sub-specialty;
• regulations that establish palliative care as a recognized type of health-care
provider with accompanying licensing provisions;
• a national strategy on palliative care implementation.

A review of the global status of all palliative care policy development wasdone by Clelland et al, 2020 and found only 55 countries with any national plan for palliative care.

Education

The vast majority of health professionals worldwide have little or no knowledge of the principles and practices of palliative care. A growing body of knowledge has been accumulated over the past 50 years on the science of palliative care and palliative medicine. There are now at least 14 professional journals devoted to palliative care, a growing body of peer-reviewed literature, and numerous books, internet sites, blogs and forums devoted to all aspects of palliative care.

Palliative care education is needed at three levels:

• Basic palliative care training for all health professionals and paraprofessionals including physicians, nurses, mental health professionals, clergy, volunteers andtherapists;

• Intermediate training for those routinely working with patients with lifethreatening illnesses;
• Specialist palliative care training for patients with more complex symptom management needs and for those who will teach palliative care and do research.

Curricula for these three levels exist, however, there is no consensus on the amount of training needed and most of the existing educational programmes are in English.

There is also a need to carry out community education and awareness campaigns about palliative care at the same time as services are established. When services are delivered patients and families also need extensive training on how to provide care including personal care, body mechanics, symptoms to expect and how to manage, along with signs/symptoms of impending death and so forth.

Medication Availability

Most medications in the WHO Model List of Essential Medicines for Pain and Palliative Care, especially controlled substances namely,
opioids, are required for the delivery of quality palliative care. Access to opioid medications for pain control is an enormous problem worldwide.

Over eighty per cent (84.25%) of the world’s population lacks adequate access to opioid medications for pain control. Australia, Canada, New Zealand, the United States, and several European countries accounted for more than 90% of the global consumption of opioid analgesics while Low-and-Middle-Income Countries (LMICs) consumed only 10% of global opioids.

The UN Single Convention on Narcotic Drugs, approved by most countries in 1961, called for balance between mitigating diversion of licit opioids and other psychoactive substances while also allowing for adequate provision of these drugs for medical and scientific use.

Since that time, the major focus has remained on control of illicit use of these drugs, and even restricting licit medicines, with little emphasis on enhancing access for medical and scientific use.

The worldwide palliative care community and related human rights organizations have advocated for balance to be restored by paying equal attention to both medical use and prevention of illicit use.

In 2016, the Commission on Narcotic Drugs (CND) included “access to controlled medicines” as an area of focus in the UN General Assembly Special Session and High-Level Meeting on the World Drug Problem.

A subsequent 2019 Ministerial Declaration reinforced the need and commitment to address the pathos of disparity in access and availability of controlled substances for medical and scientific purposes, especially for pain and palliative care.

While the true need for opioids per capita remains under debate, and will vary by country depending on age, disease rates, causes of death and many other factors, Seya et al published an estimate of opioid need for 188 countries. They used average usage in the 20 top countries in the Human Development Index (HDI) as a reference point for development of an adequacy of consumption measure (ACM).

According to this analysis 83% of the world’s countries have low to non existent access to opioids, 4% have moderate access, and 7% have adequate access, while for the remaining 6% of countries insufficient data is available.

Notably, recently, Scholten et al extended this investigation by using the “adequacy of opioid consumption” (AOC) index and compared it across countries with high HDI. Indeed, the average opioid analgesic consumption of the top-20 countries of the HDI increased from 84 morphine milligram equivalents per capita (2000) to 256 morphine milligram equivalents per capita (2015). However, the overall consumption for all countries, due to limited access in most countries was only about 33.25 mg per capita and the consumption of morphine, mainly used in palliative care was less than 5 mg per capita.

Key indicators of opioid availability are the reports of opioid usage that are published by the International Narcotics Control Board (INCB).

There is enormous variability in consumption per capita around the world and many barriers to increasing the availability and consumption of opioids for medical and scientific use. These barriers include overly strict regulation, limitations on available forms of medication particularly oral opioids, lack of supply and distribution systems, limitations on who can prescribe, fear of law enforcement intervention into medical use, and so forth.

In this regard, in using the INCB data for practical application, Gilson et al revealed the relevance of a morphine equivalence (ME) metric in demonstrating the extent that morphine consumption relates to total consumption of other widely used licit opioids. Further opioid consumption data and interactive graphics can be found at the Indiana University Walther Centre in Global Palliative Care & Supportive Oncology website at painpolicy.iu.edu.

This article was inspired by the Global Atlas of Palliative Care 2nd Edition.

——————–