Aimed at ensuring access to effective and good quality palliative care services for every person in the state, the Kerala government recently introduced revised pain and palliative care policy with a focus on home-based care.
Kerala, the first state in the country to introduce a palliative care policy, modified the previous norms in order to make them more suitable to present conditions. The revised policy also aims to enhance the capability of the health system to meet the palliative care requirements of the state.
The new policy has proposed three levels of palliative care – Primary Level, Secondary Level and Tertiary Level. At the primary level, the community will have an important role in planning and implementing the programme at village panchayats, municipalities and corporations. The new policy proposes to set up a strong and active Neighborhood Network in Palliative Care in each ward of every local government body. All the needy patients would be identified at the primary level and a comprehensive plan would be prepared for each patient. It also proposes to train all staff and field workers at the primary level to provide outreach care at the patient’s home.
At the secondary level, community health centres would be developed to act as first referral centres. They would also be equipped with beds to provide inpatient palliative care, including physiotherapy and specialist home visit services. The community health centres will facilitate services at the primary level. The government also aims to equip taluk hospitals to serve as the first referral units and train staff at taluk hospitals to deal with such emergencies.
At the tertiary level, a division of palliative medicine would be set up in all medical colleges and general or district hospitals. Initially, it would consist of existing trained personnel including doctors, nurses and allied health professionals. It will provide out-patient care, ward consultations and home visit services. It will be upgraded to a full-fledged Department of Palliative Care with service, training and research capability in a later stage.
Free training for private hospitals
“The plan to set up palliative care divisions is not only a positive sign but an absolute necessity. The revised policy meets all the requirements. Now the effective implementation of the policy is very important to make palliative care more successful,” said Dr M R Rajagopal, Chairman, Pallium India, an NGO offering palliative care services.
Unlike other parts of the world, Kerala already has palliative care units at the primary and secondary levels. But the tertiary level did not have these, he said. This resulted in a shortage of trained palliative care practitioners in the state.
The revised policy also proposes to develop standards for training centres and duly accredit existing centres to facilitate minimum standards. Mandatory training would be provided to doctors and other health professionals working in the primary, secondary and tertiary levels.
“There is a huge shortfall of medical practitioners trained in palliative care. The issue can be addressed by developing a curriculum and integrating the same with medical education. The government’s decision to set up a palliative care division is a great initiative,” said Dr C N Mohan Nair, Consultant Oncologist and Palliative Medicine Practitioner, Specialist Hospital, Kochi.
The government is also planning to provide training on different aspects of palliative care to all the elected heads of local self-government bodies and members of health-related standing committees. Training programmes will also be conducted for NGOs and CBOs working in the area to develop their capacity for service delivery and training. Free training will be provided to the staff of private hospitals that volunteer to join the palliative care programme, according to the revised policy.
Ensuring medicine availability
The state government stated that it will revise the essential drug list to include drugs and supplies relevant to palliative care. The government will make palliative care medicines available at all government hospitals. However, in order to avoid inappropriate use, proper documentation would be ensured. The government will also put in place mechanisms for the effective delivery of medicines and other supplies. “Currently even trained doctors don’t have access to medicines like morphine. The issue will be addressed with the implementation of the revised policy,” said Dr. Rajagopal.
Meanwhile, Dr Mohan Nair said that the palliative care policy can be made successful only if medicines are made available at primary health centres.
All the non-governmental organizations and community-based organisations providing medical and nursing services at home will be given accreditation and a group of experts would be constituted for the same. The government will also prepare a plan to train non-governmental organizations and community-based organizations to attain minimum standards in palliative care.
Local governments will make medicines and other aids free of cost to non-governmental organizations and community-based organizations, as per the palliative care policy. The local bodies will also coordinate and support all care providers in their jurisdiction. They will assign the care providers to different patients according to priority. The local bodies will also initiate schemes for the socio-economic rehabilitation of palliative care patients.
Meanwhile, private hospitals, including medical colleges, would be brought into the palliative care network through a process of advocacy and dialogue.
The policy also proposes to initiate special efforts to provide palliative care to needy children as children constitute almost 30% of patients with serious health-related suffering. The government will set up a Palliative Care Grid on the lines of the National Cancer Grid. It will facilitate networking of institutions providing palliative care, developing authentic palliative care service providers including non-governmental organizations and community-based organizations, mutual consultation, sharing of data and conducting joint research.
The state government is aiming to develop common guidelines for sensitization and training programmes in the first year. Palliative Care modules would be developed and incorporated in medical, dental, nursing, pharmacy and other allied health courses. The state government is also aiming to provide introductory training to a minimum of 25% of all government doctors, nurses, pharmacy and allied professionals in palliative care in the first year itself.