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Barriers to Integrating palliative care in our country :

# Lack of awareness and knowledge among not onlly the community people but also the main stream health service provider

#Lack of Education on PC / specialization

# government policy on PC implementation

# Lack of recognition

#Health service infrastructure

#Funding

How to overcome

It is not possible to overcome these barrieres for integrationa over the night. Rather it needs integrated solution to all these major barriers to have an integrated palliative care service.

# Awareness creating is the foremost thing both among the mass people and the health care stakeholders
that leads to the two major issues : those are
* to include the palliative care basics in the national academic curriculums in school and collage level.
* to include the PC as a must course in the mainstream medical curriculum.

# Furthermore the Government needs to
* develop a policy on PC and along with a strong roadmap mandatory for any healthcare service /institution targeting the holistic approach in health care.

* Need to change the perception toward the PC with social Recognition  - that will also attract people to enroll in PC specialization program and take it as their career

* The opportunities will be created only when the health infrastructure is ensure in the communities

# GO/NGO needs to create funding in their respective manner ( PC should bring under the National budget allocation etc. )

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Barriers of integration of palliative care in Australia.

General Practitioners (GPs) often play an important role in caring for people at the end of life. While some international studies suggest that GPs experience a number of barriers to providing palliative care, little is known about views and experiences of GPs in Australia. This study explored Australian GPs’ perceptions of barriers and enablers to the provision of palliative care and provides new insights into how to implement best practice care at the end of life.
GPs reported difficulties with palliative care provision due to i) the complex and often emotional nature of doctor-family-interaction; ii) a lack of evidence to guide care; and iii) the need to negotiate roles and responsibilities within the healthcare team. GPs listed a number of strategies to help deal with their workload and to improve communication processes between healthcare providers. These included appropriate scheduling of appointments, locally tailored mentoring and further education, and palliative care guidelines which more clearly outline the roles and responsibilities within multidisciplinary teams. GPs also noted the importance of online platforms to facilitate their communication with patients, their families and other healthcare providers, and to provide centralised access to locally tailored information on palliative care services. GPs suggested that non-government organisations could play an important role by raising awareness of the key role of GPs in palliative care provision and implementing an “official visitor” program, i.e. supporting volunteers to provide peer support or respite to people with palliative care needs and their families.

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Barriers To Integration of Palliative Care In Ghana-

1. Absence of Policies: As of now, there is no supporting policy for the practice of palliative care in Ghana. The Ghana Palliative Care Association has been on a journey to get the palliative care policy passed by the Ministry of Health of Ghana but has not successfully reached that objective though drafts went into discussion many years ago.
2. Myths and Wrong Perceptions of Palliative Care-
Someway, somehow, the general perception of most health practitioners in Ghana is that palliative care is equivalent to hospice care and therefore the need to delay cases until there is nothing medically possible to be done. This gives the notion to patients and their significant others that, once one is referred to palliative, the patient is then on his way to exit the world (hospice).
3. No Insurance for Chronic Care-
Generally, chronic care is not catered for by the Ghanaian National Health Insurance and palliative care which deals with mostly chronic ailments and is not on health policy is not catered for as well. As of now, there is no public or private insurance for chronic diseases.
4. Lack of Training- Most healthcare personnel in Ghana believe that they know what palliative care is and they do practice it without taking the time to understand the actual principles of palliative care and establishing the fact that it is a specialty area they have to appreciate and acknowledge so they learn the best out of it. Palliative Care by now should have been part of every healthcare professional curriculum and have assigned practical requirements before one is passed out.
5. Wrong Mentality of Setting of the practice of palliative care- as a result of the mentality that palliative care is the same as a hospice; the practice of the specialty in OPD and primary care centers seems highly impossible for most practitioners limiting the dynamics of this care.

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A. What are the current barriers to integration in your area of clinical practice? (Answers by country)

In Bangladesh, India, Iran, Myanmar, Pakistan

Answer:

In Bangladesh

Individual level:

1. Lack of knowledge and training.

Family level:

1. Lack of knowledge and training.

Community level:

1. Lack of interest and poor investment.

State/National level:

1. Lack of funding for training.

2. Lack of funds being developing country.

3. Lack of infrastructure for training.

4. Medical business tendency especially in providing home-based palliative care.

5. Misconception of palliative care as a Nonprofitable business.

6. Lack of interest and poor investment.

7. Empathy for investment in end-stage patients, being a poor outcome.

8. Inequal distribution of health services among different strata of society.

9. Long and complex process for getting benefits of palliative services specially from NGOs.

In India

Individual level:

1. Lack of knowledge and awareness.

2. Unemloybility causing Financial hardship.

3. Lack of knowledge about the staging of cancer.

Family level:

1. Lack of knowledge and awareness.

2. Some families have poor affordability of palliative care services

3. India is moving towards a Nuclear family model from a joint family so less availability of helping hands.

Community level:

1. More focused on career and economic issues nowadays, Less time to contribute.

State/National level:

1. Inequal distribution of health services among poor, middle class, and rich.

2. Lack of funding for palliative care services.

3.No adequate publicity about the palliative care domain through print, and electronic media.

4. Very few government and non-government investors.

5. No training and skill development programs are presently available in the country.

6. Palliative care services have not reached till primary care level.

7. Geographical diversity, and culture, across the country, poverty is still an issue.

8. Strict morphine distribution regulation.

8. Transportation challenges in hard-to-reach areas, tribal areas, jungles, etc.

In Iran

Individual level:

1. Knowledge deficit regarding palliative care.

Family level:

1. Knowledge deficit regarding palliative care

Community level:

1. Knowledge deficit regarding palliative care

2. Lack of manpower trained in palliative care services.

State/National level:

1. Lack of manpower trained in palliative care services.

2. Lack of funds and financial support by the government.

3.No written plan of specialized services in accordance with the proportionate share of the overall demand

4. Absence of government strategies, consistent national policies

5. Inadequate training and lack of awareness and expertise of palliative care staff.

6. Lack of educational guidelines and protocols on healthcare, lack of transparency of duties, poor teamwork, and inefficacy of Insurance.

In Myanmar

Individual level:

1. Poor knowledge about palliative care.

2. Low income(financial problem)

Family level:

1. Poor knowledge about palliative care.

2. low income (financial problem)

Community level:

1. Poor knowledge/attitude about palliative care.

2. Poor Budget.

3. Preexisting rituals and misconceptions about palliative care

State/National level:

1. No Government policy related to palliative care.

2. Expensive opioids hence poor affordability for common people.

3. Lack of opioid stocks due to poor government policy.

4. Afraid of opioid addiction if it is easily available in the country.

In Pakistan

Individual level:

1. Lack of awareness, misconceptions regarding palliative care.

Family level:

1. Lack of awareness, and misconceptions regarding palliative care.

Community level:

1. Lack of awareness, and misconceptions regarding palliative care.

2. Poverty.

3. Long and complex process for getting benefits for palliative services especially from NGOs.

State/National level:

1. Lack of awareness, and misconceptions regarding palliative care.

2. Poverty.

3. Unavailability of suitable Painkillers.

4. Long and complex process for getting benefits for palliative services especially from NGOs.

5. Unavailability of opioids and threat of misuse of opioids and benzodiazepines.

B. As a group, select ONE of these and develop an action plan “SMART” (specific, measurable, achievable, realistic, time-oriented)

Answer: What we found common issues among all countries are:

1. Lack of awareness, and knowledge towards palliative care among the general public, health care staff, and even among policymakers.

2. Lack of infrastructure, and curriculum for the training of manpower in the domain of palliative care.

3. No clear policies, guidelines, or protocols regarding palliative care in the country.

We want to enhance awareness, and knowledge of palliative care among the general public, healthcare staff, and even policymakers.

S -Specific
1. We want to enhance awareness, and knowledge of the general public and health care staff as well as of policy makers/administrators.
2. By this we want the on-the-ground application of palliative care services so that an individual, family, and the community can easily, access, and afford the services.
3. Each and every person should have died in a painless, without suffering and dignified death.
4. This we want to achieve within the next 5 years.
5. We need to include syllabi of palliative care in all domains of medical studies so that a set of trained primary care physicians, technicians, and support staff can be developed. 6. Awareness and knowledge about palliative care are very less at present, causing costly, inaccessible, and unaffordable palliative care services in countries. Few palliative care services are available which are mainly clustered in metro and bigger cities, and also few investors are interested in these services.
7. General public is still deprived of knowledge about various health & financial schemes, and facility provisions in respect of palliative care services which can be better shared by awareness and knowledge enhancement.

M-Measurable Indicators can be used:
1. Increase in OPD loads due to end-stage patients seeking palliative care services.
2. Increase in No. of end-stage disease patients admitted in hospitals (as compared to base year).
3. No. of specific beds (medical oncology and surgical oncology)created at nursing homes, hospitals, and tertiary care centers.
4. Increase in the number of palliative care trained health personnel (Doctors/Nurses/Technicians)
5. Budget and Fund allocation dedicated to palliative care services.Policies/guidelines/protocols developed by the government.
6. Persons enrolled in various Governmental schemes as beneficiaries.

A-Achievable
1. Awareness and knowledge through lectures, print media, electronic media, campaigns, and other means will definitely enhance.
2. This can also be achieved by community participation and the inclusion of members of Panchayati Raj Institutions for sharing knowledge.
3. Developing countries are still way behind developed countries like USA, UK, and western countries where it is an old concept and already has evolved. When we see their method of development it is clear this is achievable in the next 5 years.
4. NGOs, Social Groups, and charity organizations can be motivated to invest and participate in campaigns.

R-Relevant
1. Elderly population is neglected in many poor resource countries, especially when they are in their terminal stage of disease, each person has the right to leave in a dignified manner.
2. This will also help in the social, cultural, and moral development of the youth of the country.
3. As per the 95% Rule patients in Palliative care spend 95% of their time outside institutions of care means care is delivered by family, friends, and neighbors. An informal way of palliative care is prevalent in poor and developing countries so awareness and knowledge enhancement among families, communities, and healthcare staff seem relevant.
4. Palliative care not only includes care for suffering but also social. Psychological, and spiritual issues, can only be fulfilled by families, and communities and NOT as much by any hospital/institution.

T-Timely
1. It will take a minimum of 5 years to achieve a decent level of awareness and knowledge among families, community, healthcare staff, and stakeholders.
2. We will assess the level of awareness and knowledge after 1 year, 3 years, and 5 years of submission of the action plan.

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barriers to integrate palliative care in clinical practice

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Current barriers to the integration of palliative care
Inequality of healthcare
Lack of funding
Lack of awareness
No trained personnel
SMART action plan:
S: Set up a training for staff or personnel in a clinic or hospital
M: The goal is to have 5-10 trained staff in PC this 2023
A: A palliative care physician will lead the acitivity and dedicate time to the project
R: This palliative care training is being done to incorporate palliative care in all applicable OPD cases
T: This training should be accomplished in 6 mos

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Barriers to integrate palliative care in clinical practice.

Lack of knowledgeable skilled and motivated health workforce    to deliver palliative care services because provision of palliative care services is multidisciplinary.

Action plans

1 Deployment of adequate and dedicated trained workforce for the provision of holistic palliative care services at different levels of healthcare.

2. Build the capacity through of the existing workforce to provide holistic palliative care services through continued in service training

3. Develop and implement strategies and support systems to prevent burnout among palliative care providers

4. Develop structures to promote career growth and progression, remuneration and recognition including retention and development of appropriate schemes of service for palliative care providers

5. Promote task shifting and task sharing for human resources in provision of palliative care services including opioid prescription as per relevant scopes of practice through engagement with relevant regulatory bodies.

6. Integrate palliative care training into all curricula for health-related courses at diploma, undergraduate and graduate level so that all health workers are trained on palliative care.

7. Liaise with Ministry of Education to develop curricula and roll out relevant palliative care training programs at diploma and postgraduate level

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Barriers of integration of palliative care
Kenya
1 lack of funds to support the program
2 lack of knowledge on importance of pallative care in service delivey
3 Few health providers trained on palliative care
4 Competing activities in the health care systems
5 Lack of community involvement in matters of palliative care
6 Poor job placements for the health workers trained on palliative care.
7 poor infrastructure in the health care
systems
8 lack of ownership

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Further than the individual’s thoughts and feelings, illness also disrupts relationships, social and spiritual aids, financial stability, and trust in the health care system to deliver adequate care. Psychological, social, and cultural factors merge within the patient’s developmental stage, family structure, financial security, and spirituality. As such, the ability to attend to these factors efficiently and effectively is a key component of palliative care.

Psychosocial assessments relate to setting and circumstance and extends beyond the physical to the domains of feelings, family, supports, and finances.  the objective is to create a “private” window.

Several questions can be customized to setting, person, and circumstances for patients with serious illness and/or caregivers. Critical thinking, setting, triage, and attention to emotional and cognitive responses should inform in-tune clinicians as they decide which questions are important, when to abort an interview, when to move on to a different topic, when to explore further, and when to engage social work or spiritual care specialists.

Suggested topics to assess
• Coping with emotions, functional changes, symptoms etc.
• Culture influences.
• Lived experience of illness, impact on self, others, and quality of life.
• Patient’s thoughts and feelings about illness, treatment, and care.
• Social context.
• Suffering and the existential/spiritual domain.

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Integrating palliative care :
Barriers:
1. lack of knowledge about the palliative care, in the community and between physicians. - will awareness about the concept of palliative care and the need of it will encourage the hospitals and the government to integrate the PC in each hospital.
2. lack of education- we have small curriculum for nurses only, but for physicians no training or curriculums were given in the medical schools. - starting small courses and lectures for physicians, nurses and pharmacists and paramedics.
3. lack of manpower - most of physicians and nurses and other paramedics have  left the country  due to the crisis that we are facing in Lebanon.
4. shortage of medications - even opioids are not available in most common used forms and doses .

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IN MY ORIGINAL COUNTRY SUDAN LACK OF MONEY THE PROPLEM THAT WE HAVE NO PALLIATIVE CARE CENTRE AVAILABLE FOR US ...ALSO LACK OF KNAWLEDGE OF IMPORTANT OF PALLIATIVE CARE MAKE GOVERMENT NOT TO TRY TO MAKE CENTRE FOR IT ..THEY THINK OTHER HEALTH PROPLEMS MORE PRIATORY THAN IT..ALSO THERE IS NO WELL TRAINED STAFF ABOUT PALLIATIVE CARE..ALSO SOCIALY OWER COMMUNITY DONOT LIKE TO PUT END LIFE PATIENT FAR FROM THEM THEY WANT HIM AT HOME SO THEY ARE THE ONE DO CARE FOR HIM...

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BARRIERS to Palliative Care in Barbados (West Indies)

1. Lack of emphasis on teaching about Palliative Care in medical and nursing curricula and as a result there is minimal familiarity with palliative care and its application in patient care.

2. There is a Caribbean Palliative Care Association (CARIPALCA) in which Barbados is a member country (caripalca.org). However the access to palliative care is limited to the private sector.

3. Palliative Care and its provision is not a service provided in the public sector (inclusive of the community polyclinics/ primary health care clinics and the country's sole tertiary care institution/hospital). There is little corroboration between the private and public sector and as a result the patients' access to palliative care is limited.

4. The general consensus (based on local qualitative research done by yours truly) revealed an interchangeable use of palliative care with end-of-life care. Healthcare professionals locally are primarily focused on curative efforts and broaching the realm of death in terms of life limiting, chronic and/or life endangering conditions have been taboo especially in the scope of caring for the paediatric patient.

5. Palliative care is not viewed as part of universal health care coverage as per the  UN SDG-3 (sustainable development goals). It is not usually integrated from the time of diagnosis in order to achieve maximal attainable quality of life but rather when death is imminent or a poor prognosis is given.

PROPOSED SOLUTIONS

1.  Implement a proposal to create a service  in the public health care system as a subsidiary of pre-existing departments for both adult and paediatric populations in conjunction with the Barbados Palliative Care Association (a pre-existing entity)

2. Formulate a curriculum/course to familiarise healthcare professionals and affiliates such as social work, religious/spiritual figureheads and psychology with the concept of palliative care. By educating staff, the ability to sensitise the public about palliative care and what it entails would be that much easier. Palliative care would be viewed a support modality aimed at providing the best attainable quality of life and a pillar of comfort for patient and family alike as opposed to a "death plan"

3. Once educated, healthcare professionals will be better equipped about what already exists and how and when to make referrals. As a result, an avenue for advocacy for palliative care and its provision would be created.

4. Utilisation of social media (in this technology driven era) to inform the public as to what palliative care is (to remove stigma and misconceptions about it entails). This will in turn increase the reciprocity of patients and their families to  palliative care.

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Barriers to integrating palliative care:
1. Lack of knowledge about  palliative care in the community and among the health care professionals.
2. No national policy for palliative care.
3.No national guideline for palliative care.
4.Lack of palliative care provider
5. Lack of referral to palliative care
6.Very few  government and private hospitals for palliative care, mainly in  the capital ,Dhaka. Lack of centre in the rural area.
7.Lack of collaboration between  government and NGOs.
Action Plan:
1. Increase awareness about palliative care.
2.Adoption of national policy for palliative care.
3. Increase the number of palliative care provider.
4.Strong referral system to palliative care.
5.Community based palliative care should be introduced.
6.Introduction of palliative care in the course curriculum of MBBS level.
7.Home based palliative care should be encouraged.

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Green - Ravi: Barriers to integrating palliative care in my clinical practice.

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Green - Ravi: Barriers to integrating palliative care in my clinical practice.

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1.           Ours is a  tertiary oncology center where all types of cancers are offered systemic therapy, radiotherapy, and surgery. We have been in this service to the people for the past five years and are in process of treating as well as building state-of-the-art infrastructure for cancer care.

2.           Barriers to the growth of palliative care in my area of clinical practice are

·       There is disbelief amongst the medical fraternity at large in palliative care and hence it is not integrated with the very first multi-disciplinary tumour board held every day in the hospital to discuss the treatment plan of a newly diagnosed cancer patient.

·       Also, most of our clientele are from very poor backgrounds and are unaware of palliative care and its value.

·       Limited & insufficient prescription of narcotics is another reason for inadequate and sub-optimal pain relief in cancer patients.

· Non-availability of trained manpower in palliative care at all levels of clinical practice.

3.           To overcome these barriers, a specialist in palliative care should be made part of the multidisciplinary tumour board, who would be participating in all the discussions and treatment plans of newly detected cancer patients.

Creation of a palliative care team consisting of consultants, nurses & patient care attendants, to attend to the needs of patients.

Training of medical & paramedical staff in palliative care, along with training sessions for patients & caregivers can be organized.  Dedicated IPD services to affordable clientele can be considered. Training the doctors on opioid uses, doses, abuses, side effects, and regulations will also help in prescribing an appropriate dosage of narcotic drugs for adequate pain relief.

Systematic and continuous education for medical staff and training of new staff to cater to the community at large can be brought about. This along with community training during outreach programs for cancer detection can be a holistic approach to overcoming the existing barriers to palliative care.

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Barriers to Palliative Care in the Philippines:
1. Limited knowledge by the majority of healthcare practitioners and professionals
2. Limited number of palliative care provider
3. Lack of support from legislations, private and public health iinsurance coverage
4. Lack of awareness by the public

Solutions include:
1. The recognized national organization, Hospice Philippines, can implement programs that will increase awareness and creare capacity building trainings in palliative care
2. Palliative Advocacy groups to influence legislators to pass laws that will improve palliative care services in the country

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Current barriers to integration.  Of clinical practice -      Action plan to tackle this barrier. Try to make action plan SMART – specific, measurable, achievable, realistic, time oriented.

Barriers

Barriers identified in relation to integrating palliative care in daily clinical practice included lack of hospital policies about palliative care activities, cultural influences, denial or rejection of diagnosis by patients, inappropriate attitude of health care workers, patients failing to keep check-up appointments and financial implications of setting up a dedicated palliative care team.

Key issues in the early integration of palliative care include relationship-building across multiple health systems and specialties; development of a standardized definition of palliative care, making clear that it should be fully integrated with cancer and other terminally ill diseases.

Action plan

Specific

The goal of palliative care is, therefore, to improve the quality of life of both patients and This is why it is best administered by an interdisciplinary, multi-dimensional team, comprising doctors with various specialties or systems, nurses, counsellors, social workers, and volunteers.

Obstacles in the growth of palliative care in India are too many and not only include factors like population density, poverty, geographical diversity, restrictive policies regarding opioid prescription, workforce development at base level, but also limited national palliative care policy and lack of institutional interest in palliative care

WHO and other international organizations lay emphasis on providing physical, psychosocial, and spiritual needs and to help patients achieve quality of life with supportive families. It was to address such needs and so provide holistic care that the concept of friendly neighbours who have been trained in palliative care took shape and so the Neighbourhood Network of Palliative Care (NNPC) was formed in 200.

This is a joint venture with four NGOs and eight palliative care centers which attempts to develop a sustainable “community led” service capable of offering comprehensive Long Term Care (LTC) and Palliative Care (PC) to those in need. NNPC proved the theory that community ownership can work wonders even in financially poor communities.

Indian palliative care development at its most successful has innovated and produced services like NNPC which provides an exemplar model of community-based palliative care for low-resource countries worldwide. The NNPC is designated a WHO Demonstration Project for providing cost-effective community-based home care for late stage cancer patients.

Measurable.

In India, the earliest facilities to deliver palliative care within cancer centers were established in some places like Ahmedabad, Bangalore, Mumbai, Calicut, Trivandrum, and Delhi in the late 1980s and the early 1990s. Palliative Care was initiated in Gujarat in 1980s with the opening of a pain clinic and palliative care service under the department of Anaesthesiology at Gujarat Cancer and Research Institute  a Regional Cancer Centre in Western India. One of the important steps in the history of palliative care development in India was also began from here; forming of Indian Association of Palliative Care (IAPC). In 1986, Professor D’Souza opened the first hospice, Shanti Avedna Ashram, in Mumbai, Maharashtra, Central India. At a similar time, pain clinics were established at the Regional Cancer Centre, Trivandrum, Kerala, with the assistance of a WHO subsidy. Demonstrated through both an expansion in the number of services as well as other key events and initiatives The IAPC was registered as Public Trust and Society in March 1994 in Ahmedabad.

Morphine availability was a considerable problem to the provision of hospital and palliative care. The Narcotic Substances and Psychotropic Substances (NDPS) act of India brought out in 1985 made procurement of morphine so difficult and had a negative impact such that use of morphine in the country dropped steeply in succeeding years.

The Government of India in 1998 gave instructions to all state governments to amend their narcotic regulations, simplifying them. But response from the state government was so poor such that workshops were done in many states in order to improve the situation.

Palliative care is an important and essential part of cancer care therapy and twelfth 5-year plan makes a special provision for it. At least 10% of the budget needs to be earmarked for these services at level of cancer care services. For palliative care there will be dedicated 4 beds at the district hospital. Doctors, nurses, and health workers will be trained in basic palliative care. One of the doctors in the District hospital needs to have a 2 weeks training in palliative care.

Achievable.

Approaches to improve the application of palliative care include education, training, and research endeavours. Educational efforts in palliative and end-of-life care have targeted nurses, physicians, and other disciplines associated with clinical care.

WHO recommended three foundation measures for developing Palliative care—Governmental policy, Education, and Drug availability. They are important for establishing a sustainable Palliative care, and achieving meaningful coverage.

The introduction of Palliative care into the curricula of the under graduate education of all doctors and nurses is recommended as an efficient way to broaden the base of Palliative care coverage at the national level.

A milestone has been achieved in Palliative care as MCI has recognized MD in Palliative Medicine from this year and this will help it to develop as a specialty in our country

Realistic

Home-based palliative care services are becoming increasingly popular with care being taken to the doorstep of the patient. Ideally, this is where people are most comfortable at the end of their lives, surrounded by their loved ones. It is also well suited to conditions in India where a family member is usually available and willing to nurse the sick person. The aim of home-based care is ultimately to “promote, restore, and maintain a person's maximum level of comfort, function, and health, including care toward a dignified death.”

Home-based care models are also generally person-centered and comprehensive, with the aim to take into account factors such as culture, religion, and value systems, and respect people's rights to privacy and dignity, which fits in well with its “community-driven” philosophy.

And the central government will have to develop a policy which would provide guidelines for general application and provide an umbrella of support, especially in matters relating to opioid availability and education. Coordination and partnerships with hospital  programs is a major feature as palliative care.  As an interdisciplinary endeavour, the field of palliative care includes medicine, nursing, social work, psychology, nutrition, and rehabilitation although depth of support available from each discipline varies from institution to institution. Palliative care does require passion and commitment

Time oriented

Educating people in palliative care through programs offered overseas can be useful in some instances, but it is not always an ideal solution. The way forward is to draw on the existing, successful models that have been described, to develop usable and dynamic educational initiatives within India itself, from model palliative-care teaching centers attached to inpatient or community units, thereby making close and relevant partnerships between theory and practice.

The centers for palliative care teaching should be culturally sensitive and relevant to the Indian situation. Collaborations between the government of India, Indian Association of Palliative care and WHO, provide further optimism regarding future development. India has the potential to lead the way and enlighten others rather than being subservient to those countries that enjoy resource wealth. IPM Calicut is doing good work in this regard.

Unfortunately, there are various obstacles to fulfilling patients’ and their families’ hopes because of the heterogeneity of various geographical, social and medical backgrounds among the various geographical areas. One model cannot fit all. Given the diversity each region will need to develop its own policy that suits its needs and its social and cultural background with holistic approach.

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Barriers in integrating Pal Care in Bangladesh

There is a saying `Palliative Care adds life to the days, not days to the life.’ This adding life to the dying is not that much easy. Because Pal Care is a Holistic approach. The barriers in integrating this approach are

1)      Lack of knowledge – Lack of knowledge among the general people and the Health care providers. The health care providers still focus on the disease, not the patient.

2)      Absence of a policy—As there is not a complete policy on it, the service is fragmented, incomplete.

3)      Lack of collaboration among the primary, secondary and tertiary level health services.

4)      Absence of leadership

5)      Absence of involvement of the community leaders like Union Parishad Chairman, ward councilor, city corporation Mayor and others.

6)      Urbanization also a barrier here. Because in the cities, people are so busy and isolated that they find it difficult to build a compassionate relationship with their neighbours and offer help.

7)      The health service system itself is a barrier in integrating PC. The system don’t pay attention to the patients’ emotional and spiritual need. They  just focus on their physical need.

8)      Lack of manpower---- There is a shortage of trained doctors, nurses and social workers/volunteers on PC.

9)      Lack of funding--- In this  middle income country, the financial crisis hinders us to provide free of cost medicine, home care and other support.

Action Plan

1)      A strong policy needs to be prepared so that every sector understands their role. The policy must emphasize collaboration among different level health care service (primary, secondary and tertiary).

2)      Strong leadership to strengthen community’s involvement to provide emotional, financial and spiritual support

3)      Increased budget in primary health care service. So that the dying person can visit his nearby health care centre and get symptomatic treatment and home care service if needed.

4)      More awareness raising programme in community

5)      Changes need to be brought in medical curriculum so that every physician learns to treat a patient, not a disease. PC should be incorporated in MBBS and BSc nursing.

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Barrier to proper palliative care include :
-lack of knowledge regarding natural death and palliative care in the community
-lack of national policy that integrate community and NGO as equal partner with health system In providing care for terminal I’ll patient-
-lack of trained staff and man power
- lack of proper evaluation and assessment tools and comprehensive care
-lack of coordination between different health care levels
-lack of patient centred treatment
- lack of home care

Solution will include:
. Introduction of concept of natural death and palliative care early in corriculam  or high schools and universities and to  Increase public awareness .
. The adoption of national strategises that incorporate community and NGO as equal partner in providing support for terminal patient
.more investment in training qualified staff in all concerned discipline in paliative care.
- establishment of proper infrastructure and assessment tool
-broaden the concept of home care and hospices

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Palliative care in the Republic of Moldova is underdeveloped, fragmented; palliative care is mostly addressed in the context of oncology, whereas it includes a much wider range of chronic and degenerative conditions. Patients have limited access to palliative care services both at primary care level and for specialised care services, only 8% of patients in need of palliative care receive it, although there has been progress in the development of these services in the country, they are still insufficient to provide adequate palliative care according to international recommendations and the needs of the population.

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Some barriers regarding palliative care integration in Rwanda may include:

-          Lack of coordination between health care facilities where there is no a well-planned system to share patient’s information.

-          Lack of specialist in palliative care field we steel have few stall received palliative care as specialty and those one’s are not employed in that field.

-          Lack of integration of palliative care as a specialty in medical school is big problem in the country where to produce palliative care specialist steel a challenge.

-          Lack of hospice and palliative care centers we have only two and they are located in the Kigali city people from village can’t benefit from them.

-          Lack of trained community volunteers,

-          Lack of social support from NGOs.

-          Lack of staff most of palliative care team into different health facilities do palliative care as additional responsibility and this may affect services they deliver to patients due to work overload.

-          Lack of infrastructure, no places where to create palliative care unit into different health facilities.

Action plan:

Increasing palliative care awareness and advocacy.

Government to make effort in palliative care activities and put it in budget plan.

Involves donors and NGOs for financial support

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Turquoise Abigail
Barriers to Palliative care
1. Ignorance about palliative care integration
Most people do not understand palliative care, some people associate palliative care to dying or end of life. Meanwhile palliative care is started immediately a patient diagnosed with chronic condition is established.
In Ghana palliative care is underestimated, most physicians refer patients when they have gotten to end of life. However, patients and family did not actually get full benefits of palliative care although they are much appreciated with the care at the latter stage.
2. Financial challenge.
Palliative care has not fully recognized by the government on the need to make policy to capture their medications on National Health Insurance. Patients are not able to purchase the medications pain medication called Morphine sulfate.
3. There are few hospitals who provide specialist palliative care service. The health care providers too are not many to render the care.

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Magenta-Winnie                  Integrating Palliative Care

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Magenta-Winnie                  Integrating Palliative Care

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One thing I would love to see in the medical practice before I retire is the proper integration of palliative care into the primary care system.

By the original definition of palliative care, it is clear that it is a mindset that a healthcare professional needs to have and is not dependent on the specialty of the professional. We just need to see that just like every specialty in the medical profession, there always comes a time that we need to call in the specialist however, every qualified professional has basic skills in all areas to a "save a soul" level.

It is therefore imperative that just as it is essential that there can be some basic level intervention for all specialty areas for patients, the story for palliative care must not change.

Perhaps the actual problem is the fact that practitioners are often tempted to generalize palliative care so much that, they don't take the time to understand that there is so much to learn about it and that there is so much we can do with the knowledge acquired in it.

If we can really take our time on it, we can of course come to the realization that even at end of life stages or when a person has set into an actively dying phase, there is so much that is expected of us as practitioners from the affected person and their significant others.

If we had the chance to see through all that our actual responsibilities are in a dying patient, then we would have appreciated that we lose precious time when we don't "comfort care" (hospice care) in time and would probably learn to call in hospice at the right time, and eventually call in palliative care to be inculcated at the very onset of disease trajectories to give our patients the best.

In a world where the primary caregiver at the OPD is palliative-oriented, we can be sure that we indeed get the best that our patients deserve and we intend to have the best satisfaction for a job well done- setting a pace that we will intend to benefit from in the future. For we all shall die one day and have no idea if we will benefit from the proper palliative care we are practicing, that is why it is essential to infect everywhere we go with the best we learn.

In the approach

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Barriers :
1
In Bangladesh there is formal and informal setup for providing palliative care yet there is misconceptiona that palliative care is only given when people is dying, so one of the main barrier in lack of adequate knowledge
2. Weak referral system :  a tendency to put on chemotherapy even in the last day of life, doctors also keep denying the fact that curative treatment will no longer work
3. Patient sometimes feel himself as burden and let himself suffer until death and do not seek support
4. Tendency to deny among doctors and families aboutand put the the symptoms of last days and put the patient to ICU and other futile treatment
5. No govt. policy is available. So poor people cannot avail service even morphine which is such a less costly medication

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As a volunteer, I would address the struggle to accept palliative care by the patient and their family is a critical part. They always believe that lying freezing in a superspeciality ICU sorrounded by machines will offer good quality care for their beloved ones. They seems confused about the best way to get taken care of. Palliative care is only considered at the last few days of patients life. They seems to neglect it throughout. If someone who has this knowledge about Palliative care is disputably abondoned.

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Amber Avani
1. Reference given towards the end that leaves no time to prepare family or comfort patient.
2. Sometimes patient feels himself as Financial burden on family where there is no purpose of survival. Hence no motivation to opt for palliative care if no active treatment is given.
3. Medical fraternity do not refer at the time diagnosis thinking that patients will discontinue their chemo protocol and only take palliative care as symptoms are managed
4. NGO that offers palliative care has very high pressure of performance to prove to the funders n hence the flow of funds are not always smooth or uniform. Hence even the employees are at times unsure about their salaries due to lack of funding.
I remember my Program associate struggling to show numbers rather than quality of care and comfort provided to the patients.
5. Collusion also plays important role as patient who doesn't know about diagnosis or prognosis will be always protected by the family members in the fear of revealing the truth, family prefers not to take palliative care option.

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BARRIERS TO INTEGRATION

1 . Limited knowledge on palliative.
In Kenya, majority of Health Professionals have not had training on palliative care and only a few and especially those working in palliative care centres have previously had training on the same. Untill recently, palliative care was not included in nursing curriculum.

2.  Awareness and advocacy
Not much emphasis has been put on palliative care especially at the community. To make people know of the service and what it entails.

3. Infrastructure
Palliative care centres are only in the major government Hospitals which in Kenya are reffered to as Level 5;and 6 plus some private hospital. The smaller hospitals level 3 and 4 which are the majority do not offer these services. This leads to challages in accessibility and availability.

4.  Acceptability
In Kenya, palliative care is still not well accepted since majority of people including health workers think talking about death is a norm.

5. Governance.
Until recently, not much emphasis and support had been put by the government on palliative care and therefore allocation of resources on the area was quite limited. This made the service provision a challage. However the Kenya Hospice and Palliative Care Association and other support bodies have taken the burden and palliative care is now taking shape.

ACTION PLAN
1. Training of Health Professionals on palliative care throu workshops, continuous medical education, in the medical and nursing schools etc.

2. Awareness and advocacy at all levels including community level inorder to make it acceptable.

3. Support of existing palliative care centres and in setting up others by the government and NGOs.

4. Making palliative care services accessible, affordable and Available by having the service at all levels of Hospitals.

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Barriers
(1). Lack of knowledge about palliative care in Lesotho is the big challenge,some patients die  at their homes without given pain management drugs.

(2).Lack of funds  or resourcesfor providing for providing drugs and all equipment to be used when doing home visits.

(3)Lack of skills from health professionals to give awareness about palliative care and the importance of palliative care in Lesotho.

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The summary for barriers & the suggested solutions as in this picture above.

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Integration of Palliative Care in KSA is started in 2019 through the Palliative Care Network Center of Excellence, which the lead for all health cluster & the policy maker. We reach 40% in 2022 and by the end of 2023 it will be > 60% nationally.

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Green - Samsudheen

Barriers

1.  In Kerala palliative care giving centres are more in both Government and  NGO level. Still access to existing palliative care services are difficult. In middle and high income group they are not availing the services due to mainly prestige issues and access to very sophisticated hospitals with well equipped life supporting system. Even though the multi system failed cases  they are admitting in Critical care ICU and giving all medical support. Lack of awareness among the medical fraternity, pressure  from the relatives to do something with the dying patient.

2. Various medical system (Modern
medicine & Ayush) can be integrated,  for a common cause, betterment of the problem, but various reasons that is not materialised.

3.  Lack of awareness among
the general public and the medical fraternity about the availability of palliative care services. Public should be educated the need of palliative care and die with dignity and pride.

4.   Most of the  of the Palliative
care service are mainly focussing to relief from physical symptoms and ignoring
psychosocial and spiritual components.

Action Plan

a. Awareness programmes to  the medical fraternity, for this a proper mindset should develop, for    that various sensitasion programmes to be conducted. Along with proper orientation and teaching  from school level.

b. Mind set of the family should be addressed. For this various programmes can be arranged with the help of community  leaders, religious leaders, and many social working group. With the help
of print and social media we can achieve the result very fast .Give proper training and orientation should be given.

C. Also seek the support of
Local Governing Bodies (such as panchayats, municipalities, corporations), ASHA workers, Community nurses and identifying local volunteers and providing them training sessions on palliative care. In kerala the community volunteer participation is much more and working very effectively.

d. Muti disciplinary approach with the help of various system and
departments, including psychiatry, rehabilitation, surgical, medical etc

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Some of the barriers in Ernakulam district of Kerala, India, include:
1. medical fraternity's aversion towards referring patients to palliative care citing territorial insecurities or loss of patients to other specialities.
2. lack of awareness amongst the general public about the availability of palliative care services or when can palliative care be sought along the patient's illness trajectory
3. Inequitable access to existing palliative care services
4. Limiting palliative care service to merely relief of physical symptoms and ignoring psychosocial and spiritual components.
ACtion Plan
Focusing on one barrier alone may not offer a complete solution. In my opinion a three pronged approach can be sought and this action plan can then be phased out.
3 pronged plan:-
a. Increase awareness amidst the medical fraternity through short course training sessions for nurses and doctors. Contact hospitals and conduct on site training sessions.
b. Seek the support of Local Self Governing Bodies ( panchayats, municipalities, corporations), coun sellors/ASHA workers/Community nurses in identifying local volunteers and providing them three day or 5 day training sessions on palliative care and how they can contribute.
c. EMploy services of medical social workers in offering psychosocial support

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Barrier of palliative care
1) Lack of knowledge about palliative care and also pain management. This makes it sometimes impossible to manage symptoms effectively especially when it comes to pain. The concern of health workers about opioid addiction does not help pain management
2) Financial constraint: Most of our palliative care drugs and services are not captured by insurance and this makes it quite impossible for most of the patients to assess service and drugs
3) Lack of understanding of palliative care since palliative care has been associated with dying most people who do not want to talk about death do not want to have anything to do with palliative care

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Integrating Palliative care:

So, in my country, Lebanon, palliative care is not integrated within health care insurance plan since it is not part of the national integration strategy. Some hospitals have their own palliative care team but still not very well spread.
Adding on we have to home based palliative care serving in the community covering all over Lebanon, doing a great job, but definitely more is needed to cover the need among all the country.
Also, I would like also to mention, that lack of knowledge is strongly present, as palliative is only for end-of-life care. So, a lot of education and awareness is needed.
Among the health care providers, it is also important to highlight that communication among different specialties is an important factor.

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Some of the barriers for proper holistic palliative care in my country include the followings ;
-lack of knowledge regarding natural death and palliative care in the community
-lack of national policy that integrate community and NGO as equal partner with health system In providing care for terminal I’ll patient-
-lack of trained staff and man power
- lack of proper evaluation and assessment tools and comprehensive care
-lack of coordination between different health care levels
-lack of patient centred treatment
- lack of home care
Proposed soluations:
- introduction of concept of natural death and palliative care early in curriculum of high schools and universities and increase awareness of this concept among individuals in the community
-collaboration between NGO community hand in hand with health system in care of terminally ill patient
-More investment in training of qualified staff in different disciplines and aspects of palliative care

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The barriers are lack of awareness and recognition of palliative care. And to overcome this we need to have public sensitization on palliative care.
2. Lack of funding since most people tend to have spend all their money seeking care so when it gets to palliation they sometimes have no money left. It can be overcome by early recognition of palliative care n government having some funds for palliative care.
3.lack of knowledge on palliative care. It can be overcome by educating the public on the need for palliative care in all cadre of health care.

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Amber Avani

Sometimes also insecurity of losing patients refrain them to refer to palliative care

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i think the lack of knowledge and awareness about PC consider the main barriers and the some of health care provider do not give the PC priority in care.

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India -Knowledge and lack of awareness among the doctors and relatives of patients

Awareness through audiovisual measures

With govt +semi govt funding

Volunteers + long term plans from govt

Even health workers also lack of knowledge and we have lack of funds, lack of Training facilities in our Bangladesh

In Myanmar, cause of the gov policy opioids are nearly lack of stock and price is too expensive . So patients can’t buy and the lack of knowledge, their families also afraid of opioid addiction. Also heath care worker has poor knowledge and they think time to transfer is end stage of disease.

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Barrier to Integration of Palliative Care:
Lack of Awareness about Palliative Care

How to address this barrier:
1. Form a Palliative Care Committee in the hospital that will orient hospital staff (medical and non-medical) about the concept of palliative care and the referral system.
2. Involve stakeholders in the field of medical education (medical/nursing boards) to make Palliative care a part of the Medical/Nursing curriculum.
3. Conduct lay fora about palliative care and highlight specific case scenarios to illustrate the concept of palliative care.

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Lack of knowledge about palliative care and understanding of it by social community and caregivers 

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Lack of knowledge about palliative care and understanding of it by social community and caregivers 

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We see finances as the main barrier to integrating palliative care in our regions.
our SMART plan would be to organize fundraising activities toward palliative care services.
We would do this by planning fundraising events over one year.
We would have 5 events over the course of the year particularly at times of religious celebrations such as Christmas, Eid, Divali, Chinese New Year etc.
We would also approach government facilities for funding.
this is our specific, measurable, achievable, realistic and time orientated plan.

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LAck of awareness amidst medical fraternity with respect to getting palliative care involved along the treatment trajectory

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1. Lack of awareness and understanding among medical practitioners / professionals, and the public. Therefore the delayed referrals to NGO hospices, and terminal discharge and families do not know what to do or how to handle at home.

2. Financial issues - NGO hospices are trying to survive as government are not supporting and private hospitals are not helping those who are dying, but those who can pay and continue treatment

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insufficient knowledge about other professional role

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-Lack of palliative care professionals and family not owning up palliative care
-Lack of communication in referral systems
-Lack of adequate capex or facilities
-Lack of awareness / understanding
-Lack of referrals from HCPs
-Lack of multi disciplinary team
-Stigma associated with palliative care

How to overcome
1.More awareness among communities and health care professionals.
2.Making policy changes at a governmental level
3. Integrating palliative care into regular educational programs

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-problem with truth disclosure
-limited confidence in health care providers

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Barriers:
Education
Finance
Awarness

Main Awareness:
Finance

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The most important one in my country is lack of knowledge 

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The most important one in my country is lack of knowledge 

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And policy makers
Expense
Culture

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FINANCIAL BARRIER

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team brown
Dr Samira's concern:Iran Financial aid towards the development of palliative care
Inputs : Funding to be distributed among private sectors :NGO s-but having a contnious funding is tricky
-solution more awareness about fund raising programs and crowd sourcing
-in long term plan policies involving insurance schemes for such
best solution would be for community and volunteers to be involved

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1. Misconception or lack of understanding in PC
2. Lack of awareness about available facilities particularly in rural set up
3. Delay in diagnosis
4. Lack of/Limited inclusion of in medical curriculum
5. Budget allocation scarce

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lack of sensitization among masses, awareness among health care professionals.

As a remedy:
1. public awareness through programmes and media.
2. advocacy to policy makers.
3. integration into curriculum.

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CURRENT BARRIER- LACK OF MAN POWER
Action plan
1. Proper training and education at level of health care professional,volunteers,community based.
2. Awareness programs regarding palliative care via visual media, television, newspapers
3. Funding supported by government, NGOs
4. Proper communication and participation at all levels of palliative care for example patient, doctor,nurse,volunteer

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1.Lack of common perspective
2. Absence or inefficiency of a common platform
3. Clashes of interests

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Main focus on integration of training in medical setting
Team members please contribute in the comments

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Communication and poor referral systems between hospitala or specialty and community.

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1. Interdisciplines lack of knowledge and understand about roles of others (between the professionals).
2. Lack of well-integrated roles between medical, community and informal caregivers.
3. Lack of awareness amongst general people as well as medical fraternity..
4. Insecurity about loosing patients by the consultants and hence apprehensive to include palliative care team
5. Less lucrative
6. Government doesn't provide much provision for palliative care.
7. No medical insurance company or policy covered for palliative care.
8. Some misconceptions like, palliative reference means gone case, nothing left to for the patient.
9. Fear about discussion on death and dying
10. Denial that we don't need palliative care, still treatment is available.
11. Oncologist don't want to give up till the end and keep giving some other treatments in form of chemo or radiation therapy
12. Trained palliative care professional like Dr and nurse are scarce.
13. Sometimes need is there but reach out is limited in the form of resources due to vast number of patients and vast geographical area.
14. Misconceptions about pain drugs like opioids and Nsaids.
Reluctant to commence the pain management
15. feeling of Hopelessness and helplessness

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Lack of awareness among the physicians/oncologists - Palliative Team has limited time to provide the best support & prepare the family in various area of care.

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Most important barrier is that heathcare professional do not understand the philosophy and the concept of palliative care

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Yellow Maria Elena - Barrier to integration of palliative care

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Yellow Maria Elena - Barrier to integration of palliative care

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Palliative care is not given a priority by most attending physicians whose goal for their patient is mostly curative.