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Integration of Palliative Care into Mainstream Health Care: Team Scarlet

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Integration of Palliative Care into Mainstream Health Care: Team Scarlet

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General Situation in Countries Represented in the Scarlet Group

1.     The presentations made by the Scarlet Group countries indicate that palliative care is now widely recognised as an important component of healthcare. Although the participating countries differ considerably in terms of economic development, healthcare infrastructure and available resources, they share a common objective of making palliative care more accessible to those who need it. Progress has been made in many countries through national policies and strategic plans, but implementation on the ground has not always kept pace with policy intentions.

2.     The level of development varies across the group. Countries such as the United Kingdom have relatively mature palliative care systems supported by well-established hospice networks and multidisciplinary teams. In contrast, countries including India, Bangladesh, Kenya and Ghana continue to expand their services while addressing limitations in infrastructure, workforce and funding. Bulgaria and Morocco have also taken important steps to strengthen palliative care but continue to face challenges in achieving uniform service delivery across their healthcare systems.

3.     India presents a mixed but encouraging picture. The National Health Mission (NHM) and the National Programme for Palliative Care (NPPC) have provided a clear policy framework for expanding services. Kerala, in particular, has demonstrated that a community-based model involving healthcare professionals, trained volunteers and local organisations can successfully deliver palliative care to patients in their homes. However, similar progress has not been achieved uniformly across the country, highlighting the need for stronger implementation mechanisms and greater coordination between states.

Key Gaps, Challenges and Opportunities

4.     Despite differences in healthcare systems, several common issues emerged from the country presentations. One of the most significant concerns is the uneven availability of palliative care services. Urban populations generally have better access, while rural and remote communities often have limited or no services. This disparity remains one of the biggest obstacles to achieving equitable care.

5.     Another recurring issue is the shortage of trained healthcare professionals. Many countries lack sufficient doctors, nurses and allied health professionals with formal training in palliative care. In several settings, palliative care is still viewed as a specialised service rather than an integral part of routine healthcare, resulting in delayed referrals and missed opportunities for early intervention.

6.     Access to essential medicines, particularly opioids for pain relief, also remains a concern. Although these medicines are included in international recommendations, regulatory restrictions, procurement issues and supply chain limitations continue to affect their availability in many countries. Consequently, effective pain management remains difficult for a significant number of patients.

7.     Financial constraints further limit the expansion of services. In many countries, palliative care programmes rely heavily on external funding, charitable organisations or isolated initiatives rather than stable government financing. Weak referral mechanisms and poor coordination between hospitals, primary healthcare facilities and social welfare services also reduce continuity of care, particularly for patients requiring long-term support at home.

8.     Demographic and epidemiological changes are adding further pressure on existing healthcare systems. Increasing life expectancy, together with the growing prevalence of cancer, cardiovascular diseases and other chronic illnesses, has substantially increased the demand for palliative care. Unfortunately, service expansion has not kept pace with this growing need.

Opportunities for Strengthening Palliative Care

9.     While the challenges are significant, several practical opportunities for improvement are visible across the spectrum . Integrating palliative care into primary healthcare would allow earlier identification of patients and ensure continuity of care closer to their homes. Such an approach would also reduce unnecessary hospital admissions and improve the quality of life for patients and their families.

10.   Strengthening education and training emerged as another important priority. Building the capacity of doctors, nurses, community health workers and volunteers would enable palliative care to become part of routine healthcare delivery rather than remaining confined to specialised centres.

11.   Community participation was identified as a key factor for sustainable palliative care services. Kerala's experience clearly demonstrates that active involvement of local communities and trained volunteers can complement formal healthcare services and significantly improve access, particularly for patients receiving care at home. Similarly, the United Kingdom's hospice system illustrates the value of coordinated multidisciplinary care supported by strong institutional frameworks.

12.   Advances in digital health and telemedicine also present new opportunities. These technologies can improve communication between healthcare providers, facilitate follow-up consultations and extend specialist support to remote areas where palliative care expertise is limited.

Common Issues Identified

13.   Even in these diversities, the Scarlet Group countries share several common concerns such as:-

(a)    Availability of palliative care services remains uneven, particularly in rural and underserved regions.

(b)    Shortage of trained healthcare professionals continues to affect both the quality and coverage of services.

(c)    Integration of palliative care into primary healthcare systems remains incomplete in many countries.

(d)    Access to essential medicines, especially opioids for pain management, continues to be restricted by regulatory and logistical challenges.

(e)    Rising numbers of elderly people and increasing cases of cancer and chronic diseases are creating greater demand for palliative care.

(f)     Sustainable financing, stronger policy implementation and better coordination between health and social welfare sectors remain essential for long-term development.

(g)    Community participation, workforce development and wider use of digital health technologies offer practical solutions that can strengthen existing services.

Conclusion

14.   The general scenario across the countries clearly demonstrate that, irrespective of their level of economic development, all countries are working towards improving palliative care. Although each country faces its own unique circumstances, the underlying challenges are remarkably similar—limited access to services, shortages of trained personnel, inadequate funding, fragmented care pathways and insufficient public awareness.

15.   At the same time, several encouraging examples of good practice such as Kerala's community-based model and the United Kingdom's integrated hospice system show that effective palliative care can be achieved through strong policy support, community participation and multidisciplinary collaboration. Adapting these successful approaches to local contexts can help other countries strengthen their own palliative care systems.

16.   Improving palliative care requires more than policy development alone. Sustained political commitment, adequate financial investment, trained human resources, community involvement and effective coordination between healthcare and social welfare services are all essential. If these areas receive continued attention, countries will be better positioned to provide compassionate, accessible and person-centred palliative care for all those who need it.

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Integrating Palliative Care Services into the Mainstream (Team Magenta)

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Integrating Palliative Care Services into the Mainstream (Team Magenta)

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INTEGRATION OF PALLIATIVE CARE SERVICES INTO THE MAINSTREAM

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Integrating Palliative Care Services into the Mainstream by Team Silver

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Integrating Palliative Care Services into the Mainstream by Team Silver

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Integrating Palliative Care Services into the Mainstream by Team MAGENTA

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Integrating Palliative Care Services into the Mainstream by Team MAGENTA

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INTEGRATION OF PALLIATIVE CARE SERVICES INTO THE MAINSTREAM

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Maria Paula Rondon - Colombia- Team Indigo

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Maria Paula Rondon - Colombia- Team Indigo

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In Colombia, Palliative Care is centralized, accessible for many people in major cities. It begins with consultation into PHC, referral to main speciality treating the patient (i.e. oncology, cardiology, neurology, etc) and the specialist refers the patient to Palliative Care, which is available primarily at the outpatient context, but if the patient requires it, could be referred to inpatient PC attention. Also, if the physician at primaryy considers it, could refer the patient directly to PC attention. According to the health situation of the patient, the PPS (Palliative performance Scale), PPI (Palliative Prognosis Index) and entry criteria to a PC program, patient could continue care at the outpatient, home based or hospice scenario.

In my opinion, there is a good integration of PC services in the major cities.

However, by my experience living at a peripheral small city (Santa Marta, Magdalena), access to palliative care in this locations is really poor.

I consider, that education in Palliative care is fundamental, so that Health Care professionals could treat initial symptoms and refer patients in a prompt time.

Also, universities could receive more residents per year, so that the offer of PC grows and the demand of attention could at least be near (we were just 2 specialist for a population of 1.500.000 people. Since there is no human resource educated in PC, there are no PC teams, the service at home-based care is ineffective and people could wait for attention almost 8 months to 1 year!!

In summary, there are a lot of actions to do in terms of Palliative Care in the minor cities and rural cities in Colombia, so that people could benefit from it on time.

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Integrated Palliative Care Across Countries: Progress, Persistent Gaps, and Pathways to Compassionate Systems

Introduction

The ideal of integrated palliative care (PC) envisions a seamless, continuous, and coordinated system that supports patients across the trajectory of illness and into old age, embedded within mainstream health and social welfare frameworks. This ideal, however, remains unrealized globally. The following analysis examines the state of integrated PC in five diverse contexts—Pakistan, Sudan, South Africa, the Philippines, and Singapore—highlighting country-specific realities, shared challenges, and opportunities for fostering greater compassion and well-being for patients, families, and the staff who care for them.

1. What Does Integrated Palliative Care Look Like in Each Country?

Pakistan: Emerging but Centralized
PC in Pakistan is nascent and not yet integrated into mainstream health or social welfare. Services are concentrated in a few tertiary hospitals and cancer centers (e.g., Aga Khan University) in major cities like Karachi, Lahore, and Islamabad. Integration into primary healthcare and social welfare systems is minimal, leaving most of the population without access.

Sudan: Fragmented by Conflict
Since April 2023, armed conflict has caused near-total collapse of Sudan's healthcare system. PC is now limited to relatively safer regions like Port Sudan, focusing almost exclusively on advanced cancer patients. Crucially, for many, supportive and palliative care are no longer complementary—they are the only available form of support due to the absence of curative options.

South Africa: A Tale of Two Sectors

Private sector: Integration is limited, mostly involving late referrals to home-based nursing when patients can no longer manage daily activities. Referrals are increasing due to medical aid coverage, but earlier, comprehensive PC remains unpredictable. Social workers assist primarily with welfare grants.

Public sector (pilot project): In the author’s city, a Department of Health pilot project has enabled greater multidisciplinary involvement. However, referrals remain late, and community-based resources are rarely intentionally engaged. Outside this pilot, integration is likely minimal.

Philippines: Centralized vs. Provincial Realities

Metro Manila (Capital): Formal PC is mostly hospital-based, coordinated by trained fellows and multidisciplinary teams, sometimes with dedicated wards or home care (free or out-of-pocket). Caregivers are often involved but inconsistently integrated.

Provinces: PC is fragmented, driven by solo specialists or family medicine physicians (like the author) in acute or home settings. Nurses, social workers, and formal caregivers are peripheral, contacted only through patient/family efforts or physician networks. Integration is largely absent.

Singapore: A Strategy in Progress
Singapore’s refreshed National Strategy for Palliative Care (2023) has raised end-of-life PC uptake from 46% to 51%. Yet, true continuous and coordinated care remains elusive. Key gaps include:

Workforce capacity: Home hospice demand outpaces manpower by 20–30%; hiring struggles due to specialized training needs.

Public death literacy: Only one in three knows how to access PC; one in four understands home death regulations.

Systemic limits: Over 60% of deaths still occur in hospitals, with plateauing reduction. Many referred to community PC return to acute hospitals. Non-cancer patients receive far less support than cancer patients.

2. Common Challenges Across Countries

Despite differing contexts, several shared barriers impede integration:

Fragmented health systems: Weak links between tertiary, primary, and community care.

Policy-to-action gaps: Lack of strong national PC policies or failure to implement existing ones.

Underfunding: PC is rarely prioritized compared to curative or preventable care.

Misconceptions: PC is widely equated only with end-of-life, not with symptom management across illness.

Lack of education: Among healthcare workers (HCWs), patients, and carers regarding PC principles and benefits.

Workforce shortages: Too few trained PC professionals (doctors, nurses, social workers), compounded by time/resource constraints.

Cultural factors: Poor acceptance of death, societal preference for life-prolonging measures.

Geographic and financial barriers: Rural areas lack infrastructure; families face out-of-pocket burdens.

Opioid access: Critical shortages of essential pain medications, especially in Sudan.

Conflict-specific neglect: In Sudan, humanitarian NGOs prioritize emergency response, infectious diseases, and maternal/child health—PC remains drastically under-prioritized despite overwhelming need.

3. Opportunities for Greater Compassion and Well-Being

For Patients and Families:

Community-based models: Shift from specialist-driven to community-led care, empowering local providers and families.

Early advance care planning: Introduce advance medical directives at diagnosis to normalize PC discussions.

Volunteer buddy systems: Train community volunteers—especially families who have experienced PC—to lead awareness programs, provide peer support, run helplines, assist with terminal arrangements, and act as navigators until families are connected to formal services.

Integration into primary care and community clinics: Especially critical for rural areas and non-cancer patients.

For Healthcare Workers and Staff:

Growing enthusiasm for PC courses and training among HCWs.

Promotion of PC as both a medical specialty and a community-based service to create career pathways and distributed responsibility.

Cancer boards as advocates: Existing cancer boards can champion PC needs.

Government recognition: Some governments are beginning to realize the necessity of PC, opening doors for policy change.

Nurse-led home-based care expansion to address workforce constraints and improve access.

For Conflict Settings (Sudan-specific):

Integrate PC into emergency response packages, not as an afterthought but as a core component of humanitarian aid.

Collaborate with NGOs, faith leaders, and community organizations to deliver basic PC and pain relief even in unstable environments.

For System Sustainability:

Increase PC education in medical and nursing curricula.

Address workforce capacity through targeted recruitment, retention incentives, and task-sharing (e.g., nurses and volunteers).

Improve public death literacy through community campaigns, reducing fear and enabling earlier referral.

4. Conclusion

No country has yet achieved fully integrated, continuous, coordinated, and sustainable palliative care across the full course of illness and into old age. The five countries profiled illustrate a spectrum—from conflict-induced collapse (Sudan) to well-intentioned but incomplete national strategies (Singapore). Common threads include fragmented systems, workforce shortages, cultural barriers, and the persistent prioritization of cure over comfort. However, opportunities abound: community volunteer models, early advance care planning, nurse-led services, and growing political will. Achieving greater compassion and well-being for patients, families, and staff will require not only policy and funding but a fundamental reimagining of palliative care as a shared societal responsibility—embedded in primary care, social welfare, and even humanitarian response. The path forward lies in bridging the gap between policy and practice, and between hospitals and homes.

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Dr. Shivan Mahabir - Trinidad and Tobago - Team indigo

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Dr. Shivan Mahabir - Trinidad and Tobago - Team indigo

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INTEGRATING PALLIATIVE CARE INTO TRINIDAD AND TOBAGO'S MAINSTREAM HEALTH AND SOCIAL WELFARE SYSTEM

STRENGTHS

PALLIATIVE CARE AVAILABLE BOTH AS INPATIENT AND OUT PATIENT SERVICES.

SOME PLACES OFFER PALLIATIVE CARE VIA HOME VISITS OR TELEMEDICINE.

WE HAVE A PAEDIATRIC PALLIATIVE CARE SPECIALIST IN OUR COUNTRY

ONGOING DEVELOPMENT OF PALLIATIVE CARE SERVICES BOTH PUBLIC AND PRIVATE IN THE COUNTRY.

WEAKNESSES

LACK OF NATIONAL POLICY OR DEDICATED OFFICER AT MINISTRY OF HEALTH

NOT ENOUGH MORPHINE AVAILABLE ESPECIALLY AT LEVEL OF PRIMARY CARE

NOT ENOUGH DOCTORS HAVE A GOOD GRASP OF THE MEANING OF PALLIATIVE CARE VS END OF LIFE CARE.

THE GENERAL PUBLIC MAY EQUATE PALLIATIVE CARE TO GIVING UP AND WITHDRAWAL OF ACTIVE CARE.

NO LEGISLATIVE POLICY FOR ADVANCE DIRECTIVES. DO NOT RESUSCITATE ORDERS ARE NOT COVERED BY LEGISLATION

LOSS OF PALLIATIVE CARE SERVICES IN TOBAGO.

TRANSPORTATION CAN BE A SIGNIFICANT ISSUE.

PALLIATIVE CARE STILL VERY MUCH TIED TO ONCOLOGY/CANCER

OPPORTUNITIES

LOTS OF ACTIVE NON-GOVERNMENTAL ORGANIZATIONS RAISING AWARENESS OF PALLIATIVE CARE AMONG A RECEPTIVE POPULATION WILL LEAD TO INCREASED SOCIAL PRESURE ON GOVERNMENT.

RELATIVELY HIGH NUMBER OF DOCTORS DOING THE PALLIATIVE CARE FELLOWSHIP IS A GOOD SIGN OF GROWING INTEREST IN PALLIATIVE CARE AND THIS WILL HELP SPREAD EDUCATION AMONG OTHER DOCTORS.

THREATS

PRECARIOUS FINANCIAL STATE OF THE COUNTRY’S ECONOMY LIMITS GOVERNMENT SPENDING IN MEDICAL AND SOCIAL WELFARE SECTORS.

INABILITY TO SOURCE ENOUGH MORPHINE DUE TO THE GLOBAL NORTH TAKING THE MAJORITY.

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TEAM GOLD

Integrating Palliative Care in the Philippines

The Philippines already has a strong policy foundation for integration because the Universal Health Care law and its implementing rules recognize palliative care as part of the full continuum of health services. This means palliative care should not be treated as a separate or optional service, but as a standard component of care for patients with serious illness.

However, integration in practice remains uneven. Services are still concentrated in tertiary and urban centers, while many patients in provincial and rural areas have limited access to trained providers, organized referral systems, and essential medicines for symptom control. A realistic strategy for the Philippines is to integrate palliative care at three levels. First, at the primary care and community level, basic palliative care should be part of routine family medicine, community, and home-based services, so symptom relief, communication, and family support begin early. Second, at the hospital level, palliative care teams should be embedded in government and private hospitals, especially in oncology, internal medicine, pediatrics, geriatrics, and intensive care. Third, at the specialist level, referral pathways should connect local providers to trained hospice and palliative medicine specialists for complex pain, psychosocial distress, and end-of-life care.

This tiered approach fits the current Philippine training landscape, where PSHPM, or the Philippine Society of Hospice and Palliative Medicine, continues to support a growing national network of trained and certified specialists and providers.

Major Challenges

The major challenges include limited access to palliative care services outside urban and tertiary centers, particularly in rural and underserved communities. There is also a weak policy framework in terms of implementation, since existing policies are not always translated into consistent and equitable services nationwide. Scarce resources, including trained personnel, medicines, funding, and institutional support, continue to restrict service delivery. Another important challenge is cultural stigma around end-of-life care, which may delay referral and reduce acceptance of palliative care because it is still often misunderstood as giving up treatment.

Key Opportunities

Key opportunities include strengthening workforce training so that more general practitioners, nurses, and allied health professionals can provide basic palliative care. There is also an opportunity to improve financing mechanisms to support wider and more sustainable service delivery. Addressing systemic gaps, such as weak referral pathways and fragmented coordination, can further improve integration across all levels of care. Better data integration is another important opportunity, as stronger information systems can help monitor needs, outcomes, and service coverage. Finally, active community engagement can increase awareness, reduce stigma, and encourage earlier acceptance and use of palliative care services.

In the Philippines, the challenge is no longer whether palliative care should be part of the health system, because policy already supports it. The real task is translating this into accessible, affordable, and well-coordinated services at the community, hospital, and specialist levels across the country.

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In many systems, integrated palliative care involves early, needs-based support from an interdisciplinary team working alongside curative treatment across hospital, home, and clinic settings. It combines specialist-level care for complex cases with primary palliative skills held by all clinicians.

Key improvements needed include: achieving equitable access beyond cancer and urban areas; rebalancing resources toward home and community-based care rather than hospitals; mandating foundational palliative training for all health professionals; and reforming reimbursement models to properly fund interdisciplinary, time-intensive care.

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1. What Integrated Palliative Care Looks Like (In Many High-Income Countries)

In an integrated model, palliative care is not a separate entity but a core component of the healthcare system, characterized by:

Early Integration: Palliative care teams are consulted based on patient need (e.g., serious illness diagnosis, high symptom burden, psychosocial distress), not just prognosis. They work alongside curative treatment from the point of diagnosis.

The Interdisciplinary Team (IDT) Model: Care is provided by a core team of specialists (physicians, nurses, social workers, chaplains) who consult across healthcare settings—from hospitals and clinics to patients' homes and nursing facilities.

Dual Approach:

Specialist Palliative Care: Provided by trained specialists for complex cases.

Primary Palliative Care: Basic pain/symptom management and communication skills are possessed by all healthcare professionals (e.g., oncologists, cardiologists, primary care physicians).

Multiple Access Points: Patients can access services through hospital consult teams, outpatient clinics, community-based home care services, and dedicated inpatient hospice units.

2. What Could Be Improved?

Despite this framework, significant gaps remain. Key areas for improvement include:

Equity of Access: Disparities in access based on geography (rural vs. urban), diagnosis (cancer vs. non-cancer like heart failure, COPD, dementia), and socioeconomic status are profound. Integration must be universal and equitable.

Rebalancing the Focus: The system is often still weighted towards tertiary-care/hospital-based specialist consults. Investment must shift dramatically towards strengthening community-based and home-based palliative care, which is where most patients wish to be.

Standardized Education and "Upstream" Integration: There is a critical need to mandate foundational palliative care education for all health professionals (medical, nursing, and allied health students) to create a workforce competent in primary palliative care. This "upstream" integration ensures basic skills are widespread.

Financial and Structural Barriers: Reimbursement models often favor procedural care over the time-intensive communication and counseling central to palliative care. Funding structures need to be reformed to adequately support interdisciplinary team services in all settings of care.

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As a physician working in palliative medicine at the Iranian Cancer Control Center (MACSA) in Tehran, Iran, I can provide the following insights into the state of integrated palliative care in the country:

1. Integrated Palliative Care in Iran:

MACSA has emerged as a leading institution in providing comprehensive and free palliative care services to over 20,000 cancer patients and their families, regardless of their socioeconomic status. This is a commendable achievement, as it ensures equitable access to essential palliative support.

MACSA's services are designed to cater to the diverse needs of patients and their families, offering a range of care settings, including outpatient clinics, inpatient wards, home care networks, and online counseling. This versatility allows the organization to reach a wider population and provide personalized care.

As a pioneer in research and education, MACSA plays a crucial role in advancing the field of palliative care in Iran. By gaining a deep understanding of the challenges and requirements of palliative care, the organization can better align its services with the needs of the society.

The organization's focus on educating healthcare professionals about palliative care is also commendable, as it lays the foundation for the provision of quality care throughout the country.

2. Areas for Improvement:

Despite the commendable efforts of MACSA, the lack of support from health authorities in Iran for palliative and supportive care is a significant challenge. This reliance on charitable donations to sustain the organization's operations may limit the long-term sustainability and scalability of the services.

To further strengthen integrated palliative care in Iran, it would be beneficial to advocate for greater recognition and financial support from the government. This could involve working with policymakers to incorporate palliative care as a core component of the national healthcare system, ensuring its availability and accessibility for all patients in need.

Expanding the reach and capacity of MACSA's services, particularly in rural and underserved areas, could help bridge the gap in palliative care provision across the country. This could involve collaborations with local healthcare providers and community organizations to enhance the delivery of services.

Continuous investment in research and educational programs, both for healthcare professionals and the general public, can help raise awareness and improve the understanding of palliative care, ultimately leading to better patient outcomes and family support.

In conclusion, MACSA's efforts in providing integrated palliative care in Iran are commendable, but the lack of government support and the need for further expansion and capacity-building remain areas for improvement. By advocating for policy changes, enhancing the sustainability of the organization, and continuously improving the quality and accessibility of services, the integrated palliative care landscape in Iran can be further strengthened.

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In Pakistan, its a holistic approach to PC services involving medical and psychosocial teams.

Integrated palliative care improvement would mean:

Easy accessibility to a multidisciplinary team.

Raising awareness and knowledge both in the community and the medical fraternity especially family caregivers.

Early integration of PC at the under graduate level.

Government support and funding.

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The American NCCN recommends the integration of palliative care from the start of treatment. This often leads to better quality of care and better holistic patient management.

There are several obstacles to this in Djibouti, the first of which remains a total lack of knowledge among patients, society and the health system of what palliative care is.

their full and complete integration into care and that from the start also allows a multidisciplinary approach around the patient offering care not only focused on the prolongation of life but on a better quality of life even if it is shorter.

In Djibouti we are currently working on a national cancer control plan which includes a component on palliative care. This will allow us to create an institutional gateway for palliative care in the health system with the aim of having a national palliative care plan in the future.

the other aspect on which we are currently working is associative with the creation of the first palliative care association which aims to raise awareness and educate society on the importance of palliative care in the treatment of patients with life-threatening illnesses.

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Integrating palliative care into mainstream healthcare in Palestine involves ensuring that palliative care principles and services are seamlessly incorporated into the broader healthcare system.

Here's a look at what integrated palliative care might entail in Palestine:

Training and Education of healthcare professionals on palliative care principles, including pain management, symptom control, and psychosocial support.

Early Identification and Referral of Patients with life-limiting illnesses early in their disease trajectory and referred to palliative care services as appropriate.

Multidisciplinary Approach: Palliative care teams, consisting of physicians, nurses, social workers, and other allied health professionals, collaborate to provide holistic care tailored to the needs of patients and their families.

Community-Based Care: Palliative care services extend beyond hospitals to include home-based care programs, allowing patients to receive care in familiar surroundings with the support of their families and communities.

In addition to medical care, palliative care addresses the psychosocial and spiritual needs of patients and their families, offering counseling, bereavement support, and assistance with end-of-life planning.

Access to Essential Medications: Ensure availability and affordability of essential medications for pain relief and symptom management, including opioids, in accordance with international guidelines and regulations.

Areas for Improvement:

Awareness and Acceptance among healthcare providers, patients, and the general public to overcome cultural barriers and misconceptions.

Develop and implement policies and regulations that support the integration of palliative care into the healthcare system, including reimbursement mechanisms, licensing requirements, and drug procurement protocols.

Capacity building of healthcare professionals in palliative care through ongoing training, mentorship, and professional development opportunities.

Enhance data collection systems to monitor the provision and outcomes of palliative care

Foster collaboration among government agencies, NGOs, academic institutions, and international partners to coordinate efforts and maximize resources for palliative care development.

By addressing these areas for improvement, Palestine can further advance the integration of palliative care into mainstream healthcare, ensuring that patients with life-limiting illnesses receive compassionate and comprehensive care that aligns with their values and preferences.

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In South Africa, integrating palliative care into mainstream health systems would revolutionize patient care. Recognizing the holistic approach required, pooling resources, and collaborating with various health professionals can bridge existing gaps, meeting the needs of patients and families facing life-limiting illnesses.

Challenges to be addressed include disparities in access and equity, limited integration into primary healthcare, workforce shortages, stigma, misconceptions, and sustainable funding. These efforts are crucial for ensuring equitable access to high-quality palliative care for all patients across South Africa.

Integrated palliative care involves a collaborative approach addressing physical, psychological, social, and spiritual needs:

Advocacy and Education: Initiatives that aim to raise awareness, improve access, and advocate for policy changes. Education programs for healthcare professionals, volunteers, and communities can build capacity and promote best practices.

Stigma Reduction: Persistent societal stigma leads to misconceptions and reluctance to seek palliative care. Public awareness campaigns and community engagement efforts are crucial to dispel myths and foster understanding. Providing early palliative care rather than solely focusing on end-of-life care could represent a positive shift in healthcare practices.

Integration into Primary Healthcare: While recognized as essential, palliative care integration into primary healthcare remains limited. Strengthening primary healthcare providers' capacity to identify and manage palliative care needs and enhancing collaboration with specialist services are essential steps forward.

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Palliative care is a new concept in Sudan and has been associated with cancer patients, so we did not find this care offered to the rest of the beneficiaries who suffer from life-threatening diseases.It has not been integrated into the levels of health care (primary, secondary, tertiary and rehabilitative care).Improvement in palliative care should be at the decision-making level by developing a palliative care strategy that is not linked to the cancer strategy and that includes the integration of palliative care into all four levels of healthcare.

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Halima Ibrahim , Yellow Team Improvement in palliative care should be at the decision-making level by developing a palliative care strategy that is not linked to the cancer strategy and that includes the integration of palliative care into all four levels of healthcare.

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Halima Ibrahim , Yellow Team Improvement in palliative care should be at the decision-making level by developing a palliative care strategy that is not linked to the cancer strategy and that includes the integration of palliative care into all four levels of healthcare.

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It includes training, scientific research, budgeting, raising awareness among communities and providing important medicines, especially pain medication,

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PC is growing field of medicine in my country, it is only about 15 years old, going by the hospice and palliative care association of Nigeria (HPCAN), and in terms of integrated palliative care, there is a lot left to be done, as it has not been fully integrated into the health systems as a major form of heath care as most people including health care workers still believe palliative care is reserved for those who are dying,.

however, a lot of work is currently been in place to ensure that palliative care is fully integrated into the health system, such as training of community health workers on basics of palliative care, collaboration between the oncology units and palliative care team, training of medical doctors and nurses on basics of palliative care and the importance of prompt referral to the palliative care team.

some of the things that can be improved upon include;

1. early and comprehensive involvement of health care workers in all of the levels of health care, particularly primary and secondary health care workers.

2. involvement of rural health workers, considering most patients in urban setting probably already have access to palliative care compared to rural patients

3. subsidizing cost of palliative care for patients who cannot afford it.

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Palliative care is growing field of medicine in my country, it is only about 15 years old, going by the hospice and palliative care association of Nigeria (HPCAN), and in terms of integrated palliative care, there is a lot left to be done, as it has not been fully integrated into the health systems as a major form of heath care as most people including health care workers still believe palliative care is reserved for those who are dying,.

however, a lot of work is currently been in place to ensure that palliative care is fully integrated into the health system, such as training of community health workers on basics of palliative care, collaboration between the oncology units and palliative care team, training of medical doctors and nurses on basics of palliative care and the importance of prompt referral to the palliative care team.

some of the things that can be improved upon include;

1. early and comprehensive involvement of health care workers in all of the levels of health care, particularly primary and secondary health care workers.

2. involvement of rural health workers, considering most patients in urban setting probably already have access to palliative care compared to rural patients

3. subsidizing cost of palliative care for patients who cannot afford it.

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Palliative Care is a new concept in my country, Guyana. While it may be known generally, it has not been integrated into the public or private systems as yet and the idea most persons hold currently is that palliation is done until the end of life care.

Improvement can first begin with education of the citizens of Guyana on the topic. This will further push an understanding of the role palliative care plays on the quality of life of the patients requiring such. This can be done during medical degree curriculum and also as courses offered to the general population regarding same.

Once persons have been sensitized on the topic, having further steps such as a multidisciplinary team meeting with all departments who are involved in the care of the patient can occur.

We in no doubt, have a long way to go. But little by little better care shall be provided to everyone.

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Integrated Palliative Care has started to grow in my setting. For an example, we have developed Multi Discipline Team in between community Palliative Care Provider and University Hospital for Motor Neuron Disease patients. By having this set up, it will help our patients in getting thorough medical assistance and Palliative Care at the same time. Our patient will benefit in terms of better communication in terms of continuation of care from community to hospital vice versa. It also help the community setting to do the arrangement that cannot be done at home like PEG tube insertion and BiPAP assessment.

Other example is in between Hospital Palliative Care team and Community Palliative Care team. Most of the big hospitals now will have their own team. This of course will help our patients to get easier access to the hospital intervention as they do not have to go through Emergency Department to get their symptoms managed (example: spinal cod compression that need radiotherapy). It also to ensure there will be continuity of care.

What can be improved?

to have integrated system in between hospitals, community provider so everyone can get the updatess about the same patient easily.

to ensure this integration is not only happening in the urban areas but also to the rural areas.

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1. What does Integrated Palliative Care look like in your country ?

Palliative care is still a new health care system in Indonesia, not like the other preventive, curative and rehabilitative that already have a well established policy and service across the coutry, palliative care governmental are just recently launched by the ministry of health, and its National Impact is still not yet seen. By now there is no formal education about palliative, so we have to seek online education and abroad to improve ourselves about palliative care. There only 5 major Hospital that have an integrated and established Palliative service in Indonesia with our burden of 270 millions of population.

2. What could be improved ?

Could be improved :

a. Health care Education system

b. Public awareness campaigne

c. Government policy

d. Community : care giver

e. Research

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In Pakistan, both public and private healthcare have been unable to prioritize palliative care. There are only a handful of hospitals that offer palliative care in Pakistan. The hospitals that offer palliative care have inpatient palliative medicine services, consults, palliative clinics for patients who require symptom management for terminal as well as chronic conditions. The palliative team is multi-disciplinary consisting of clinical nutritionist, psychologist, physiotherapist and palliative care specialist nurses. It is also supported by anesthesia team for interventions for pain control and also offer End-of-Life-Care to patients who are terminally ill.

There is a need to increase awareness among policy-makers, health professionals and the public about palliative care in Pakistan to improve our health systems and quality of life for patients. Another challenge is limited training opportunities on palliative care for health professionals. There are also cultural and social barriers related to the concept of pain and suffering amongst patients. It is a common misconception that palliative care is only for the last weeks of life when in reality, this approach is useful at any stage of disease and early delivery of palliative care may reduce unnecessary hospital admissions. This can be improved by educating the patients and other healthcare professionals. There is a need for hospitals in our country to invest in training opportunities in the field of palliative care to improve quality of life for our patients and acknowledging its importance.

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In Pakistan, integrated palliative care often involves a combination of medical, psychological, social, and spiritual support provided to patients facing life-limiting illnesses and their families. This care is typically delivered through a multidisciplinary approach involving physicians specializing in palliative medicine or other relevant specialties, nurses with palliative care training, social workers offering counseling and support services, and spiritual care providers attending to existential concerns. Additionally, pharmacists play a crucial role in managing medications, particularly pain relief and symptom control. However, the availability of these services can vary significantly depending on the region and resources available, with urban areas generally having better access compared to rural regions.

Despite efforts to provide integrated palliative care, several areas could be improved in Pakistan. Firstly, there is a need for increased awareness and education among healthcare professionals, patients, and the general public about the benefits of palliative care and the rights of patients to access it. Many individuals still associate palliative care solely with end-of-life care, leading to misconceptions and stigma surrounding its use. Additionally, there is a shortage of trained palliative care professionals, particularly in rural areas, highlighting the need for expanded training programs and workforce development initiatives. Furthermore, improving access to essential medications, including opioids for pain management, is crucial, as regulatory barriers and misconceptions about their use often limit availability and hinder effective pain relief for patients. Lastly, integrating palliative care into existing healthcare systems and policies, along with securing sustainable funding mechanisms, is essential to ensure its widespread availability and long-term viability.

Overall, while efforts to provide integrated palliative care in Pakistan are underway, there remain significant challenges and areas for improvement, including increasing awareness, addressing workforce shortages, improving access to medications, and integrating palliative care into healthcare systems and policies. Addressing these challenges requires collaborative efforts from healthcare providers, policymakers, educators, and communities to ensure that all individuals facing life-limiting illnesses receive the holistic support and care they deserve.

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While South Africa has a good system of primary care delivered by clinics as part of the district health system, Palliative Care is a glaring omission from the services provided. A palliative care service must be planned, funded, adequately staffed with the correct drugs and equipment and stafftrained to deliver integrated Palliative Care at the primary care level extending into the community and patients’ homes.

Initially many services start as vertical health programmes such family planning services, TB treatment, HIV treatment, syndromic management of sexually transmitted diseases and are then integrated after sometime to prevent the duplication of resources and avoid patients joining multiple queues when they could have an efficient one stop service.

The integration of services requires the development of joint policies, training and retraining of staff across all programmes being integrated, appropriate supervision, adequate medication, personnel, equipment and and the merging of information systems including patient records and programme indicators to ensure high quality patient care is delivered.

Oftentimes integration is a euphemism in trying to provide more services without enough healthcare workers causing burnout in staff. This can lead to patients interrupting their treatment, disease progression and transmission increasing the burden of disease.

Integration of Palliative Care into primary care is an essential part of universal health coverage but must be carefully planned, implemented, adequately resourced and monitor for the service to be effective.

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1. What does integrated palliative care look like in your country?

Integration of palliative care (PC) services entails combining administrative, organizational, clinical, and service elements to ensure continuity of care between all parties participating in the care network of patients.

Palliative care in Ghana is in its early stages, primarily offered at higher institutions. Teams consisting of medical officers, nurses, and social workers run clinics for those in need. However, there is limited data supporting PC integration at district or primary care levels. Institutions providing PC services work on:

a) Early Integration: Palliative care is integrated into life-limiting illness care plans alongside curative treatments, providing holistic care that addresses physical, emotional, social, and spiritual needs from diagnosis.

b) Pain and Symptom Management: Focuses on managing pain and alleviating distressing symptoms such as nausea, fatigue, and breathlessness through medications, therapies, and other interventions.

c) Multidisciplinary Team: A multidisciplinary team consisting of doctors, nurses, social workers, counselors, and other healthcare professionals collaborate to provide comprehensive care. Each team member contributes their expertise to address different aspects of the patient's well-being.

d) Psychosocial Support: Offers counseling, psychosocial support, and spiritual care to patients and their families to help them cope with the emotional and spiritual challenges that accompany serious illness.

e) Education and Training: Provides education and training programs for healthcare professionals to enhance their skills in palliative care delivery. This ensures that healthcare providers across various settings have the knowledge and expertise to offer quality care.

f) Advocacy and Policy: Advocates for policy changes and increased funding to enhance access to palliative care services, collaborating with government agencies, non-profit organizations, and other stakeholders.

2.What could be improved?"

Several barriers and challenges characterize the integration of palliative care (PC) services in Ghana, which include misperception of PC services as end-of-life care, poor referral systems, inadequate financial support, regulatory barriers, and the small size of PC professional workforce

a. incorporation of PC into the curriculum of all health and allied health programs.

All the health care providers must have baseline knowledge on palliative care to provide some level of palliative care at all levels before it comes to the specialist.

b.      Early initiation of care

Integrating PC has the potential to promote the early initiation of care. Referral of patients for palliation often delays at the point of the primary healthcare provider. Therefore, by integrating PC services, primary healthcare providers would have better understanding of the aims and the need to refer on time. Hence, resulting in early initiation of care.

c.       Enhance communication between primary healthcare providers and the PC team

PC is an interdisciplinary care that thrives on effective communication. Through integration, the primary healthcare providers and the PC team would have a harmonious relationship that would foster an enhanced communication between both parties.

d.      Strengthening staff capacity to provide PC services

Integrating PC is not limited to only the services provided, but also extends to its inclusion in the preservice training curriculum of all healthcare providers. When PC is integrated in the curriculum of healthcare education, it would create a large pool of generalist PC providers who will provide primary PC services to patients before they are later referred for specialist PC services. Such actions have the potential to increase the staff strength and augment their capacity to provide PC services.

e.       Policy framework for PC services

The provision of such a policy will guide practitioners on what is involved in PC services to develop a model applicable to Ghana.

f.        Increased awareness and education for patients, family members and communities.

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1) The existing Integrated Palliative Care in Bangladesh :

Integrated Palliative Care is not a common term in Bangladeshi Health Care System.

There is still lacking of Adequate Guideline, Policy, financial Support and Infrastructural support to establish nation wide service in this sector.

Some sporadic/Individual approach( mainly urban community based) are currently operating in my country.

a) Palliative Care department of Bangabandhu Sheikh Mujib Medical University(BSMMU) and Dhaka Medical College Hospital are working currently to provide palliative care . But their services are not sufficient to help thr larger community of my country.

b) A developmental initiative is being implemented with the support of the Non Communicable Disease Control(NCDC) Program of the Directorate General of Health Services (DGHS) at Narayanganj District , namely " Compassionate Narayanganj".

This project - titled as "Building an integral age -attuned model of supportive palliative care in Bangladesh " as a piloting initiative of AYAT Education in collaboration with WHPCA, BSMMU, St. Christopher's home and Narayanganj City corporation. This project aims to integrate palliative care into the public health system by upskilling the youth volunteers, health workers, nurses and physicians working at the sub district level and in the rural communities .

In Rajshahi district " Dingidoba Mission Hospital" run by christian missionaries works for the terminally ill patients with cancer, stroke, chronic kidney and liver failure patients. They mainly serve poor people from rural areas of northern Bangladesh . Similar services are run by Lutheran Missionaries in Dinajpur District , Sisters of missionaries of charity at Dhaka.

All these initiatives are inadequate , so a large scale Program should be taken to cover the total population .

2) What could be improved?

First we should raise awareness about the need of palliative care service in our lives. The term should be familiarized to the people of the country. By discussing this topic ,teaching and training our family members, friends and relatives, we can develop social awareness about this issue.

Integrating this topic in the educational system .

To create volunteers by arranging training sessions in the community level .

Religious leaders should advocate this issue among the believers to motivate them.

The Mass Media should be used to raise awareness about this issue .

Proper government policies and guidelines should be made along with adequate financial support and infrastructural development .

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In Malawi, integrated palliative care is gradually gaining recognition and acceptance within mainstream healthcare systems, but there is still room for improvement. Here's an overview of what integrated palliative care looks like in Malawi and potential areas for improvement:

1. Current State of Integrated Palliative Care:

Palliative care services in Malawi are primarily provided by a combination of government-run healthcare facilities, non-governmental organizations (NGOs), and faith-based organizations.

Palliative care is integrated into various levels of healthcare delivery, including primary healthcare centers, district hospitals, and tertiary care facilities.

Palliative care services in Malawi typically encompass pain management, symptom control, psychosocial support, spiritual care, and end-of-life care for patients with life-limiting illnesses such as cancer, HIV/AIDS, and other chronic conditions.

There is growing awareness among healthcare providers about the importance of palliative care, and efforts are being made to train and educate healthcare workers at all levels on palliative care principles and practices.

Community-based palliative care initiatives, including home-based care programs and volunteer caregiver networks, play a crucial role in extending palliative care services to remote and underserved areas.

2. Areas for Improvement:

Accessibility and Equity: There is a need to improve access to palliative care services, particularly in rural and remote areas where healthcare infrastructure and resources are limited. Efforts should be made to ensure that palliative care services are available and accessible to all individuals, regardless of their geographic location or socioeconomic status.

Workforce Capacity Building: There is a shortage of trained healthcare professionals with expertise in palliative care in Malawi. More investment is needed in training programs, continuing education initiatives, and workforce capacity building to increase the number of skilled palliative care providers across the country.

Integration into Primary Healthcare: While palliative care is integrated into some healthcare facilities, there is a need for further integration into primary healthcare services to ensure early identification and management of palliative care needs. This includes incorporating palliative care principles into routine clinical practice and strengthening referral pathways between primary, secondary, and tertiary care settings.

Community Engagement and Support: Greater emphasis should be placed on community engagement and support, including raising awareness about palliative care, reducing stigma associated with life-limiting illnesses, and empowering communities to provide care and support to patients and their families.

Policy and Funding Support: There is a need for the development and implementation of national palliative care policies and guidelines, as well as increased funding and resource allocation for palliative care services. Advocacy efforts are required to prioritize palliative care within the broader healthcare agenda and secure sustainable funding mechanisms for palliative care programs and initiatives.

Overall, while progress has been made in integrating palliative care into mainstream healthcare in Malawi, there are still significant challenges to overcome. Addressing these challenges will require concerted efforts from government authorities, healthcare organizations, civil society groups, and other stakeholders to ensure that all individuals in need of palliative care receive the support and services they require

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Health care in Nigeria is provided by both the public and private arm. The public health care system has three arms: The primary health care, secondary health care and tertiary health care.

The National policy and strategic plan for hospice and palliative care was just launched in 2021 and is far from being implemented. Currently the few available palliative care centers are in urban areas and majorly in the tertiary hospitals of NGO. So the integrated Palliative care is still basically in the conception stage in Nigeria.

To improve on this state

1. Health care workers at all tiers of health care delivery have to trained on basic palliative care

2. Opioids and other drugs for symptomatic management of patients with serious illness must be accessible at all tiers of health care delivery.

3. Community engagement in Palliative care delivery must be encouraged. Volunteers and community health officers/community health extension workers should also receive training in basic palliative care

4. implementation plan for the policy should be developed and disseminated

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In kenya, provision of palliative care services was initially done by NGOs notable Nairobi Hospice (the 1st Hospice in kenya), Nyeri, Meru and Eldoret Hospices. All these are situated in big towns in Kenya showing the desperation that many Kenyans were dying without accessing palliative care services. The formation of Kenya Hospices and Palliative Care Association in the year 2007 opened the doors of integration of palliative care services in government health facilities, mission and private hospitals through collaboration with the government and private sector. This effort was to make palliative care services available and accessible to all Kenyans in both urban and rural settings. Currently, palliative care services have been integrated in about 78 health facilities in 42 out of the 47 Counties in kenya. This a big stride but more yet need to be done as most of these facilities with integrated palliative care services are level 5 hospitals located in the big towns of the County headquarters. There are still many gaps in availability and accessibility of these services many Kenyans who live in remote rural areas.

National Palliative Care Policy Framework and National Palliative Care Guidelines- through the collaboration between the government and kenya Hospice and palliative care Association, we were able to achieve the above documents to provide guidance and framework within which to plan for the strengthening and implementation of palliative care services. Though we have the policy and Guidelines, implementation has remain to be a challenge due to lack or limited resources- workforce - limited number of trained palliative care professionals, lack finance- no budgetary allocation for palliative care services, lack of utilities and commodities, drugs especially morphine for pain management.

Lack of recognition of palliative care as a speciality leading to misplacement of palliative care especially nurses to other departments to general nursing.

Resistance to change.

Ho to Improve

Implementation strategies

Advocacy - creating awareness of palliative care services to the public both urban and rural settings

Training of more health care professionals on palliative care.

Availability of essential drugs and other utilities through budgetary allocation for palliative care.

Decentralisation of palliative care services to the lowest levels of health care systems to make services accessible to all patients in need.

Attitude change by health professionals about palliative care- believe it's care for patients who are at the end of life stage.

Conducting continuous medical education about palliative to health workers to to create awareness and demystify the misconceptions about palliative care and morphine.

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Integrated palliative care in my country Nigeria is still not quite developed. They are still many bias and few hands in Palliative care.

2. To improve this situation, it will be good to create more awareness on palliative care. Get many more professional trained.

The government will have to provide the necessary medical health amenities needed to cater for those in need of palliative care.

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Integrated Palliative Care in Pakistan involves a multidimensional approach aimed at addressing the holistic needs of individuals facing life-limiting illnesses and their families. The framework typically encompasses medical, psychological, social, and spiritual aspects of care. In practice, healthcare providers collaborate to manage pain and symptoms effectively, offer psychological support for patients and their families, and facilitate open communication about end-of-life preferences. However, several aspects could be improved to enhance the effectiveness of Integrated Palliative Care in Pakistan. There is a need for increased awareness and education about palliative care among healthcare professionals, patients, and the general public. Access to palliative care services needs to be expanded, particularly in rural areas where resources may be limited. Strengthening the collaboration between various healthcare disciplines and integrating palliative care principles into the broader healthcare system is crucial. Additionally, efforts should be directed towards reducing the stigma associated with discussions about death and dying, fostering cultural sensitivity in care practices, and ensuring that policies support the integration of palliative care into standard healthcare services. Addressing these areas could contribute to a more robust and accessible Integrated Palliative Care system in Pakistan.

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What does integrated palliative care system look like in your country? and how should be improved?

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What does integrated palliative care system look like in your country? and how should be improved?

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Kakwezi Jovia yellow team

In my country,the palliative care program is a new program,we are just starting to learn more about palliative care program depending how the health system is learning.

So far in our hospital,we are preparing collaboration with Rwanda bio medical center to give more trainings for doctors,Nurses social workers,psychologists Nutritionist etc,by now that palliative care team have started working in my hospital composed of comprehensive team.

On National level,integration of palliative care program is in their pipeline to work on it

But we have Acreol Africa and RBC have started trainings in referral hospitals,District hospitals and health centers.Again we have few private hospices which are working.

In conclusion,many people doesn't have knowledge of palliative care program

HOw should be improved?

_the government should provide more training and fellowship to the health workers about palliative care program.

-More infrastructure should be built in health care system and even beyond the hospital,it should be in xommunity.

-Education and training to the health community workers who deals with the patients in their villages.

-increasing the hospices and medical equipments.

-more Researchers should write on palliative care so that people should what's going on in country.

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Integrated palliative care, if implemented effectively, provides a holistic approach to supporting people with serious illnesses and their families. In many countries, including my own, integrated palliative care involves the collaboration of various health professionals such as doctors, nurses, social workers, psychologists and spiritual counselors to meet the physical, emotional, social and spiritual needs of patients. This ensures that patients receive comprehensive support throughout their illness, rather than waiting for the end phase of symptom control and quality of life. In addition, integrated palliative care often extends beyond the hospital setting to home care and support services. Education and training programs are needed to ensure that health care providers have the necessary skills and knowledge to provide effective palliative care and to have sensitive conversations with patients and families about end-of-life care preferences. These barriers include issues such as reimbursement, limited access to specialized palliative care services, and the fragmentation of care among different health care providers and institutions. Although significant progress has been made in my country in integrating palliative care into mainstream health care, there is still room for improvement. By addressing the challenges and barriers described above, we can ensure that all people with serious illnesses, regardless of their diagnosis or prognosis, receive quality, compassionate care.

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Q. What does Integrated Palliative Care look like in our country?

1. Palliative care in India is primarily available in urban areas and at tertiary healthcare facilities. Only 1-2% of the estimated 7-10 million people in India who need P.C. have access to it.

2. Although no separate budget is allocated for the implementation of the National Palliative Care Program, Palliative care is part of the 'Mission Flexipool" of National Health Mission.

Q. What could be improved ?

1. Limited Awareness: There is a lack of awareness and understanding about palliative care among the general public and healthcare professionals .

2. Many people in India are not aware of the benefits of palliative care or confuse it with end-of-life care

3. Inadequate infrastructure and insufficient training : There is a shortage of dedicated palliative care centers , hospices , and trained healthcare professionals in India .

4. Also, healthcare professionals , including doctors , nurses , and other caregivers, often lack adequate training in palliative care .

5. This limits their ability to provide appropriate pain and symptoms management and psychosocial support to the patient .

6. Lack of attention towards pediatric care: paediatric palliative care has also been neglected for a long time About 98% of children facing moderate to severe suffering during their end of life reside in lower and middle income countries like us

7. This could be due to diseases like cancer ,birth defects ,neurological conditions , etc .

8. The revised operational guidelines of NP-NCD have also not addressed this issue

9. Limited Implementation of NPCC: The implementation of the program has been slow and uneven , resulting in limited progress in expanding palliative care services.

Areas of Improvement:

a. Strengthening the implementation and monitoring of the NPPC at the State level with adequate funding, human resources, infrastructure

b. Developing and implementing National Standards and guidelines for Palliative Care Services and quality assurance

c. Enhancing the education and training of palliative care professionals and volunteers at various levels and settings.

d. The 67th World Health Assembly in 2014 urged the integration of palliative care into health systems at all levels

e. There is need to improving the referral and linkage mechanism between different levels and types of health care providers for palliative care

REFERENCE: DRISHTI-IAS: PALLIATIVE CARE INDIA

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What does Integrated Palliative Care look like in your country? What could be improved?

Currently in Malaysia, particularly in Klang Valley, Integrated Palliative Care can be seen happening in most hospitals with the community Palliative Care Provider.

As a Community Palliative Care Nurse, I always work hand in hand with the Palliative Care Consultants that work in the hospital. For an example, when I am suspecting the patient under my care is having dyspnoea from pleural effusion, I am able to contact the Palliative Care Consultant at the respected hospital about the admission that is needed to be planned so that my patient will not have to wait for long queue in Emergency Department and the patient will be seen by the Consultant and treatment plan can be discussed as soon as possible. It is also easier to communicate about patient's goal of care hence no unnecessary investigations and treatment will be done and patient can be discharged once the symptoms are better controlled.

It is also seen vice versa by my colleagues in the hospital. When they are discharging patients with Palliative Care needs, they will contact us in the community to ensure we have enough information about patient and their care preference. We also will update the hospital Palliative Care team about the medication changes or condition update to ensure there will always continuity of care.

If patients are moving out from our catchment area and the care will be transferred to other community Palliative Care services, we will ensure that proper hand over will be happening so that our patient will not be neglected and the care continues as patient's wished.

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Integrating palliative care into mainstream healthcare is a crucial step towards providing comprehensive and patient-centered care for individuals with serious illnesses. Palliative care focuses on improving the quality of life for patients and their families by addressing physical, emotional, and spiritual needs, managing symptoms, and providing support throughout the illness trajectory.

Here are some key considerations for integrating palliative care into mainstream healthcare.

1. Education and Training: Healthcare Professionals need to be trained in palliative care principles and skills. This includes physicians, nurses, social workers, and other members of the healthcare team. Educational initiatives can help raise awareness, promote understanding, and build competency in delivering palliative care.

2. Policy and Guidelines: Developing policies and guidelines that support the integration of palliative care into mainstream healthcare is essential. This includes ensuring adequate reimbursement for palliative care services and promoting the inclusion of palliative care in clinical practice guidelines.

3. Communication and Shared Decision-Making: Effective Communication is essential in palliative care. Healthcare professionals should engage in open and honest discussions with patients and their families about prognosis, treatment options, and goals of care. Shared decision-making ensures that the patient’s value and preferences are respected and incorporated into their care plans.

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In Egypt

PC is still unclear specialty within medical staff members - Hospice care is not covered by health insurance nor mentioned in the health system.

There is a lack of awareness in the healthcare system. The medical curriculum does not include PC or Hospice care.

Policy makers:

I believe the most important thing is advocating the issue with all partners and policy makers to make PC integrated in the health system and to be included in the medical curriculum

Different players and stakeholders shuld be involved along with raising the community awareness

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Integrating Palliative Care into Mainstream Health Care

1.     What does Integrated Palliative care look like in your country?

In the Philippines, the term “Palliative” is feared by patients and their families. For this reason, it is not fully accepted and not being talked about believing that it could bring more anxiety and misery to the once concerned. Physicians and allied health personnels with background of Palliative Care initiate palliative care at their work level but due to lack of proper training and infrastructure, continuity of service is difficult to achieve. In the Philippines, it is estimated that of the 80,000 new patients diagnosed with cancer every year, more than 7500 are in advanced stages and will need some pain relief and palliative care. At present, there are about 40 hospice and 272 individual service providers that offer palliative and end of life care to the undetermined huge number of Filipinos in need of such services. (Mission Report of Integrated Missions of PACT -- Programme of Action for Cancer Therapy- to DOH, March 2011)

Our constitution guarantees the right of the people to quality health care, as such the Department of Health (DOH) recognizes the need to integrate palliative and hospice care into our health care delivery system to provide holistic health care ranging from promotive, preventive, curative to rehabilitative. The inclusion of palliative and hospice care in the hospitals or health facilities and in the community and home-based levels addresses the goals of Universal Health Care or Kalusugan Pangkalahatan.

2.     What could be improved?

As a clinician, I believe that proper education and training to health personnels in basic facilities can make a big change in the aspect of providing support to the patients. Policies and protocols should be put in place and awareness about the benefits a patient and family can get from this type of care. Moreover, a good leadership to implement these policies is also necessary, to generate infrastructure and funds so that continuity of service is achieved.

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Q1:Integrated Palliative Care in Bangladesh :
The concept of palliative care in Bangladesh is mainly start when a cancer patient is suffering from severe pain or other sufferings from cancer therapy or at the end stage of dying.Here, so far remained limited to the sympathetic caring of the family members toward their loved ones with fatal illness. It is clear that palliative care in Bangladesh is set at basic level, where some could be sought from the extended family care support system. Quality of life (QOL) issues are rarely practiced or even thought in Bangladesh. Furthermore, palliative medicine, in the perspective of total palliative care service does not have its due recognition in Bangladesh.

Q2:Improvement can be occur by:
1. Awarenesses against misconception :
First of all misconception comes. The general misconception is that only whose are terminally sick and those whom health center have given up hopes of any progress, need palliative care. Palliative care is an advancement which can improve the quality of patients life and their family facing the problems associated with threatening illness which is life taking through the prevention and relief of suffering by means of early identification and faultless evaluation and treatment of pain and other problems like physical, psychological and spiritual.

2.Pain relief:In advanced stage of diseases pain is the dominant symptom. Pain makes a patient anxious and discomfort and impatient. Because of constant pain patients convoy unhappy death. Pain relief can be successfully achieved by the scientific and holistic advance of analgesic supply in palliative care.

3.Improvement of knowledge and skill: in assessment and improper medication, fear of opioid and addiction are some of the complex obstacle of palliative care. The fear which comes in mind that drugs (sedatives and opioids) prescribed in the terminal stage may accelerate the death process.

4.Fill the information gap:There are some information gaps also. Death is the most natural things and sure event in life. But the custom is not to talk about forthcoming death to a terminal ill patient in many societies in this country. Family members often do not step forward to be the ultimate decision maker when death is inevitable. For that reason health care professionals and Intensive care unit (ICU) may have been challenged for supporting patients and families only for lack of information.

5.Encourage policy makers:Living in a deprived socioeconomic condition like Bangladesh, it is very difficult to encourage the policy makers to divert more resources in palliative care as we cannot ensure curative care for most of the population.

Effective commutations with patients:

Best possible palliative care cannot be understood unless we have a complete understanding of what the patient and the family of the patient is experiencing. We can find still a gap in nursing knowledge related to care and cultural minorities. Four factors which are very important: caring, communication, support and home and family. In addition palliative care employees working with Bangladeshi families need to be conscious of the further stresses that these families may experience and be clever to recommend approaches to facilitate them to deal with them.

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In Bangladesh, integrated palliative care primarily focuses on treating cancer patients in advanced stages. However, access to such care is largely determined by financial stability, resulting in affluent individuals being able to seek treatment for symptom relief while those facing financial constraints may suffer silently and eventually succumb to their illnesses. Additionally, the existing organizations providing palliative care are predominantly private, leading to limitations in accessibility.

Challenges and Areas for Improvement:

1. Lack of Awareness:

One of the key challenges in palliative care in Bangladesh is the lack of awareness among the general population and healthcare providers. Initiatives such as educational campaigns can play a crucial role in enhancing awareness, dispelling misconceptions, and promoting early integration into the healthcare system.

2. Financial Accessibility:

Financial barriers prevent many individuals from accessing palliative care. Developing financial assistance programs, subsidies, or insurance coverage can ensure equitable access to palliative care services.

3. Ethical Considerations:

Ethical challenges exist in palliative care in Bangladesh, including misconceptions about its role, fear of opioids, and difficulties in communicating end-of-life decisions. Establishing a clear ethical framework that considers cultural and religious nuances is essential. This framework should address issues related to pain management, end-of-life decisions, and family involvement.

4. Lack of Guidelines:

The absence of proper guidelines hinders the delivery of effective palliative care. Developing and implementing clear clinical guidelines and standards specific to Bangladesh can enhance the quality and consistency of care provided.

5. Insufficient Allocation of Funds:

A significant barrier to palliative care services is the insufficient allocation of funds in the government healthcare budget. Advocacy for increased budget allocation for palliative care is crucial to address this issue.

6. Limited Number of Organizations:

The limited number of organizations providing palliative care, particularly relying on private entities, poses a challenge. Encouraging the establishment of more public and non-profit organizations can help broaden the availability of services.

7. Community Engagement:

Engaging communities in understanding and supporting palliative care initiatives is vital. Establishing community-based support networks and involving volunteers can contribute to a more compassionate and widespread approach to palliative care.

8. Collaboration between Government and Private Sector:

Encouraging collaboration between the government and private sector can lead to a more comprehensive and accessible palliative care system. Public-private partnerships can help address the resource constraints faced by the healthcare system.

9. Strengthening Interdisciplinary Teams:

Collaborative efforts between palliative care teams and other healthcare providers need to be strengthened. Building interdisciplinary teams that include oncologists, cardiologists, nurses, and social workers is essential to address the diverse needs of patients comprehensively.

Recommendations for Improvement:

To improve integrated palliative care in Bangladesh, the following actions should be taken:

1. Comprehensive Awareness Campaigns:

Initiate comprehensive awareness campaigns to educate the public about palliative care and its benefits.

2. Policy Advocacy:

Advocate for policies that recognize and support palliative care at both the national and regional levels.

3. Cultural Sensitivity:

Consider cultural sensitivity by tailoring palliative care approaches to align with local norms and values.

4. Allocation of Sufficient Resources:

Allocate sufficient resources, including funding and trained personnel, to support the expansion of palliative care services in both urban and rural areas.

5. Public-Private Partnerships:

Explore public-private partnerships to enhance the availability and accessibility of palliative care services.

6. Continuous Training and Professional Development:

Provide continuous training and professional development opportunities to healthcare providers to keep them updated on the latest palliative care practices and approaches.

By addressing the challenges of financial accessibility, awareness, guidelines, budget allocation, organizational infrastructure, community involvement, and collaborative efforts, Bangladesh can significantly enhance the landscape of integrated palliative care in the country.

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Dr Veenakshi bhagat -team white.

Integrated PC at primary health centre level ,aim is to provide active and holistic care to all individuals facing health related sufferings like any chronic illness and terminal illness, focusing on enhancing the quality of life of patients and their family members. In our set up in India the families living in the rural areas are in direct contact with the health workers working in PHCs especially ASHA workers and ANMs. In order to strength the PC services we should give trainings to health care workers at PHCs. we should organise camps and awareness programmes regarding PC. In urban set up more and more doctors are trained in PC so that we can improve the quality of life of patients, relieve their sufferins upto maximum and hepl them psychologically, spiritually and socially.

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1) In Brazil we have a public health system with universal access. It serves mostly 2/3 of the population, around 124 million inhabitants. In parallel, there is a supplementary (private) healthcare system, which serves around 1/3 of the country's richest population (another 80 million inhabitants). PC services are present in both.

Brazil has isolated, non-integrated PC services (a little more widespread than a few years ago) and concentrated in the most developed regions of the country - classification 3b. There are some PC education initiatives available and growing, especially private postgraduate courses; available access to opioids, with availability limitations and low prescription in relation to the total population.

Social participation in the formulation of public policies is guaranteed by law in the constitution. In this way, many Brazilian palliative care activists came together in 2023 to lead social participation in the various instances of health conferences, and we were able to approve at the national conference the National Palliative Care Policy, to be implemented from 2024 as a component of primary health care. health.

Concomitantly, another driving force was, in 2022, the publication by the National Education Council of a resolution that determines the inclusion of CP in undergraduate Medicine courses. But we have not yet seen an evolution in practice and how this will happen.

2) Broad and continued education of primary health care professionals about CP, increasing the population's access to qualified assistance in CP at community health centers and at home; expanded access to medications to control symptoms, with the resolution of bureaucratic issues that act as barriers. Development of integration processes between PC services, with access to health information in computerized systems. Rapid access by primary care to PC specialists to manage complex refractory cases and availability of services to receive referrals if necessary. Greater interaction and connection between services and the community, with the active participation of people in service improvements. Expansion of the mandatory inclusion of PC in all undergraduate courses in the health area. Increase in community communication initiatives about CP.

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There is a need for follow-up in the four areas of policy, education, drug access, actions and implementation. He stated: The problems in the field of policymaking are the lack of a national plan, guidelines, national association and standard in the field of palliative care. Considering that we have a better situation in the field of education, education should still be implemented in the three main areas of the individual, society and treatment. Due to the type of legislative policy in our country, access to opioids (especially oral opioids such as morphine) is at a very low level, and this is if our factories do not have a problem in manufacturing medicine. There is no comprehensive system of providing palliative and supportive care in the country, and services are provided sporadically, and the only available place for this is hospitals. Universities of medical sciences should act in line with the goals of the nursing department of the Ministry of Health

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In Lebanon palliative still needs a lot of work so it can be integrated in the healthcare system.

Currently we can see a change in the primary physicians regarding the palliative care and their referrals for their patients increased. We are doing a lot of awareness sessions for the population and the health care provider.

Some of our hospitals have a mobile team(consultation team) for palliative patients. One hospital has a palliative care ward.

The problem is that all of these services are not reimbursed, the patient has to pay for it.

When the patient is discharged home there's the problem because the family can't afford to bring a health care professional to take care of the patient. We have NGOs who provide palliative care at home, free of charge service, I work in one of them. However these NGOs can't cover the country, and they don't have enough resources to take care of the needs in the country.

What can be improved, is to develop a curriculum for the health care professional, to reimburse palliative care, and not to be paid. And to support these NGOs who provide home palliative care so they can have more resources so they can see more patients.

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Katayoon

In Iran, adult patients who suffer from cancer have some options for palliative care, but it is not well-known for chronic patients, pediatrics, and end-of-life care. There is informal palliative care such as DNR for some patients. Unfortunately, we have no clear rules about this. We must teach healthcare providers after introducing this phenomenon to society.

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In Cameroon palliative care is relatively new among many health workers. For the few who have embraced it, there is the challenge of practice to the fullest. Conflict with some doctors who buy see things in the same perspective with palliative care

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In Pakistan, palliative care is still in the infancy stage. We do not have community based integration of palliative care on a larger scale. Mostly individual institutions and non governmental organizations are coming forward and leading the establishment of these services

what can be improved?

training and education at postgraduate and undergraduate level of all health care professionals

Research

Infrastructure and administrative systems

Policy making at government level

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Palliative care in Oman involves a multidisciplinary approach to provide a comprehensive care for individuals facing life-limiting illnesses. The multidisciplinary team including: physicians, nurses, social workers, psychologists, and other healthcare professionals working collaboratively to meet the diverse needs of patients. Palliative care provide a holistic care in Oman it is not only the physical symptoms of the illness but also the psychological, social, and spiritual needs of patients and their families. Oman may involve community resources and support in providing palliative care. This could include engaging local organizations and volunteers to create supportive environment for palliative care patient, but it is not strongly active in Oman. The practice of palliative care in Oman are likely to be culturally sensitive, respecting individual and family beliefs traditions, and preferences related to end-of-life care. Integrated palliative care often includes home-based care options allowing patients to receive support in familiar surroundings. This can contribute to enhanced quality of life for patients and increased family involvement. Healthcare professionals involved in palliative care in Oman are likely to receive ongoing education and training to stay updated on best practices and provide high-quality care.

However, integrative palliative care in Oman need a lot of resources and human resource to work actively .

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In Malaysia, integrative palliative care has a long way to go due to the lack of integration and resources. While palliative care focuses very much on symptom management, there isn't a lot of emphasis on the mental health component. Most hospices in Malaysia are supported via donation from the public, of which there is a stigma present, as it is a "death denying" society.

I believe that mental health support for patients and caregivers are part of the integrative palliative care blueprint. The "total care" concept in palliative care should include more of the mental health component in order to supplement what we already have and reduce caregiver burden as well as existential support during the diagnosis.

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Despite being a global healthcare priority, integrated palliative care remains largely out of reach for most Pakistanis. Limited availability, underdeveloped infrastructure, restricted pain medication access, and public unawareness create a formidable barrier. However, there's hope. Advocating for policy changes, expanding education and training, decentralizing services, and raising public awareness through targeted campaigns could pave the way. Considering the underrated status and limited accessibility, starting small with pilot projects, highlighting cost-effectiveness, engaging community leaders, and leveraging technology can be game-changers. Collaboration between policymakers, healthcare professionals, community organizations, and the public is key to unlocking the potential of integrated palliative care and ensuring a dignified end-of-life experience for all Pakistanis.

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Palliative care begins at the time of diagnosis of a life-threatening disease (eg. cancer) and continues throughout the disease process until death and into the family's bereavement period. In Sri Lanka a new concept (better concept) as shown in the above Figure -1 which activated to intergrade when considering PC and the Old concept & current concept of spectrum of palliative care is shown as above.

Strategies taken to intergrade the PC with HC workers in Sri Lanka

1. It has ensured that palliative care is recognized and resourced as an integral component of the health system by making palliative care as an essential component of comprehensive health care.

2. It has facilitated the effective integration of specialist palliative care and palliative care services across all levels of service settings, namely at tertiary, secondary, primary and at community level.

3. Developing and making available skilled multi disciplinary human resources and infrastructure for delivery of palliative care services at institutional and at community levels.

4. Ensuring that patients and their families receive palliative care services they need when and where required & adherence to protocols & guidelines in palliative care

5. Ensuring availability of essential drugs & technologies for provision of palliative care at all levels: tertiary, secondary, primary and community level

6. Building partnerships with government and non-governmental organizations for delivery of palliative care

7. Empowering family members, care givers and general public for the provision of palliative care

8. Encouraging research related to palliative care in assessing needs for palliative care and suitable models for implementation of palliative care services.

9. Ensuring adequate financing & resource allocation for cost effective delivery of palliative care

10. Strengthening legislative framework for delivery of palliative care

11. Ensuring monitoring & evaluation framework for palliative care services

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1.Palliative care in India is primarily available in urban areas and at tertiary healthcare facilities. Only 1-2℅ of the estimated 7-10 million people in India who need palliative care have access to it. The South Indian state of Kerala which has 3℅ of India's population, stands out in terms of achieving coverage of Palliative care. This has been achieved initially by Non-Government Charitable activity, which catalysed the creation of a Government Palliative care policy. On the national level a National Program for Palliative Care (NPPC) has been created by the Government of India in 2012. In 2014,Indian Parliament amended Narcotic Drugs and Psychotropic Substance Act, thus overcoming many of the legal barriers to opioid access.

2.India needs a systematic approach to improve Palliative care. These improvements including the workforce, better application of policies, good political support, and educating health care workers and patients requiring palliative treatment.

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TEAM RUBY DR SARA SAJID Palliative Care in Pakistan 

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TEAM RUBY DR SARA SAJID Palliative Care in Pakistan 

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The country is currently facing a double burden of disease with NCD accounting for more than 50% of adult mortality with a projection of around 3.9 million deaths by 2025 as a result of NCD alone [10]. Cancer has also emerged as a major health issue which is reflected by the estimates for new cancer cases in the country standing at a staggering figure of 170,000 to 200,000 yearly.
In this setting palliative care needs are staggering. However due to economic and political instability there is no unified governmental palliative care system being applied. Most of the palliative care is imparted by private hospitals which are usually expensive and unregulated and few scattered hospices many of which are religious or community based - again unregulated

What can be improved ?
1. Countrywide
Need for laws.
Need for palliative care training centres under the govt providing affordable palliative care assessment and consultation
Setting up hospice care and home based care
Regulation of privately owned models of palliative care
2. Hospital based - departments should  developed with palliative care focus. To deal with cancer based as well as NCD related end of life care
3. Community based/ home based- available of trained health care workers for home health care and to support for families
3. Individual based - availability of training and teaching in palliative care. At all levels of health care workers

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In India, integrating palliative care into our primary health care system is underway in some states like Tamil Nadu. Here, a health worker trained in palliative care is appointed to identify people in need of palliative care and to provide necessary care. This has been an integral part of the program 'Makkalai Thedi Maruthuvam' . This is a welcoming step to care for people with incurable illness closer to their homes as possible. Such initiative requires a strong political will as it requires resources like specially trained manpower, drugs and vehicle for home visits. Other parts of the country have isolated palliative care programs run by voluntary organizations.

To make Palliative care accessible and available to all, mainstreaming palliative care into the routine healthcare system services is essential. This needs resource allocation in terms of manpower training, drugs and consumables and dedicated vehicle for the home visits. The already burdened primary care physicians can get help with the appointment of dedicated team to provide palliative care. The awareness among the state governments about the dire need about palliative care, starting with non-communicable diseases is important. Further this program can be expanded to serve all in need. There is a need to educate the community members about palliative care who can build a safety net for a sustainable program. Palliative care education and training should be made a part of undergraduate and postgraduate training courses for medical and paramedical courses. The availability of drugs especially opioids should be ensured by the state government to make 'pain-free' a right of every individual.

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1. What does integrated palliative care look like in your country?- To address the challenges in the early delivery of palliative care to reduce hospital admissions

and use of health services in the Philippines, a bill from the 19th Congress in August 2022 was passed to integrate palliative and hospice care into the

country’s health care system. However, this has not been implemented in the hospitals(government institutions located in Manila) where I am currently

connected. Most of the PC services are being provided in big private hospitals in the urban areas(Manila, Davao, Cebu..). The issue is we

do not have an allocated position for a palliative care provider. But we (Pain specialists, Oncologists, Orthopedic tumor specialists, Rehabilitation medicine, Psychiatry)

are currently discussing to start it in our hospital. And hopefully by the end of this program, we may be able to do that.

2. What could be improved?- Training for healthcare providers, then eventually for this trainees to be trainors. Awareness, Education, and persistent pressure to the

people in health policy to make this a priority. Also start to make PC a part of the healthcare providers curriculum(doctors, nurses, pharmacist, psychologists,

Physical therapists, occupational therapists, social worker, etc).

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Hosemin Islam, Team Gold. Integrated Palliative Care in Bangladesh (Example Perspective):

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Hosemin Islam, Team Gold. Integrated Palliative Care in Bangladesh (Example Perspective):

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Palliative care in Bangladesh may involve collaboration between different healthcare providers, including physicians, nurses, social workers, and other specialists, to address the physical, psychosocial, and spiritual needs of patients facing life-limiting illnesses.

Integration might involve incorporating palliative care principles into various healthcare settings, such as hospitals, primary care facilities, and home care services.

Training programs and educational initiatives may be in place to enhance the skills of healthcare professionals in providing palliative care.

Community engagement and awareness programs could aim to reduce stigma and increase understanding about the benefits of palliative care.

Areas for Improvement:

Workforce Training: Continuous training and education for healthcare professionals to enhance their palliative care skills are crucial. This can include specialized training programs, workshops, and certification courses.

Public Awareness: Efforts should be made to increase public awareness about palliative care, its benefits, and the available services. This could help reduce cultural or societal barriers to accessing palliative care.

Policy Support: Advocacy for supportive policies at the national level can play a significant role. This involves integrating palliative care into healthcare policies and ensuring adequate resources and funding.

Interdisciplinary Collaboration: Strengthening collaboration among different healthcare disciplines, including physicians, nurses, psychologists, and social workers, is essential for providing holistic care.

Community Involvement: Involving local communities and religious leaders in discussions about palliative care can help address cultural sensitivities and encourage community support.

Research and Data Collection: Continuous research on the effectiveness of palliative care interventions and collecting data on patient outcomes can inform improvements and contribute to evidence-based practices.

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there are 226 accredited palliative care facilities across uganda 135 districts .

the integrated palliative care system in uganda involves all health care providers , including health care aids , nurses , physicians and other multidisciplinary team members .

the approach also aims at pain and symptom management ,psychological , social, emotional , spiritual and practical support .

atleast each referral hospital offers palliative care services in uganda .

there are also other non governmental organisations that do exist and they are offering palliative care services uganda.

the following could be improved

coordination

communication

continued learning

care in the dying phase

career support.

more funding organisations.

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Integrated Palliative Care in the Phlippines has not reached its maturity. In 2015, the National Policy on Palliative and Hospice Care in the Philippines was created in response to strengthening palliative care in the country. In 2019, palliative care are mentioned in the Implementing Rules and Regulations (IRR) of the National Integrated Cancer Control Act and in the Universal Health Care Act. Thereafter, in 2021, Palliative and Hospice Care has been integral in the healthcare system and crafted its first edition of Manual Operations, Procedures, and Standards (MOPS) for National Palliative and Hospice Care Program covering all levels of care from primary to advance health care settings. The realization of this program is in collaboration of the Department of Health and its health partners such as Hospice Philippines, Philippine Cancer Society, Philippine Society of Hospice and Palliative Medicine, Pain Society of the Philippines, and other stakeholders.

Easy accessibility for basic palliative care services with equal opportunity for all has gradually grown amidst adversities like Human Resources to provide palliative care which service providers are limited in numbers and the reach to cover the archipelago has yet to achieve. With the current thrust of the government, a comprehensive understanding of the importance and impact on the quality of life of an individual will provide relief and prevent suffering of the patient and of the carers.

Opportunities to create awareness, translate knowledge and skills into clinical practice, and establish support and networks are being identified to address the gaps on basic palliative care. It would be a good opportunity to involve local government units, Barangay or community health workers, and primary health care physicians, and even inclusion in the curriculum of the medical students and hopefully in the allied health care programs in expanding the reach of palliative care.

In the health institutions, involving the Top Management to create champions and prime movers in integrating palliative care to patient care management. Implementing the government programs that is people-centered and utilizing the Public Health Unit for population-based or community based programs to expand the reach of caring.

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In Kuwait,  we have palliative care centre consist of 3 wards, not full capasity. We have only 4 consultant for adult.  And 13 doctors are oncologist.. We have OPD daily from 2 to 3 clinics. Nearly the total number of the patient per day 8-12. Working hour from 7:30 -2 pm.  We have over time duty from 2-6 pm for OPD .  We have doctors working for KCC cancer centre, and some doctors go for peripheral general hospital according to referal letter. We face some broblems like there is no cooperative between departments. Also, some of the doctors and nurses refuse to follow the rules of ministry for openinig the file, check the papers of the patients. About dealing with narcotic and psychotropic medicine. Also, some doctors from other hospital not sending patient for taking palliative care early , they wait until the situation became worse and the case deteriorated in the end stage. Some doctors in other hospital, they don't want to have high number of mortality in there hospital, so, they send the patient to our centre before the death in one or two days when they see the vital sign. This thing let the family and the relative afraid from our centre , they think that any patient admit to our centre, he will be die.  I hope we can change the situation, and make our centre good. I hope to have cooperation between department and make policiy for our work.

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Team Magneta

palliative care situation in Iran

palliative care situation in Iran

The history of modern palliative care for cancer in Iran dates back to year 2000Currently, There are currently no systematic structures for providing

palliative care in Iran and only about 5 to 6 centers are active in this field in Tehran, Isfahan, and Zanjan. some of the progress indicators of palliative

care, the status of palliative care is expected to progress significantly in the next few years in Iran. However, according to the 2006 ranking, Iran was placed within the second group of countries, that is, countries seeking to build capacities for providing palliative care. Given the leaps made in this area,

Iran’s ranking improved to the 3A group in 2011.

What could be improve?

More training the health care staff, publicity on the importance palliative care, integrating palliative care setting in health ministry.

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Palliative Care Current status in Bangladesh:

1. Isolated palliative care services is developed.

2. All most all of the services and organizations are based on capital city.

3. Acknowledged palliative medicine as medical speciality. MD (PM) started from 2016 in BSMMU. BSMMU conduct Basic Fundamental course in Palliative care.

4. 3 government institutions and few number of private organization provide palliative care.

5. Government took initiative training for doctors and nurses who are working in primary health care level.

6. We have training modules

7. Integration with Upazilla Health Complex (pilot project is started, single centre ) in primary health care service.

8. Two community based palliative care project are going on.

What could be needed for future development:

1. Special centre who can provide skill manpower by conducting training and support by government.

2. Palliative care national policy and monitoring committee.

3. Integration with ongoing services under Non communicable disease control program like DM,HTN etc.

4. Nation wide awareness programs and encourage community engagement.

5. To develop Inter-relationship among existing palliative care organizations.

6. To developed Public Private partnership.

7. Bottom to Top and Top to bottom follow up system.

8. Central data based documentation.

9. Program Follow up and evaluation commity.

10. Add palliative care as a topic in medical and nursing curriculum.

11. To create academic post for Palliative Medicine Specialist in Government hospital.

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If we define integrated palliative care as the comfort care that is begun at the time of diagnosis of a life threatening/limiting illness, for all intents and pruposes, integrated palliative care does not exist in Jamaica. We have one public institution that provides hospice type care for the entire country of population roughly 3 million. We have pain clinics in two or three of the major public hospitals and only in the past few years (5-6) has there been an attempt to provide some palliative care consultation at our university hospital that is our main teaching hospital. In the private setting we have perhaps a half a dozen doctors who offer some sort of palliative care services...but this essentially equates to end of life care in that they often are not part of the team of care providers until the other specialists decide that "nothing more can be done". There in lies the answer to the second question of what could be improved. We need to begin with educating our care providers on the suffering that goes beyond physical symptoms, of the inevitability of death and the value of being able to talk openly and compassionately with our patients about how they wish to draw their last breath. Death is the one guaranteed life experience we all will have, yet we have no language and capacity to talk about it in a way that makes a difference to how we live and how we manage aging and sickness which are also an unavoidable part of life.

The general population understands palliative care to be synonymous with end of life care and also believe it only happens when the doctors have given up.

So education needs to occur at two levels : to the population at large and to health care providers...to provide the understanding that palliative care can begin at the time of diagnosis of a life limiting illness, or even before a diagnosis, when we as care providers feel comfortable to initiate a conversation about what in life is important to the patient, and encourage them to think about how they want to draw their last breath. Before we can raise those issues with our patients, we have to contemplate these things for ourselves...and this needs to be an integral part of the medical student training, if we want to be able to offer integrated palliative care to our people.

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As already mentioned by my fellow Iranians, there is no systemic provision of palliative care services in Iran, and, as a result, palliative care is not quite integrated into the mainstream healthcare system in our region. In addition to the mentioned challenges in our country, I want to emphasize the challenges regarding our cultural and religious perspectives, shortage of healthcare professionals trained in palliative care, lack of adequate and stable access to medications, and geographical disparities–especially in rural areas of Iran. However, in my opinion, the stigma surrounding Palliative Care – as an end-of-life care, with some individuals equating it with "giving up" on treatment – might still be the first target for any intervention for improvement in our country.

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1. Integrated Palliative Care in my country :

In India, integrated palliative care is evident in institutions like AIIMS, New Delhi, with dedicated postgraduate branches and specialized sections within hospitals. Collaboration among departments enhances patient care. Furthermore, smaller hospitals are increasingly including palliative care teams, conducting regular OPD services, and providing home care visits in certain areas.

2. Areas for Improvement:

While progress is notable, the lack of palliative care in some small villages underscores an opportunity for improvement. Expanding palliative care services to underserved rural areas could enhance accessibility and address the needs of patients in those communities. This extension of services would contribute to more comprehensive and equitable healthcare nationwide.

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1. What does Integrated Palliative Care look like in your country?

I am not yet familiar with how our palliative care system looks in the PH because I'm relatively new in the industry. However, upon researching, I have discovered that we have some institutions/hospitals that offer palliative care. Moreover, palliative care is part of family medicine.

2. What could be improved?

I am yet to find out what needs to be improved, which I hope I will learn in this programme.

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What does Integrated Palliative Care look like in your country?
While we have made strides in establishing a standardized palliative care system nationwide, its implementation in all areas remains challenging due to various factors. Nonetheless, notable models exist, particularly in the Northeastern region of Thailand, exemplified by the Karunruk Center in Khon Kaen.

What could be improved?
Enhancements are needed in several areas, including the training of healthcare providers in palliative care concepts and management. Additionally, establishing robust connections within healthcare systems to facilitate seamless exchange of patient information, along with the integration of comprehensive medical histories, would significantly enhance accessibility to medications for symptom control and early intervention across diverse care settings such as homes, nursing homes, hospices, and hospitals.

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In Lebanon, there is still a lot of work that needs to be done in the purpose of integrating palliative care into the current healthcare system. However, there are many steps that have already been taken in that direction

1- Palliative care is recognized as a medical specialty and the ministry of health has extended their service coverage to include palliative care services in the hospital units.

2- The ministry of health has also dedicated a chapter for palliative care in the national cancer plan that as launched in 2023

3- There is an increased awareness on the importance of palliative care among physicians (especially oncologists) which is seen through the increased referrals to the in-patient palliative care units / teams and home palliative care services

4- many hospitals already have their own inpatient palliative care units

Even though the previous steps are very important, There is still a lot of work that needs to be done such as developing a palliative care curriculum for medical and paramedical students, supporting home palliative care services through extending the coverage (since the major barrier facing access to this service is financial), raising awareness in the community, having a legal framework for home palliative care services, improve and centralize data collection and encourage research.

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Nahid -Oman {Team Brown}                                        "What does Integrated Palliative Care look like in Oman? What could be improved?"  

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Nahid -Oman {Team Brown}                                        "What does Integrated Palliative Care look like in Oman? What could be improved?"  

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Integrated Palliative Care in Oman it may recently be started in tertiary hospitals which provide the service, which typically involves a multidisciplinary approach aimed to improve the quality of life for individuals facing serious illnesses and their families. The focus is not only on the physical symptoms but also the emotional, social, and spiritual aspects of the patient's & family's experience. improving the Integrated Palliative Care service in Oman might consider the availability of human resources, easy Access to Services when required, Community Awareness about the services and the importance of early decision or discussion about the care that should be offered for such patients, Continuous training for healthcare professionals who is providing the service and finally if all resources are available to provide this service in primary health care through community health services.

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Despite the development in the advancements Palestinians have witnessed in the last few years, The care is still suffering from major deficiencies. Only seven hospitals provide cancer care for the Palestinians; two governmental hospitals located in the West Bank, and two non-governmental facilities. The other three hospitals are governmental organizations located in Gaza Strip. Palliative care services are partially provided in these hospitals, and specialized palliative care doctors or nurses are very limited. The only registered non-governmental organization (NGO), Al-Sadeel Society, provides palliative care services in Bethlehem focusing on educating physicians, nurses, patients and their families about fundamental practices. The organization has two qualified palliative care workers (a nurse and a social worker). This NGO provides consultation for cancer patients and their families through its team along with occasional consultations from a trained oncologist who received six months of training in palliative care. Recently, Al-Sadeel started a recent program with the MOH and Augusta Victoria Hospital at Ibn-Sina College for Health Sciences to train undergraduate nursing students on palliative care. Hospice and end-of-life care services are very limited available for terminally ill Palestinian patients, and the teams working with cancer patients and geriatric departments lack knowledge and training in these areas. Recently, In the West Bank and Gaza, palliative care is a requirement in nursing curricula and training programs. Although, recently Bethlehem, Berzait University started a master and higher diploma program in oncology and pallative care nursing, moreover, Al-Quds university integrated palliative care in all undergraduate nursing courses. Availability of research in a particular country reflects the size of attention directed toward developing palliative care. Few researches were conducted in West Bank and Gaza Strip to assess this need. A recent, study conducted reported low attitude toward caring for dying patients among nursing students, which was attributed to lack of knowledge and skills. Another cross-sectional study assessed the knowledge and attitude of nurses towards palliative care. 45.8% of the subjects had a low-level of knowledge in palliative care, whereas 56.2% had a moderate score for attitude towards palliative care. The study also found a significant influence of the qualifications, years of experience and palliative care training, on knowledge scores among Palestinian nurses.

The status of palliative care in Palestine is gradually evolving, but challenges remain. Access to palliative care services is limited due to various factors including limited resources, infrastructure challenges, and political instability. However, there has been some progress in recent years with the establishment of palliative care programs and initiatives by local healthcare providers and NGOs. Despite these efforts, there is still a need for greater awareness, training of healthcare professionals, and improved access to essential medications and equipment.

Integrated palliative care in Palestine needs collaboration between different healthcare providers and organizations to ensure that patients with life-limiting illnesses receive comprehensive support. This includes medical care, pain management, psychosocial support, spiritual care, and support for families. Integrated palliative care seeks to address the physical, emotional, social, and spiritual needs of patients and their families throughout the illness trajectory. This approach requires coordination between hospitals, primary care centers, home care services, and community-based organizations to provide seamless care across different settings. but still we didnt get this situation. Due to the unique challenges faced in Palestine, such as political instability, limited resources, and restricted access to healthcare services, so the delivery of palliative care can be complex.

Several aspects of palliative care in Palestine could be improved to better meet the needs of patients and their families. These include:

a. Increased access to palliative care services, especially in rural and underserved areas.

b. Enhanced training and education for healthcare professionals in palliative care principles and practices.

c. Improved availability of essential medications, including opioids for pain management.

d. Strengthening of community-based palliative care programs to provide support closer to patients' homes.

e. Greater awareness and acceptance of palliative care among patients, families, and the general public.

f. Addressing cultural and religious beliefs that may influence attitudes towards end-of-life care.

g. Advocacy for policies and funding to support the expansion and sustainability of palliative care services in Palestine.

Overall, by addressing these challenges and working towards a more integrated approach to palliative care, Palestine can improve the quality of life for patients with life-limiting illnesses and their families.

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Zahra Amrollah Majdabadi - (Team Indigo)

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Zahra Amrollah Majdabadi - (Team Indigo)

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Palliative care is provided sporadically and in a limited number of centers in Iran, especially for cancer patients. In recent years, cancer research centers and the Ministry of Health have emphasized palliative care. The challenges in providing palliative care in Iran include:

Lack of Specialized Services: Iran's health system faces a lack of specialized palliative care services, leading to patients receiving care in hospitals rather than in dedicated palliative care centers or hospices

Limited Awareness and Familiarity: Many patients and health professionals in Iran are unfamiliar with palliative care and the traditional view of health personnel in the treatment of incurable diseases leading to a lack of referrals and underutilization of services. This is due to the sporadic and limited availability of palliative care centers in the country

Structural Barriers: Structural impediments such as inefficient insurance services, lack of transparency in the law to support health personnel in providing palliative care, and inadequate training and awareness of palliative care staff pose significant challenges to the provision of palliative care in Iran

Integration with Primary Health Care: While Iran's health system is equipped with the infrastructure to integrate palliative care with primary health care, there are obstacles in the integration process that must be reevaluated and revised. This includes the need for improved management practices, monitoring indicators, and measuring and evaluating services

Addressing these challenges will be crucial in improving the provision of palliative care in Iran, ensuring that terminally ill patients receive the support and care they need.

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In my country Lebanon, Palliative Care is not widely practiced as it should be. Despite all the laws and self trials made, the lack of funds remain the main barrier to PC. That's why PC is only seen in few hospitals in the capital Beirut, whereas the concept is fully absent in remote areas. Unfortunately we do not have any specialized PC hospital, however we do have NGOs dedicated to PC along with few hospital wards where certain HCPs like oncologists, geriatricians, and pain specialists do provide PC services. What is missing in Lebanon is the implementation of the laws set along with both financial and insurance coverages. On top of that, education is still an area for improvement where patient centered approach remain the focal point. In my opinion the MOH should prioritize the activation project of PC as the need is on the rise; encouraging doctors and nurses to specialize in PC

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I am nurse and i am working in sharisti hospital with palliative care team.Palliative care in my country, Iran, has a long history. But unfortunately, it is not cultured and it is often considered to be care at the time of death. These cares are not covered by insurance when not hospitalized. One of the goals of the palliative care team in Iran is to oblige insurance companies to pay the costs.The palliative team includes a doctor, nurse, psychologist, nutritionist, and assistant. They are linked together by the team coordinator, and each of them is assigned to the patient. First, the patient is identified and evaluated by the assistant or coordinator. And the needs are assessed. After that, other team members come into action and the case is jointly discussed and the best decision is made for the best palliative care.

Training, research, practice and empathy of members can help in achieving the goals of the team.

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In my country integrating palliative care is not force full , i likes to improve palliative care in regions of somalia to get access of palliative care every patient suffering chronic illness.

Education:

It's important to improve palliative care system in the country to develope the education of health care profisionals like : doctors , PHC ,nurses and every one who works integrating palliative care in somalia

Awareness :

I my countery awareness of palliative care is not good , me i will implement pblic awareness of palliative care and how important to improve this care .

Our country most of the people they beleive only needs palliative care patients having cancer disease .

Our country more important to understanding integarating of palliative care.

Improvement:

First the goverment especialy minstary of health somalia and WHO to work to gather to developing many centers of palliative care to make workshorps and training programs of plliative care to develope health profisoinals who are working palliative care centers ,after that the imlrovement of care will be good in the countary.

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In Lebanon, significant efforts have been ongoing to develop PC since 1995. These include, introduction of PC during a National Cancer Control workshop, conduction of the first Palliative Care and ethics symposium, initiation of the Lebanese Pain and Palliative Care Initiative within the Lebanese Cancer Society, introduction of PC as a patient right in the first article of the law 574, amendment of Narcotic law, introduction of PC as a patient right, establishment of the National Committee for Pain Relief and Palliative Care, introduction of new narcotics in the market, launching a national strategy to raise awareness about PC, and recognition of palliative medicine as a medical specialty.

In Lebanon, the main barrier to access PC services is the lack of financial coverage. A national PC program has been proposed to the MOPH to provide financial coverage to PC services in hospitals and homes but is not implemented yet . To this date, public and most private insurance parties do not cover PC services. This limits access to PC services and also discourages health professionals from pursuing PC as a profession. Therefore, healthcare providers interested in providing PC in Lebanon are mainly family physicians, geriatricians, oncologists or pain specialists and only devote part of their time to providing PC.

What could be improved:

1. Education:

• Recommend a core curriculum for the training of healthcare professionals with emphasis on knowledge, attitudes, and skill development.

• Recommend specialization trajectories for physicians and nurses.

• Institute the importance of continuing professional education in the field as a requirement for recertification and licensure.

• Develop strategies for public education and awareness in the field of palliative care.

2. Practice:

• Develop national standards and competencies for pain relief and palliative care.

• Implement strategies to engage professionals from different disciplines in the care process such as the use of multidisciplinary care pathways.

• Recommend models for service delivery such as home care and residential care and the use of palliative care teams in hospitals.

• Develop mechanisms to empower the family and the patient to be actively involved in the care process emphasizing the importance of family and patient-centered care.

3. Research:

• Develop national research priorities for the field of pain relief and palliative care that target gaps in treatment, knowledge transfer, education, and policy.

• To recommend research methods to address the gaps in information related to pain relief and palliative care in Lebanon.

4. Public Policy:

• Promote legislation that ensures the availability, accessibility, and prescription rights of opiates.

• Recommend strategies that will ensure the practice of interdisciplinary palliative care teams in the care process.

• Develop models for cost allocation and reimbursement for pain relief and palliative care services.

• Recommend the institution of pain relief and palliative care as integral parts of the healthcare system in Lebanon.

References :

https://www.aub.edu.lb/k2p/Documents/K2P%20Policy%20Brief-%20Palliative%20Care-August%207%202018.pdf

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Md Ashraf Uddin Ahmed-Team Orange

What does Integrated Palliative Care look like in your country?

“Many a penny makes a pound; drops of water make ocean.”

I am working as a consultant of medicine in a tertiary care hospital of Bangladesh, which is a low resource country in terms of health care facilities. Palliative care is a relatively new concept in Bangladesh, although it is known worldwide and established as a specialty in many countries of both developed and developing part of the world. Bangladesh, one of the most densely populated resource constrained countries in the world. Unfortunately, integrated Palliative care is almost non-existent in the general medical and social practices. While there is increasing recognition of the importance of integrated palliative care, there is little guidance on how integrated palliative care can be operationalized and in the contexts of constrained healthcare budgets, what should be prioritized for implementation.

Due to lack of awareness, early diagnosis and intervention hundreds of thousands of people in Bangladesh, including children, require palliative care assistance today as they are often diagnosed at final stages of their non-communicable diseases. The Government of Bangladesh has recognized the pertaining need for integrating Palliative Care into the mainstream medical practices.

It was found that Bangladesh has an extensive health care system, with substantial infrastructure and trained health care personnel, but health care professionals and policy makers in Bangladesh have not yet recognized palliative care-i.e. holistic care of the patients with incurable illnesses and lifelimiting diseases as a specific discipline as it is in many countries of the world. There is low awareness of palliative care amongst patients, their families, and the general public also. There is no national policy, guideline, or standard on the organization of palliative/hospice care; neither is there a legislative framework for palliative care. Either preventive or a disease focused, cure oriented approach are the predominant features of the mainstream health care system. As a result, this group of patients with incurable life-threatening illnesses with their unique needs is either cared for by non-trained health care providers or majority by the family members without any knowledge or skill-based concept for such care.

In Bangladesh there are 3 Govt. institutes and some informal private organizations providing palliative care services through inpatient, outpatient and home-based care.

What could be improved?

If we can follow International public health approach to palliative care current conditions can be improved. The components comprise of:

Ø  availability of essential medicines

Ø  especially access to opioids

Ø  education and training in core palliative care principles and skills for health professionals to build work force capacity

Ø  national health policies and strategic plans that incorporate palliative care and earmark resources

Ø  implementation of a range of services

While recommendations were generated in all four areas, there is an apparent shift in prioritization to education and policy domains. International evidence suggests that the inclusion of palliative medicine in medical curricula remains limited in most countries. If we can adopt following principle the conditions can be improved

Education

Experts regarded education as a priority. It is considered that palliative care should be integrated into mandatory education for undergraduate medical, health and social care professionals. Also, important although lower ranked is the inclusion of integrated palliative care in the continuing professional development of health and social care professionals. This indicates that experts regard education about integrated palliative care to be a higher priority for those at the beginning of their health and social care careers.

Awareness raising

Experts felt that raising public awareness of palliative care and its integration with healthcare was a key priority. However, raising awareness of palliative care amongst senior managers is viewed as a lesser priority. It seems, consider the publics’ lack of awareness as a greater challenge to integrated palliative care. Furthermore, it is considered that greater clarification of language and terms used to describe integrated palliative care and associated services is needed  suggesting that the lack of public awareness may be affected by the complexity of language and terms used within this context, and a lack of professional agreement about terminology used.

Leadership

Strong leadership to advocate for integrated palliative care is also considered a priority by experts. However, the development of leadership skills is not prioritized. The need to identify ‘champions’ and succession plan for these people was seen as more important than merely offering leadership skills training.

Policy making

Experts shared a consensus about the need to include integrated palliative care at policy level. It is noted that palliative care for cancer patients is well established however the provision for patients with other conditions is often less accessible. Experts thus prioritized the extending of national palliative care regulations and policies to all patients with palliative care needs, not just those with cancer. In addition to this, it was felt that palliative care should be integrated into all national policies relating to specific diseases.

Ensuring quality of care

It is strongly prioritized the need for ensuring quality of services through auditing and benchmarking. However, emphasis should placed on the development of tools to be able to assess outcomes, suggesting that there is a gap in this area. The practices of auditing and benchmarking these outcomes should given less priority suggesting that benchmarking is not relevant without reliable data. Thus, the development of assessment tools that monitor integration has greater urgency.

Building relationships

It is observed that for experts the building of relationships is considered important for integrating palliative care, but was not considered a top priority. Within this, there should be greater emphasis placed on developing alliances within and between health care sectors care  than on exploring opportunities to establish informal relationships.

Improving systems and infrastructure

Although considered important, recommendations relating to the development of better systems and infrastructure were not highly prioritized by experts. Similarly, the development of an information hub, (online or a face-to-face central resource for the coordination of information exchange), with a care co-ordination team to contribute to the integration of palliative care services across geographical areas was perceived as less important. Nonetheless, this should be prioritise the digital transfer of information within and across different palliative care services and generalist services such as GPs, community nurses and hospital teams.  There is a strong need about establishing a single point of contact for integrated palliative care at local level  indicating a more urgent need to organize care clearly. It is also favored the introduction of a clinical protocol to ensure integration of palliative care services for patients and families regardless of the setting where they are treated.

In relation to maintaining a work life balance for health care practitioners, providing adequate out-of-hours integrated palliative care is regarded as lower priority. This may suggest that concerns about work/life balance for integrated care practitioners are less visible to experts.

Funding and finance

The recommendations also highlighted concerns around the funding of integrated palliative care. It prioritised the importance of establishing new and creative ways of securing resources in order to support the infrastructure of palliative care .There must be national level strategic lobbying as a way to develop and fund better integrated palliative care. In relation to medication however, the need for readily available and affordable essential medicines for integrated palliative care is ranked lower suggesting that experts’ concerns around funding are macro-level related.

Conclusion

The National Task Force for Palliative Care should be urgently established under the auspices of the Ministry of Health. The National Palliative Care Guidelines for the symptomatic management of cancer pain, dyspnea, nausea and others should be prepared and published and disseminated urgently. To achieve an optimal level of pain and symptom control, we must harness the expertise of a wide range of medical, nursing and paramedical discipline.

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At present, supportive and palliative care is not provided in a systematic way in Iran. Incomplete services, without official support, dependent on donors, limitations. At present, the few supportive and palliative care centers in Iran operate locally and the existence of military There is no unit that manages and standardizes the structure, operational processes and educational protocols related to supportive and palliative care. The estimated percentage of those who benefit from supportive and palliative care at the time of death compared to all those who They need these cares at the time of death. Based on this evaluation, the capacity to provide these supportive and palliative cares in Iran is very small, in such a way that only about 1 person out of every thousand people who need these cares at the time of death in Iran benefits from it. Development of supportive cares and palliative care in a country depends on the support of the government, the activity of charities and the cooperation of experts, the awareness of the people. To these services, on the one hand, it increases the desire and request to start it, and on the other hand, it increases the social capital for its development. For morphine, care is mostly provided at home and training of specialist staff is not done in these countries.

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Integrated Palliative Care (IPC) in Kenya represents a multifaceted approach to addressing the complex needs of individuals facing life-limiting illnesses and their families. At its core, IPC in Kenya aims to enhance the quality of life for patients by providing comprehensive physical, psychosocial, and spiritual support throughout their illness trajectory.

One aspect that characterizes IPC in Kenya is its emphasis on a holistic approach. This involves a collaborative effort among various healthcare professionals, including doctors, nurses, social workers, psychologists, and spiritual counselors, to address the diverse needs of patients and their families. By integrating medical treatment with psychosocial and spiritual support, IPC in Kenya seeks to alleviate suffering and enhance overall well-being.

Additionally, Integrated palliative care in Kenya recognizes the importance of community involvement and cultural sensitivity. Given the diverse cultural landscape of Kenya, IPC programs often incorporate traditional healing practices and community resources to provide culturally appropriate care. This approach helps foster trust and acceptance within local communities, ultimately improving access to palliative care services.

However, despite these strengths, there are several areas where IPC in Kenya could be improved.

One significant challenge is the limited access to palliative care services, particularly in rural and underserved areas. This is exacerbated by a shortage of trained healthcare professionals and insufficient funding for palliative care programs. To address this issue, there is a need for increased investment in training healthcare providers in palliative care and expanding access to services in remote regions.

Another area for improvement is the integration of palliative care into existing healthcare systems. While there have been efforts to incorporate palliative care into primary healthcare settings, there is still a lack of awareness among healthcare providers about the importance of palliative care and how to deliver it effectively. More training and education initiatives are needed to equip healthcare professionals with the necessary skills and knowledge to provide comprehensive palliative care.

Furthermore, there is a need for greater collaboration between palliative care providers and other sectors, such as social services and community organizations, to address the social determinants of health that impact patients' quality of life. This includes addressing issues such as poverty, lack of access to education, and inadequate housing, which can exacerbate suffering and diminish the effectiveness of palliative care interventions.

In conclusion, Integrated Palliative Care in Kenya represents a vital approach to improving the quality of life for individuals facing life-limiting illnesses. While there have been significant strides in providing holistic and culturally sensitive care, there are still challenges to overcome, including limited access to services, inadequate integration into healthcare systems, and the need for greater collaboration across sectors. Addressing these challenges will require continued investment, innovation, and collaboration to ensure that all individuals in Kenya have access to high-quality palliative care when they need it most.

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The establishment of the PC system is one of the goals of the health system of Iran.

In order to develop palliative care in Iran, we must first solve its infrastructure challenges.

Existing studies have mentioned the necessity to modify and extend PC at home, specialized PC, modification of rehabilitation services, insurance system definition, appropriate referral system, poor teamwork quality, and lack of PC training guidelines as the PC challenges in the health system of Iran.

lack of PC definition in the health system and weaknesses of PC providers are presented as the most important PC challenges.

the process challenges of providing PC including weaknesses in policy-making, standard care provider, and the use of educational and research approaches are the main PC challenges.

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In Latin America, we are characterized by a warm family and community support system; however, we face a situation of stigmatization when it comes to palliative care. At least in Mexico, discussing palliative care is associated with imminent death in a short time, without medical support or curative treatment. This stigma compels both healthcare professionals and patients to avoid engaging with palliative care services. In terms of the growth of palliative care, there is a need for education for both the general population and healthcare workers about what palliative care truly entails. It is crucial to raise awareness and educate the population about the potential benefits of palliative care.

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Palliative Care in Bangladesh ( Shahana Sharmin, Team Pink)

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Palliative Care in Bangladesh ( Shahana Sharmin, Team Pink)

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Palliative care is still unknown to the majority of Bangladeshis and is not widely available in hospitals. The majority of people believe that those who work in palliative care are the messengers of death. We need to change people's perceptions of what palliative care entails and how we can best support our patients and their families...

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In jorday, there are only 2 organizations that provide palliative care, king hussain medical center, they only care thier patients and known to have cancer,, the other organization ;proudly; is al malath foundation where i work, inegration in palliative care between medical, psycho-social support and volunteers

Things to improve: financial aid for low soci-economic status patient is neccesary to be provided by govermental and non-govermental organization. Also to be improved, is the legal issues regarding restriction of opiods

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In Iran the palliative care underpinning was an familycare giver that his wife had cancer. He helped with financial charity to oncology centers in Iran . This palliative part was named ALA PALLIATIVE CARE in firouzgar hospital 🏥.

In this center oncology spicialist, nurses, Rouhanies(=chaplains); phisyiotherapist; psychologists have a collaboration works all of the times.

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Palliative care is very much in its infancy in the UAE, there is a growing recognition of the value and the need for palliative care practitioners. While the general population’s expectation of what modern medicine can provide is constantly being raised, this is also tempered by increasing awareness of the relevance of quality of life, particularly for patients approaching the end of life. Pain remains the symptom most commonly associated with suffering and a worse quality of life. Over the past few years, access to opioid analgesics has improved dramatically. However, there still remain challenges to prescribing in the outpatient setting and for patients who wish to have end-of-life care at home. Palliative care services have been available in the UAE since 2007. Still, they are limited to a small number of healthcare institutions in Abu Dhabi and Dubai and remain closely affiliated with oncology services.

Integrating Palliative care to medical and nursing education is a crucial step in UAE—a very comprehensive training and education need to be initiated in the healthcare system. Main palliative centres in the UAE (Tawam Hospital and also the American hospital), there is a desperate need for the addition of counsellors, care coordinators as well as nursing staff especially trained in palliative medicine to help with grief support and alleviate existential suffering.As evident in ASCO clinical guidelines, there is a need for the integration of palliative medicine into standard oncologic practices. Palliative care and supportive services are very limited in the UAE. Cancer patients in the UAE are having major difficulties in accessing palliative care due to limited palliative care facilities and qualified palliative physicians and nurses. Currently, there is no cancer hospice in the UAE. We need to bring the changes together by integrating these services with major health stream

References

1. https://symbiosisonlinepublishing.com/palliative-medicine-care/palliative-medicine-care61.php

2. file:///C:/Users/PV00032/Downloads/Palliative_Care_in_the_United_Arab_Emirates_A_Nurs.pdf

3. https://pubmed.ncbi.nlm.nih.gov/12849583/

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Integrating palliative care in to mainstream

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I believe that integration of palliative care into PHC services is essential for the development of health care outcomes.

But one or more barriers are present in my country kuwait :
- we need to update a policy to this integration
- we need to improve the access to essential palliative medicines prescription
- we need more trained healthcare workers
- and more community education about what really is PC

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Presently, a notable gap exists in medical education as palliative care is not integrated into undergraduate curricula across vast majority of medical colleges in India, relying on the initiatives of a few individuals. To address this, a comprehensive solution involves implementing a policy by the National Medical Commission. This policy should mandate the inclusion of palliative care as a compulsory subject in undergraduate medical education and necessitate the establishment of separate departments in all medical colleges. This approach aims to bridge the existing lacunae and ensures a standardized and widespread integration of palliative care principles.

Integrating palliative care into undergraduate medical education and establishing dedicated departments in all medical colleges is a crucial step. Making it a compulsory subject for examination ensures comprehensive training for healthcare professionals. A policy by the National Medical Commission could provide the framework needed for standardizing and prioritizing palliative care education across the country. This approach aligns with the goal of incorporating palliative care seamlessly into mainstream healthcare.

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I would need to do more research to describe the integration of palliative care in the SA health care system. From own experience I have seen in the last years that both in the public and private sector there is more understanding of the role of palliative medicine and palliative teams work alongside oncologists and other specialists and provide home visits after patients are discharged from hospital. There's a network for palliative physicians, nurses and social workers in several provinces and a national organization for palliative practice (PALPRAC). The University of Cape Town has a department of palliative medicine and the department of family medicine at the university of KZN provides training in palliative medicine. The bi-annual conference for oncology (SACO) had a pre-conference workshop and stream for palliative medicine in 2023 as part of their programme. I think much advocacy needs to be done at all levels to integrate palliative medicine in the healthcare system in SA

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                   Vedaste   ,Rwanda               Rwanda PC Integration into Health care System   

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                   Vedaste   ,Rwanda               Rwanda PC Integration into Health care System   

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In Rwanda, Palliative care service is integrated into health care system from Teaching hospital, referral hospital, Provincial hospital, District hospital , health center and Home/ community however there quality of service provided there is not enough especially at the lower level.

The National policy is there available and Palliative care guideline is available.

There is regular mentorship of health care providers on palliative care service provision at the health facility

Health care providers are being trained on pain management

There is a local production of oral morphine solution

The palliative care is integrated into service delivery it is not an isolated area

Palliative care course is been provided to medical and nursing schools

Areas to improve include:

1. Improve referral system to ease access to palliative care

2. Strengthening community based palliative care by trough training and mentoring

3. Decentralization of pain medicine to the primary health care service especially oral morphine solution

4. Increase human resource and continuous capacity building

5. Improve patient navigation and social support

6. Integrate Palliative care specialization or subspeciality within medical and nursing curriculum

7. Research and community awareness about palliative care service delivery

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In the Philippines, palliative care is unpopular. Some medical doctors are not even aware of its value in the management of the patient. In some medical schools, it is not even introduced. Hence, the concept of the Integrated Palliative Care is still a work to pursue in my country.

What could be improved?

1. Create national policies and tailored local policies on palliative care

2. Increase manpower or human resources by having more institutions with training program for those who wants to go into the field of palliative medicine. There should also be a flexible practice based training for those who cannot go on straight duty hours.

3. Advocate for palliative care awareness of not just the medical field, or allied health professionals but also the laypersons or community members.

4. Enhance availability of common and essential palliative care equipment and medicine.

5. Improve access and delivery of health care specifically palliative care, in all settings- hospital-based, community-based or home-based

6. Just like the principles of PHC (primary health care), palliative care should be integrated in all health levels

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Palliative care in my country is mostly available only in tertiary level hospital. People in remote area have little access of palliative care. Many people are not aware about palliative or hospice care even when they are in need of it. So I think it's necessary to increase availability of integrated palliative care in all area throughout the whole country. Also with this public awareness about palliative care should be raised.

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THE STATUS OF SUPPORTIVE AND PALLIATIVE CARE SERVICES IN IRAN

Currently, supportive and palliative care is not provided systematically in Iran. the status of supportive and palliative care in different countries have been reported by International Observatory on End-of-Life Care (Lancaster University, UK) and the World Health Organization. According to the results, the countries of the world are divided into 4 main groups based on the status of palliative care.

Group 1) countries without any known supportive and palliative care activity;

Group 2) Countries that are building capacity to provide supportive and palliative care though no service has yet been established;

Group 3) Countries with Isolated palliative care provision. This category of countries is divided into two subcategories:

Group 3. a) Isolated palliative care provision: patchy in scope and not well supported, mostly, donor-depended services, limited access to morphine, home based services are more common in these countries and specialized palliative education is not available.

Group 3. b) Generalized palliative care provision; There are adequate financial resources to provide care, adequate access to morphine, in some cases, there are some education and training opportunities available.

Group 4) Countries where supportive and palliative care is provided in the health system and its services are integrated with other health care providers. This category includes 2 subcategories:

Group 4a) Countries where hospice-palliative care services are at a stage of preliminary integration into mainstream;

Group 4b) Countries where hospice-palliative care services are at a stage of advanced integration into mainstream service provision.

This classification is made based on the following criteria:

The coverage of supportive and palliative care in the country;

The level of public awareness of supportive and palliative care;

Access to opioids;

Quality of supportive and palliative care specialized education and training;

The cost of supportive and palliative care;

Structure, level and settings of service delivery;

Existence of national policies on supportive and palliative care;

Existence of a comprehensive range of supportive and palliative care services;

Coordinating supportive and palliative care with the curative treatment plan:

Research status in the field of supportive and palliative care.

According to a report published by the World Health Organization (WHO) in 2014, Iran is classified under the “3-B” category. this indicates that, Iran’s status has improved compared to the previous evaluation period of 2006, when Iran was classified within Group 2.

currently, there are few supportive and palliative care centers in Iran, and there is no integrated system to manage and standardize the structure, operational processes, and training protocols for supportive and palliative care.

IRAN’S STATUS IN VARIOUS ASPECTS OF SUPPORTIVE AND PALLIATIVE CARE AND THE QUALITY OF DEATH

According to «The 2015 Quality of Death Index. Ranking palliative care across the world, (published by the Lien Foundation in collaboration with The Economist Intelligence Unit in 2015), 80 countries were evaluated in terms of supportive care, palliative care, and quality of death.

CAPACITY TO DELIVER PALLIATIVE CARE

This index indicates the estimated percentage of people who receive supportive and palliative care at death compared to all those who need such services at the time of death. According to this assessment, the capacity to provide these supportive and palliative care in Iran is very small, so that only 1 of every 17 people who need this care at the time of death, benefits from the service.

Presence of specialized and professional human resources

There is a direct relationship between the presence of trained human resources in supportive and palliative care and the development of these services in each country. Supportive and palliative care is recognized and taught as a separate specialty in many developed countries. In Economists’ 2015ranking, among 80 countries were evaluated, Iran did not rank better than 78th among 80 countries in terms of the presence of the professional workforce for palliative care.

AFFORDABILITY OF SUPPORTIVE AND PALLIATIVE CARE

Governmental support and charitable activities facilitate access to supportive and palliative care for all classes of the society. Although Iran performs very poorly in providing palliative and supportive care in the absence of government support and insurance coverage, the country ranks 56th in affordability of supportive and palliative care among 80 countries.

This rank has been obtained thanks to the activities of charities and non-governmental organizations. These organizations may provide palliative and supportive services free of charge or fulfill other overlooked needs of the patients and their families.

The community engagement in supportive and palliative care

Iran ranks 77th in terms of the community engagement in supportive and palliative care. The link between the services and the community is shaped as a result of public awareness, social demand, voluntary activities and the cooperation of philanthropists. as the community awareness of these services increases, the desire and demand for palliative services increases, in parallel with the inclination for other forms of social engagement like charitable donations.

Overall ranking

In a country, the development of supportive and palliative care depends on government support, charitable activities, the presence of specialized workforce and public awareness. While most of the leading countries in the overall ranking are developed and wealthy countries known for their high social welfare, countries such as Mongolia, Panama, Uganda and Jordan have also been able to establish higher living standards for people with serious illnesses, and specifically for the cancer patients in recent years with the cooperation of government, people and professionals. Iran ranks 73rd out of 80 countries in overall ranking of supportive and palliative care and quality of death.

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1. Palliative care is still a new health care system in Indonesia, recently launched by the ministry of health, but not yet fully covered by the national health care insurance. Started with primary health care system ( where the national health care insurance covered). By now there is no formal education about palliative, so we have to seek on line education etc to improve ourselves about palliative care.

2. To be improved : a. education, every physician especially the primary health care should be trained about palliative, how to take care of the palliative patients, how to improve the quality of life etc.

b. Government policy

c. Public awareness campaigne

d. Community : care giver

e. Research

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In Egypt palliative care mainly in governmental hospitals there are special units but they are few in number
Regarding Hospice care i'm working as assistant manager in NGO "Hospice Egypt"
This is the first & only organization providing hospice services for terminally ill patients till now.
However, Hospice Egypt established in 2010 but still the challenges regarding the culture &difficulty in talking about death is a huge challenge
What can be improved is more dissemination of the concept of end of life care in the Egyptian community

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In Iran, palliative care is a brand‑new concept with no written plan of specialized services in accordance with the proportionate share of the overall demand. Sporadically delivered, PC does not enjoy adequate support to the extent that patients usually do not receive essential care such as nursing as well as those associated with social, psychological, physical, and spiritual needs. Although government’s noncommittal approach to the philosophy of PC is said to be the greatest stumbling block to gaining access to and running the PC programs in the developing countries, and that the majority of problems to the implementation of PC services arise from absence of government strategies, consistent national policies, and broad negotiations with countries involved, it seems that structural hurdles to be the main concern of the health system structure of such countries, thereby considering the hindrance to establishing a palliative care system.

In Iran, the Ministry of Health and Medical Education is the top‑level agency in charge of the health system and is responsible for planning and implementing health policies at the national level; part of this responsibility is delegated to medical science universities across the country. Considering that health‑care services are classified into different levels in Iran, community‑based health‑care providers such as health workers (behvarz), midwives, GPs, and nurses can help in providing community‑based palliative care. The interdisciplinary nature of palliative care with a team approach consisting of caregivers is a factor that contributes to the provision of services, cost reduction, and quality of life

Today one of the challenges of the health system is the provision of palliative care services to chronically‑ill patients. In Iran is at the mercy of structural impediments such as improper definition of palliative care services, including home care, palliative care and specialized rehabilitation programs, inadequate training and lack of awareness and expertise of palliative care staff, lack of educational guidelines and protocols on healthcare, lack of transparency of duties, poor teamwork, and inefficacy of Insurance. In Iran, Palliative care is a new discipline and its objectives are not yet fully achieved.

Although In the past 7 years, attention to palliative care has increased significantly as a result of the National Cancer Research Network with the support of the Ministry of Health. It is hoped that in near future, the system will be all‑set by improving staffs’ professional awareness in the health system and removing the existing structural barriers.

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In Malaysia, integrated palliative care is still evolving, with ongoing efforts to embed palliative care principles into the mainstream healthcare system. The current state of integrated palliative care in Malaysia includes the availability of palliative care services in some hospitals, hospices, and through home-based programs by government funded health clinic, primarily concentrated in urban areas. Education and training in palliative care for healthcare professionals are increasing but remain insufficient to meet the growing demand. Collaboration between various healthcare providers is present but not yet standardized across all healthcare settings.

However, private general practitioner(GP) is missed. The main reason is that there is no easy way to reach out most of the GP, either for training or policy development. Personally I think this group of GPs have great potential as they are spread all over the country and has better relationship with the local community.

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1. Informed by policies such at the National Development Strategy 1&2, Island Hospice and Healthcare in Zimbabwe together with OAK Foundation embarked on a project targeting vulnerables with the purpose of integrating them into the existing Chitungwiza Community Hospice Palliative Care Program. The integrated working approach in place includes the Ministry of Health and Child Welfare, National Aids Council (NAC), Chitungwiza Hospital, local authorities, NGOs, traditional leadership and community caregivers. Services provided include mentorship, on-site training, creation of referral linkages to identify marginalized members of the community through the wide range of services available within palliative care. Faith based organizations such as Karanda have made milestone developments in reaching people of low income in accessing Palliative care.

2. Health service delivery should evolve to embrace the escalation of chronic illnesses. Though Palliative care services have been decentralised in Zimbabwe, there is need for continued monitoring and evaluation of available systems, revamping and further established of more than 1 Palliative care facility. These systems need to be financed in order for them to effectively obtain desired outcomes. Capacity building is paramount for provision of quality end of life services and good dying. Political Will to protect citizens sould be implementation to bridge the gap created by social inequalities in access to Palliative care. Delivery of intensified health education for service users and families living with

chronic health conditions is paramount. Research and development in rural areas would ensure implementation of programs that speak to the needs of the community. Zimbabwe is believed to have a very good health policy which however, needs to be implementated at mico macro and mezzo levels, adjusting its strategies in order to meet the complex needs of patients. The tenacity of world economic crisis calls for Zimbabwe to utilise available resources in a thoughtful

manner.

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Integrating palliative care into mainstream healthcare involves collaboration among healthcare providers,education and policy changes. specialised training programs for doctors, nurses,social workers and families.Encourage inter deciplinery teamwork and communication to address the holistic needs of patients.Additionally policy changes that support integration of palliative care services at various levels of healthcare to be established and implemented.

In india ,in andhra Pradesh - still there is no separate treatment and policy for palliative care patients. Most of the palliative care the families are doing with limited resources and medicines no one in the phc s and in general hospitals give morphine like drugs also to relieve from pain . Needy patients and families suffer a lot . So palliative care is an essential healthcare it is patients right . it can establish by—— 1)Increase awareness about the importance and benefits of palliative care through education as a curriculum both in medical students and nurses and health care workers and also as a subject from tenth class onwards.

2)Training programmes for healthcare providers both doctors, nurses , social workers to enhance their skills in providing palliative care.

3)Inter disciplinary collaboration mainly in PHC and CHC s to ensure holistic approach to patient care. Facilities communication and team work between doctors, nurses and psychologists. So that the routine work done by PHC and CHC will not interfere.

4) policy changes that support the integration of palliative care into existing healthcare system to be evaluated.This may involve working with policy makers to establish guidelines and allocating resources for palliative care services.

5)Educate local communities and family members to involve in palliative care and also in acceptance.

6) Infrastructure development to ensure healthcare facilities, resources, to provide palliative care trainers as personal and in giving drugs like morphine and other opioids .

7) Research and evaluation used to improve the quality of palliative care services.

8) Association with NGO s and medical institutions and international organisations for leverage in expertise, resources and best practices.

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Integrating palliative care into the mainstream of the Indian health system involves raising awareness, training healthcare professionals, and establishing dedicated facilities. Collaborative efforts between government, NGOs, and medical institutions can play a pivotal role in implementing policy changes to prioritize and normalize palliative care services. Education about the benefits of palliative care and addressing cultural beliefs can also foster acceptance and integration within the broader healthcare framework.