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Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report

Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report Felicia Marie Knaul, Paul E Farmer, Eric L Krakauer, Liliana De Lima, Afsan Bhadelia, Xiaoxiao Jiang Kwete, Héctor Arreola-Ornelas, Octavio Gómez-Dantés, Natalia M Rodriguez, George A O Alleyne, Stephen R Connor, David J Hunter, Diederik Lohman, Lukas Radbruch, María del Rocío Sáenz Madrigal, Rifat Atun, Kathleen M Foley, Julio Frenk, Dean T Jamison, M R Rajagopal on behalf of the Lancet Commission on Palliative Care and Pain Relief Study Group The Lancet Published: October 12, 2017
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In agonising, crippling pain from lung cancer, Mr S came to the palliative care service in Calicut, Kerala, from an adjoining district a couple of hours away by bus. His body language revealed the depth of the suffering. We put Mr S on morphine, among other things. A couple of hours later, he surveyed himself with disbelief. He had neither hoped nor conceived of the possibility that this kind of relief was possible. Mr S returned the next month. Yet, common tragedy befell patient and caregivers in the form of a stock-out of morphine. Mr S told us with outward calm, “I shall come again next Wednesday. I will bring a piece of rope with me. If the tablets are still not here, I am going to hang myself from that tree”. He pointed to the window. I believed he meant what he said. Stock-outs are no longer a problem for palliative care in Kerala, but throughout most of the rest of India, and indeed our world, we find near total lack of access to morphine to alleviate pain and suffering. Dr M R Rajagopal, personal testimony The lack of global access to pain relief and palliative care throughout the life cycle constitutes a global crisis, and action to close this divide between rich and poor is a moral, health, and ethical imperative. The need for palliative care and pain relief has been largely ignored. Yet, palliative care and pain relief are essential elements of universal health coverage (UHC). This Lancet Commission aims to (1) quantify the heavy burden of serious health-related suffering associated with a need for palliative care and pain relief; (2) identify and cost an essential package of palliative care and pain relief health services that would alleviate this burden; (3) measure the unmet need of an indispensable component of the package—off patent, oral, and injectable morphine; and (4) outline national and global health-systems strategies to expand access to palliative care and pain relief as an integral component of UHC while minimising the risk of diversion and non-medical use.
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Global access to palliative care and pain relief: five key messages

The findings and evidence presented by the Commission demonstrate that:

1 - Alleviation of the burden of pain, suffering, and severe distress associated with life-threatening or life-limiting health conditions and with end of life is a global health and equity imperative. Most high-income countries have responded with effective interventions, yet the needs of poor people have been neglected, and people living in low-income and middle-income countries (LMICs) have little or no access to pain relief or palliative care.

2 - An affordable, Essential Package of palliative care and pain relief interventions can ameliorate a large part of the preventable burden of serious health-related suffering (SHS), and this package can be made universally accessible to remedy the abyss in access to care.

3 - LMICs have enormous but unrealised opportunities to improve the welfare of poor people at modest cost. Publicly financing and fully integrating the Essential Package into national health systems as part of universal health coverage, using cost-effective models that can be applied in all countries, offers a solution.

4 - International collective action is necessary to ensure that all people, including poor people, have access to palliative care and pain relief for life-threatening and life limiting health conditions and end-of-life care. A well functioning and balanced global system must both prevent non-medical use and misuse of medicines and ensure effective access to essential medicines for palliative care, including opioids for pain relief.

5 - Effective policy making requires better evidence and priority-setting tools to adequately measure the global need for palliative care, implement policies and programmes, and monitor progress toward alleviating the burden of pain and other types of SHS.

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