Showing the way forward: Pain and Palliative Care Policy of the Government of Kerala
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.41936
Source of Support: None, Conflict of Interest: None
It is not unusual for governments to bring out policies. But the Pain and Palliative Care Policy declared by the government of Kerala is unique in the following respects.
It stresses the need for governments to work together with community based organisations and other palliative care providers towards improving the quality of and access to palliative care. The "Panchayathi Raj" envisages decentralisation of governance and in Kerala most of the responsibilities with health services has already been transferred to the Local Self Governments Institutions (LSGI). This gives the local governments the power to make decisions regarding health that are locally relevant and implement them. This commitment from the government is very impressive as it comes at a time when governments in general are fast withdrawing from service sectors.
It took almost two years for the government to make this policy and process it through the various stages of approval before unveiling it on 15th April 2008. The government had consulted the key stake holders of palliative care in the state and held a series of consultations before policy was finalised. The palliative care service providers in the state were involved in a democratic way in the process that led to policy formulation.
The policy endorses the WHO observation that suffering amongst patients can not be eased "unless palliative care has priority status with in public health and disease control programmes" (National Cancer Control Programmes, Policies and Managerial Guidelines. WHO, Geneva 2002) It further declares that "this policy is aimed at ensuring palliative care services are established and integrated into routine health care in the state".
The aim of the policy is ''to provide palliative care to as many of the needy in Kerala as possible". The objectives are short term and long term.
The short term goals (described else where in this article) and a detailed action plan to achieve those goals are the back bone of the policy. The emphasis is on training professionals and non professionals including volunteers, setting up palliative care services both in the public sector and in the community, integrating palliative care in to the activities of LSGIs and making essential drugs including morphine available, amongst a few others.
The long term objectives proposed strategies to consolidate the achievements of short term objectives and develop a system for monitoring the palliative care service in the state to facilitate quality assurance, develop a system to document and compile data on palliative care related activities, develop post graduate courses in palliative care in Medical and Nursing Colleges in the state and most importantly to establish palliative care as part of basic health care available at the community level.
In the section on development of services, home-based care is identified as the "cornerstone" of palliative care in the state. It raises the importance of making both the patient and the family focal points of palliative care programmes. The policy highlights the important work done by Community Based Organisations (CBO) and Non Government Organisations (NGO). It suggests that the experience of these bodies in training and delivery of palliative care in the state be utilised while further developing palliative care services.
To prepare the government sector for achieving the goals of the policy it suggests that there be adequate facilities in government hospitals for providing palliative care services at the institutional level and field level. The government is expected to work closely with the CBOs and NGOs under the overall coordination of the LSGIs. It further describes the activities to be planned at various levels of the government health services. They are making use of Male and Female Multi purpose health workers in delivering primary palliative care, empowering Primary Health Centres and Community Health Centres to provide the necessary institutional level palliative care, developing full fledged palliative care services at Taluk Head Quarter hospitals and tertiary level palliative care services and training centres at District Hospitals & Medical Colleges.
The policy puts forward minimum criteria for involving Community Based Organisations (CBOs) in palliative care. It states that they should be local organisations having a clearly stated interest in the care of patients needing palliative care in their area. The CBO should take a leading role in providing home care services to the bedridden patients with out charging patients or families for their services and the persons involved in the care of patients needing palliative care - volunteers, nurses, doctors and other health care workers - should have basic training in palliative care.
The responsibilities of CBOs will be identifying patients, assessing the needs of each patient and providing appropriate care, providing home care service, empowering the patients and their families, providing social support and rehabilitation, conducting awareness and basic training programmes. They are expected to work together with Local Self Governments and Government / Non Government Health Institutions in the area towards improving the care received by the patients.
The policy highlights the role of Local Self Government Institutions (LSGI) in identifying and supporting CBOs and the need for working with CBOs, Governmental and Non Governmental Health Institutions for organising support for the patients and families. The LSGI should take steps to provide medicines and other accessories to disadvantaged patients with chronic diseases identified by the CBOs, with the help of existing Government health care systems.
The policy observes that the "Issues associated with patients needing palliative care are as much social as emotional or physical. The society can pool its resources through CBOs to address many of these issues. As shown by experience in some Northern districts of Kerala, there is tremendous improvement in palliative coverage where CBOs are active. So participation of CBOs in palliative care should be encouraged."
Kerala has a strong network of private hospitals and many provide palliative services to needy patients gratis. The policy suggests that the palliative care initiatives by private hospitals should also conform to the quality control and training criteria set by the palliative care policy.
To implement a policy such as this requires a clear understanding of the man power and training required. The policy has a section on capacity building at various levels for this purpose. The government expresses its commitment to train its staff - doctors, nurses and other health staff- in palliative care. The government will incorporate palliative care content within existing educational programs, depute staff for training programmes and develop training programmes for other categories of staff including pharmacists, public health nurses, health inspectors etc.
The policy hopes to use the experience the NGOs and CBOs have in training to formulate and initiate palliative care training programmes in government sector and there is a suggestion to validate the training programmes run by various CBOs/NGOs. The extent of support the patient and family will get depends on the volunteers and the policy encourages government institutions, CBOs and NGOs to recruit and train volunteers at the local level in larger numbers.
A rational drug policy is a must for effective palliative care. Many persons with incurable and other chronic illnesses will not be able to afford medicines for prolonged periods. The efforts by CBOs and NGOs to provide medicines are only marginal when compared to the need. The policy suggests medicines to be included in the essential drug list of the government hospitals. Step I medicines of the WHO Analgesic Ladder must be made available in all the hospitals including primary care centres and step III medicines in secondary care centres and above. With decentralisation of governance, health institutions come under LSGIs and they should have provisions to purchase and distribute medicines and other equipments based on the need in their area.
The policy clearly states the need for clear and adequate guidelines for procuring, storing and dispensing medicines needing special licenses like morphine. The doctors-in-charge of Recognised Medical Institutions (RMI) for storage and dispensing of oral Morphine should have an degree MBBS with successful completion of internship and an Indian Medical Council Registration and a minimum of ten days 'hands on' training in palliative care with three days of interactive theory sessions. The policy also puts forward the criteria for the Recognised Training Centres which can give such training. The training centre should have out patient services, home care services, an inpatient unit or access to inpatient care facilities, a minimum of 100 patient contacts every week and a minimum of 20 % of the working time of the doctors and nurses identified as trainers should be kept protected for the training activities. The Government will notify the training programmes conducted by the Recognised Training Centres.
The policy favours locally relevant audit and research at various levels for improving the programmes and sharing useful experience.
A major aspect of the policy is the proposal to have a separate budget allocation for palliative care services under Directorate of Health Service, Directorate of Medical Education, Local Self Government Institutions, National Health Programmes and Employees State Insurance Scheme. Government doctors and nurses can be deputed to palliative care services to support clinical work and training programmes. The policy identifies palliative care as a component of many existing health programmes like National Cancer Control Programmes, National AIDS control Programme, National Non-communicable Disease Control Programme, National Rural Health Mission etc.
Even though the financial needs of the palliative care services will continue to depend heavily on community support, this budget allocation will supplement the existing support provided by the CBOs / NGOs.
A policy with out an action plan to achieve its stated goals will remain only in print. The policy hopes to achieve its goals in the next two years. The policy also puts an evaluation and monitoring system in place to evaluate the progress of the programme.
Following are the highlights of the short term objectives and the action plans were made with these objectives in mind.
Having a policy is great. But it does not achieve any thing on its own. It just creates a favourable atmosphere for activities. It will be up to the stake holders of palliative care in Kerala to get the best out of this land mark policy.
The copy of "Pain and Palliative Care Policy" of the Government of Kerala can be downloaded from http://www.kerala.gov.in/annualprofile/ the official website of the government. It is also available at http://www.palliativecare.in/, the web site of the Indian Association of Palliative Care and at http://www.arogyakeralam.gov.in/ the website of National Rural Health Mission, Kerala