The Lancet Commission on Global Access to Palliative Care and Pain Relief

The Lancet Commission on Global Access to Palliative Care and Pain Relief is the result of a three year project involving 61 co-authors from 25 countries. The authors have developed an essential package of palliative care services – including medicines, equipment and staffing models – to be made available by health systems worldwide, and call for more balanced global policies to facilitate access to opioid analgesics to meet medical need, while limiting non-medical use.

The Lancet Commission aims to:

  1. Quantify the  heavy burden of serious health related suffering (SHS)
  2. Identify and cost an essential package of Palliative Care and Pain relief – medicines considered for children as well as adults
  3. Measure the unmet need for the use of opioids
  4. Outline global strategies to expand access to Palliative Care and Pain relief as an integral part of Universal Health Coverage (UHC)

In the video above Professor Julia Downing responds to the publication of the Lancet Commission on Global Access to Palliative Care and Pain Relief and its relevance to children’s palliative care. 

In the first analysis of its kind, the authors estimate the global need for palliative care and pain relief by devising a new measure of serious health-related suffering. They analyse the 20 life threatening and life-limiting health conditions (including HIV, cancers, heart disease, injuries and dementia) and 15 corresponding symptoms (including pain, fatigue, wounds, anxiety and depression) that are most frequently associated with the need for palliative care and pain relief.

In 2015, an estimated 25.5 million people died with serious health related suffering – equivalent to nearly half of all deaths worldwide. This includes 2.5 million children aged under 15 years (representing more than a third of child deaths). Almost all (98%) of these children live in low and middle-income countries.

In addition, 35.5 million people who did not die also experienced serious health-related suffering, meaning that the total number of people needing palliative care per year was over 61 million, including 5.3 million children. More than 80% of people needing palliative care live in low and middle-income countries.

The authors note that almost 80% of deaths requiring palliative care in low income countries are preventable with adequate prevention, treatment and care interventions. They highlight that palliative care cannot be a substitute for improved access to public health interventions and treatments that could have prevented much suffering and premature death in the first place. But, equally, no health system can expect to meet the needs of its people without providing access to basic pain relief and palliative care.

Commenting on the report, Jim Yong Kim, President of the World Bank, says: “Failure of health systems in poor countries is a major reason that patients need palliative care in the first place. More than 90 percent of these child deaths are from avoidable causes. We can and will change both these dire situations.”

The most common symptoms of suffering were pain, depressed mood, anxiety, fatigue and weakness. The Commissioners propose an essential package for palliative care as the minimum standard any health system should make available as a core component of Universal Health Coverage. Designed to be low-cost and covering medicines, basic equipment and human resources, one of the minimum requirements is the availability of oral or injectable morphine.

Although the Commission did not undertake a separate analysis for children, we recognise and emphasise these distinctions throughout the report.

Key points in the Lancet Commission relating to children

Key points in the full report relating to children include the following:

  • Palliative care for children is a human right – no child should be left in pain and suffering
  • The majority of children needing Palliative care live in Lower and Middle Income Countries (LMIC)
  • More than 98% of children aged 15 years or younger who die with SHS live in LMICs
  • Need for PC and pain relief in children has been largely ignored
  • Essential elements of Universal Health Coverage
  • Barriers exist and removing barriers for children in need must become a priority:
    • Access to medicines
    • Opiophobia
    • Focus on cure and extending life
    • Global neglect of NCDs
  • Caregiving for children with serious, complex, or life-limiting health problems can cause or exacerbate poverty
  • There is a need for more health systems research on PC for children and lessons learnt to be published and disseminated

Findings related to children

  1. Alleviation of burden of pain, suffering and severe distress re PC is a global health and equity is imperative
    1. Worldwide, the burden of SHS in children is primarily associated with HIV disease (40%), premature birth and birth trauma (20%), and congenital malformations (more than 10%). In low-income countries, more than 50% of the burden of paediatric SHS is associated with HIV disease.
    2. Children and their families have specific and intensive palliative care needs that can easily be overlooked because the absolute number of paediatric patients is low compared with adults.
    3. The Commission stresses that access to paediatric palliative care is imperative everywhere, including and especially in LMICs because of the concentration of cases.
    4. Integration
      1. Integration is important and expansion of PC to children has been slow – a systemic and not disease specific approach is needed
      2. There is a need for more training and capacity building in children’s palliative care
  1. An affordable essential package of PC and pain relief interventions can be made universally accessible to remedy the gap
    1. Cost to cover morphine – equivalent pain treatment for all children<15 years with Serious Health related Suffering in LICs in $1 million per year
    2. Countries should develop a palliative care and pain relief package for children, taking special account of their specific social and spiritual needs.
  2. LMICs have enormous but unrealised opportunities to improve the welfare of the poor through publically financing and integrating the essential package
  3. International collective action is necessary – must ensure effective access to essential medicines for PC including opioids
  4. Better evidence and priority setting tools to monitor progress on PC and pain relief is important

Key Recommendations for Children’s Palliative Care

The Commission recommends that:

  • Future global efforts to develop a metric of Severe Health-related Suffering especially in primary data collection include a specific focus on children and their needs for palliative care and pain relief.
  • The World Bank, Global Fund, WHO, and UNICEF take the lead in establishing a special fund for children in need of opioids for the relief of pain and palliative care.
    • This should be part of a larger effort to create a financing facility for palliative care medicines, linked to broader efforts to facilitate treatment of chronic and non-communicable diseases and spearheaded by a global financing entity such as the World Bank.
  • Countries should expand and build on the Essential Package in line with population need, cultural norms, human resources, health infrastructure capacity, and financial resources, and they should work to provide a package specific to the needs of children and other especially vulnerable groups.
  • Afterlife of the Commission: advocacy, accountability, and analysis. Set up a working group of leaders from global, national, and regional palliative care advocacy institutions. The mandate of the working group is to:
    • develop monitoring frameworks and public accountability tools, including indicators and targets that can be adapted and adopted by both countries and global governance institutions;
    • support national commissions through training and capacity building;
    • catalyse national planning for palliative care and pain relief;
    • encourage the production and dissemination of knowledge from implementation and health-systems research, especially in LMICs; and
    • forge linkages between the palliative care community and the non-communicable diseases movement.
  • Call for future Lancet Commissions to focus on vulnerable groups beginning with children and humanitarian emergencies.

Download the Lancet Commission Report: Lancet Commission report

MORE DOWNLOADS RELATED TO THE REPORT

KEY FACTS – LANCET

10 FACTS CHILDREN-LANCET PALLIATIVE CARE

HEALTH SYSTEM LESSONS – LANCET

KEY MESSAGES AND RECOMMENDATIONS

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