Palliative care: an essential facet of universal health coverage
Authors: Felicia Knaul, Afsan Bhadelia, Rifat Atun, Liliana De Lima, Lukas Radbruch
Journal: The Lancet Global Health (2019)

Katherine Sleeman and colleagues (July, 2019)1Sleeman KE de Brito M Etkind S et al.The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions.Lancet Glob Health. 2019; 7: e883-e892Summary Full Text Full Text PDF PubMed Scopus (123) Google Scholar use the concept and methodology of the Lancet Commission on Global Access to Palliative Care and Pain Relief2Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (328) Google Scholar to project the need for palliative care to 2060, contributing to scant literature on this topic. Their findings reinforce the Commission's call-for-action by showing that the burden of serious health-related suffering (SHS) will almost double, with the fastest increase in low-income countries, and overall among older people and those with dementia. The Commission report included a research agenda that is steadily moving forward. A group of authors of the Commission report are generating updated estimates of SHS and access to pain relief medication. The initial calculations in the report were based on mortality data from the WHO Global Health Estimates for 2015 combined with limited evidence on disease-specific prevalence, while SHS 2.0 uses 2017 mortality and prevalence data from the Institute for Health Metrics and Evaluation (IHME). Further, SHS 2.0 includes an historical time series going back to 1990. These new data required a revised methodology for estimating non-decedent SHS to incorporate the country-specific, IHME over-time prevalence data. SHS 2.0 will be the first update to the 2017 Lancet Commission report. SHS 2.0 data from 1990 to 2017, matched with time series data on access to opioid medications from the International Narcotics Control Board, are being applied to develop country-specific, health system performance indicators of access to palliative care as an essential facet of universal health coverage (UHC). Although inexpensive, off-patent, injectable and immediate-release oral morphine is only one component of the essential palliative care package put forward by the Commission, it is a salient tracer of overall access that can be tracked over time. The next step is to expand the access indicator to include the rest of the essential palliative care package. The Commission's Implementation Working Group is embarking on a wider project, foreshadowed in the Commission report, that includes data collection to develop estimates of the value to patients of alleviating the symptoms of SHS, especially pain. These data will serve to produce Suffering intensity Adjusted Life Years (SALYs), a novel metric conceived by the Commission.2Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (328) Google Scholar SALYs are intended to serve as a priority-setting tool to assess the efficacy of interventions in terms of suffering averted to complement existing multi-attribute instruments such as QALYs and DALYs. SHS 2.0 and new data on patient valuation of reduced suffering will provide a stronger base from which to project future palliative care need and health system performance. We recommend that future projections consider the impact of avoidable mortality, especially in LMICs. The Commission estimates of avoidable mortality are large and highlight the importance of adopting a continuum-of-care approach to UHC. Improved health systems performance, including prevention and treatment as part of UHC, would change the short-term trajectory of SHS and hence palliative care need. While SHS will, as shown by Sleeman and colleagues, increase with demographic and epidemiological transition, the trajectory and underlying set of SHS-associated health conditions, particularly in low-income settings, may be very different under a positive UHC scenario. Such an outlook on access to prevention and treatment demonstrates why universal access to palliative care is a necessary and essential, but by no means sufficient, condition for effective UHC and acceptable health system performance. We declare no competing interests. The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditionsThe burden of serious health-related suffering will almost double by 2060, with the fastest increases occurring in low-income countries, among older people, and people with dementia. Immediate global action to integrate palliative care into health systems is an ethical and economic imperative. Full-Text PDF Open Access