How to design and implement palliative care public health programmes: foundation measures. An operational paper by the WHO Collaborating Centre for Public Health Palliative Care Programmes at the Catalan Institute of Oncology.

This paper summarises the recommendations of the WHO Collaborating Centre for Palliative Care Public Health Programmes with respect to design and implementation of palliative care national or regional public health palliative care programmes in their initial phases. We describe the elements of a programme (leadership and aims; needs and context assessment; definition of the target patients; general measures in conventional services; specialist services in different settings; sectorised networks; education and training; availability and accessibility of opioids and essential drugs; legislation; standards; budget; valuation and improvement of quality; and evaluation of results and indicators) and the specific recommendations to implement the first steps of each component. Palliative care planning needs to be systematic, inserted in all levels of the healthcare system and adapted to the cultural and organisational status of the system. Coverage for all types of patients in need, together with equity and quality, are the main aims of programmes.

Integrating palliative care into national policies.

Good policies lay the groundwork for an effective health care system and society. They facilitate the implementation of palliative care programs aimed at providing care for all people in need of these services, and they ensure equitable access to affordable medications and therapies. The lack of good policies can lead to unnecessary suffering and costs for patients, families, and society. Three-quarters of cancer patients worldwide are incurable when diagnosed. Because the size of the problem--and the suffering associated with cancer--is enormous, development of a national cancer control policy is an effective point of entry to begin integrating palliative care into a country's health care system. To be comprehensive, every cancer center must include palliative care. Ideally, palliative care is incorporated as a priority within all aspects of each country's national health plan, so that all patients living with or dying from any chronic disease may have their suffering relieved, including children and the elderly. To this end, policies that address essential medicines must include a list of palliative care medications. Supplies of affordable, generic medications that are "equally efficient" must be adequate and available throughout the country wherever patients live (especially opioids for pain control).

Catalonia WHO palliative care demonstration project at 15 Years (2005).

Since 1990, a wide range of palliative care services has been implemented throughout the Catalan Health Care System. In 2005, 21,400 patients received palliative care; 59% had cancer (79.4% of all cancer patients) and 41% had other noncancer diagnoses (25.0%-56.5% of all noncancer patients). Today, more than 95% of Catalonia is covered by palliative care services. Fourteen districts have comprehensive palliative care networks. A total of 140 full-time physicians work in 183 specialty programs, including 63 palliative care units (with a total of 552 beds), 34 hospital consult teams, 70 home care teams, 16 outpatient clinics, and specialized pediatric and HIV/AIDS consult teams. Opioid consumption increased from 3.5mg per capita in 1989 to 21 mg per capita population in 2004. The cost of the specialist palliative care network is more than 40 million Euros annually. However, the cost efficiency is striking. Due to the radical change in the use of acute and emergency beds, the project saves the Catalan Health Care System an estimated 48 million Euros annually, a net savings of 8 million Euros annually. Additional preliminary data suggest that symptom control and patient/family satisfaction are both improved by these services.

Palliative care: the public health strategy.

There is the knowledge to improve the Quality of Life, Dying and Death of cancer sufferers, other patients dying of chronic diseases, HIV/AIDS and the children and elderly terminally ill and their caring family members, an estimated 100 million people globally, if palliative care and pain relief would be available. Tragically however, palliative care is only reaching a lucky few. Two third of those in need of palliative care are in the low or middle income countries. The World Health Organization (WHO) has pioneered a public health strategy to integrate palliative care into existing healthcare systems as this offers the best approach for translating new knowledge and skills into evidence-based, cost-effective interventions that can reach everyone in the population, when incorporated by governments into all levels of their healthcare systems and owned by the community. The WHO Strategy starts by establishing four foundation measures, key components that are: 1) appropriate policies, 2) adequate drug availability, 3) education of the public, policymakers and the public and 4) implementation. The WHO Model has shown that it provides an effective strategy for countries to establish palliative care. The Open Society Institute has actively supported countries to establish National Palliative Care Programs according to these principles. Combined with a community strategy that involves the society through collective and social action"Palliative Care for All" indeed could become a reality.