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9
A WHO guide for planners, implementers and managers
Access to palliative care
In 2014, the Sixty-seventh World Health Assembly resolved that “it is the ethical duty of health care 
professionals to alleviate pain and suffering, whether physical, psychosocial or spiritual, irrespective 
of whether the disease or condition can be cured … .” (Annex 4) 
(2). The same resolution states that 
“palliative care is an ethical responsibility of health systems … ” and that integration of palliative care 
into public health care systems is essential for achievement of Sustainable Development Goal 3.8: universal 
health coverage (UHC). Thus, palliative care is not an option but a medical and ethical necessity that should 
be accessible by anyone in need at all levels of health care systems.
Despite compelling evidence of a huge burden of remediable suffering and of the effectiveness of palliative 
care to relieve suffering, palliative care is poorly accessible in some HICs and is rarely accessible in 
LMICs 
(7). Data from the International Narcotics Control Board (INCB) show that 91% of the morphine 
consumed worldwide in 2013 was consumed in HICs, which have only 19% of the world’s population. 
People in LMICs, which account for 81% of the world’s population, only consumed 9% 
(8). Given that 
morphine is essential to relieve moderate and severe pain and that morphine consumption is the most 
common – although imperfect – measure of access to palliative care, the data reveal an enormous disparity 
between rich and poor in access to relief, both of pain in particular and of suffering in general 
(9,10). 
Available data indicate that 74% of countries – virtually all of them LMICs – had at best isolated palliative 
care provision as of 2013 
(11).
A variety of barriers have impeded development and accessibility of palliative care services. There have been 
misunderstandings about the definition of palliative care. Most notably, sometimes it is not understood 
(1):
n
that palliative care is not only for the dying but for any patient suffering in association with serious 
or life-threatening health problems;
n
that palliative care is not an alternative to disease prevention and treatment but should be 
integrated with them;
n
that palliative care not only relieves suffering, but also anticipates and prevents it;
n
that there is a massive burden of unnecessary suffering due to pain, other physical symptoms, and 
psychological, social and spiritual distress; and
n
that palliative care is essential to achieve UHC.
Additional barriers include:
n
lack of a national palliative care policy, a national palliative care strategic plan, and national 
palliative care clinical guidelines in many countries;
n
lack of basic, intermediate and specialist training programmes in palliative care;
n
lack of inpatient and outpatient staff positions that include palliative care as an official responsibility 
and that enable trained clinicians to be paid for practicing palliative care;
n
lack of insurance coverage of palliative home care;
n
excessive fear of opioid side effects, addiction and diversion, resulting in excessively restrictive opioid 
prescribing regulations; and
n
lack of financial incentive for importation or local production of oral and injectable morphine.

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Integrating palliative care and symptom relief into primary health care
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Throughout the world, but especially in LMICs, most people, when given the choice, wish to die at home, 
and most people in need of palliative care are at home. Therefore, it is essential that palliative care be 
accessible in the community and in patients’ homes. This requires integration of palliative care into PHC 
in keeping with the WHO Framework on integrated, people-centred health services, adopted by the 
Seventy-ninth World Health Assembly in 2016 
(6). The Framework calls for a reorientation of health care to 
prioritize primary and community care services and coordinated and continuous care – including palliative 
care – over time, for people with complex health problems. It is neither feasible nor necessary for most 
palliative care to be provided by palliative care specialist physicians. Rather, most palliative care can and 
should be provided by primary care practitioners with at least basic training in palliative care of at least 35 
hours (Annex 5). These practitioners may include general practitioners, family physicians, clinical officers, 
assistant doctors, nurse-practitioners, feldsher, nurses, social workers and trained and supervised lay 
counsellors based at community health centres (CHCs). Community health workers (CHWs) can provide 
frequent emotional support for the patient and family and report to a clinician at CHCs.

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11
A WHO guide for planners, implementers and managers

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