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Box 3. Uganda: community-based palliative care with 
minimal integration into PHC
Uganda was the first country in the world to enable specially trained and registered nurses to prescribe morphine 
(79) and it 
was one of only two African countries in the top 50 of the Economist Intelligence Unit’s 2015 Quality of Death Index 
(80). It 
achieved this ranking despite an underfunded and underdeveloped public health care system. Nongovernmental organizations 
(NGOs) play a major role in providing palliative care at the community level. Basic palliative services now exist in 75% of the 
countries districts. However, these services often are provided by only one trained nurse at only one site in a district, which may 
be quite large 
(81). Palliative care is not yet well integrated into the public health care system at all levels (82). Barriers to this 
integration include inadequate health infrastructure, shortage of trained palliative care staff, and insufficient and unstable 
funding 
(83).

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Integrating palliative care and symptom relief into primary health care
38
Box 4. Kerala, India: integration of palliative care into PHC 
using a public health approach 
The state of Kerala in southern India has integrated palliative care into much of its well-developed PHC system. In this state of 
33 million people, an NGO in the city of Calicut created a palliative care service for the poor in the early 1990s. The success of 
its leaders at fostering community participation throughout the state resulted in a Neighbourhood Network in Palliative Care 
(NNPC). Inspired by the concept of PHC in the Declaration of Alma-Ata, the NNPC is an attempt to empower local communities 
in LMICs to create and manage sustainable long-term and palliative care for the poor 
(67,84). Volunteers from communities 
receive training to identify problems of the chronically ill in their area and to intervene effectively with active support from a 
network of trained professionals. Based on the rapid growth and popularity of NNPC supported only by NGOs and local govern-
ments, the Government of Kerala in 2008 issued a pain and palliative care policy that included a commitment to integrate pal-
liative care into the existing PHC system 
(85). The government followed this policy with a project to inform doctors and nurses, 
from all levels of the health care system, as well as local politicians and potential community volunteers, about palliative care 
for the most vulnerable as part of community-based PHC. The goal was to stimulate the development of palliative care pro-
grammes by local governments fostering community spirit. The project also provided six months of training in palliative care for 
nurses and hired one trained nurse for each panchayat (community) in the state. As of 2017, all the 1000 PHC centres in Kerala 
had a government nurse trained in palliative care who typically leads a home care programme staffed by local volunteers. 
Some 200 of the panchayat have created local NGOs that increase the capacity of palliative home care, and some support the 
salary of a second palliative care nurse who collaborates with the government nurse. In addition, palliative care units are being 
developed in the 14 district hospitals in the public health care system to support the staff of PHC centres.
The following factors have contributed to the success of the programme:
n
advocacy by local NGOs about the imperative of caring for the chronically and terminally ill poor, resulting in:
o large-scale involvement by local people and communities; and
o political commitment by the state government;
n
state government policy on palliative care as part of PHC;
n
state funding for palliative care nurses in PHC centres;
n
decentralized system of governance in Kerala with empowered local governments; and
n
use of nurses, home care leaders.

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39
A WHO guide for planners, implementers and managers

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