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Stepwise integration of palliative care into health care systems
Inclusion of palliative care in national health care policies is crucial. Without policies that mandate palliative 
care services, it is unlikely that palliative care will become widely accessible or sustainable. In general, the 
first steps towards integration of palliative care into health care systems should be:
n
a national palliative care policy that requires access for all to palliative care and to pain control with 
opioid pain medicines;
n
a national palliative care strategic plan to create this access within a certain time period; and
n
inclusion of palliative care in any national policies or strategic plans on cancer, noncommunicable 
diseases (NCDs), older persons, paediatrics, HIV/AIDS, drug-resistant tuberculosis or PHC.
Once such policies and strategic plans are in place, efforts can focus on ensuring availability of all essential 
medicines, including oral fast-acting and injectable morphine, and on training (Chapter 4 and Annex 5). 
If policies do not precede training, most trainees may be unable to practise palliative care and be paid 
for doing so. Training can be initiated at a basic level either for primary care physicians or physicians 
whose specialties entail caring frequently for patients with serious or life-threatening health problems. 
Physicians who complete basic palliative care training should be empowered to prescribe oral fast-acting 
and injectable morphine for inpatients and outpatients. As soon as possible after implementing basic 
palliative care training for physicians, other palliative care training programmes should be established:
n
intermediate-level training should be implemented for physicians whose specialties entail caring 
frequently for patients with serious or life-threatening health problems;
n
basic palliative care training for practising nurses; and
n
integration of basic training in palliative care into undergraduate medical, nursing and pharmacy 
training.
Next, or simultaneous with essential medicine procurement and training, palliative care services should 
be integrated into existing service delivery. This can begin at any level of the health care system. However, 
it may be easiest to implement palliative care where the need is most obvious to most staff members: 
in cancer centres. Initial services can be an inpatient ward, a consultation service or an outpatient clinic. 
National policies should require palliative care services at all cancer centres and, within a period of time, at 
all levels of the health care system:
n
second- and third-level hospitals (provincial, regional, specialty hospitals)
n
first-level (district) hospitals
n
CHCs
n
home care.

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A WHO guide for planners, implementers and managers
The palliative care interventions that should be available at each level are described in Table 2.