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Table 2. Palliative care interventions, delivery platforms and providers
Intervention
Delivery platform
Mobile outreach/home 
care
CHCs
First-level (district) 
hospitals
Second- and third-level 
(provincial, regional, 
specialty) hospitals
Ongoing care for 
patients with well-
controlled symptoms 
related to serious, com-
plex or life-limiting 
health problems
n
CHWs provide 
surveillance and 
emotional support 
as often as daily
n
Visits as needed 
by a nurse, doctor, 
social worker 
or trained lay 
counsellor from 
the CHC with 
basic training in 
palliative care
n
Nurse and 
possibly also a 
doctor, social 
worker or lay 
counsellor with 
basic training 
in palliative 
care provide 
outpatient care 
and possibly 
home visits as 
needed
n
Inpatient hospice 
care in some cases 
if the family is 
unable to provide 
adequate care at 
home
n
Small palliative 
care team 
consisting of one 
or two part-time 
doctors with basic 
or intermediate 
training in 
palliative care
n
Inpatient hospice 
care if the family is 
unable to provide 
adequate care at 
home and if no 
inpatient care is 
available at CHCs
n
Outpatient 
palliative care 
clinic
Initial control of 
moderate or severe 
symptoms related to 
serious, complex or 
life-limiting health 
problems / Control of 
refractory suffering
n
Small palliative 
care team 
consisting of one 
or two part-time 
doctors with basic 
or intermediate 
training in 
palliative care
n
Inpatient 
palliative care
n
Outpatient 
palliative care 
clinic
n
Palliative care 
team consisting 
of full- or part-
time doctors with 
intermediate 
training in 
palliative care
n
Ideally, a 
palliative 
care specialist 
physician should 
lead the team 
at major cancer 
centres and 
general hospitals
n
Inpatient 
palliative care 
ward
n
Outpatient 
palliative care 
clinic
Source: Adapted from Krakauer et al. 2018 (7).

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Integrating palliative care and symptom relief into primary health care
32
PHC practitioners who staff CHCs and district hospitals should have basic palliative care training that 
enables them to provide basic palliative care as part of their standard responsibilities. If possible, at least 
the leader of the palliative care team at district hospitals should have intermediate-level training. This 
would enable the team leader to serve as a resource for clinicians at CHCs in need of consultation about 
palliative care problems.
Palliative care tasks in PHC
PHC, as per the Declaration of Alma-Ata, should be responsive to local needs, accessible, comprehensive, 
coordinated and continuous 
(58). To integrate palliative care into PHC, palliative care services should: 
n
be designed based on local needs and values;
n
be accessible where the patients are and want to be, including in their homes;
n
provide comprehensive prevention and relief of suffering of any kind: physical, psychological, social or 
spiritual;
n
be coordinated with other tasks of PHC such as health promotion, disease prevention, disease-
modifying or rehabilitative treatment; and
n
be provided by clinicians who know the patient and family and who accompany the patient throughout 
the course of illness.
Palliative care needs are not the same in all places 
(25); however, any given patient may experience any 
type of suffering 
(59,60). In post-conflict settings, the need for mental health care may be especially 
great. Ideally, palliative care should be part of a system of seamlessly integrated illness prevention, early 
detection, treatment and rehabilitation. Ideally, PHC provides all of these services for people whose needs 
are uncomplicated and provides prompt referrals with secure transfer of health information and reasonable 
transport for patients with more complex problems.
Primary care clinicians play a crucial role in recognizing palliative care needs, including uncontrolled 
physical or psychological symptoms, social distress, and in identifying people approaching the end of life 
(61). In many low-income settings, patients may not complain of problems such as pain, anxiety or lack of 
food because they think nothing can be done about them. Early identification of palliative care needs by 
primary care providers has been found to depend on 
(62):
n
clinicians’ knowledge, skills and communication styles;
n
patients’ communication styles;
n
quality of the clinician–patient relationship;
n
patient’s perceptions of the clinician’s role;
n
level of collaboration between the primary care clinician and other clinicians; and
n
patient’s fears and beliefs about the prognosis.
Skill in identifying palliative care need is crucial for primary care providers, and tools for this purpose are 
available. Once the need is identified, appropriate assessment and intervention can follow 
(61).
In integrating palliative care into PHC there is a risk of overwhelming already overburdened primary care 
clinicians with yet another responsibility and set of tasks 
(63). To avoid this, adequate funding is required 

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33
A WHO guide for planners, implementers and managers
to employ an adequate number of primary care staff and thereby to strengthen the PHC system. In light of 
the evidence that palliative care services that include home care can reduce costs for health care systems, 
there are medical, ethical and financial arguments for integrating palliative care into primary care 
(1,7).
Another risk is that sending patients home to receive palliative care can overburden family caregivers. 
Caring for disabled or seriously ill patients often is extremely demanding physically, mentally and 
financially 
(32,64). Training family members in basic nursing skills may help to reduce their stress, but 
the home situation should be carefully assessed to make sure that the well-being of family caregivers is 
not jeopardized by the patient’s presence at home. An alternative would be for terminally patients whose 
symptoms are well controlled but whose families cannot care for them at home to be allowed to receive 
end-of-life care at a CHC that is staffed around the clock. This would enable family to visit without having 
the burden of providing 24-hour care and would be less expensive than having the patient in a hospital.