The topic of this year’s World Hospice and Palliative Care Day on October 9 was “Leave no one behind: Equity in access to palliative care”. The provision of palliative care in most countries lags far behind the need.

Each year, more than 56.8 million people, including 25.7 million in the last year of life, need palliative care, of whom 78% live in low- and middle-income countries. It is estimated that only about 12% receive it.

WHO predicts that global demand will grow as populations age and the burden of noncommunicable diseases rises. By 2060, the need for palliative care is expected to nearly double.

Palliative care is one of the most inequitable areas of healthcare. There is strong evidence that the poor and marginalised are less able to access it. Of 25,000 palliative care services globally, only 30% are in lower and middle-income countries.

People are less likely to access pain treatment if they live in low- and middle-income countries. Morphine-equivalent opioids are an important aspect of pain treatment. Of the 298.5 metric tonnes distributed globally per year, only 0.1 metric tonne is distributed to low-income countries. This is despite the fact that the greatest need for palliative care and pain treatment is in low- and middle-income countries.

Palliative care is often not financed as part of the health system. Health care workers and community carers are not trained in palliative care and pain treatment is often not part of health training curricula.

The WHO has identified about seven areas of concern for palliative care:

The elderly: Older people are more likely to have untreated pain, less access to palliative care and more information needs than younger people. The specific palliative care needs of older people include issues such as management of frailty, disability and multi-morbidity, and dementia.

Children and teenagers: 21 million children globally need palliative care, including 8 million with specialised needs. Nearly all live in low- and middle-income countries, but palliative care servers are rarely available. Even in high income countries, there are significant barriers to access. The result is unnecessary pain and suffering for children and their families and carers.

Women: 57 million people have palliative care needs annually. A conservative estimate suggests that there are also 114 million family carers, mostly women. Women also do 50% more care than men. Nurses and social workers in palliative care are more likely to be women.

Poverty: deprivation impacts on many end-of-life symptoms. Pain, breathlessness, psychological and spiritual wellbeing are negatively impacted when people live in deprivation. Family carers living in poverty are more likely to experience moderate to severe depression.

The disabled: People with intellectual and physical disabilities are less likely to access palliative care than those without disabilities.

LGBTQI+: Barriers for LGBTQ + people include discrimination, criminalisation, persecution, fear, distress, social isolation, disenfranchised grief, bereavement, tacit acknowledgment, homophobia and mistrust of healthcare providers.

The incarcerated: Prison populations in many counties are rapidly ageing; by 2030, older prisoners are expected to account for one-third of the incarcerated population in the US. Incarceration shortens life expectancy and hastens physiological ageing, compounding existing health issues and heightening the risk that prisoners will develop palliative care needs. For many prisoners with serious illness, palliative care is not available.

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Michael Cook

Michael Cook edits BioEdge, a bioethics newsletter, and MercatorNet, an on-line magazine whose focus is human dignity. He writes from Sydney, Australia.

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