Call to Improve Quality of Death -- Critical for Governments to Make Palliative Care Part of Comprehensive Healthcare

Responding to findings of the 2015 Quality of Death index, global & regional palliative care organisations call for governments to act on the resolution of the World Health Assembly (WHA) on palliative care [1], ahead of World Hospice and Palliative Care Day on 10 October 2015

Study showed some low-income countries with innovation and initiative bucked the trend and did better than developed countries

SINGAPORE, Oct. 6, 2015 (Antara/PRNewswire) -- The Lien Foundation calls on governments and policy makers to hasten and improve their provision of palliative care, regional and country palliative care organisations from around the world highlighted the urgency for action as key findings of the 2015 Quality of Death (QOD) Index by the Economist Intelligence Unit revealed:

  • National palliative care policies and strategies are vital for extending access to palliative care. Many top-ranked countries have comprehensive frameworks that integrate palliative care into the healthcare systems. For example, Chile (27th) integrates palliative care into its healthcare services and has policies for opioid access. [2]
  • Palliative care needs investment but offers savings in healthcare costs. Recent research has shown how early introduction of palliative care can reduce healthcare costs. This is well-recognised by several top-ranked countries.
  • Even though income levels are a strong indicator of the availability and quality of palliative care, less wealthy countries can still improve standards of palliative care quickly. Mongolia (28th), Panama (31st) & Uganda (35th) advanced in palliative care through innovation and individual-led initiatives.
  • Demand for palliative care will grow rapidly in some countries that are ill-equipped to meet it. Countries like Hungary (41st), Greece (56th) & China (71st) have limited supply but rapidly increasing demand for palliative care. They will need active investment to meet public needs.
  • Community engagement is crucial for raising awareness and encouraging conversations about death. Taiwan (6th) successfully used mainstream and social media to increase awareness of palliative care.

Noting the above findings, palliative advocates worldwide called for policy makers to take active steps to act on the WHA resolution on palliative care passed at the 2014 World Health Assembly. The resolution recognises palliative care as fundamental to the improvement of quality of life, wellbeing, comfort and human dignity. The resolution urges Member States to:

  • Include palliative care in all national health policies and budgets 
  • Integrate palliative care into healthcare systems
  • Ensure palliative care is embedded in the basic and continuing education and training for all health workers
  • Make available adequate supply of all essential palliative care medicines, including strong pain medicines, to all patients

All member states are to report their progress on the implementation of the resolution before the Director-General's update to the upcoming World Health Assembly in 2016. [3]

Commissioned by the Lien Foundation, a Singaporean philanthropic house, the 2015 QOD Index is an expanded and improved ranking of palliative care in 80 countries, stemming from its first release in 2010 [4]. The recent study consulted more than 120 experts worldwide. "Palliative care has to be a fundamental pillar of a humane healthcare system, guided by the duty to relieve suffering," said Mr. Lee Poh Wah, Lien Foundation's Chief Executive Officer, "It is incumbent upon each of us to dig deeper and remove the barriers buried in our healthcare systems, institutions, and cultural practices; as well as demand greater accountability from our governments to improve care for the dying."

While the latest QOD rankings show positive effects of policy interventions and public engagement in some countries, more remains to be done for palliative care implementation globally. Estimates show fewer than 10% of those who require palliative care actually receive it [5]. In addition, the proportion of ageing people and prevalence of cancer is rising in many countries. The Index also highlighted that even top-ranked nations "struggle to provide adequate palliative care services for every citizen" [6].

Fundamental to integrate palliative care into healthcare systems

"The biggest problem is that our healthcare systems are designed to provide acute care, when what we need is chronic care ... That's still the case almost everywhere in the world," said Dr. Stephen Connor, Senior Fellow, Worldwide Hospice Palliative Care Alliance. The situation can start to change if countries implement national policies to integrate palliative care into health systems. The U.S (9th), for example, has a high level of spending on palliative care through the government-funded reimbursement for hospice care, Medicare [7].  It also has a Care Planning Act to guide end-of-life decisions. Other less well-off countries like Mongolia and South Africa have benefited from integrating palliative care. Mongolia is ranked a commendable 28th and has succeeded in incorporating palliative care as part of its health and social welfare legislation, and national cancer control programme. South Africa (34th) has a highly integrated model of palliative care due to its hospice movement.

Spread palliative care knowledge and training in health workers

Health workers have to be given better knowledge and training in palliative care in order for it to be part of comprehensive care in the course of life. "It might take a long time to make the change," said Dr. Sheila Payne, President of the European Association for Palliative Care (2011-2015). "But if everyone has palliative care in their basic education, then no one will come out not understanding pain management, how to communicate with patients and families or that psychological, social and spiritual care is part of palliative care, not an optional extra."

In the Asia Pacific, demand for palliative care will grow rapidly in countries like China (71st), India (67th) and the Philippines (78th). Commented Dr. Cynthia Goh, Chair, Asia Pacific Hospice Palliative Care Network, "Asia holds just over half of the world's population, including the two huge nations, China and India. The gap between the provision and need for palliative care in these countries is already vast. In addition, China's population is ageing and both countries face big challenges in the increase of non-communicable diseases, such as cancer, heart disease and diabetes."

Need to ensure adequate supply of pain medicines 

However, there can be little improvement in the quality of palliative care without access to sufficient opioid analgesics. Mr. Emmanuel Luyirika, Executive Director of the African Palliative Care Association said, "Pain being a major source of suffering for many palliative care patients, its management is key in quality palliative care. The lack of availability and access to strong pain medications, especially opioid analgesics, remains a major barrier to this care. Every effort must be made to ensure access for all."

The EIU reported only 33 of the 80 countries surveyed have freely accessible and available opioid painkillers. Obstacles to getting pain medicine include red tape, legal restrictions, lack of training and awareness, as well as social stigma. More than 90% of the global consumption of opioid analgesics occurs in a handful of developed countries, while 80% of countries have low or very restricted access to such medications. [8]

It pays to invest in palliative care

Urging governments to open up budgets and release greater resources for palliative care, Dr. James Tulsky, Chair of the Department of Psychosocial Oncology and Palliative Care at the Dana-Farber Cancer Institute and Chief of the Division of Palliative Care at Brigham and Women's Hospital, U.S., said, "Palliative care represents one of those rare opportunities that we can do well by doing good. The evidence shows that we can improve quality and even quantity of life, while reducing costs." Although palliative care takes considerable investment, it will reap savings in healthcare costs [9].  For example, a recent study found that if palliative care were introduced to advanced cancer patients within 2 days of diagnosis, it could lead to a cost savings of up to 24%. The QOD study pointed out that "shifting from strictly curative health interventions to more holistic management of pain and symptoms can reduce the burden on healthcare systems and limit use of costly but futile treatments."

Concludes Dr. Connor, "The 2014 World Health Assembly Resolution on Strengthening Palliative Care is the most important development for global palliative care that has occurred, probably since the inception of our movement. It is a critical opportunity for countries and the W.H.O to spur progress in building palliative care, especially in low and middle income countries where the unmet needs are greatest."

The 2015 Quality of Death Index by the Economist Intelligence Unit, covered 80 countries using 20 quantitative and qualitative indicators across 5 categories: palliative and healthcare environment; human resources; affordability of care; quality of care; and level of community engagement.

About the Lien Foundation ( )

The Lien Foundation is a Singapore philanthropic house noted for its model of radical philanthropy. It invests in innovative solutions, convenes strategic partnerships and catalyses action on social and environmental challenges. The Foundation seeks to foster exemplary early childhood education, excellence in eldercare and effective environmental sustainability in water and sanitation. In the sphere of eldercare, the Foundation focuses on end-of-life care through initiatives such as the commissioning of the first-ever global Quality of Death index in 2010, and the Design for Death competition on deathcare innovations. It also enhances palliative care leadership and capacity in developing countries through the Lien Collaborative For Palliative Care in partnership with the Asia Pacific Hospice and Palliative Care Network.

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The World Health Assembly, a decision-making body of the WHO comprised of representatives of its member states, passed the Resolution.


Brenda Cameron and Anna Santos Salas, "Understanding the Provision of Palliative Care in the Context of Primary Health Care: Qualitative research findings from a pilot study in a community setting in Chile", Journal of Palliative Care, vol. 25 no. 4, 275-283, 2009. Available at



The inaugural Quality of Death Index sparked policy debates over the provision of palliative care across the world. The 2015 Index has an expanded range of 20 indicators in 5 categories:  palliative and healthcare environment; human resources; the affordability of care; the quality of care; and level of community engagement.


Global Atlas of Palliative Care at the End of Life, Worldwide Hospice Palliative Care Alliance and World Health Organization, January 2014. Available at


2015 Quality of Death index, The Economist Intelligence Unit


Medicare is the US federal programme providing health insurance coverage to all individuals over the age of 65.


Global Atlas of Palliative Care at the End of Life, Worldwide Hospice Palliative Care Alliance and World Health Organization, January 2014. Available at


Peter May et al, Prospective Cohort Study of Hospital Palliative Care Teams for Inpatients With Advanced Cancer: Earlier Consultation Is Associated With Larger Cost-Saving Effect, Journal of Clinical Oncology, June 2015.