Palliative care in Latin America

Is the WHO strategy working?

Over 20 years ago the World Health Organization (WHO) established pain relief and palliative care as components of its Cancer Control Programme. However, palliative care is still not available to millions of patients worldwide, including in Latin America.

WHO advocates a three-part strategy for including palliative care in national health systems (Figure 1, below).

Figure 1: WHO strategy for implementing palliative care programmes

Education

Most palliative care providers in Latin America do not receive formal training but gain their knowledge through lectures and self-taught programmes after graduation. Few programmes offer palliative care education including classroom-based and bedside teaching. The basic principles of palliative care need to be learned at undergraduate level, palliative care curricula must be integrated into undergraduate nursing and pharmacy programmes, and into the design of curricula and programmes at graduate level.

Drug availability

Developed countries use most of the morphine consumed globally while only a small percentage is consumed in approximately 100 developing countries. Latin America and the Caribbean consume less than one percent of the total. Countries such as Uruguay, Argentina, Chile and Costa Rica with mature palliative care programmes report higher consumption than countries where programmes are only beginning or non-existent.

Barriers to the availability of medication include regulations limiting the dosage prescribed per patient, the number of doses given each day, the number of days a patient can receive opioids (pain relief drugs) and how much pharmacies can stock. These are in addition to excessive bureaucracy, inefficient distribution channels, a lack of knowledge amongst health care professionals and a shortage of pharmacists licensed to dispense the medication.

Government policy

Seven Latin American countries offer some form of palliative care through public institutions and only Argentina, Chile, Colombia, Cuba, Peru, Brazil and Paraguay have stated the need for a public health approach to the issue. If palliative care is left out of national health care policies, countries and institutions are unable to include it in their budgets, health care workers are not paid for their services, and it is not included in insurance programmes.

What about access?

The WHO approach ignores access. However, making medication and services available is not enough - patients need to be able to reach the services. What can be done to make this happen?

• Educate health care professionals in providing palliative care.
• Establish advocacy programmes to generate more demand for services at the grass-root level.
• Pressure governments to eliminate barriers in laws and regulations.
• Allocate funds to provide palliative care - ideally a mix of international and local support.
• Include palliative care in national health care policies and establish a network of support within government.

Liliana De Lima
International Association for Hospice and Palliative Care, 5535 Memorial Dr. Suite F - PMB 509, Houston TX 77007, USA
ldelima@iahpc.com

See also

Cancer Pain Relief with a Guide to Opioid Availability (2nd edition), World Health Organization: Geneva, 1996

Framework for a Regional Project on Cancer Palliative Care in Latin America and the Caribbean, Pan American Health Organization: Washington DC, 1997

'Legislation Analysis according to WHO and INCB Criteria on Opioid Availability: a Comparative Study of Five Countries and the State of Texas', Health Policy 56, pages 99-110, by Liliana De Lima et al, 2001

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