6 October 2015

Public Health in the post-2015 Development Agenda Series: Addressing Inequalities of End-of-Life Care Through a Public Health and Integrated Approach: from MDG 6 to SDG 3, by Liz Grant, University of Edinburgh

This is the second article of the UNAI series “Public Health in the post-2015 development agenda”. Schools and departments of public health at UNAI member institutions were asked to submit articles highlighting research and work relating to the proposed SDGs and to showcase the importance of public health in the post-2015 development agenda. Please note that the articles are for discussion, and do not necessarily reflect the views of the United Nations.




Sustainable Development Goal 3: Ensure Healthy lives and promote well-being for all at all ages, draws together a vast range of aspirations marrying public health, primary healthcare, and patient centred and integrated healthcare into a package that requires a multi-sectorial investment. Building on MDG 6, which focused on reducing the impact of specific diseases, particularly HIV/AIDS, Malaria and TB, this goal shifts momentum asserting that everyone everywhere, regardless of age, condition or geography has a right to a healthy life from birth to death.  In promoting and protecting health and well-being, in preventing ill health and prolonging life, public health has championed the importance of dying well as an indicator of good health.

Palliative care is recognised under the human right to health as it addresses suffering beyond physical symptoms. Palliative care uses a holistic approach to improve the quality of life of patients and their caregivers by preventing and relieving suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual. Palliative care includes a variety of integrated health services specific to the needs and preferences of individuals such as, providing opioid analgesics for treating pain and bereavement counselling. According to the World Health Organization (WHO), every year 40 million people are in need of palliative care yet a significant number receive no palliative care services at all. To address the unmet need for palliative care national health policies and systems must include palliative care, health professionals must be trained to provide palliative care and everyone must have access to essential medicines, such as opioid analgesics. 

Funded through the UKaid’s Department of International Development and the Tropical Health Education Trust, the Primary Palliative Care Group and the Global Health Academy of the University of Edinburgh delivered a 3 year programme of work from April 2012- March 2015 which sought to strengthen and integrate palliative care into the health systems of four African countries through a public health primary care approach. Working with technical partners based in Uganda - the African Palliative Care Association (APCA) and the University of Makerere Palliative Care Unit (MPCU), the National Palliative Care Associations (PCAs) and through the Ministries of Health (MOH) in Kenya, Rwanda, Zambia and Uganda a programme was developed to build replicable models of integrated palliative care provision that would enable countries to rapidly scale up accessible palliative care services.  

Twelve hospitals, three in each country, each serving different populations and delivering at different service levels (university teaching hospitals, provincial hospitals, and district hospitals) became the hubs of the programme. These 12 hospitals charted their vision of what an integrated palliative care pathway could look like, and through a 4 pillar multi-layered approach actioned their vision. These pillars were:

  • Advocacy – Achieving recognition of palliative care in national, district and hospital health plans.
  • Service Delivery – building palliative care approaches and services including appropriate use of pain relief, which were integrated into wards, into staff roles, into service systems
  • Staff Capacity – Training sufficient generalists and specialist staff to provide palliative care within each hospital network to establish a critical mass
  • Partnership – Strengthening the linkages between hospitals, and building active international mentorship programmes with 12 mentor hubs in UK and in the hospitals

The trained staff put into place early identification systems in hospitals and communities for recognising those patients who would benefit from palliative care. They developed and documented referral pathways for patients, made country-specific Care Protocols developed for the programme by Makerere Palliative Care unit, built planning templates for health service management to record and keep patient documentation to draw together all palliative care work.  Morphine, not available in half the hospitals at the commencement of the programme, was soon available in all after staff began prescribing morphine confidently and pharmacies began ordering adequate stocks. A telling and repeated comment from all hospitals were those made by ward leads saying their wards, though full, were quieter, as people were no longer screaming in pain. 

The programme was built on shared ownership, recognition that all development is about strengthening what is already available.  The programme united multiple community responses to palliative care, and built on community capital through a public engagement approach with local champions and opinion makers.  Through this public health approach to this most personal of care, care at the end of life, shifts have been achieved that will begin to ensure that all people, at all ages, can not only live well, but live well till death. 

Shifting from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs) requires a paradigm shift in ownership and responsibility for change. Both sets of goals focus on shifting the parameters of development, but whereas the MDGs established a silo driven field of development with specific disease and issue related health goals – reduction in maternal and child death, HIV/AIDS, Malaria and TB, the SDGs are built on a relational paradigm of change. Public health therefore has an increasingly important role to play in framing connections and in establishing the evidence base on a population wide scale of how individual and corporate interactions can create improvements. 

Dr. Liz Grant is Assistant Principal Global Health, and Director of the Global Health Academy at the University of Edinburgh where she oversees the university’s wide portfolio of global health related programmes of teaching, research and partnership development. Dr Grant’s research portfolio covers palliative care, cancer in primary care, mobile health, and faith and health intersections. She co-directs the online distance learning Masters in Family Medicine, the MSc Global Health Non Communicable Diseases focused on NCDs in low and middle income countries and the Certificate in Global Health Challenges and teaches courses on global palliative care. This public health discussion series was created and curated by UN Academic Impact Intern Zinnia Batliwalla.