By Dr. Gayatri Palat (India)
Palliative care is a well-defined medical specialty in many parts of the world and is recognized by the World Health Organization as a vital part of health care provision. The vast majority of India's population, however, still does not have access to palliative care services. Among one million patients with cancer, the estimated cure rate is only 10% and 0.5–0.8 million patients are estimated to die of cancer every year. But still most cancer hospitals in India do not have any formal palliative care services.
The Government of India mandates Universal Health Coverage (UHC) that guarantees every citizen access to an essential National Health Package of primary, secondary and tertiary healthcare services. Health, however, is a subject determined and defined by each state. Delivering appropriate care for people with incurable progressive diseases is a largely neglected part of health system in most states.
Andhra Pradesh (AP) is one of the states in India, which has a unique community health insurance scheme, which aims to remove financial barriers and provide access to quality medical care for people who are poor. In this system, the government insures for major illnesses in all members of households who are poor. In a landmark decision, the government has made a provision for palliative care and supportive care in the comprehensive cancer care package.
MNJ Institute of Oncology, a tertiary cancer center for the state, played a key role its planning, implementing and pioneering the utilization of the public palliative care insurance scheme. Since the launch of this scheme in 2008, 6200 patients with advanced cancer have benefited from free palliative and supportive care. This scheme provides financial protection for in-patient care (including free consultation, medication including oral morphine and other opioids, and diagnostics), reimbursement of the patient's transportation costs and medicines provided by the hospital after the discharge. The package is renewed every month. A few innovative features of this program are the impressive use of information and communication technologies, electronic beneficiary registration, utilization tracking, a patient's choice of providers, and the targeting low-income groups all significant in an Indian context.
The package has provided great credibility and visibility to palliative care services among professionals and policy makers. The revenue generated by this model ensures financial viability and sustainability of the palliative care program in the hospital.
Even though there has been criticism about the viability and effectiveness of the program, the scheme in general has received widespread public and political support and has moved beyond the "Below poverty line" population to cover the “vulnerable poor,” extending its reach to nearly 85 percent of AP's population.
In light of current trends, several states are expected to introduce similar schemes over the next few years. This will hopefully increase the utilization of services, coverage, and spending on palliative care.
The current system of insurance targets only patients with cancer and is entirely focused on hospital networks. Most people with a life limiting illnesses choose to be cared for and, often, die at home. In order to prevent unnecessary hospitalization and maximize care outcomes, the scheme should be applicable to people who do not reach hospitals or cannot access hospital based care.
The public insurance scheme for palliative care is an innovative flagship scheme introduced by the Government of Andhra Pradesh, India for patients with advanced cancer. MNJ Institute of Oncology, Hyderabad has played a crucial role in planning and implementing this model program. The program is effective and sustainable and can be replicated and utilized in other parts of the country.
The current scheme encourages a hospital's centric delivery system. In view of a growing burden of chronic disease that is emerging in India, a reform is required where the district health system managers may eventually be able to purchase insurance and enhance the quality of palliative care at primary and secondary levels. This will ensure continuity of care to patients by facilitating discharge from the inpatient units while providing care in their homes.
Dr. Gayatri Palat is the Program Director, Palliative Access (PAX) Program, India. She is also member of the International Network for Cancer Treatment and Research (INCTR) and Consultant in Palliative Care at the MNJ Institute of Oncology and RCC, Hyderabad, India.
Dr. Palat is also a Member of the IAHPC Board. Her bio may be found here.