Barriers to the delivery of palliative care

At present, palliative care reaches only a small fraction of those who could benefit from it. Why this should be so is a complex and multi-factorial matter.

According to projections carried out by the World Health Organization (WHO) and published in early 2006⁽¹⁾, the world will experience a substantial shift in the distribution of deaths from younger age groups to older age groups, and from communicable diseases to non-communicable diseases during the next 25 years. Large declines in mortality are projected to occur between 2002 and 2030 for all of the principal communicable, maternal, perinatal, and nutritional causes, with the exception of HIV/AIDS. Global deaths from HIV/AIDS are projected to rise from 2.8 million in 2002 to 6.5 million in 2030 under a somewhat optimistic baseline scenario that assumes antiretroviral drug coverage reaches 80 per cent by 2012. Although age-specific death rates for most non-communicable diseases are projected to decline, the ageing of the global population will result in significant increases in the total number of deaths caused by most non-communicable diseases. Overall, non-communicable conditions will account for almost 70 per cent of all deaths in 2030 under the baseline scenario. The implications of all this for palliative care are enormous; if appropriate palliative care is to be made available to all who need it, then it becomes vital to address the key barriers to wider coverage that currently exist.

The total number of deaths in the world each year is around 56 million. The great majority of these, some 44 million, occur in the developing countries. It has been estimated that around 60 per cent of those dying would benefit from palliative care⁽²⁾.

Methods now exist that are acceptable and maintainable at community level and which can ensure the relief of end-of-life suffering on a large scale^(3,4,5). The WHO has promoted these through public-health policies and advice for the rational implementation of pain relief and palliative care^(6,7) Despite this, palliative care is not available in many settings where it has a vital contribution to make to the relief of suffering. There are many barriers to the efficient and effective delivery of high quality palliative care and these vary with factors such as geographical setting, economic resources, and the availability of education and training. In this chapter, we provide an overview of these issues beginning with a global perspective, progressing through societal, social, and organizational issues, to professional and, finally, individual barriers.