The 2015 Quality of Death Index - Ranking palliative care across the world A report by The Economist Intelligence Unit
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The 2015 Quality of Death Index
Ranking palliative care across the world
A report by The Economist Intelligence Unit
Commissioned byThe 2015 Quality of Death Index
Ranking palliative care across the world
Contents
Acknowledgements2
Executive summary 6
About the 2015 Quality of Death Index 9
A note on definitions 10
Introduction11
Part 1: The 2015 Quality of Death Index—Overall scores 14
Case study: Mongolia—A personal mission 19
Case study: China—Growing awareness 20
Part 2: Palliative and healthcare environment 22
Case study: Spain—The impact of a national strategy 28
Case study: South Africa—Raising the palliative care profile 29
Part 3: Human resources 30
Case study: Panama—Palliative care is primary care 34
Part 4: Affordability of care 35
Case study: US—Filling in the gaps 38
Case study: UK—Dying out of hospital 39
Part 5: Quality of care 40
The World Health Assembly resolution 42
Children’s palliative care 44
Part 6: Community engagement 45
Palliative care and the right to die 48
Case study: Taiwan—Leading the way 49
Part 7: The 2015 Quality of Death Index—Demand vs supply 51
Conclusion54
Appendix I: Quality of Death Index FAQ 56
Appendix II: Quality of Death Index Methodology 60
Endnotes66
1 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
Acknowledgements
The Quality of Death Index was devised and interviewed palliative care experts from across
constructed by an Economist Intelligence Unit the world. Their time and insights are greatly
(EIU) research team led by Trisha Suresh. Ebun appreciated. The EIU takes sole responsibility for
Abarshi, Tania Pastrana, Marco Pellerey and the construction of the Index and the findings of
Mayecor Sar contributed to research in building this report.
the Index. Sarah Murray was the author of this
report and David Line was the editor. Marco Interviewees, listed alphabetically by country:
Pellerey wrote the country summary appendices. Graciela Jacob, director, Argentinian National Cancer
Laura Ediger provided additional research, Institute, Argentina
reporting and writing. Joseph Wyatt assisted Roberto Wenk, director, Programa Argentino de Medicina
with production and Gaddi Tam was responsible Paliativa-Fundación FEMEBA, Argentina
for layout. Amanda Bresnan, executive manager, policy, programs
and research, Alzheimer’s Australia, Australia
For her time and advice throughout this project, Liz Callaghan, chief executive officer, Palliative Care
we would like to extend our special thanks to Australia, Australia
Cynthia Goh, chair, Asia Pacific Hospice Palliative Tim Luckett, member, Managing Advisory Committee,
Care Network. Improving Palliative Care through Clinical Trials,
University of Technology Sydney, Australia
For their support and guidance in construction Yvonne McMaster, advocate, Push for Palliative, Australia
of the Index we would also like to thank
Margaret O’Connor, professor of nursing, Swinburne
Stephen Connor, senior fellow at the Worldwide University, Australia
Hospice Palliative Care Alliance, Liliana de
Leena Pelttari, chief executive officer, Hospice Austria,
Lima, executive director of the International Austria
Association for Hospice and Palliative Care,
Herbert Watzke, head, president, Austrian Society for
Emmanuel Luyirika, executive director of the Palliative Care, Austria
African Palliative Care Association, and Sheila
Rumana Dowla, chairperson, Bangladesh Palliative &
Payne, emeritus professor at the International
Supportive Care Foundation, Bangladesh
Observatory on End of Life Care at Lancaster
Paul Vanden Berghe, director, Federation Palliative Care
University.
of Flanders, Belgium
In addition, during research for the construction Johan Menten, president, Research Task Force, Federation
Palliative Care of Flanders, Belgium
of the Index and in writing this report, the EIU
2 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
Maria Goretti Maciel, president, National Academy of Ximena Pozo, coordinator for palliative care, Ministry of
Palliative Care, Brazil Public Health, Ecuador
Irena Jivkova Hadjiiska, member, Bulgarian Association Mohammad ElShami, director of psychiatry, Children
for Palliative Care, Bulgaria Cancer Hospital 57357, Egypt
Nikolay Yordanov, head, Palliative Care Department, Yoseph Mamo Azmera, associate director, Care and
Interregional Cancer Hospital, Bulgaria Treatment of HIV-Aids, University of California San Diego-
Sharon Baxter, executive director, Canadian Hospice Ethiopia, Ethiopia
Palliative Care Association, Canada Tiina Surakka, president of the board, The Finnish
Anna Towers, associate professor, Palliative Care Division, Association for Palliative Care, Finland
McGill University, Canada Eero Vuorinen, president, Finnish Association for
Maria Alejandra Palma, chief, Continued and Palliative Palliative Care, Finland
Care, Department Intern Medicine, University of Chile Régis Aubry, president, French National Observatory on
Clinical Hospital, University of Chile, Chile End-of-Life Care, France
María Margarita Reyes D, executive director, Clínica Anne de la Tour, head, Department of Palliative Care and
Familia, Chile Chronic Pain, Centre Hospitalier V Dupouy, France
Cecilia Sepulveda, senior adviser, Cancer Control, Chronic Lukas Radbruch, director, Department of Palliative
Diseases Prevention and Management, World Health Medicine, University of Aachen, Germany
Organization, Chile Edwina Addo, director, Clinical Services, Office of the
Cheng Wenwu, director, Department of Palliative Care, President, International Palliative Care Resource Centre,
Fudan University Cancer Hospital, Shanghai, China Ghana
Li Wei, founder, Songtang Hospice, Beijing, China Mawuli Gyakobo, specialist, Family Medicine and Public
Ning Xiaohong, oncologist, Peking Union Medical College Health, Dodowa Health Research Centre, Ghana
Hospital, China Eva Duarte, director, Palliative Medicine and Support Care
Shi Baoxin, director, Hospice Care Research Centre, Unit, Sanatorio Nuestra Señora del Pilar, Guatemala
Tianjin Medical University, China Lam Wai-man, chairman, Hong Kong Society of Palliative
Wang Naning, nurse, Chinese Association for Life Care, Medicine, Hong Kong
China Gábor Benyó, medical director, Tábitha House, Hungary
Juan Carlos Hernandez, president, Palliative Care Sushma Bhatnagar, head of anaesthesiology, pain and
Association of Colombia, Colombia palliative Care, All India Institute of Medical Sciences’ Dr
Marta León, chief, Pain and Palliative Care Group, B R Ambedkar Institute-Rotary Cancer Hospital, India
Universidad de La Sabana, Colombia Mohsen Asadi-Lari, director, Oncopathology Research
María Auxiliadora Brenes Fernández, president, Caja Centre, Iran University of Medical Sciences, Iran
Costarricense de Seguro Social, Costa Rica Mazin Faisal Al-Jadiry, doctor, Oncology Unit, Children
Martin Loučka, director, Centre for Palliative Care, Czech Welfare Teaching Hospital, Baghdad University, Iraq
Republic Netta Bentur, associate professor, Stanley Steyer School
Ondřej Sláma, co-chair, Local Organising Committee, for Health Professionals, Tel-Aviv University and Myers-
Czech Society for Palliative Medicine, Czech Republic JDC-Brookdale Institute, Israel
Mai-Britt Guldin, postdoctoral researcher, Department of Augusto Caraceni, director, Virgilio Floriani Hospice and
Health, Aarhus University, Denmark Palliative Care Unit, National Cancer Institute of Milan,
Italy
Helle Timm, director, Knowledge Centre for Rehabilitation
and Palliative Care, Denmark Carlo Peruselli, president, Italian Society of Palliative
Care, Italy
Tove Vejlgaard, consultant, Specialist Palliative Care
Team, Vejle, Denmark Adriana Turriziani, director, Hospice Villa Speranza,
Università’ Cattolica del Sacro Cuore, Italy
Gloria Castillo, doctor, Palliative Care Unit, Santo
Domingo, Dominican Republic Naoki Ikegami, professor emeritus, Keio University, Japan
3 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
Mohammad Bushnaq, chairman, Jordan Palliative Care Liz Gwyther, chief executive officer, Hospice and Palliative
Society, Jordan Care Association of South Africa, South Africa
Zipporah Ali, executive director, Kenya Hospices and Joan Marston, chief executive, International Children’s
Palliative Care Association, Kenya Palliative Care Network, South Africa
Lucy Finch, co-founder, Ndi Moyo Hospice, Malawi Yoonjung Chang, chief, Hospice & Palliative care Branch,
Richard Lim, chairman, Malaysian Hospice Council, National Cancer Center, South Korea
Malaysia Maria Nabal, head, Supportive Palliative Care Team,
Celina Castañeda, programme coordinator, Palliative Care Hospital Universitario Arnau de Vilanova, Spain
for the Mexican Social Security Institute, Mexico Javier Rocafort Gil, former president, Spanish Association
Odontuya Davaasuren, president, Mongolian Palliative for Palliative Care, Spain
Care Society, Mongolia Nishirani Lanka Jayasuriya-Dissanayake, national
Mati Nejmi, coordinator, Center of Pain and Palliative professional officer, Noncommunicable Diseases, World
Care, Hôpital Cheikh Khalifa Bin Zaid, Morocco Health Organization, Sri Lanka
Wim J.A. van den Heuvel, professor, University Medical Ajantha Wickremasuriya, chairperson, Shantha Sevana
Centre, University of Groningen, Netherlands Hospice, Sri Lanka
Bregje Onwuteaka-Philipsen, programme leader, Bertil Axelsson, Department of Radiation Sciences, Unit of
Quality of Care, Institute for Health and Care Research, Clinical Research Centre, Umeå University, Sweden
Netherlands Peter Strang, consultant, professor, Department of
Kate Grundy, palliative medicine physician, Christchurch Oncology-Pathology, Karolinska Institutet, Sweden
Hospital, New Zealand Steffen Eychmüller, doctor, Center of Palliative Care, Bern
Olaitan Soyannwo, president, Society for the Study of University Hospital, Switzerland
Pain, Nigeria Andreas Ullrich, senior medical officer, Cancer Control,
Rosa Buitrago, vice dean and professor, School of Department of Chronic Diseases and Health Promotion,
Pharmacy, University of Panama, Panama World Health Organization, Switzerland
Gaspar Da Costa, national coordinator, National Palliative Co-Shi Chantal Chao, professor, Medical College, National
Care Programme of Panama, Panama Cheng Kung University, Taiwan
Mary Berenguel, chief, Department of Palliative Medicine Ching-Yu Chen, professor emeritus, National Taiwan
and Pain Management, Oncosalud-AUNA, Peru University Hospital, Taiwan
Maria Fidelis Manalo, head, Palliative Care Unit, Cancer Rongchi Chen, chairman, Lotus Hospice Care Foundation,
Center, The Medical City, Philippines Taiwan
Wojceech Leppert, chair, Department of Palliative Sharlene Cheng, founder, Taiwan Research Network
Medicine, Poznan University of Medical Sciences, Poland Council, Taiwan Academy of Hospice Palliative Medicine,
Taiwan
José António Ferraz Gonçalves, medical director,
palliative care unit, Portuguese Institute of Oncology, Sheau-Feng Hwang, chief, Hospice Palliative Care Center,
Portugal Taichung Veterans General Hospital, Taiwan
Jenny Olivo, president, Puerto Rico Hospice and Palliative Siew Tzuh Tang, professor, Chang Gung University School
Care Association, Puerto Rico of Nursing, Taiwan University Hospital, Taiwan
Georgiy Novikov, chairman, Russian Palliative Care Yingwei Wang, director, Heart Lotus Hospice at Tzuchi
Academy, Russia General Hospital, Taiwan
Alexander Tkachenko, founder, St. Petersburg Pediatric Elias Johansen Muganyizi, executive director, Tanzanian
Palliative Care Hospital, Russia Palliative Care Association, Tanzania
Vanessa Yung, chief executive, Singapore Hospice Srivieng Pairojkul, president, Thai Palliative Care Society,
Council, Singapore Thailand
Kristina Krizanova, head doctor, Department of Palliative Kadriye Kahveci, anaesthetist, Department of Palliative
Medicine, National Oncology Institute, Slovakia Care Center, Ulus State Hospital, Turkey
4 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
Elly Katabira, professor of medicine, Makerere University David Casarett, director of hospice and palliative care,
College of Health Sciences, Uganda University of Pennsylvania Health System, US
Simon Chapman, director, Policy, Intelligence & Public Barbara Coombs Lee, president, Compassion & Choices,
Affairs, National Council for Palliative Care, UK US
Richard Harding, director, African Programmes, Cicely Mark Lazenby, assistant professor of nursing, Yale School
Saunders International, UK of Nursing, US
David Praill, former chief executive, Hospice UK, UK Diane Meier, director, Centre to Advance Palliative Care,
Katherine Sleeman, clinical lecturer in palliative US
medicine, King’s College London, UK James Tulsky, chair, Department of Psychosocial Oncology
Mark Steedman, manager, PhD Programme, End-of- and Palliative Care, Dana-Farber Cancer Institute, US
Life Care Forum, Institute of Global Health Innovation, Holly Yang, assistant director, International Palliative
Imperial College London, UK Medicine Fellowship Program, Institute of Palliative
Ros Taylor, national director, Hospice Care at Hospice UK, Medicine, San Diego Hospice, US
UK Patricia Bonilla, programme director, National Cancer
Viktoriia Tymoshevska, director, Public Health Program Institute, Venezuela, Venezuela
Initiative, International Renaissance Foundation, Quach Thanh Khanh, head, Palliative Care Department,
Ukraine Ho Chi Minh City Oncology Hospital, Vietnam
Eduardo García Yanneo, chairman, Latin American Njekwa Lumbwe, national coordinator, Palliative Care
Association for Palliative Care, Uruguay Alliance of Zambia, Zambia
Ira Byock, executive director and chief medical officer, Eunice Garanganga, director, Hospice and Palliative Care
Institute for Human Caring, Providence Health & Services, Association, Zimbabwe
US
5 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
Executive
summary
Everyone hopes for a good death, or rather, “a communicable diseases such as heart disease
good life to the very end”1, but until recently and cancer are on the rise. The need for palliative
there was little dedicated effort and investment care is also therefore set to rise significantly. In
to provide the resources and education that supplementary analysis we compare expected
would make that possible. Public engagement growth in the “demand” for palliative care to the
and policy interventions to improve the quality existing “supply” for each country (as shown in
of death through the provision of high-quality their Index rankings). The demand analysis is
palliative care have gained momentum in based on forecasts of the burden of disease, old-
recent years, and some countries have made age dependency ratio, and rate of population
great strides in improving affordable access to ageing over the next 15 years.
palliative care. The Economist Intelligence Unit’s
Despite the improvements this research reveals,
Quality of Death Index, commissioned by the Lien
much more remains to be done. Even top-ranked
Foundation, highlights those advances as well as
nations currently struggle to provide adequate
the remaining challenges and gaps in policy and
palliative care services for every citizen. Cultural
infrastructure.
shifts are needed as well, from a mindset that
This is the second edition of the Index, updating prioritises curative treatments to one which
and expanding upon the first iteration, which values palliative care approaches that regard
was published in 2010. The new and expanded dying as a normal process, and which seeks to
2015 Index evaluates 80 countries using 20 enhance quality of life for dying patients and
quantitative and qualitative indicators across their families.
five categories: the palliative and healthcare
Key findings of our research include:
environment, human resources, the affordability
of care, the quality of care and the level of
l The UK has the best quality of death, and
community engagement. To build the Index the
rich nations tend to rank highest. As in 2010
EIU used official data and existing research for
the UK ranks first in the 2015 Quality of Death
each country, and also interviewed palliative
Index, thanks to comprehensive national
care experts from around the world.
policies, the extensive integration of palliative
In many countries, the proportion of older care into its National Health Service, and a
people in the population is growing and non- strong hospice movement. It also earns the
6 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
top score in quality of care. In general, income frameworks that integrate palliative care into
levels are a strong indicator of the availability their healthcare systems, whether through
and quality of palliative care, with wealthy a national health insurance scheme like the
countries clustered at the top of the Index. UK or Taiwan, or through cancer control
Australia and New Zealand come second and programmes such as in Mongolia and Japan.
third overall, and four other comparatively Effective policies can create tangible results:
rich Asia-Pacific countries achieve rankings the launch of Spain’s national strategy, for
in the top 20: Taiwan at position six, joined by example, led to a 50% increase in palliative
Singapore at 12, Japan at 14, and South Korea care teams and unified regional approaches.
at 18. Otherwise, European countries dominate
the top 20, with the addition of the US and l Training for all doctors and nurses is
Canada at positions 9 and 11, respectively. essential for meeting growing demand. In
high-ranking countries such as the UK and
l Countries with a high quality of death share Germany palliative care expertise is a required
several characteristics. The leading countries component of both general and specialised
have the following elements in place: medical qualifications, while several top-
• A strong and effectively implemented scoring countries have established national
national palliative care policy framework; accreditation systems. Countries without
sufficient training resources experience a
• High levels of public spending on
severe shortage of specialists, while general
healthcare services;
medical staff may also lack the training to use
• Extensive palliative care training resources
opioid analgesics appropriately.
for general and specialised medical
workers; l Subsidies for palliative care services are
• Generous subsidies to reduce the financial necessary to make treatment affordable.
burden of palliative care on patients; Whether through national insurance or
• Wide availability of opioid analgesics; pension schemes or through charitable
funding (such as in the UK), without financial
• Strong public awareness of palliative care.
support many patients are unable to access
l Less wealthy countries can still improve adequate care. The top scorers in terms of
standards of palliative care rapidly. Although affordability of care—Australia, Belgium,
many developing countries are still unable Denmark, Ireland, and the UK—cover 80 to
to provide basic pain management due to 100% of patient costs for palliative care.
limitations in staff and basic infrastructure,
l Quality of care depends on access to opioid
some countries with lower income levels prove
analgesics and psychological support.
to be exceptions, demonstrating the power
In only 33 of the 80 countries in the index
of innovation and individual initiative. For
are opioid painkillers freely available and
example, Panama is building palliative care
accessible. In many countries access to
into its primary care services, Mongolia has
opioids is still hampered by red tape and legal
seen rapid growth in hospice facilities and
restrictions, lack of training and awareness,
teaching programmes, and Uganda has made
and social stigma. The best care also includes
huge advances in the availability of opioids.
inter-disciplinary teams that also provide
l National policies are vital for extending psychological and spiritual support and
access to palliative care. Many of the physicians who involve patients in decision-
top countries have comprehensive policy making and accommodate their care choices.
7 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
l Community efforts are important for raising demographic shifts to an older population,
awareness and encouraging conversations combined with the rising incidence of
about death. The Dying Matters Coalition non-communicable diseases like diabetes,
set up in the UK by the National Council for dementia and cancer, will create additional
Palliative Care, a global movement of informal pressure for countries that already struggle to
meetings called Death Cafés, and the US-based meet demand.
Conversation Project encourage people to
openly discuss their end-of-life wishes and The EIU’s 2010 Index sparked a series of policy
normalise the conversation about dying. Use debates over the provision of palliative care
of television, newspapers and social media by around the world. Since then, several countries
government and non-profit groups in many have made significant advances in terms of
countries—for instance Brazil, Greece, and national policy. Colombia, Denmark, Ecuador,
Taiwan—has also helped to make headway in Finland, Italy, Japan, Panama, Portugal, Russia,
mainstreaming awareness of palliative care. Singapore, Spain, Sri Lanka, Sweden and Uruguay
have all established new or significantly updated
l Palliative care needs investment but offers guidelines, laws or national programmes, and
savings in healthcare costs. Shifting from countries such as Brazil, Costa Rica, Tanzania
strictly curative health interventions to more and Thailand are in the process of developing
holistic management of pain and symptoms their own national frameworks. The momentum
can reduce the burden on healthcare systems being gained on palliative care at a policy level
and limit use of costly but futile treatments. has also been strengthened by the international
Recent research has demonstrated a resolution at the 2014 World Health Assembly
statistically significant link in use of palliative calling for the integration of palliative care into
care and treatment cost savings, a fact several national healthcare systems.
high-ranking countries have recognised in
their bids to expand palliative care services. Each country will need to craft its own unique
approach by identifying the most significant
l Demand for palliative care will grow rapidly gaps, addressing regulatory and resource
in some countries that are ill-equipped to constraints, and forming partnerships between
meet it. Countries like China, Greece and government, academia, and nonprofit groups.
Hungary with limited supply and rapidly Approaches will vary by context and culture, but
increasing demand will need active investment share the overall objective of enabling a better
to meet public needs. More generally, quality of life for patients facing death.
8 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
About the 2015 Quality of Death Index
In 2010, the EIU developed an Index that l Quality of care (30% weighting, 6 indicators)
ranked the availability, affordability and
quality of end-of-life care in 40 countries. The l Community engagement (10% weighting, 2
Index, which was commissioned by the Lien indicators)
Foundation, a Singaporean philanthropic Each indicator is allocated a weighting in
organisation, consisted of 24 indicators in its category, and each category is given a
four categories. The study garnered much weighting in the overall Index. Parts 1 to 6 of
attention and sparked a series of policy debates this paper consider in turn the overall results
over the provision of palliative and end-of-life and scores for each of the five categories.
care around the world. As a result, the Lien
Foundation commissioned a new version of the This year, the EIU also prepared a
Index to expand its scope and take into account supplementary assessment of the need for
global developments in palliative care in recent palliative care provision, to enable assessment
years. of the “demand” for such care alongside the
quality of “supply” revealed in the main Index.
In this, the 2015 version, the number of This is based on three categories:
countries included has been increased from 40
to 80. The Index, which focuses on the quality l The burden of diseases for which palliative
and availability of palliative care to adults, care is necessary (60% weighting)
is also structured differently from the 2010 l The old-age dependency ratio (20%)
version (meaning the direct comparison of
scores between years is not possible). Now, the l The speed of ageing of the population from
Index is composed of scores in 20 quantitative 2015-2030 (20%)
and qualitative indicators across five categories.
The results of this analysis are discussed in Part
The categories are:
7.
l Palliative and healthcare environment (20% A more detailed explanation of the
weighting, 4 indicators) methodology behind the Index and the demand
l Human resources (20% weighting, 5 score calculation, and a list of frequently asked
indicators) questions about the construction, composition
and limitations of the research, are included as
l Affordability of care (20% weighting, 3 appendices to this paper.
indicators)
9 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
A note on definitions
The Quality of Death Index measures the • intends neither to hasten or postpone death;
quality of palliative care available to adults in
80 countries. Although the terms “palliative • integrates the psychological and spiritual
care” and “end of life care” are sometimes used aspects of patient care;
interchangeably, the latter is often taken to • offers a support system to help patients live
mean care delivered only in the final stages as actively as possible until death;
of a terminal illness. The Index is designed to
measure palliative care as defined by the World • offers a support system to help the family
Health Organization: cope during the patients illness and in their
own bereavement;
“Palliative care is an approach that improves
the quality of life of patients and their families • uses a team approach to address the needs
facing the problems associated with life- of patients and their families, including
threatening illness, through the prevention bereavement counselling, if indicated;
and relief of suffering by means of early
identification and impeccable assessment and • will enhance quality of life, and may also
treatment of pain and other problems, physical, positively influence the course of illness;
psychosocial and spiritual. Palliative care: • is applicable early in the course of illness,
• provides relief from pain and other in conjunction with other therapies that are
distressing symptoms; intended to prolong life, such as chemotherapy
or radiation therapy, and includes those
• affirms life and regards dying as a normal investigations needed to better understand and
process; manage distressing clinical complications.”2
10 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
Introduction
As governments across the world work to palliative care. (Given better palliative care is
improve life for their citizens, they must also generally available in richer countries with older
consider how to help them die well. It is a populations, this rises to 27% of the population
challenge not to be underestimated. In many aged 65 or over. The Index covers 91% of the
countries, older people make up an ever-growing global population of those aged over 65.5)
proportion of the population. Meanwhile, the Separately, the WHPCA estimates that globally
prevalence of non-communicable diseases, such under 10% of those who require palliative care
as heart disease, diabetes, dementia and cancer, actually receive it.6
The biggest
is increasing rapidly. Taken together, this means
problem that Even those countries that do well in the Quality
that the need for palliative care is set to rise
persists is that our of Death Index cannot meet all the needs of
sharply.
healthcare systems those requiring palliative care, with evidence of
are designed to “We’ve seen unprecedented changes in the shortfalls continuing to emerge in nations that—
provide acute care way the world population is moving, with more in relative terms—have highly sophisticated
when what we need people over the age of 65 than under the age services.
is chronic care. of five,” says Stephen Connor, senior fellow at
Take the UK, which tops the overall Index. In
the Worldwide Hospice Palliative Care Alliance
That’s still the case May 2015, an investigation by the Parliamentary
(WHPCA). “That’s never happened in human
almost everywhere and Health Service Ombudsman into complaints
history before and it’s going to continue to get
in the world. about end-of-life care highlighted 12 cases
more pronounced.”
it said illustrated problems it saw regularly in
Yet many countries remain woefully ill-equipped its casework.7 Failings included poor symptom
Stephen Connor, senior fellow, to provide appropriate services to these citizens. control, poor communication and planning,
Worldwide Hospice Palliative
Care Alliance Despite improvements in recent years and greater not responding to the needs of the dying,
attention to the issue, just 34 countries have inadequate out-of-hours services and delays in
above-average3 scores in the 2015 Quality of diagnosis and referrals for treatment.
Death Index. Together these account for just 15%
The fact that the UK, an acknowledged leader
of the total adult population of the countries
in palliative care, is still not providing adequate
in the Index (which themselves account for
services for every citizen underlines the
85% of the global adult population)4, meaning
challenge facing all countries. Because while
the vast majority of adults lack access to good
11 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
greater numbers of people are living longer, “A key factor limiting research is that it’s really
they are not necessarily doing so in good health. poorly funded,” says Katherine Sleeman, clinical
Often they may have several illnesses, making the lecturer in palliative medicine at King’s College
process of dying more drawn-out and demanding London. “This is something that arguably will
increasingly complex forms of treatment. affect every single person and yet we invest
almost nothing in trying to work out how to do it
This places a heavy burden on healthcare
better.”
systems, most of which are struggling to adapt—
and one of the hardest shifts to make is cultural. More worrying, many developing countries are
“The biggest problem that persists is that our unable to offer basic pain management, leaving
healthcare systems are designed to provide acute millions of people dying an agonising death.
care when what we need is chronic care,” says Dr
Nevertheless, evidence of innovation is coming
Connor. “That’s still the case almost everywhere
from unexpected quarters. Mongolia and Panama
in the world.”
(in positions 28 and 31 respectively in the Index),
This is something This is also true in the US, another country that are showing that even less wealthy countries
that arguably will performs well in the Index. “Our health systems can increase the availability and quality of care,
affect every single focus on diagnosing and treating diseases and relatively quickly.
person and yet are demonstrably negligent in meeting the needs
And when it comes to the availability of
we invest almost of patients and families going through these
morphine, Uganda has made striking advances in
difficult experiences,” says Ira Byock, executive
nothing in trying to pain control through a public-private partnership
director and chief medical officer of the Institute
work out how to do between the health ministry and Hospice Africa
for Human Caring at Providence Health & Services
it better. Uganda, a pioneering institution founded by
and author of the book, The Best Care Possible.
Anne Merriman—a nominee for the 2014 Nobel
The irony is that as countries struggle to cope Peace Prize. “The government now supports
Katherine Sleeman, clinical with rising healthcare costs, palliative care the availability of oral morphine to anyone who
lecturer in palliative medicine,
King’s College London could be a more cost-effective way of managing needs it for free,” explains Emmanuel Luyirika,
the needs of an ageing population. One recent executive director of the African Palliative Care
literature review found that palliative care was Association.
frequently found to be cheaper than alternative
Some developing countries can move forward
forms of care and that, in most cases, the cost
relatively rapidly because of the absence of
difference was statistically significant.8 Another
entrenched systems, says Mark Steedman, PhD
recent study found that the earlier palliative care
programme manager for the End-of-Life Care
was administered to patients with an advanced
Forum at Imperial College London’s Institute of
cancer diagnosis, the greater the potential
Global Health Innovation. “We think there are
cost savings. If palliative care treatment was
places where there’s a lot of potential,” he says.
introduced within two days of diagnosis this led
“When you’re starting from zero you can leapfrog
to savings of 24% compared with no intervention;
a lot of the problems.”
its introduction within six days saved 14%.9
Richard Harding, who developed the African
Yet, despite evidence of its economic benefits, a
programme for Cicely Saunders International
tiny proportion of healthcare research goes into
(an NGO focused on research on and education
research on palliative care (about 0.2% of the
about palliative care) at King’s College London,
funds awarded for cancer research in the UK in
sees this principle at work in Africa. “African
2010, for example, and just 1% of the US National
countries have succeeded in delivering high
Cancer Institute’s total 2010 appropriation10).
quality effective palliative care in the face of low
12 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
resources and overwhelming need,” he says. “And The question that lies ahead is how quickly
high- and middle-income countries would be wise and effectively member states can put in place
to learn lessons from them.” measures that can meet the recommendations
of the WHA resolution and increase access to
When looking more broadly, Sheila Payne,
opioids and palliative care. And while developing
emeritus professor at the International
countries need to scale up promising pioneer
Observatory on End of Life Care at Lancaster
programmes, countries that already have
University, sees progress being made. “There’s
sophisticated palliative care provision need to
a general trend in which we’re moving from the
find ways to meet the growing demands of a
pioneer stage in many countries to people seeing
rapidly ageing population.
how they can embed palliative care in healthcare
systems,” she says. “That’s really important However, some argue that, even without large
because that’s about sustainability.” investments, significant improvements can be
made in palliative care. “The things that make
In a major step forward, the World Health
a better death are so simple,” says Ros Taylor,
Assembly—WHA, the forum through which the
national director for hospice care at Hospice UK.
World Health Organization is governed—last
“It’s basic knowledge about good pain control
year published a resolution on palliative care
and conversations with people about the things
calling on member states to integrate it into
that matter—that could transform many more
national healthcare systems (see the box in Part
deaths.”
5). “That sets the policy context and legitimises
governments getting engaged,” says Dr Payne. For policymakers, major issues to consider
“In the policy context, that’s a big development.” are availability of care, human resources and
training, affordability of care, quality of care
In addition, in its global action plan for the
and community engagement through public
prevention and control of non-communicable
awareness campaigns and support volunteers.
diseases for 2013–2020, the WHO has included
These issues are covered by the five categories
palliative care among the policy areas proposed
in the 2015 Quality of Death Index. In each, the
to member states. The WHO is also shifting
Index looks at how countries measure up against
its focus to place more attention on non-
other nations, as well as against their regional
communicable diseases.
peers and those with similar income levels.
13 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
1 The 2015 Quality of Death Index—
overall scores
In assessing the results of the 2015 Quality in some African, countries, for example—have
of Death Index, it is no surprise to find that been catalysts for innovation and investment.
wealthy countries dominate the top of the list,
while their poorer counterparts are clustered As was the case in 2010, the UK tops the Index,
together in its lower sections. In fact, income followed by Australia and New Zealand (which
levels are a strong indicator of the availability took second and third in 2010). The UK’s leading
and quality of palliative care. However, there are position reflects the attention paid to palliative
exceptions to this rule, often in places where care in both public and non-profit sectors.
an individual is championing the cause or where With a strong hospice movement—much of it
certain circumstances—the spread of HIV-Aids supported by charitable funding—palliative
Figure 1.1
2015 Quality of Death Index—Overall scores
0 20 40 60 80 100
14 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
and end-of life care are both part of a national Figure 1.2
strategy that is leading to more services being
2015 Quality of Death Index—Overall scores
provided in National Health Service hospitals,
Rank Country
as the country works to integrate hospice care 1 UK 93.9
2 Australia 91.6
more deeply into the healthcare system.11 3 New Zealand 87.6
4 Ireland 85.8
“People have woken up to the fact that we may 5 Belgium 84.5
6 Taiwan 83.1
be able to save money overall for society by 7 Germany 82.0
investing in dying better,” says Dr Sleeman. 8 Netherlands 80.9
9 US 80.8
10 France 79.4
11 Canada 77.8
While Australia and New Zealand are in the top 12 Singapore 77.6
13 Norway 77.4
three, four other Asia-Pacific countries make 14 Japan 76.3
15 Switzerland 76.1
it into the top 20, with Taiwan at position six, 16 Sweden 75.4
17 Austria 74.8
Singapore at position 12, Japan at position 18 South Korea 73.7
14 and South Korea at position 18. For these 19 Denmark 73.5
20 Finland 73.3
countries, government engagement has been 21
22 Hong Kong
Italy 71.1
66.6
crucial. Among other factors, Taiwan benefits 23 Spain 63.4
24 Portugal 60.8
from the country’s National Health Insurance, 25 Israel 59.8
26 Poland 58.7
which determines insurance coverage and the 27 Chile 58.6
28 Mongolia 57.7
level of reimbursement for specific services.12 29 Costa Rica 57.3
30 Lithuania 54.0
Japan (which performed relatively poorly 31 Panama 53.6
32 Argentina 52.5
in the 2010 Index, at position 23 of 40) is 33 Czech Republic 51.8
34 South Africa 48.5
instituting a new cancer control programme, 35 Uganda 47.8
36 Cuba 46.8
which is expected to prompt an increased focus 37 Jordan 46.7
on palliative care from the early stages of the 38 Malaysia 46.5
39 Uruguay 46.1
disease along with the incorporation of palliative 40
41
Ecuador
Hungary
44.0
42.7
care centres into the national budget.13 42 Brazil 42.5
43 Mexico 42.3
44 Thailand 40.2
45 Venezuela 40.1
And in Singapore, which is grappling with a 46 Puerto Rico 40.0
47 Turkey 38.2
rapidly ageing population, caring for people 48 Russia 37.2
towards the end of their lives has risen up the 49 Peru 36.0
50 Kazakhstan 34.8
agenda for healthcare policymakers. Singapore 51
52
Ghana
Morocco
34.3
33.8
recently developed a national palliative care 53 Indonesia 33.6
54 Tanzania 33.4
strategy and the Ministry of Health is working 55 Slovakia 33.2
=56 Egypt 32.9
both to increase the number of services =56 Greece 32.9
58 Vietnam 31.9
available and to empower individuals to make 59 Zimbabwe 31.3
60 Saudi Arabia 30.8
their own decisions on end-of-life care.14 61 Zambia 30.3
62 Bulgaria 30.1
63 Kenya 30.0
However, while the European, Asia-Pacific 64 Romania 28.3
65 Sri Lanka 27.1
and North American countries in the top of 66 Malawi 27.0
67 India 26.8
the Index benefit from relatively high levels 68 Colombia 26.7
69 Ukraine 25.5
of government support, several less wealthy 70 Ethiopia 25.1
71 China 23.3
countries with less well developed healthcare 72 Botswana 22.8
73 Iran 21.2
systems stand out. These include Chile, 74 Guatemala 20.9
75 Dominican Republic 17.2
Mongolia, Costa Rica and Lithuania, which 76 Myanmar 17.1
77 Nigeria 16.9
appear in the top 30, at positions 27, 28, 29 and 78 Philippines 15.3
30 respectively. 79 Bangladesh 14.1
80 Iraq 12.5
15 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
Figure 1.3 Mongolia is an impressive case. The driving
2015 Quality of Death Index—Ranking by region force behind the increase in palliative care in
Country
the country is Odontuya Davaasuren, a doctor
US 80.8 who is helping to build a national palliative care
Canada 77.8
Chile 58.6 programme, pushing to change prescription
Costa Rica 57.3
Panama 53.6 regulations to make generic opioids available,
Argentina 52.5
Cuba 46.8 training palliative care specialists, and working
Americas
Uruguay 46.1
Ecuador 44.0 to include education on palliative care in the
Brazil 42.5
Mexico 42.3 curricula for doctors, nurses and social workers.
Venezuela 40.1
Puerto Rico 40.0
“She’s a brilliant teacher, leader and visionary,”
Peru 36.0
says the WHPCA’s Dr Connor. “And leadership is
Colombia 26.7
Guatemala
Dominican Republic
20.9
17.2
critical to any change process in anywhere in the
Australia 91.6
world.”
New Zealand 87.6
Taiwan 83.1
Singapore 77.6
Japan 76.3 By contrast, some countries that might be
South Korea 73.7
Hong Kong 66.6 expected to perform more strongly, given
Asia-Pacific
Mongolia 57.7
their rapid recent economic growth, rank at
Malaysia 46.5
Thailand 40.2
low positions in the Index. India and China
Indonesia 33.6
Vietnam
Sri Lanka 27.1
31.9
perform poorly overall, at positions 67 and 71
India 26.8 in the Index. In the light of the size of their
China 23.3
Myanmar 17.1 populations, this is worrying.
Philippines 15.3
Bangladesh 14.1
UK 93.9
Ireland 85.8
In China’s case, a rapidly ageing demographic
Belgium 84.5
presents additional challenges. The adoption
Germany 82.0
Netherlands
France
80.9
79.4
of palliative care in China has been slow, with
Norway 77.4 a curative approach dominating healthcare
Switzerland 76.1
Sweden 75.4 strategies. This may be about to change, as
Austria 74.8
Denmark 73.5 recent shifts in policy, mainly at the municipal
Finland 73.3
Italy 71.1 level, indicate greater government support
Europe
Spain 63.4
Portugal 60.8 and investment in hospice and palliative care
Poland 58.7
Lithuania 54.0 services.
Czech Republic 51.8
Hungary 42.7
Turkey 38.2 Regional variations are present in the Index,
Russia 37.2
Kazakhstan 34.8 and there are surprises here, too. In the
Slovakia 33.2
Greece 32.9 Americas, the US and Canada top the list, as
Bulgaria 30.1
Romania 28.3 might be expected. But Chile is in third place,
Ukraine 25.5
Israel 59.8 making it a leader in Latin America—with the
South Africa 48.5
Uganda 47.8 highest number of palliative care services in the
Jordan 46.7
Ghana 34.3
region.15 Chile’s position in the Index reflects
Morocco 33.8
the efforts made to incorporate palliative care
Middle East & Africa
Tanzania 33.4
Egypt
Zimbabwe
32.9
31.3
into healthcare services and to develop policies
Saudi Arabia 30.8 for access to opioids since the country launched
Zambia 30.3
Kenya 30.0 its palliative care programme in 1996.16, 17
Malawi 27.0
Ethiopia 25.1
Botswana 22.8
Iran 21.2
Nigeria 16.9
Iraq 12.5
16 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
Figure 1.4
Correlation with per-capita GDP
(2013, US$, ppp)
Quality of Death overall score (100=best)
R2 = 0.652
100
Taiwan UK
Australia
Germany
New Zealand Belgium
Ireland
France US
80 Japan Netherlands
Canada Sweden Switzerland Norway Singapore
South Korea
South Africa Italy Finland Austria
Mongolia Denmark Hong Kong
Cuba Portugal Spain
60 Costa Rica Israel
Jordan Chile Poland
Panama Lithuania
Uganda Argentina Czech Republic
Indonesia Uruguay
Morocco Malaysia
Vietnam Ecuador Brazil Mexico Hungary
40 Zambia Thailand Venezuela Puerto Rico
Ghana Peru Russia
Tanzania Turkey Kazakhstan
Zimbabwe Egypt Bulgaria Slovakia
Sri Lanka Saudi Arabia
Romania
Malawi Kenya India Colombia Greece
Ethiopia Botswana
20 Guatemala Ukraine China Iran
Nigeria Dominican Republic
Philippines Iraq
Myanmar
Bangladesh
0
0 10000 20000 30000 40000 50000 60000 70000 80000 90000
Income per capita (US$, PPP, 2013)
Income levels correlate quite strongly with countries. However, some countries do not
relative success in delivering palliative care perform as well as one might expect, given their
services (as Figure 1.4 demonstrates). The top wealth. This is the case for Singapore, for example,
10 countries in the Index are all high-income which does not make it into the top 10, and Hong
countries, although within the high income Kong, which is only at position 22 in the Index.
group, some countries experiencing economic
In the case of Singapore, the government is
difficulties—such as Greece (equal 56th place)
working to catch up following years when it
and Russia (48th)—can be found among the
invested relatively little in palliative care.
poorer performing nations (Figure 1.5).
“Singapore has one of the fastest ageing
Within regions a similar principle applies. Israel populations in the world but until about 25 years
(a high income country) and South Africa (a ago, we had a young population,” says Cynthia
middle-income country) earn the first and second Goh, chair of the Asia Pacific Hospice Palliative
highest scores among the 18 Middle Eastern and Care Network. “So we built up a pretty good
African countries. Meanwhile, four of the last acute care system, but when it comes to chronic
five countries in the Index—Myanmar, Nigeria, diseases and end of life, there is a lot of catching
the Philippines and Bangladesh—are low-income up to do.”
17 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
Figure 1.5
The discrepancies that emerge between income
2015 Quality of Death Index—Ranking by income group
and Index performance and the presence of
Country
UK 93.9 outliers such as Mongolia are in themselves
Australia 91.6
New Zealand 87.6 enlightening. They serve to demonstrate that
Ireland 85.8
Belgium 84.5 there are no simple answers for countries
Taiwan 83.1
when it comes to providing the care that is so
Germany 82.0
Netherlands 80.9
essential for their ageing and dying citizens.
US 80.8
France 79.4
Canada 77.8
Singapore 77.6 A complex range of factors—economic, social,
Norway 77.4
Japan 76.3 cultural and political—need to be taken into
Switzerland 76.1
Sweden 75.4 account before palliative care can be delivered
High income
Austria 74.8
South Korea 73.7
effectively. By factoring in everything from
Denmark 73.5
certifications for specialist palliative care
Finland 73.3
Hong Kong
Italy
66.6
71.1
workers to the availability of opioid analgesics,
Spain 63.4 the following five categories that together
Portugal 60.8
Israel 59.8 constitute the Index provide insights into why
Poland 58.7
Chile 58.6 some countries are succeeding while others are
Lithuania 54.0
Czech Republic 51.8 failing.
Uruguay 46.1
Puerto Rico 40.0
Russia 37.2
Slovakia 33.2
Greece 32.9
Saudi Arabia 30.8
Costa Rica 57.3
Panama 53.6
Argentina 52.5
South Africa 48.5
Cuba 46.8
Jordan 46.7
Malaysia 46.5
Ecuador 44.0
Hungary 42.7
Brazil 42.5
Middle income
Mexico 42.3
Thailand 40.2
Venezuela 40.1
Turkey 38.2
Peru 36.0
Kazakhstan 34.8
Bulgaria 30.1
Romania 28.3
Colombia 26.7
China 23.3
Botswana 22.8
Iran 21.2
Dominican Republic 17.2
Iraq 12.5
Mongolia 57.7
Uganda 47.8
Ghana 34.3
Morocco 33.8
Indonesia 33.6
Tanzania 33.4
Egypt 32.9
Vietnam 31.9
Zimbabwe 31.3
Low income
Zambia 30.3
Kenya 30.0
Sri Lanka 27.1
Malawi 27.0
India 26.8
Ukraine 25.5
Ethiopia 25.1
Guatemala 20.9
Myanmar 17.1
Nigeria 16.9
Philippines 15.3
Bangladesh 14.1
Note: Low income countries are those that had 2013 GNI per capita of less than US$4,125; middle income countries more than
US$4,125 but less than US$12,746; and high income countries more than US$12,746.
18 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
Case study: Mongolia—A personal mission
Rank/80 Score/100 awareness among the public, health professionals and
Quality of Death overall score (supply) 28 57.7 policymakers, to develop specialised training in palliative
care, and to increase access to painkilling drugs.
Palliative and healthcare environment 24 51.3
Human resources 21 61.1 However, Dr Davaasuren admits that the work has not always
Affordability of care =36 65.0
been easy, particularly as when she started neither the public
or health ministry officials were aware of the existence of
Quality of care =32 60.0
palliative care services. “No one talked about it,” she says.
Community engagement =27 42.5 “And policymakers are very conservative, so it was very
difficult to change the laws and regulations.”
Mongolia
Average
While much work remains to be done to accommodate
Highest
everyone in need of care, as a result of Dr Davaasuren’s efforts
Palliative and the situation today is vastly improved. Ulaanbaatar, the
healthcare environment
capital, now has ten palliative care services (with the largest
100
facility at the country’s National Cancer Center). Outside the
80
city, provincial hospitals now accommodate patients in need
60
of palliative care.
Community 40 Human
engagement 20 resources Palliative care is also now included in Mongolia’s health and
0 social welfare legislation and its national cancer control
program. Since 2005, all medical schools and social workers
receive palliative care training. And, since 2006, affordable
morphine has been available.19 In 2013, Dr Davaasuren says,
Quality of care Affordability of care the country started non-cancer palliative care provisions,
outpatient consultation and nursing, home care, and spiritual
When in 2000 the Mongolian Palliative Care Society (MPCS) and social services.
was established, it marked the start of efforts to fill a gaping
hole in palliative care services. Until then, the country had All this is reflected in the Index, in which Mongolia makes it
no hospices or palliative care teaching programmes, it used into the top 30 in the overall ranking (at position 28) as well
just 1kg of morphine each year, and no government policy on as in three of the Index’s categories (palliative and healthcare
palliative care existed.18 environment, human resources and community engagement).
It ranks first among its peers in the “low income” bracket—
“We did not even have the terminology for palliative care,” around ten points ahead of the second-ranked country in
explains Odontuya Davaasuren, the driving force behind the this group, Uganda. Plotting Index scores against per-capita
creation of palliative care services in Mongolia. income (see Figure 1.4) reveals that Mongolia overachieves by
It was in 2000, after attending a conference in Stockholm some margin given its resources.
of the European Association for Palliative Care, that Dr The next challenge, Dr Davaasuren says, is to expand the
Davaasuren decided to take action. On returning to Mongolia, provision of non-cancer and paediatric palliative care services
she made visits to patients with her postgraduate students while also increasing the availability of home care and services
and recorded the conversations with families. “I saw so much for those living in the provinces.
suffering in families—not just physical but also psychological
and economic,” she says. For Dr Davaasuren, the ability for those in pain and with
incurable diseases to receive palliative care is not just a case of
Funding from the Ford Foundation and the Open Society expanding services to meet rising need—it is about meeting a
Foundations helped Dr Davaasuren in her efforts to build basic human right.
19 © The Economist Intelligence Unit Limited 2015The 2015 Quality of Death Index
Ranking palliative care across the world
Case study: China—Growing awareness
Rank/80 Score/100 to palliative care. Shanghai planned to add 1,000 beds for
Quality of Death overall score (supply) 71 23.3 hospice patients by the end of 2014, some in hospitals and
Palliative and healthcare environment 69 21.1
some in community-based health care centres,22 and Tianjin
recently added hospice care to the official list of government-
Human resources 70 21.0
funded social services.23
Affordability of care =65 37.5
Quality of care 69 16.3
Shi Baoxin, director of the Hospice Care Research Center
at Tianjin Medical University, says that despite improved
Community engagement =45 25.0
awareness and expansion of palliative care in China over the
past 20 years, it’s still early days. “It’s hard for hospice care to
China
develop mainly because of the lack of education about death,”
Average Dr Shi says, adding that this also makes effective psychological
Highest treatment of dying patients more challenging.
Palliative and
healthcare environment
100 This lack of awareness extends to medical professionals. Ning
80 Xiaohong, an oncologist at Peking Union Medical College
60 Hospital, says that teaching of palliative care concepts in
40 medical training is extremely limited, which means that most
Community Human
engagement 20 resources practicing professionals have never been exposed to essential
0 concepts or techniques. In response, Dr Ning is developing an
online course on palliative care to be used on an annual basis.
Cheng Wenwu, director of the Department of Palliative Care
at Fudan University Cancer Hospital, agrees that the lack of
Quality of care Affordability of care professional knowledge and low public awareness mean that
both patients and doctors focus on curative treatments, and
The adoption of a palliative care approach in China has been don’t think about palliative care
slow, with most healthcare resources focused on curative options. However, public awareness
treatment. Although the national Ministry of Health officially is gradually increasing, spread via
endorsed the establishment of palliative care departments TV and newspapers and also word of
The biggest
in hospitals in 2008,20 public awareness of and access mouth. Dr Ning reports an increase challenge is to
to palliative care is still limited. Outside of China’s 400 in the last few years, and says she change people’s
specialised cancer hospitals, there are only a handful of now sees some patients at her clinic minds, to let them
charity hospitals and community health centres that offer coming in with questions about
palliative care services to patients. palliative care options.
know that society
can take good care
China’s overall rank of 71st out of 80 countries reflects this Without government subsidies,
limited availability and the poor quality of palliative care in financial costs are a major challenge,
of their parents in
general. Service accessibility stands at less than 1% with most as palliative care is generally not the late stages of
hospices concentrated in the urban areas of Shanghai, Beijing supported through the national illness and help
and Chengdu; there is no national strategy or guidelines; health security system. Songtang them die with
use and availability of opioids is limited; and patient-doctor Hospice in Beijing was one of the
communication is poor.21 In addition, if care is not covered by earliest palliative care institutions,
dignity.
charitable donations the financial burden on patients can be founded in 1987, and currently cares
quite high. As with most medical treatments in China, public for around 320 patients. While the
subsidies do not fully cover the cost and patient contributions costs of care are relatively low, on Li Wei, founder, Songtang
Hospice, Beijing
are required. average RMB1,000-2,000 (US$160-
A recent shift in government policy, mainly at the municipal 320) per month, patients still
level, signals a trend of greater support and investment in struggle to afford it, says Li Wei, the hospital’s founder.
hospice care services. Cities like Shanghai, Shenzhen and In addition to financial barriers, cultural beliefs also hinder
Tianjin have set new targets and policies to increase access the widespread use of palliative care. According to Dr Li, most
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