Joint Position Statement between Indian Association of Palliative Care and Indian Association of Preventive and Social Medicine – A Collaborative Effort to Expand Primary Palliative Care throughout the Country

BACKGROUND AND PROBLEM STATEMENT Worldwide, there is a rise in morbidity and mortality from both non-communicable and communicable diseases with non-communicable disease alone accounting for 71% mortality.[1] Low- and middle-income countries face the highest burden, as high as 77%.[1] Premature mortality results in reduction of the productive population and patients belonging to poor socio-economic strata are the most vulnerable, resulting in poor socio-economic growth and increased illiteracy rates.[1-3] To compound this further, decreased productivity with resultant poverty, lack of health insurance, and out-of-pocket expenditure inhibit people from accessing health care services.[4] India staggers at 59th position on the global quality of death index with abysmally poor integration of palliative care into the healthcare system.[5] This population of patients may benefit from palliative care. It is estimated that 40 million people each year will need palliative care, and 78% of this population lives in LMIC.[6] Although it is difficult to estimate the number of patients actually receiving palliative care due to lack of palliative care registries across the globe, definitely large majority of the population in need has difficulty in accessing palliative care.[7] THE NEED FOR PRIMARY PALLIATIVE CARE Palliative care has been recognized as a fundamental component of universal health coverage as per the sustainable development goal 3.8.1[4] and primary palliative care with its patient-centered care,[8,9] ensures that care is provided at the patient's doorstep in alignment with their wishes and values.[10] Primary palliative care aims at providing symptom management to patients with chronic, life-threatening illnesses.[11] It empowers general practitioner/family physician (GP/FP) to facilitate discussions around the goals of medical care, coordinate care between specialists and patients in the community, and provide appropriate referrals to specialist palliative care teams for complicated end-of-life needs.[11] This will ensure that palliative care is universally accessible to those who need it.[12] PRIMARY PALLIATIVE CARE Palliative care, when provided to patients close to their homes, will purportedly reduce the health care cost, travel burden, improve accessibility, and align care to the preferences of the patients and their families and increase at-home deaths.[13-15] Primary palliative care in the community can be offered in a variety of ways and may encompass training of GP/FP or community nurses, GP/FP providing palliative care, or specialists collaborating with GP/FP and community nurses in delivering care. An interdisciplinary team approach including social workers, volunteers, and spiritual care providers will ensure a holistic care.[15] Some of the benefits of community-based primary palliative care include patient and caregiver education, 24 h a day, ongoing telephonic support, respite services, and domiciliary services.[15] Some of the key factors for a successful primary palliative care model include impeccable coordination between specialists and GP/FP, single point of contact, preferably a GP/FP, a trusting relationship between the patient and treating team, seamless transition from specialists to GP/FP, reassurance of support from GP/FP and specialists, and availability of GP/FP for out-of-hours care.[16] Furthermore, continued collaboration between GP/FP and specialists, ongoing training through case discussions, and amicable relationships will ensure the sustainability of the program.[17] Multiple exemplars from the country and the globe have proven the beneficial effects of palliative care integration into the community.[18-20] These models have succeeded in establishing a robust community-based palliative care program and have been accorded as demonstration projects by the WHO. DEVELOPMENT OF COMMUNITY-BASED PRIMARY PALLIATIVE CARE PROGRAM-A COLLABORATION BETWEEN INDIAN ASSOCIATION OF PALLIATIVE CARE (IAPC) AND INDIAN ASSOCIATION OF PREVENTIVE AND SOCIAL MEDICINE (IAPSM) A memorandum of understanding was signed between Indian Association of Palliative Care (IAPC) and Indian Association of Preventive and Social Medicine (IAPSM) on 05th April 2023 in Kolkata with the intention of developing a community-based primary palliative care model. The main goal of this five-year program is to empower Community Medicine physicians to provide primary palliative care in the community. This will entail educating the faculties of Community Medicine, residents in Community Medicine, MBBS students posted to community medicine departments, and allied specialties associated with the department. THE PROPOSED OUTCOME OF THIS PROGRAM INCLUDE The training will certify community medicine physicians to provide primary palliative care in the community through urban health centers, rural health centers, and home-based care. The trained community medicine physicians will educate the residents, MBBS undergraduates, MBBS interns and other faculties in association with the local palliative care teams to augment and sustain palliative care delivery. IAPC and IAPSM will work to ensure that opioids and other essential palliative care medicines are available to patients at the primary health care level. IAPC and IAPSM will collaborate to prepare IEC material to improve community awareness of palliative care and educate the community on the identification and navigation of patients with palliative care needs. The teams will work together to empower NGOs, community-based organizations, and faith-based organizations to advocate for and support the palliative care cause. DELIVERING THE TRAINING A taskforce comprising faculties from Indian Association of Palliative Care and Indian Association of Preventive and Social Medicine will be formed. IAPC-IAPSM will develop a pool of master trainers from among Community Medicine faculties. Faculties from IAPC will provide training and support to Community Medicine faculties via a blended learning approach. The blended learning approach will comprise web-based teaching, hands-on experience, and ongoing case-based discussion. The training and service development will stretch over 5 years. The master trainers will disseminate training to MBBS students (when posted in the community medicine department), MBBS interns, MD students, and allied health care staff posted to their department. DEVELOPMENT OF PRIMARY PALLIATIVE CARE SERVICE The Community Medicine faculties will identify patients with palliative care needs and provide palliative care to their patients. With the support and guidance of the local palliative care team they will develop the palliative care facilities in the general outpatient department, urban and rural health centers and community. They will ensure that there is a seamless flow of essential medicine including strong opioids. Community Medicine faculties will collaborate with local palliative care team for ongoing training and development. Thus, the concerted effort between IAPC and IAPSM will ensure the disseminate palliative care to the patients and their family close to their homes in alignment with patients' wishes and preference. Author's contribution Both the authors contributed to the concept and writing of the paper. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.