1. Dr Suresh Kumar, Institute of Palliative Medicine, India

2. “ So much is known in palliative medicine, but unfortunately this knowledge is not benefiting most of those in need of it. In spite of all the effort over the last two decades, the great majority of individuals that need palliative care are not getting it” -Stjernsward J and Clark D:” Palliative Medicine-a Global Perspective” in Oxford Textbook of Palliative Medicine, 3rd Edition Eds. Doyle D, Hanks G et al Oxford University Press, Oxford.2004 Chapter21, 20 Pubhealth Pallcare 2009

3.  “Meaningful palliative care requires a combination of socio-economic, cultural, and medical solutions. All three must be addressed. Not purely a medical issue, the cultural and socioeconomic factors determine what kind of death we face. Today’s overemphasis on medical approaches can be balanced only by the people taking ownership” – Dr Jan Stjernsward Pubhealth Pallcare 2009

4.  The challenge before palliative care workers anywhere in the world is to find a way to assure continuous and meaningful care to most of those who need it  How successful are we in meeting this challenge?

5. Pubhealth Pallcare 2009  Looks after more than 9000 patients at any point of time- all the services are free  More than 10,000 community volunteers offer their services with out any remuneration  All the expenses for delivery of care (including salaries, cost of medicines, food for the family, educational support for the children) raised locally

6. Pubhealth Pallcare 2009  Empowerment of the local community to look after the bed- ridden patients in their area  To develop a cost- effective method for the provision of palliative care

7. Pubhealth Pallcare 2009 Community volunteers do  Regular, continuous emotional support for the patients and family  Data collection/ needs assessment  Social support to the patients  Wound care, bedsore prevention, mobility  Organisation & administration of palliative care services including fund raising

8. Pubhealth Pallcare 2009  Anyone who wants to contribute in the efforts to reduce the suffering of people living with advanced diseases  Structured training given to those who are willing to spend at least two hours per week for the work

9. Pubhealth Pallcare 2009  Training as part of generation and dissemination of knowledge  16 hours of theory  4 days of practical work

10. Pubhealth Pallcare 2009  Network of trained volunteers in the community  Support system by trained professionals, institutions and organisations  Palliative care institutions as nodal centers

11. Pubhealth Pallcare 2009  >98% of the total money raised locally  30% from the local government  20% from Government of Kerala  The rest from the community  >75% of this as donations of less than 25 cents

12. Pubhealth Pallcare 2009  Specialists have a definite but small role  Primary care physician in the periphery to be involved  Massive involvement from the local community

13. Pubhealth Pallcare 2009  The volunteers identify people in need of care in their area (panchayath).  They identify the needs and plan the services that can be offered  Seek the help of health care professionals for addressing medical and nursing issues  Existing NNPC groups gives the support for initiation of these services  As the service grows the local support increases and other NNPC groups gradually withdraws from the facilitator role

14. Pubhealth Pallcare 2009  Can reach inaccessible populations through informal community networks  Ability to tailor the intervention to the needs and resources of the community  Can maximize social pressure and encourage structural changes such as policy and service reorientation  Use local resources, knowledge, expertise  Create conditions in which people can become empowered  Can be a cost effective strategy for community outreach

15. First government in Asia to have a palliative care policy Drafted in consultation with existing palliative care groups Emphasises community based home care Gives guidelines for the development of services with community participation Aims to integrate the existing services with the main stream health care and Local Self Government Institutions Pubhealth Pallcare 2009

16. Building Awareness  General public  Health care professionals  LSGI members Capacity building  Health care professionals  General community Demonstration projects linked to Local Self Government Institutions Establishing Training centers Establishing a Resource and Co ordination center Pubhealth Pallcare 2009

17. Palliative Care in Kerala –The emerging model Community owned initiatives in palliative care Home care projects by the local governments Government of Kerala’s initiative to reorient the primary health care system to work closely with the community initiatives Pubhealth Pallcare 2009

18.  Public health approach in palliative care  Community participation as the core principle  No blue print for development  Need based evolution Pubhealth Pallcare 2009

19.  Catalonia: Good coverage for cancer patients; Integration into all levels of health care system; coverage for non cancer patients poor; community participation poor/ nil? Batiste 2007  “Some countries such as Spain have taken a coordinated public health approach to planning and implementing palliative care services from the outset” - Sheila Payne Pubhealth Pallcare 2009

20.  “Palliative care needs to be regarded as a public health issue rather than a specialist provision for the few” - Foley  Involvement of health care institutions  “Whole-community interventions” ( Byock et al -2001 )  But only awareness issues when it comes to the role of the community  “Potential benefits in professionalising dying”- Sheila Payne  Over medicalisation of dying - Stjernsward  “Creeping Medicalisation in palliative care”- Conway Pubhealth Pallcare 2009

21. Top down  Stjernsward  Foley  Kasa  Bruera Bottom up  Stjernsward  Kellehear  Conway  Kumar/ Numpeli Pubhealth Pallcare 2009

22.  A public health approach  Which model?  Top down?  Bottom up? Pubhealth Pallcare 2009