From Paper to Patients: Why India must put Palliative Care Policies into Practice

From Paper to Patients: Why India must put Palliative Care Policies into Practice

– Ms. Smriti Rana, Thiruvananthapuram

Only 4% of India’s population has access to palliative care. Many of the right ideas have already been written into policies: the National Programme for Palliative Care (NPPC, 2012), the National Health Policy (2017) that recognizes palliative care, operational guidelines to deliver services through Health and Wellness Centres (HWCs), and, crucially, legal reforms to ease access to opioid analgesics for severe pain. The challenge is not a lack of frameworks policies; it is uneven, incomplete, and inconsistent implementation. Converting policies on paper into services at the bedside will determine whether the estimated millions of Indians who need palliative care each year can actually get it.

Without implementation, policies amount to nothing. India’s burden of serious health-related suffering is huge, and growing, driven by cancer, neurodegenerative disease, other NCDs and multimorbidity in an ageing population. Although the NPPC and subsequent guidance outline delivery models, medicine, training, and financing channels, coverage remains sparse and highly variable. The result is a postcode lottery: a patient’s access to symptom control, psychosocial support and appropriate end-of-life care depends on where they live and which facility they can reach. Kerala’s experience shows what consistent state-level implementation can achieve; after adopting a statewide policy in 2008 and embedding community- and home-based care into the public system, Kerala sustains broader coverage than most states. This doesn’t mean that this is the only workable model, but that a state-backed policy with clear roles, financing, and community partnerships can scale quickly and sustainably.

Policies on access to medicine illustrate how implementation closes life-altering gaps. A 2025 comparative analysis by Parth Sharma and colleagues examined India’s national and state essential medicines lists (EMLs) against the International Association for Hospice and Palliative Care (IAHPC) recommendations. They found major shortfalls: no list included all recommended formulations of morphine, and many state lists omitted oral morphine altogether—despite morphine’s centrality to cancer pain relief and its use as an NPPC performance indicator. The study also showed that while symptom control is theoretically possible using alternatives, several states lack adequate substitutes, leaving real clinical gaps. Updating and enforcing EMLs—procurement, stocking, and rational/ safe prescribing—are implementable, near-term steps that can relieve suffering at scale.

The legal framework tells a similar story. India amended the Narcotic Drugs and Psychotropic Substances (NDPS) Act in 2014 to improve access to opioids by centralizing certain licensing steps and reducing the paperwork burden. Yet, reports after 2014 show that ground-level access still lags where state rules, institutional practices, or provider fears remain unchanged. Policies must be implemented in hospitals and districts: single-window licensing actually used; hospital committees constituted; supply chains stabilized; prescriber training made routine; and monitoring aligned to patient outcomes, not just kilograms procured. Where states act on these steps, morphine and other essential opioids can be made both available and accountable; where they do not, patients remain in avoidable pain.

At the National level, implementation policies must look at:

1. Creating standards: The Ministry of Health and Family Welfare can translate the NPPC and HWC operational guidelines into a short set of measurable national standards: a minimum palliative care package at primary, secondary, and tertiary levels; drug availability indicators (including oral morphine); and competency based training for doctors, nurses, and community health workers.
2. Financing that follows services: The NPPC already provides a mechanism for states to propose activities through their Programme Implementation Plans. Making allocations conditional on performance against a few core indicators (coverage of home-based care, essential drug availability, trained teams per district) would align money with service delivery rather than plans alone.
3. Capacity-building at scale: Governments can designate training hubs to deliver structured, modular courses for primary-care teams and specialists, with online components to reach remote districts and credit linked to career progression. Evidence from Indian programs shows training increases clinician confidence to manage common palliative needs; national scaling would normalize palliative care as a core skill set rather than a peripheral option.
4. Drug policy enforcement: National bodies can require EML alignment with IAHPC-consistent lists (adapted to India) and verify procurement down to district warehouses. A one-time, centrally supported revision of state EMLs—using Sharma et al.’s gap analysis as a template—would be a concrete starting point.

At the state level, implementation needs to be closer to the ground realities of health services and communities:

• Adopt or update a state palliative care policy (as Kerala did) that defines service models (home-based, outpatient, inpatient consult), referral pathways, and roles for local self-government institutions and accredited civil society partners. Embed palliative care explicitly within existing noncommunicable disease and cancer programs to leverage staff and budgets already in place.
• Make palliative care part of comprehensive primary health care: HWCs are designed to deliver home-based and community-based services; states should integrate palliative care registers, regular home visits for bed-bound patients, and family caregiver training supported by simple tools and tele-mentoring from district hospitals.
• Last-mile linkage for essential drugs: Once EMLs are updated, districts must place and track orders, ensure secure storage, and institute monthly stock audits. Sharma et al.’s finding that many lists omit needed formulations is a solvable administrative problem.
• Invest in training and mentorship networks: Short courses for primary-care physicians, nurses, and ASHAs should be routine, with periodic refreshers and case-based mentoring. Kerala’s experience with community volunteers and NGO partnerships shows how a trained, supported network can multiply reach while keeping care person-centred.
• Include people with lived experience in the feedback loop: States should add patient-reported pain scores, caregiver burden indicators, and place-of-death metrics to their monitoring systems. This keeps the focus on relief of suffering and dignity, not just patient contacts.

Implementation also demands policy coherence across sectors. For example, legal reforms to the NDPS Act only improve access when drug controllers, hospital administrators, and prescribers follow simplified procedures without reverting to older, more restrictive habits. Similarly, national EML updates must reflect in procurement, logistics, and dispensing; each link is a potential failure point if not monitored. SOPs, audit tools, and supportive supervision can be provided nationally—while states can ensure that district officers and facility heads are accountable for meeting standards.

All of this cannot remain a cerebral exercise. Studies by Sharma et all look at Indian data and demonstrate how misalignment with palliative care needs, particularly around opioid formulations, translates into avoidable suffering. Their earlier state-wise mapping and access work underscore geographic inequities and provide a framework for improving access to palliative care. Policymakers should use these analyses not merely as evidence of gaps, but as a practical to-do list: update EMLs; ensure morphine is present in appropriate formulations and build capacity statewide.

India does not need new masterplans to improve palliative care access. The blueprints exist in the NPPC, national policy, HWC guidelines, state exemplars like Kerala, and legal reforms to pain-relief access. What is needed now is disciplined implementation that is aligned with reality; fund and staff home- and community-based services; train the workforce that already serves most patients; and track patient outcomes. Doing so will not only reduce suffering and prevent catastrophic financial toxicity — it will also honour a fundamental promise of the health system: that every Indian, wherever they live and whatever they earn, has a right to affordable, accessible, and quality care.

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References:

1. National Program for Palliative Care, Directorate General of Health Services: https://dghs.mohfw.gov.in/nppc.php
2. Palliative Care in India: Past,Present and Future: Salins N, Bhatnagar S, Simha S, Kumar S, Rajagopal MR. Indian J Surg Oncol. 2022 Dec;13(Suppl 1):83-90. doi: 10.1007/s13193-022-01556-0. Epub 2022 Jun 9. PMID: 36691499; PMCID: PMC9859967.
3. Operational Guidelines for Palliative Care at HWCs: https://nhsrcindia.org/sites/default/files/2021-06/Operational%20Guidelines%20for%20Palliative%20Care%20at%20HWC.pdf
4. Home-based Palliative Services under Two Local Self-government Institutions of Kerala, India: An Assessment of Compliance with Policy and Guidelines to Local Self-government Institutions: Jayalakshmi R, Suhita CC. Indian J Palliat Care. 2017 Jan-Mar;23(1):65-70. doi: 10.4103/0973-1075.197947. PMID: 28216866; PMCID: PMC5294441.
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