Implementing large-scale palliative care training in LMICs: Experiences and challenges

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Published: 21 Nov 2022
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Dr Eric Krakauer - Harvard Medical School, Boston, USA

Dr Eric Krakauer speaks to ecancer about the experiences and challenges in implementing large-scale palliative care training in low-middle-income countries.

He explains why large-scale palliative care training in LMICs is required and what are some of the challenges to implementing such programmes. 

The training programme supported by WHO aims to overcome some of these challenges and there are several institutes across the globe which are collaborating with this training programme. 

This means that palliative care will be more accessible and improved in those areas.

Dr Krakauer concludes by discussing the future of this training programme and explains how one can join this programme.

I’m chairing a session on implementing large-scale palliative care training in low- and middle-income countries. We have some of the most amazing, impressive leaders in palliative care education from low- and middle-income countries.

What are the challenges to implementing large-scale palliative care training in low-and middle-income countries and how can these be overcome?

First I think I should say that palliative care is never a substitute for cancer prevention, diagnosis and treatment. Even as a palliative care specialist, all of us in palliative care should support in any way we can access to cancer prevention, diagnosis and treatment. That said, cancer treatment without palliative care also is inadequate, it’s second-rate. The two, cancer treatment and palliative care, need to go together and, in fact, prevention, diagnosis, treatment and palliative care, those four, all need to go together. 

About training, training is not that difficult to implement; more difficult is to make sure that the trainees are able to use what they learn. That can require policy changes and buy-in from governments and medical schools and public health leaders. But otherwise it just takes recognition that palliative care is important and should be part of basic medical training and also specialist training. So WHO has recommended that there be at least three levels of palliative care training. Basic training in palliative care, lasting approximately 35 hours, one week full time or longer or extended over a semester or even years, for all medical students, all nursing students and all primary care providers. Most people who need palliative care are not in hospitals, they’re at home, in the community. So WHO has said that palliative care is an essential part of primary healthcare and those who provide primary healthcare and care in the communities need to have basic training in palliative care.

Intermediate level palliative care, lasting about twice as long, approximately 70 hours, should be required for all specialists in disciplines where care is provided for patients with serious illnesses. So that means all specialists in oncology, haematology, internal medicine, family medicine, geriatrics, paediatrics, critical care, cardiology, they should have more advanced training in palliative care because a lot of their patients need it. 

Finally, and this is the most difficult part, there needs to be palliative care specialist training in the developing world. It’s not adequate for specialists like me from rich countries to go and do training. That is, in itself, not adequate. There need to be specialists in palliative care who are home-grown, home-grown leaders in palliative care, teachers, leaders, implementers. So my group at Harvard Medical School is working with colleagues around the world in specifically chosen sites to create centres for palliative care training that provides all levels of training – basic, intermediate and specialist training. So, for example, at the University of Medicine and Pharmacy in Ho Chi Minh City we now have our fourth cohort of specialist trainees in palliative care and our first cohorts are already leading palliative care programmes around the country. The plan is to make this training accessible to doctors from other countries in the region so it becomes a regional palliative care training centre. A similar project is underway for Latin America at the Pontifical Catholic University of Chile with whom we also partner and the earlier stages are underway in other sites in Africa, the Caribbean, Russia and China. 

The challenge there is that for our specialist trainees to be able to work there needs to be an official speciality approved by the government in palliative care and there needs to be policy that states that palliative care services in the major cancer centres and general hospitals should be led within a certain number of years by a palliative care specialist. So policy is a major challenge and if, for example, at our training programme in Ho Chi Minh City, if we are able to get funding to welcome trainees from Cambodia, Laos, Myanmar, Indonesia, the Philippines etc., they need to be able to have their specialist training recognised in their home country. So it’s not just a question of training specialists to be the teachers and the leaders and the supervisors, they need to have their training recognised in their home countries. So those are some of the… The training in itself is not expensive but those are some of the challenges.

What does the future look like?

We have six or seven sites with whom we’re working. They’re basically all medical schools, as I mentioned: in Santiago, Chile; the University of the West Indies in Kingston and in other sites in the Caribbean; the Université Cheikh Anta Diop in Dakar, Senegal; the University of Global Health Equity in Rwanda; I’ve mentioned Vietnam; Sechenov University in Moscow; Peking Medical College Hospital in China and we’re also doing a lot of work in the Middle East with the Eastern Mediterranean regional office. But the challenge is that although the idea is to create the home-grown leaders and that will make the training sustainable because the programmes will develop internally, there needs to be this input, a sort of catalyser from outside, and that’s us from Harvard Medical School. 

So my team, we have people who are fluent in all six UN languages and we have training curricula of all levels and we can go and train and mentor the trainers, the leaders for other countries. But funding is terribly difficult to find. With funding we can in three years help partners in developing countries create these training programmes, again all levels – basic, intermediate and specialist, and mentor the specialists long term so that over some years they don’t need us anymore, they don’t need the input from the West. But at the beginning it’s really needed to get these programmes going and to train the first leaders so it’s a desperate search for funds that are only, again, needed for a few years but it’s sine qua non – I just can’t do it all on vacation time and have my junior colleagues donate their vacation time to do this training. 

How can one become a part of this palliative care training programme?

My programme is based at Harvard Medical School and our faculty consists of palliative care specialists so people are welcome to contact my group at the Programme in Global Palliative Care at Harvard Medical School or any of the sites that I mentioned around the world. People can also contact their national palliative care societies, many countries have national palliative care societies, and there are also regional palliative care societies. In Latin America, for example, the Asociación Latinoamericana de Cuidados Paliativos, I think it’s called in Spanish; the African Palliative Care Association; the European Association for Palliative Care; the Asian Hospice Palliative Care Alliance, I think it’s called or Asia-Pacific Hospice Network, I think, is its name. So contact the regional and they all have websites. Contact the regional societies.

Anything else to add?

I guess I would just say that palliative care is most simply a response to suffering. It’s to relieve human suffering. Treatment of cancer is also a way to relieve suffering but, again, treatment without palliative care is not as good as it could be so palliative care needs to be a part of cancer care. At the same time palliative care is never an adequate response alone to cancer, there needs to be prevention, diagnosis, treatment and palliative care all together.