Quality of Death Index 2015 Released – Need for palliative care outstrips services

QODThe Quality of Death Index, commissioned by the Lien Foundation, a Singaporean philanthropic organisation, is based on extensive research and interviews with over 120 palliative care experts from across the world.

It shows that in general, income levels are a strong indicator of the availability and quality of palliative care, with wealthy countries clustered at the top. The UK is top of the list, as it was in the previous index released in 2010. Australia and New Zealand take second and third place, as they did in 2010, while rich European and Asian countries dominate the top 20, along with the US in ninth place and Canada in 11th.

As expected, many developing countries are still unable to provide basic pain management due to limitations in staff and basic infrastructure. Yet some countries with lower income levels demonstrate the power of innovation and individual initiative.

For example, Panama (31st) is building palliative care into its primary care services, Mongolia (28th) has seen rapid growth in hospice facilities and teaching programmes, and Uganda (35th) has made huge advances in the availability of opioid painkillers.

For the first time The EIU has also compared the supply of palliative care – as revealed in the Index – with the demand for such care.

The demand analysis, based on countries’ demographic profiles and the burden of diseases for which palliative care is necessary, shows China to be among the most vulnerable from population ageing and the rising incidence of conditions such as cardiovascular disease, which accounted for one-third of all deaths in the country in 2012.

Many other developing countries will also need to work hard to meet rising future need as the incidence of non-communicable disease increases and their populations grow older.

David Line, the editor of the report, said: “Since the first Quality of Death Index was published this issue has certainly risen up the global agenda, as shown by the World Health Assembly resolution last year calling for improved standards of palliative care across the world.

“But much more can be done, even in countries that rank highly in the Index. It is an issue that will affect us all – a good quality of death should be regarded as a human right.”

The release of the report coincides with World Hospice and Palliative Care Day, a unified day of action organised by the Worldwide Hospice Palliative Care Alliance (WHPCA) and the International Children’s Palliative Care Network (ICPCN) to raise awareness of the need for hospice and palliative care worldwide.

Dr Stephen R Connor, WHPCA Senior Fellow, said: “This new report, released ahead of World Hospice and Palliative Care Day, will help highlight the enormous work that still needs to be done to bring palliative care especially to low and middle income countries where lack of education on palliative care, lack of essential medicines, and lack of government support continue to lead to unnecessary suffering.”

The report can be accessed at www.qualityofdeath.org. Besides the full report, it includes bite-sized country profiles and infographics.

Please feel free to share the findings with your stakeholders to further our collective goal of improving palliative care for communities around the world.

Lien Collaborative for Palliative Care Teaching Schedule




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Dates Country Activity
January 2015 Myanmar 4th teaching programme
June 2015 Sri Lanka 3rd teaching programme
July 2015 Myanmar 5th teaching programme
September 2015 Bangladesh 3th teaching programme
January 2016 Myanmar 6th teaching programme
February 2016 Sri Lanka 4th teaching programme
March 2016 Bangladesh 4th teaching programme

Overseas Clinical Attachment program

The inaugural program commences September. Two doctor participants from Myanmar are scheduled to visit Singapore for 3 months, hosted by the Department of Palliative Medicine, National Cancer Centre Singapore. It is envisioned that this program will sharpen their palliative skills and broaden their perspectives through experiencing different care settings.

Please continue to follow us on our website on the latest updates on the Lien Collaborative.

Members who are interest to help us as teaching faculty during this period, kindly email us at aphn@aphn.org or call +65 6235 5166 to find out more.

Palliative Care service starts in Myanmar

By Dr Wah Wah Myint Zu, Palliative Care Clinic, Yangon General Hospital

13 August 2015 was the opening ceremony of the first Palliative Care Clinic in Myanmar, based at the main general hospital, Yangon General Hospital (YGH). I have been so busy and tired with the preparations. But seeing that the opening ceremony was successful, it feels like all my tiredness was gone and I feel refreshed again! I am so excited and looking forward to giving value added Palliative care service to our patients!!

Our multidisciplinary palliative care team comprises of all the participants from YGH who attended the Lien Collaborative for Palliative Care (LCPC)  Training-of-Trainer in Palliative Care program conducted by the Asia Pacific Hospice Palliative Care Network (APHN). The doctors in the team are Dr Khin Thin Mu from the medical oncology specialty, Dr Yin Thu Win, Dr Lin Lin Kyi and myself from the radiotherapy department (RT) , Dr Soe Thant from the orthosurgical unit, Dr Soe Soe Khaing from PM&R department. May Mar Min Aung and Chaw Kalayar are the palliative care trained nurses. We also have two members, Thin Thin Soe and Thin Thin Wai from medical social work. The team will be taking care of patients using the interdisciplinary holistic care approach like symptom management, nursing care, psycho-social care and spiritual care.

I am very thankful to Prof Myint Thaung (Head of Orthopaedic Department and President of Myanmar Chapter in ASEAPS) who gave the speech at our opening ceremony. He presented on how the Palliative care training is established, about the collaboration between Lien Foundation and APHN group. He highlighted our intention of Palliative care training which is to develop champions in Palliative care service and to train other health personnel about Palliative care.

I will also like to thank Prof Khin Myo Hla (President of the Myanmar Chapter of the International Association for the Study of Pain and Head of the Rehabiliation Department) for supporting us; A/Prof Daw Khin Cho Win (Head of the Radiotherapy Department), Prof U Myo Myint Maw (Head of the Medical Oncology Department) and Prof Win Min Thit (Head of Neuro-Medical Department), consultants from our department; Dr Moe Hlaing, Dr Mie Mie Thwe, consultants from Medical Oncology Department; Dr Phyu Phyu Theint , Dr Shwe Sin Win,Dr Zun Thynn , specialist assistant surgeons and post graduate students from RT, Matron, Patron , Sisters and Staff nurses form both OPD and ward and from the Pain treatment centre, physicists from our RT department and medical social officers. They have all taken time to attend the opening ceremony in spite of their busy workload.  Last but not least, I will like to thank Ms Mona and Dr Reddy's company for helping us and those companies who sent us flowers in support of us.

As this phase of our training program is slowly drawing closer to an end, I will really miss the other palliative care participants. We have a bulletin board showing photos of our Palliative Care Training activities by the APHN, right from the first module which started in Dec 2012 to the fifth module which ended in July 2015. They showed our hardwork, role playing and team spirit building activities, group presentations and at one occasion, a remarkable relaxing dinner. Our 6th and last module will be in Jan 2016.

To all the other participants of the LCPC program, we welcome you anytime to visit our clinic and any help you offer to us will be very much appreciated.

If you are interested to find out more about the Lien Collaborative for Palliative Care or contribute articles on palliative care services in your country, please contact Joyce at aphn@aphn.org or +65 6235 5166.


Lien Collaborative for Sri Lanka Module 3 of 6 – The trip report

Large group discussions
Bedside teaching in Oncology ward at National Cancer Institute, Maharagama
Group photo at Distric Hospital in Vauniya, Northern province of Sri Lanka
Visiting a ward in District Hospital, Vauvniya
Palliative Care Unit and referral centre at District Hospital, Vauvniya

Case discussion with visiting faculty

New hospice at Cheddikulam, Northern province to open in August 2015

Patients gathering at the prayer area to fold lantern wicks at Cancer Care Hospice in Kurundankulama, Anuradhapura, Northern Province

The 3rd module of the Lien Collaborative for Palliative Care – Training of Trainers in Palliative Care Programme for Sri Lanka took place from 29th June to 3rd July this year at the National Cancer Institute, Maharagama in Colombo. The faculty comprise of 4 doctors and 2 nurses from Singapore and Australia. They are Associate Professor Cynthia Goh (Project Lead), Associate Professor Ghauri Aggarwal (Country Lead), Dr Allyn Hum, Dr Suharsha Kanathigoda, Mr Joshua Cohen, and Ms Peggy Chen.

The key topics covered in the teaching included service development, care for non-cancer patients, ethical issues in palliative care, symptom management and scope of palliative care.

The teaching model consists of large group and small group discussions, lectures, case discussions and ward rounds. In addition to those, a brainstorming session on the last day was added into this module to discuss learning points of the programme and for participants to provide feedback and ask questions. Many questions were raised and everyone wished that this session could have been even longer. The participants were interested for more information on the issues facing them in providing care and to discuss the challenges when starting palliative care services in Sri Lanka.

We had the opportunity during this module to visit the newly set up hospices and palliative care services around Sri Lanka. On the 4th of July, the team went to the District Hospital in Vavuniya, located in the Northern Province of Sri Lanka. There are currently no separate palliative care unit with full time doctors and nurses in the hospital. However, one of our module participants, Dr Ranjan Mallawaarachchi, an oral and maxillofacial (OMF) surgeon at the hospital, has established a team within the OMF unit to care for patients who needs palliative care. He has also founded the Regional Association for Palliative Care – Northern Province to work on developing palliative care services in Sri Lanka.

The team also went to visit a hospice set up by Dr Ranjan and his team in Cheddikulam, the Northern province of Sri Lanka. According to Dr Ranjan, the service will open in August this year. We are all excited and looking forward to it. As palliative care is something new to many in Sri Lanka, creating awareness and trust among healthcare professionals is important to get referrals for admission to the hospice.

Another hospice which we visited is the Cancer Care Hospice. According to Dr Samadhi W.Rajapaksa, director of the Cancer Care Association, there was no doctor willing to refer their patients to the hospice until the director of a hospital was convinced by him and came personally to admit the first patient.

As the palliative landscape in Sri Lanka continues to develop, both the government and non-profit organizations are working hard to increase awareness of palliative care among the healthcare workers and members of the public. Relative to the need, there are only a few institutions providing palliative care or hospice services in the country. Palliative Care is not yet an established medical or nursing specialty in Sri Lanka.  The APHN hopes to continue to engage and support the various initiatives to strengthen the development of palliative care in Sri Lanka.

If you will like to contribute to the Lien Collaborative for Palliative Care, we welcome you to email us at aphn@aphn.org and visit our website http://aphn.org/lien-collaborative-for-palliative-care/ to find out more.

Sri Lanka – Training program on integrating the services of hospices for provision of community based palliative care for cancer patients.

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Dr. Samadhi Rajapaksa delivering the lecture

The above mentioned training program organized by the National Cancer Control Program of the Ministry of Health & Indigenous Medicine, Sri Lanka, with the intention of strengthening the partnership between organizations providing palliative care in Sri Lanka for further expansion of community based palliative care, was held in Shantha Sevana Hospice Colombo, on 17th March 2015.

Dr. Samadhi Rajapaksa as one of the main resource personal specializing in the development of Home Based Palliative Care in Sri Lanka, delivered a highly informative lecture addressing the importance and the value of such an initiative in uplifting palliative care in Sri Lanka. The practical challenges that arise when implementing it at ground level, was also highlighted based on the experiences the CCASL has had when conducting home visits in remote areas of Gall, Anuradhapura and Colombo. Dr. Suharsha Kanathigoda (a palliative care specialist from Sydney, Australia and also founder of the Shanti Foundation) and Dr. Suraj Perera (Consultant Community Physician) also participated in this event.

From APHN Sri Lanka News Team – Cancer Care Association of Sri Lanka


Commencement of Home Base Palliative Care Service in Colombo and Anuradhapura, Sri Lanka

Written by Cancer Care Association Sri Lanka (CCASL) – APHN Editorial Team (Sri Lanka)

In commemoration of the World Cancer Day which falls on 4th February of every year, Cancer Care Association Sri Lanka (CCASL) expanded its Home Based Palliative Care Service (HBPCS), first of its kind to treat Sri Lankan underprivileged cancer patients, to the districts of Colombo and Anuradhapura.

This service was first inaugurated in the district of Gall, in southern Sri Lanka, by the Karapitiya branch of CCASL under the guidance of Dr. Samadhi Rajapaksa (current president of CCASL) and Dr. Iresh Jayaweera (then president of the Karapitiya branch). The objective of HBPCS is to treat palliative cancer patients in the comfort of their own home and amongst loved ones.

A team of volunteers comprising of a medical doctor, a nurse and trained palliative care practitioners from CCASL visit the homes of cancer patients in need of palliative treatments, mostly in remote areas. They engage in activities such as pain management, treating cancer related wounds and bed sores, monitoring the vital signs of patients such as blood pressure, blood glucose level etc., administering relevant drugs (done by the medical practitioner accompanied by the team) and most importantly religious activities such as meditation, counseling etc., to uplift the spiritual well being of the patient (which is of utmost importance, at the palliative care stage).

Hence on 4th February 2015 (World Cancer Day), the CCASL Home Based Palliative Care team visited pre-identified patients in the districts of Colombo and Anuradhapura to inaugurate the expansion of its services to the above mentioned districts. A total of four patients were visited within two days and the patient feedback was immensely positive and highly commendable. CCASL will continue to provide similar services to the underprivileged cancer patients of Sri Lanka, in months to come.

Given below are some pictures of the event.

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Dr. Iresh Jayaweera and Dr. Samadhi Rajapaksa treating the patients









Home Base Palliative Care Team during a home visit in Anuradhapura

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Patient monitoring and counselling 

Brought to you by APHN Editorial Team (Sri Lanka) : Dr. Samadhi Rajapaksa (President, CCASL); Mr. Hasitha Premathilake (Secretary, CCASL); Dr. Iresh Jayaweera (Chief Organizer, CCASL)

Lien Collaborative builds palliative care capacity in Myanmar

IMG_2584 ver3January 2015 saw the 4th instalment of the training-of-trainers in palliative care program at Yangon General Hospital, Myanmar.

The training was implemented by a volunteer faculty of doctors and nurses from the Asia Pacific Hospice Palliative Care Network (APHN) coming from Australia, Malaysia and Singapore.

As part of the Lien Collaborative for Palliative Care initiative, the program aims to develop palliative care leadership and capacity in the mainstream government health system.

Small group discussions, case-based learning and teaching on the wards by interacting with patients featured prominently throughout the teaching week.

The in-country training is complemented by overseas clinical attachments for selected participants. This is planned to start from September 2015, with the first batch visiting Singapore for a 3 month-long attachment which aims to enhance each recipient’s understanding of running a palliative care service as well as clinical skills.

The APHN team also supports its local partners, such as the Myanmar Medical Association (MMA) in their efforts to engage the Health Ministry.

This advocacy is aimed at better access to essential pain medications, the introduction of palliative medicine into the medical and nursing curriculum, and the establishment of palliative care services at the principal tertiary hospitals.

The MMA has just ratified the creation of a Palliative Medicine special interest group to advance the development of this area of healthcare in Myanmar, including the intention for this group to spearhead the formation of a national strategy for palliative care.

Local media organisations have also been helpful in raising the awareness of hospice and palliative care, read this related article by Mizzima Media.

The Lien Collaborative is also active in Bangladesh and Sri Lanka with several more in-country training programs scheduled over the course of the year.

If you or your organisation would like to be a partner in the Lien Collaborative, please contact the APHN at aphn@aphn.org.

From ehospice

Media reports on the Lien Collaborative for Palliative Care – Sri Lanka

Media reports by:

Source: Lien Foundation

Lien Collaborative for Palliative Care launched in Sri Lanka

ColomboThe APHN, together with Singapore philanthropic house, the Lien Foundation, partnered Sri Lanka’s National Cancer Institute (NCI) Maharagama and the Sri Lanka Ministry of Health’s National Cancer Control Programme (NCCP) to launch the 1st Module of the Training of Trainers in Palliative Care Course for medical professionals in Sri Lanka on 24 March 2014. Sri Lanka’s Ministry of Health and the National Cancer Institute have made the provision of palliative care a key priority in the country. This is in line with a historic resolution on palliative care…read more

Lien Collaborative for Palliative Care launched in Sri Lanka

“Palliative care is a new field in Sri Lanka which needs attention. While Sri Lanka is a developing country with a free health system, the development of palliative care in Sri Lanka is very slow due to lack of funds and expertise.”

~ Dr.Iresh Jayaweera (MBBS,Certificate in Palliative Care), Secretary, Cancer Care Association- Sri Lanka

The APHN, together with Singapore philanthropic house, the Lien Foundation, partnered Sri Lanka’s National Cancer Institute (NCI) Maharagama and the Sri Lanka Ministry of Health’s National Cancer Control Programme (NCCP) to launch the 1st Module of the Training of Trainers in Palliative Care Course for medical professionals in Sri Lanka on 24 March 2014.

Palliative care a national priority for Sri Lanka
Sri Lanka’s Ministry of Health and the National Cancer Institute have made the provision of palliative care a key priority in the country. This is in line with a historic resolution on palliative care adopted by the World Health Organisation (WHO) in January 2014. The WHO resolution urges countries to integrate palliative care in their healthcare systems, improve training for healthcare workers, and to ensure relevant medicines are available to patients.

The Lien Collaborative in Sri Lanka aims to help Sri Lanka develop a mainstream health strategy incorporating palliative care. It will scale up palliative care training in the country, and aid the expansion of palliative care services to nine major cancer centres across Sri Lanka.

Urgent need for palliative care
Even though Sri Lanka has a rather advanced healthcare system with free universal healthcare, there are currently insufficient trained professionals and hospices in the country. While an estimated 17% of deaths are caused by cancer in Sri Lanka (WHO, 2008 estimates), the country is categorised as having only “isolated palliative care provision” (Global Atlas of Palliative Care at the End of Life, 2014). Globally, it is estimated that less than 10% of the need for palliative care is currently being met; and while 80% of the global need for palliative care is in low and middle-income countries, most palliative care is provided in high-income countries (The NCD Alliance, January 2014).

Building palliative care expertise in the region
The Lien Collaborative for Palliative Care is a regional initiative co-developed by Lien Foundation and APHN to enhance capacity for palliative care services provision in selected Asian countries with little or no such services. The Collaborative’s mission is to spearhead the development of palliative care capabilities and build up a core interdisciplinary group of clinicians capable of training others and to act as champions for palliative care within those countries. Started in 2013, the four-year S$1.8million programme has launched in Myanmar and Bangladesh. Sri Lanka is the third of four countries to join the Lien Collaborative, on the back of funding from a Sri Lankan donor.


Multi-national medical team of trainers
Taking place from 24 to 28 March 2014, the Lien Collaborative in Sri Lanka involves a multi-disciplinary medical faculty headed by Singapore’s Associate Professor Cynthia Goh and includes three other doctors and two nurses from Singapore and Australia. Three of the doctors have Sri Lankan origins, making this mission a personal voyage for them.

Strong interest from Sri Lanka – largest batch of trainees
The Lien Collaborative for Palliative Care has met with strong interest in Sri Lanka. 50 participants registered to attend the course. This includes 16 consultant oncologists out of 31 oncologists in the whole country (28 in the government sector, three in private practice). Other attendees include one consultant who is an oncology surgeon, 16 consultant physicians from various disciplines, 4 medical officers, 11 nurses and nurse educators, one psychologist and one social worker, coming from the various universities and government hospitals around the country. This is the biggest batch of medical specialists trained by the Lien Collaborative to date.


Related Media Reports:
The New Paper – read article
Tamil Murasu (in Tamil) – read article
Straits Times – read article

Lien Collaborative – the progress so far


Yangon General Hospital

The Lien Collaborative for Palliative Care was inaugurated in Myanmar when the first training was rolled out from 16-22 June 2013. Five expert faculty, 3 doctors and 2 nurses from Singapore and Australia, taught 27 selected candidates from around the country, doctors, nurses and medical social workers, from 11 hospitals and 1 hospice. The host was the Department of Oncology at Yangon General Hospital, the country’s largest teaching hospital. A National Seminar on Opioids was held in Yangon on 5 Oct 2013, organised by the Myanmar Society for the Study of Pain and supported by 3 overseas faculty from the APHN and the Pain and Policy Study Unit, Wisconsin, USA.

Bangladesh was the second country to have this programme. Six faculty, 3 doctors and 3 nurses from Australia, India and Singapore, taught 50 doctors, nurses, pharmacists and social workers from 25-31 July 2013. The teaching took place at the Palliative Care Unit of the Bangabandhu Sheikh Mujib Medical University and at the Oncology ward of the National Institute of Cancer Research and Hospital in Dhaka. A seminar on Opioid Availability was held on 11 April 2013, attended by the Director of Narcotics and his staff. Work is also in progress on a MD curriculum for Palliative Care, supported by APHN faculty. When completed in Dec 2013, this will enable the discipline to be recognised as a medical specialty…more

Lien Foundation to develop palliative care initiatives in Myanmar

CNA_130711The Lien Foundation initiative hopes to train about 30 doctors and nurses in better understanding what palliative care is and how to roll it out in a sustainable manner.

The week-long programme will be conducted bi-annually over three years.

Dr Cynthia Goh, chairperson of the Asia Pacific Hospice Palliative Care Network, said: “Here is something which is low-tech, which is easily available and cheap that we can do right now. For example, a radiotherapy machine costs $1 million and you need to set it up and you need to have the manpower to run it. We already have the doctors and nurses on the wards looking after the patients. We just improve their capabilities.”

Although no official data exists, Myanmar’s medical association has identified a rising number of patients with chronic diseases cancer…read more

From Channel News Asia