Comment
A milestone for palliative care and pain relief
Universal health coverage (UHC) has assumed an iconic
place in work to achieve the Sustainable Development
Goals (SDGs). Its central importance for achieving
SDG 3—ensuring healthy lives for all—is proven by
the increasingly sophisticated efforts to measure
UHC and to estimate to what extent UHC can be
achieved by 2030. An example is the Global Burden of
Disease (GBD).1 The GBD team constructed a UHC Index
by beginning with the idea of access to quality essential
health-care services and access to safe, effective, quality,
and affordable essential medicines and vaccines. They
then took a collection of tracer indicators, including
for vaccines, antenatal care, skilled birth attendance,
facility births, antiretroviral coverage, and treatments
for several diseases amenable to personal health care.
The GBD’s UHC Index was based on a comprehensive
assessment of these components. Palliative care and
pain relief were not among these measures.
Palliative care and pain relief are some of the most
neglected dimensions of global health today. They are
barely even afterthoughts in discussions about the
scope of UHC. The Lancet Commission on palliative care
and pain relief2 seeks to redress these perilous omissions.
Why have palliative care and pain relief been so
ignored in global health? Two reasons might be
considered. First, palliative care and pain relief are
often seen as luxuries for health-care systems. Even
high-income countries with advanced health services
struggle to provide access to comprehensive palliative
care programmes. It would be unreasonable, some
may argue, to include palliative care and pain relief as
core services for UHC. Second, in those high-income
countries where palliative care and pain relief are
available, there is often vigorous and passionate
disagreement about the role of palliative care services
in end-of-life settings. If the professional, public, and
political communities cannot agree on the place of
palliative care in society, introducing this element
into discussions of what should be included within
UHC is unlikely to be helpful or productive. This
Lancet Commission shows that these arguments and
assumptions are entirely fallacious.
Felicia Knaul, who chaired our Commission, and a
team of diverse experts have produced nothing less than
a landmark report:
www.thelancet.com Published online October 12, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32560-6 1
• The Commission describes a new measure of serious Published Online
October 12, 2017
health-related suffering, which captures for the first http://dx.doi.org/10.1016/
time the crisis that must be addressed. S0140-6736(17)32560-6
• It makes a clear call to take more seriously the See Online/The Lancet
Commissions
alleviation of the burden of pain, suffering, and http://dx.doi.org/10.1016/
severe distress associated with life-threatening or life- S0140-6736(17)32513-8
limiting conditions.
• It identifies a cost-effective essential package of
interventions for palliative care and pain relief.
• It sets out feasible actions to “remedy the access abyss”.
• It proposes international collective action to advance
the goals of the Commission.
The Commission’s work does not end with
publication of this report. The Commission will
establish a Working Group to track progress on the
delivery of its recommendations. As WHO, the World
Bank, and other global health institutions continue
to grapple with the task of implementing policies to
accelerate progress towards UHC, palliative care and
pain relief should be included within their vision. Death
and disability are important metrics for describing the
state of the world’s health. But suffering is important
too. Measures of suffering have been absent, and so
the need for palliative care and pain relief services has
been easy to miss. That excuse no longer holds. The
scale of human suffering is massive—61 million people
in 2015 and 6 billion physical and psychological
symptom days annually (4 out of 5 of these days
being accumulated in low-income and middle-income
Kieran Dodds/Panos
 Comment

settings).2 The Commission has uncovered an appalling 1 GBD 2015 Healthcare Access and Quality Collaborators. Healthcare Access
and Quality Index based on mortality from causes amenable to personal
oversight in global health. It is time for that oversight health care in 195 countries and territories, 1990–2015: a novel analysis
to be remedied. from the Global Burden of Disease Study 2015. Lancet 2017; 390: 231–66.
2 Knaul FM, Farmer PE, Krakauer EL, et al, on behalf of the Lancet
Commission on Global Access to Palliative Care and Pain Relief Study
Group. Alleviating the access abyss in palliative care and pain relief—an
Richard Horton imperative of universal health coverage: the Lancet Commission report.
The Lancet, London EC2Y 5AS, UK Lancet 2017; published online Oct 12. http://dx.doi.org/10.1016/
richard.horton@lancet.com S0140-6736(17)32513-8.

I declare no competing interests. I thank Felicia Knaul for leading an

extraordinarily collaborative, innovative, and far-reaching Commission. I also
thank the Commissioners and all those who contributed to the work described in
the final Commission report.

2 www.thelancet.com Published online October 19, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32560-6