With the largest population any single country has ever seen, India faces a dual challenge. First, the country’s ageing population is rapidly increasing. The 60+ age group, which was 71 million in 2001, will grow to be 301 million by 2051. Taken independently, 301 million people would constitute the fourth-most populous country in the world—after India, China, and the United States. The second challenge comes in the form of the rising burden of non-communicable diseases (NCDs). A national study published in 2023 found that diabetes now affects one in every 10 adults, while more than a third live with hypertension in India. Similarly, cancer incidence in India is projected to rise from 1.46 million cases in 2022 to 1.57 million by 2025.
However, this change in the composition of the population will not be uniform across the country. By 2051, South and West India are expected to house the highest proportion of the elderly population in India. Much like ageing, the burden of NCDs will also not fall uniformly across the country. Each State will be navigating its own stage of transitions in population and disease burden, earning India the moniker of ‘nations within a nation’.
As Indians live longer and with a higher burden of chronic diseases, the need for palliative care becomes unmistakable. Moreover, the pressures on the healthcare system will vary significantly across States, underscoring the need for State-specific palliative care policies tailored to these realities.
Progress of palliative care
Palliative care was introduced in the modern form that we know it today in India, in the 1980s. Every year, an estimated 7-10 million people in India require palliative care for serious health-related suffering, out of which fewer than 4% receive it. However, palliative care services are progressively improving in India.
According to the Atlas of Palliative Care in the Asia Pacific Regions 2025 report, India has 818 specialized palliative care services; their access however, is limited. A recent study found that, on average, only one in four people in the country can reach their nearest palliative care center within half an hour using a motorised vehicle, assuming good roads without traffic, ownership of a private vehicle, and fair weather.
The picture is equally grim for access to pain relief. India consumes less than 550 kilograms of morphine annually, a figure that has been stagnant for nearly a decade. Despite legislative reform with the Narcotic Drugs and Psychotropic Substances Amendment Act of 2014, opioid availability has not kept pace with the rising, serious health-related suffering in India.
The workforce for palliative care, though on the rise, is still not sufficient. While it is now a recognised MD specialty, its implementation in undergraduate training for doctors and nurses is inconsistent.
Beyond these gaps lie the profound human consequences of chronic, life-limiting illness. In a recent study in Delhi, nearly half of the households with a bed-bound patient had to cut down on meals and cancel festivals. Caregivers left their jobs, children dropped out of school, and medical care for other family members was delayed or neglected. What begins as illness often escalates into a cycle of generational poverty. Palliative care not only alleviates avoidable physical, psychological, and social suffering but also prevents neglect and overtreatment, thereby reducing unnecessary healthcare expenditure and its associated consequences.
As the demand for palliative care rises, one question looms large — is India’s underfunded health system ready to meet it?
Gaps in existing programmes
In 2012, the country launched the National Programme for Palliative Care (NPPC), which was followed up with the inclusion of palliative care in the National Health Policy in 2017. Among States, Kerala has been a pioneer, introducing a State policy on palliative care in 2008, followed by Maharashtra (2012), Karnataka (2016), Tamil Nadu (2019), and Goa (2023).
The policies that exist vary wildly in their coverage and focus. All States have addressed adult palliative care, but only a few extend a fraction of that attention to children or the elderly. Paediatric palliative care receives minimal mention and support except in Maharashtra’s policy, while only Goa’s policy addresses end-of-life care for older people. Maharashtra’s policy mentions palliative care for only people with cancer, neglecting the burden of non-cancer chronic illnesses that require similar care.
In terms of service delivery, the social welfare and pain relief components remain weak. Only Tamil Nadu’s policy mentions involvement of social welfare departments, but it does not clarify which schemes will include palliative care patients. Similarly, pain relief lacks concrete instructions; access to opioids remains inadequately addressed. Policies merely cite adherence to the NDPS Act, without detailing supply chain management, monitoring, or auditing, leaving a critical component of pain relief largely theoretical.
Financing structures for the palliative care systems are also not well-detailed. Most policies list the National Health Mission as a funding source without any clarity on distributions, sustainability, or accountability. Kerala stands out for proposing a more detailed model, one-third funded by the community, one-third by the panchayat, and one-third by the State government.
While policies and programmes exist on paper, the extent of their implementation remains unstudied. Despite more than a decade since the introduction of NPPC, no formal audit has been conducted to assess its impact. At present, we lack State-level data on how many people need palliative care and on the distinct needs of various groups, including individuals with rare diseases, transgender persons, and older adults with neurocognitive disorders. Only investment in palliative care research can fill these knowledge gaps and pave the way for better evidence-backed policies.
Need for better policies
Palliative care policies need to draw inspiration from other effective public health policies in India. We need not look far, as India’s achievements with maternal and child health offer powerful lessons for palliative care.
The declines in maternal, neonatal, and infant mortality rates were driven by community engagement through ASHAs, who are incentivized to conduct home visits, monitor pregnancies, ensure immunisations, and deliver basic health services. Evidence indicates that areas with active ASHA involvement report higher antenatal care coverage and institutional births. This shows that sustained community participation supported by clear incentives is key to reaching vulnerable populations.
ASHAs are also assigned roles in the NPPC, including identifying suffering patients, facilitating home-based care, and linking them to medical officers. Yet, unlike maternal health programmes, no incentive exists for ASHAs in palliative care. Maternal health programmes used ASHA home visits and cash incentives to reach vulnerable women. Emulating this, palliative care policy could fund ASHAs to identify home-bound patients, conduct follow-ups, and link them to clinics. The Janani Shishu Suraksha Karyakram provides free ambulance transport, medicines, diagnostics, and hospitalisation for pregnant women and infants. Similarly, Surakshit Matritva Abhiyan provides free monthly antenatal check-ups for all expectant mothers. These schemes reduce out-of-pocket costs. Palliative care interventions in India could borrow such ideas.
The National Tuberculosis Elimination Programme is yet another model that palliative care can take inspiration from. Under the Nikshay Poshan Yojana, every notified TB patient receives ₹1,000/month for nutrition. The Nikshay Mitra initiative recruits volunteers or donors to provide food baskets and vocational support to TB patients. Over 1.6 lakh ‘Mitras’ have been paired with TB patients so far. NTEP also introduced ‘TB Champions’ and ‘Nikshay Saathi’ roles to guide patients through treatment. Palliative care must similarly incorporate support systems for food security, education support, and vocational training for caregivers of people with life-limiting illnesses.
Policies must be not only context-specific and evidence-based but also supported by dedicated funding mechanisms to ensure meaningful implementation. Their rollout should be monitored and evaluated through a robust framework that guarantees accountability and transparency.
‘Health in All’ approach
The Health in All Policies (HIAP) approach recognises that improving health outcomes requires looking beyond the healthcare system, meaning policies across all sectors should be designed through the lens of health. Applying this approach to palliative care, education, transportation, and social security schemes should be redesigned to explicitly include patients in need of palliative care.
Patients with life-limiting illnesses who require palliative care should be made eligible for existing social security schemes, with expedited approvals to ensure timely access to benefits. Doorstep delivery of pensions, nutritional supplements, and home-based healthcare services must be prioritised. Caregivers, too, need support through flexible work arrangements, digital learning opportunities, and vocational training. Insurance schemes should explicitly cover home-based care and essential medicines, ensuring that the financial burden of caregiving does not push families into poverty.
Collectively, these measures can transform India’s palliative care landscape. At its core, palliative care reflects our shared humanity. Ultimately, how a society cares for those who suffer, its most vulnerable, defines its character. India must ensure that care, comfort, and dignity are not privileges, but rights for all.
(Ojaswi Phal Desai is a third-year medical student ojaswiphaldessai@gmail.com; Parth Sharma is a community physician and a public health palliative care researcher. parth.sharma25@gmail.com. Both are researchers at the Association for Socially Applicable Research (ASAR). )
