India’s palliative-care challenge is no longer only about whether hospitals can control pain. It is about whether the health system can reach patients who are too frail, elderly or bedridden to travel. The contrast between Kerala’s extensive community network and Uttar Pradesh’s much smaller home-care reach shows why home-based palliative care is becoming a test of last-mile healthcare delivery.
The issue is especially significant for people living with cancer, advanced heart or lung disease, neurological disorders, frailty, dementia and multiple chronic illnesses. For these patients, repeated visits to hospitals can be physically difficult, financially burdensome and practically impossible when mobility is severely restricted. A palliative-care unit may exist within a district, but that does not necessarily mean that a patient in a rural or semi-urban household can access it.
The report in the Times of India points to a shift that healthcare systems must make: palliative care cannot remain organised primarily around hospitals. It must be connected to primary healthcare, community workers, local institutions, trained nurses, voluntary organisations and families. The question is therefore not simply how many facilities a state has created, but how effectively those facilities remain connected to people living with serious illness at home.
This distinction also changes how pain itself is understood. Dr Abhishek Shukla, a geriatric and palliative-care specialist at Aastha Centre of Geriatric Medicine, Palliative Care & Hospice, said pain management should not be reduced to prescribing medicines or lowering a pain score. The more important question is what pain prevents a patient from doing: sleeping, eating, walking to the dining room, speaking with family or carrying out a meaningful daily activity.
That approach matters particularly for older people who may have communication difficulties, dementia or several illnesses at the same time. Pain may appear through agitation, withdrawal, disturbed sleep, loss of appetite, reduced mobility or changes in behaviour rather than through a direct verbal complaint. Assessment therefore depends on listening, observation and understanding the patient’s circumstances, not simply recording a number.
Patients with similar diseases can experience pain differently. Anxiety, fear, previous experiences, emotional condition, social circumstances and expectations can influence how suffering is expressed. The cause may also vary, from the disease itself and nerve involvement to inflammation, pressure, injury, constipation or immobility. Treatment can consequently include appropriate medicines, physiotherapy, positioning, mobility support, psychological assistance and other non-pharmacological interventions.
Opioids can be clinically important for moderate to severe pain in advanced illness, but their use requires appropriate assessment, prescribing and monitoring. At the same time, fear of these medicines should not prevent legitimate pain relief. The objective is not always complete elimination of pain. For one patient, comfort may be the priority; another may value alertness to communicate with family; a third may prioritise walking independently or eating without discomfort.
This is where palliative care becomes an institutional question rather than only a clinical one. Persistent, uncontrolled pain can affect sleep, appetite, mobility, communication and independence. It can increase the demands placed on family caregivers and make patients dependent on others for activities they might otherwise continue performing. A health system that treats comfort and dignity as secondary may technically provide treatment while failing to address the lived experience of serious illness.
Kerala’s experience demonstrates what happens when palliative care is built as a community service over time. The state’s initiatives began with voluntary efforts in 1993, and Kerala announced India’s first comprehensive palliative-care policy in 2008. Government institutions, local self-government bodies, healthcare professionals, voluntary organisations and community volunteers subsequently became part of the service network.
According to the figures cited in the report, Kerala has 1,141 primary palliative-care units covering gram panchayats, municipalities and corporations. It also has 113 secondary-level units in major hospitals and 231 units at community health centres. More than 500 non-government and community organisations provide home-based medical and nursing services.
The defining feature is the connection between facilities and households. Bedridden patients can be linked to trained volunteers in their neighbourhoods, while nurses and healthcare teams conduct home visits. Kerala’s Kerala Care palliative-care grid, launched in March 2025, is intended to connect government institutions and voluntary organisations. The state health department reported that the grid included more than 1,300 government institutions and over 1,000 voluntary organisations, with information on more than 158,000 bedridden patients.
The data on home visits shows the scale of the difference between Kerala and Uttar Pradesh. In 2024–25, Kerala recorded 9,77,879 patients visited at home for palliative care, while Uttar Pradesh recorded 33,832. Kerala also recorded 13,47,566 patients using palliative outpatient services, compared with 3,68,834 in Uttar Pradesh.
These figures should not be treated as a simple ranking. The two states differ in population, geography, healthcare infrastructure, administrative arrangements and reporting practices. Kerala’s smaller geographical area may also make community coordination easier than in Uttar Pradesh. Yet the figures still indicate a substantial difference in the scale of home-based service delivery. For patients unable to travel, that difference is more consequential than the number of hospital units alone.
Uttar Pradesh began implementing the National Programme for Palliative Care in 2016–17. The state health department’s objectives include improving the availability and accessibility of services, developing facilities at different levels of the healthcare system and increasing community participation. However, government data cited in the report showed functional NPPC services in 23 districts of Uttar Pradesh as of October 2025, compared with all 14 districts of Kerala.
The challenge for Uttar Pradesh is not merely administrative underperformance measured against another state. It is also a problem of scale. The state has a vast geographical spread and a large rural and semi-urban population. A hospital-centred arrangement requires patients or their families to repeatedly overcome distance, transport costs, physical limitations and caregiving pressures. For a bedridden person, a service that is technically available at a district hospital may remain effectively inaccessible.
This makes primary healthcare central to the next stage of palliative-care delivery. Dr Shukla said palliative-care skills should become part of routine healthcare rather than being placed in an entirely separate system that families encounter only after serious illness has advanced. Frontline workers can help identify symptoms, support families, conduct or facilitate home visits and refer complex cases to higher levels of care.
Such a system requires clear institutional coordination. Hospitals may provide specialist intervention, community health centres may support continuity, nurses may manage home visits, local bodies may help organise community participation, and voluntary organisations may extend the system’s reach. Families, meanwhile, often provide much of the daily care, including administering medicines, helping patients move, assisting with feeding, managing wounds and observing changes in behaviour or appetite.
Caregiver education is therefore not an optional addition. Families need to understand how medicines should be administered, how pain and other symptoms may change, and when professional help is required. Kerala’s experience also highlights the role of community participation, with the state estimating that more than one lakh volunteers are active in palliative-care activities. In a state as large as Uttar Pradesh, community networks could help address the limits of specialist teams alone, although the report does not establish how such a network would be funded or organised there.
Another institutional barrier is the perception that palliative care begins only after curative treatment has ended. The report emphasises that palliative care can be provided alongside disease-directed treatment, depending on the patient’s needs. Its scope includes physical, psychological, social and spiritual concerns, not pain relief alone. This broader understanding is important for people with cancer, advanced heart or lung disease, neurological conditions, frailty and multiple chronic illnesses.
The evidence supplied in the report supports a clear conclusion: access to palliative care depends on proximity, continuity and coordination. Kerala’s network shows the value of combining primary-care units, home visits, local governments, volunteers and voluntary organisations. Uttar Pradesh has a programme framework and services in 23 districts, but its home-visit figures remain far below Kerala’s, and the material does not establish that the gap is closing.
The larger urban and regional planning question is how health systems are designed for people who cannot travel through them. Hospitals remain essential, but they cannot be the only point at which care becomes real. For a bedridden patient, the decisive service may be a nurse reaching the household, a trained worker recognising distress or a family receiving practical guidance. The next developments to monitor are the expansion of functional services across Uttar Pradesh, the integration of palliative care with primary healthcare, and whether home-based support becomes a routine public service rather than an exceptional arrangement.
