Palliative care education and training is provided at different levels by numerous organisations that include: medical colleges; individual hospitals and hospices; NGOs such as Cancer Relief India, Global Cancer Concern; international organisations such as WHO, the Oxford International Centre/WHO Collaborating Centre; and overseas universities.

Palliative care training in India began in the early 1990s⁹⁷ and it has been a key focus of the Indian Association of Palliative Care.⁹⁸ There are palliative care training courses available in India for physicians, nurses and volunteers (Table 12), and in Pune, Maharastra, central India, ‘Cipla’, a purpose-built cancer and palliative care training centre has been established with funding from a pharmaceutical company.^35,99 Despite these developments, training and education facilities are recognised to be inadequate for the country’s requirements.¹⁰⁰ Unfortunately, there is only one approved training program through an Indian university (at Amrita, Kerala, south India) and there are only about four medical colleges in the country which have some palliative care undergraduate training.¹⁰¹ The Indian Medical Council has yet to press for national palliative care training 34 and there are insufficient qualified specialists within the country to provide training. In a survey of  doctors training during residency, Mohanti et al¹⁰² demonstrated that participants felt their palliative care training was inadequate and concluded that palliative care training should form an integral part of training during residency.

Table. 12 Key training centres for palliative care 

In India, one of the most prominent palliative care programmes is run jointly by the Institute of Palliative Medicine (IPM), Calicut and the Christian Medical Association of India (CMAI).⁸⁴ This is a  Post Graduate Fellowship Program in Palliative Medicine for doctors in India which aims¹⁰³ :

• To give training to doctors so that they receive the knowledge and professional skills to render palliative care services

• To give new insights and perspectives and positively influence their outlook towards the practice of medicine i.e. from being medicine and doctor centric to person centric and being an equal partner in a team.

It is a programme which has been widely cited by palliative care professionals working across India  as a key component to the development of services. Dr Mallika Tiruvadanan, Lakshami Pain and Palliative Care Clinic, Chennai, Tamil Nadu, south India¹⁰⁴ talks about the impact of this training:

And then of course I had been hearing about Dr Rajagopal and his work in Calicut and I just said, ‘Let’s go there,’ I’d never seen my father cry and become weak like that, so he used to have very bad neuropathic pain. And we went to Calicut - I wanted to learn from Dr Rajagopal the various pain techniques. And then we stayed for ten days in Calicut and I think those ten days really changed me: there was a kind of a transformation. I really don’t know where it began and when it started flowing, because I used to take my father to the clinic, we never used to ask Rajagopal anything, he just did whatever had to be done for my father, and I used to observe all these patients in the outpatient clinic. And I used to walk every day through the medical college to get some, you know, food for my father and mother and things like that. But I think during the course of those days something changed. I never really voiced it at that time, but I told Rajagopal that I’m coming for the foundation course in November… But I just kept my mind open, those ten days I felt like a kindergarten student, you know, because this is something so new, something that’s never been taught in my medical curriculum. And it was just amazing how much I liked it [chuckles]. Then I went back and I started practising straight away, because we have a basic medical knowledge and I kind of knew, and of course I used to refer to Calicut for any doubts I had, I used to call them, talk to them, any doubts I had. And I started treating: we did not have morphine at that time but with the best of my knowledge, and the anaesthesia techniques that I know of, whatever I could do for a patient at a particular time. That’s how I started my palliative care service. In 2001 I established ... I started giving free treatments from day one, my services were free, and never charged the patients. And in 2001 I established a Trust in the name of Lakshami Pain and Palliative Care Clinic, and I’ve been running that now, and down the line I have also done my six-weeks course in Calicut and that was also tremendous exposure and tremendous knowledge I gained by that. And then of course took the Diploma in Palliative Medicine with the University in Australia.

Although palliative care training is not widely available, many organisations provide education opportunities. Dr Stanely Macaden outlines the Christian Medical Association of India’s (CMAI) approach:

I am Co-ordinator for CMAI, for its palliative care programme, so we have been conducting workshops, you know, in different places through the CMAI and that’s how our team and I have been involved in workshops. Usually, what we have encouraged is to get Mission Hospitals to send teams of people from their institutions, you know, so doctor, nurse, social worker, chaplain. So that it will help to result in some positive action after they go back. So, in each of these workshops we have had about 25/30 participants, and we have been doing this now for the past three or four years, or more actually, yeah, two or three workshops.⁷¹

Mr Kishore Rao, managing director of Bangalore Hospice Trust, Karnataka, south India describes how they train health assistants:

We train health assistants: we have two batches a year and the training lasts six months. This is actual theoretical training plus hands-on training in the wards: this is done and it’s supervised by one of the doctor on the trust. We have a general practitioner who is a trustee and he oversees this entire programme of training of the health assistants. So these girls are trained, we place an advertisement in the newspapers, and we take girls between the ages of 18 and 25. We don’t insist on any advanced educational qualifications, as long as they have a school final, or what you would call ‘O’ levels in the UK. As long as we’ve got that we take them. The other thing we see is that we see that they come from relatively poor families, so we’re teaching them a trade and helping them to earn a living, so that’s another thing we do. And in each batch we train 12-14 girls, so in a year we are training about 25 girls in this. Our entire need for health assistants in our wards is met from this resource, but the rest of them we place on a home care basis. There are many patients who want to be at home, not only our patients of cancer, it could be anybody, it could be a geriatric patient lying at home who needs some round-the-clock help, so we place these girls at such homes and the homes pay them directly.⁸

A significant feature of education and training within Indian palliative care is training provided for volunteers and patients’ families. For example, Dr Bhatia, Rajasthan, Gujurat, north west India  describes how and why they train patients and relatives:

Rajasthan hospital is a charitable private hospital, it is run by a private charity, they don’t have any government grant, they have their own financial outlay and there’s about 300 beds at the hospital and it’s situated as you see in the heart of the city...we have oncologists operating, chemotherapists but we don’t give medicines free except oral morphine, oral morphine is the only medicine which we can give free and we can admit the patient in a free bed but our restriction is that we train the relatives for 5, 6 days and let him go. So our idea is to treat the patient at home by training him on video programs which are run automatically, they are in the local language so the nurse can run the program repeatedly for them, if they are not very comfortable with earphones, we have a room in which we run the program loudly with speakers, they listen to it, they see how to do it and then they go and do it on the patient who is admitted and the next day come back and tell us what are the problems and we are able to sort it, so this is a training program for relatives which we run on video.⁶⁸

The Neighbourhood Network for Palliative Care in Kerala, south India, has been strikingly successful in pioneering a palliative care service which is based upon a network of trained volunteers in the community with a support system of trained professionals. Volunteers are given structured training providing they are willing to donate at least two hours every week to the palliative care home care programme. The volunteer training involves 16 hours of interactive theory and 4 days of practical work as part of an ‘initiation’.⁵⁸