India
The one case in the set where a single statute is visible in the national morphine curve.
9 domains reviewed · 7 high-confidence · 7 dated estimates · 8 material gaps
WHO region: South-East Asia. World Bank income group: Income group not yet retrieved.
- Domains reviewed
- 9 of 9
- Hospice: 4 of 4
- Backed by a primary document
- 2 of 9
- Open questions
- 10
- Sources behind this dossier
- 35
- Newest source 2026
Lessons from India
- The 2014 amendment changed the law, but a decade later most surveyed Kerala government providers still could not prescribe morphine and several states confined dispensing to hospital pharmacies. Statutory reform needs provider enablement beside it: registered institutions, trained prescribers and stock.121,119
- A national programme launched by the centre reached states years apart and unevenly. Where health is devolved, a national programme needs budgeted support for subnational implementation, not a single central launch.117
- Kerala's engine is a paid nurse in every panchayat, funded from the local government budget, with volunteers in support. Where local government lacks that fiscal autonomy, the budget line for a salaried community cadre has to come from a higher tier.126,124
- Replication of the Kerala model elsewhere in India stalled on administrative capacity, political will and community participation, and even inside Kerala visits and volunteers are uneven. Adopters should take the funded-nurse mechanism rather than the whole model, and monitor quality from the start.125,127
- Tracking time from referral to death shows whether patients reach hospice too late; a median stay under two weeks points to gaps in referral pathways from oncology.281
- Local volunteer networks can extend home-based palliative care, but they still need regular professional visits, volunteer training and access to morphine to cover rural need.375,127,121
- Amending a narcotics law to ease medical access needs implementation support and prescriber training to reach patients, as India's slow rollout of its 2014 NDPS amendment shows.540,541,543
- Screening children with cancer with a validated tool such as PaPaS can reveal palliative needs that oncologists' referral judgments miss.549
Palliative care
Is morphine available in India?
Opioid supply. Is a therapeutic opioid physically available in the wards that need it? Every country on this question
- 3.45 MME per 1,000 people per daySOURCE-CHECKED · 2019 DATA
Opioid analgesic consumption, India, 20193
Method: IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access. Last checked 2026-09-25.
Cite this figure: - 1.39 MME per 1,000 people per daySOURCE-CHECKED · 2015 DATA
Opioid analgesic consumption, India, 20153
Method: IQVIA MIDAS pharmaceutical sales data for opioid analgesics, in morphine milligram equivalents per 1,000 inhabitants per day (Ju et al. 2022; abstract read September 2026). A sales-based proxy for availability, not a measure of palliative access. Last checked 2026-09-25.
Cite this figure: - 716 kg per yearSOURCE-CHECKED
Medical morphine consumption, India, 1985158
Method: Annual morphine consumption reported by India to the INCB, as compiled by the Pain and Policy Studies Group and quoted by Jacob and Mathew (2017). Last checked 2026-09-25.
Cite this figure: - 18 kg per yearSOURCE-CHECKED
Medical morphine consumption, India, 1997158
Method: Annual morphine consumption reported by India to the INCB, as compiled by the Pain and Policy Studies Group and quoted by Jacob and Mathew (2017). Last checked 2026-09-25.
Cite this figure: - 278 kg per yearSOURCE-CHECKED · 2014 DATA
Medical morphine consumption, India, 2014158
Method: Annual morphine consumption reported by India to the INCB, as compiled by the Pain and Policy Studies Group and quoted by Jacob and Mathew (2017). Last checked 2026-09-25.
Cite this figure: - 0 percentSOURCE-CHECKED · 2020 DATA
Kerala government palliative care providers able to prescribe oral morphine, India, 2020121
Last checked 2026-09-24.
Against 36 percent of non-government providers. Five years after the 2015 rules.
Cite this figure:
No peer-reviewed before-and-after evaluation of the 2014 amendment's effect on consumption was found. Years after it, dispensing was still confined to hospital pharmacies in several states, and in Kerala no surveyed government provider could prescribe oral morphine.3,11,119,121
Did national consumption rise because of the 2014 amendment, on an INCB-comparable series?
Help answer it:Search PubMedHow does India regulate opioids for pain?
Narcotics regulation. What licensing regime governs stocking and dispensing, and when did it last change? Every country on this question
The 2014 NDPS amendment created an Essential Narcotic Drugs class regulated centrally and replaced multiple state licences with a single state-level Recognised Medical Institution approval from the State Drug Controller, under uniform central rules.11,50
Who can prescribe morphine in India?
Prescriber authority. Who is legally allowed to prescribe, and can that group be widened? Every country on this question
- 10 daysSOURCE-CHECKED · 2015 DATA
Hands-on training required before a physician may prescribe oral morphine, Kerala, Kerala, India, 201551
Last checked 2026-09-22.
Describes practice in Kerala. National rules require training in pain relief and palliative care but do not set a length.
Cite this figure:
The amendment created no new prescriber class. A registered medical practitioner still signs, but for essential narcotic drugs must additionally have completed training in pain relief and palliative care. Stocking and dispensing sit with the recognised medical institution, not the individual.50,51
How many recognised medical institutions are registered nationally?
Help answer it:Search PubMedHow does palliative care reach patients in India?
Service delivery. Through what structure does care actually reach a patient at home? Every country on this question
- 83 of 139 nationallySOURCE-CHECKED
Palliative care delivery points located in Kerala, India, 2008124
Last checked 2026-09-24.
Kerala held about three percent of India's population.
Cite this figure: - 19 centresSOURCE-CHECKED · 2018 DATA
Palliative care centres in West Bengal's first phase of the national programme, India, 2018117
Last checked 2026-09-24.
Phased rollout from 2017 to 2018, years after the 2012 national launch.
Cite this figure:
The National Programme for Palliative Care, launched in 2012, is implemented state by state and unevenly, with some states starting years later. Primary care wellness centres studied in Odisha offered inadequate palliative care. Services were heavily concentrated in Kerala.124,117,122
How many services exist by state today, and how much post-2014 growth lies outside Kerala?
Help answer it:Search PubMedWho pays for palliative care in India?
Financing. Who pays for the drug, the visit and the workforce? Every country on this question
Palliative care associations report poor allocation and use of government funds and little insurance cover for home and outpatient palliative care. Patients at a national cancer centre called for palliative care to be added to the national insurance benefit packages.118,120
Who pays for morphine procurement at recognised medical institutions, and what does the national programme spend?
Help answer it:Search PubMedHow are palliative care clinicians trained in India?
Training and recognition. What credential exists, who awards it, and does anyone recognize it? Every country on this question
- 24 percentSOURCE-CHECKED · 2020 DATA
Kerala palliative care providers with a full-time trained physician, India, 2020121
Last checked 2026-09-24.
Cite this figure:
The national programme trains district medical officers through a short cascade model, and a 2024 assessment found most training need unmet afterwards. Even in Kerala, most providers had no full-time trained physician.117,121
When was the MD in Palliative Medicine recognised, and how many graduates and certificate holders are there?
Help answer it:Search PubMedHow does India prevent opioid misuse without blocking pain relief?
Opioid safeguards. How are misuse and diversion controlled, and are treatment and naloxone available, without blocking pain relief? Every country on this question
India's 1985 NDPS Act set harsh custodial sentences even for minor clerical errors in hospitals stocking opioids, and the 2014 amendment to improve medical access has been slow to implement. Opioid substitution therapy with buprenorphine, buprenorphine-naloxone and methadone grew through the National AIDS Control Programme, though coverage targets are still far off. Delhi doctors named tough opioid regulations as their most common barrier to prescribing, and people who use opioids in Kashmir reported low naloxone knowledge and poor access.540,541,542,543,544
How many Recognized Medical Institutions stock oral morphine under the 2014 NDPS amendment, state by state, and is take-home naloxone available outside deaddiction centers?
Help answer it:Search PubMedHow do children get palliative care in India?
Children's palliative care. How do children with life-limiting conditions get palliative care and the medicines they need? Every country on this question
Across three tertiary cancer centres, 2.7% of 150 children with cancer needed palliative care as the focus of treatment and 49.3% had moderate needs, yet clinicians judged only 7 of 150 likely to benefit from referral. Family caregivers had more psychological distress (57%) than the children (33%). A Tamil-language bereavement needs tool for parents of children who died of cancer (CANCOPE-PI) was co-developed with bereaved caregivers in south India.549,550
How many children receive pediatric palliative care in India each year, and are child-appropriate oral morphine formulations available at those services?
Help answer it:Search PubMedHospice care in India
How the hospice model works here, who can use it, who pays and who it reaches. Covered 4 of 4.
What does hospice care look like in India?
Hospice model. What does hospice mean here, who runs it, and in what settings? Every country on this question
Indian palliative care grew out of an early hospice movement in the 1980s, and hospice is discussed as one setting within palliative care. A leading example is Karunashraya, a 73-bed nonprofit hospice in Bangalore that has given free inpatient and home care to advanced cancer patients for over 30 years.281,283
How many dedicated hospices exist in India, and how many are run by NGOs, faith groups or the state?
Help answer it:Search PubMedWho can get hospice care in India?
Hospice eligibility. Who can enter hospice, on what criteria, and how late do patients arrive? Every country on this question
At the Bangalore hospice, admissions were advanced cancer patients referred mainly by doctors, with word of mouth, friends and relatives of former patients also common routes. Median time from admission to death was 8 to 10 days in 2021 and 2022, which shows very late arrival (single site, pandemic period).281
Who pays for hospice care in India?
Hospice funding. Who pays for hospice care: a public benefit, insurance, charity or families? Every country on this question
The Bangalore hospice provides care free of charge with support from the Indian Cancer Society and a Rotary club. A pediatric perspective reports limited government funding and little private philanthropy for hospice care, and names financial burden as one reason hospices are underused.281,282
How many people reach hospice in India?
Hospice reach. How many dying people use hospice, and who is left out? Every country on this question
Dedicated pediatric hospices are limited because most hospices focus on adults, so many children receive end-of-life care in general hospitals or at home. At the Bangalore hospice, high-income patients were about 2% of admissions and women were the majority, and less than 2% of India's population is reported to have access to palliative care.282,281
What share of deaths in India, by state and by diagnosis, occur with hospice involvement?
Help answer it:Search PubMedWhat fills the gap in India
How people get care outside formal services: families, faith communities, volunteers, health workers, healers, other medicines and charity. Described, not scored.
- Family caregiving
In the oldest community clinic in Malappuram, 96% of patients had a caregiver at home and 85% of these caregivers were female. Caregivers, mainly women caring for relatives, described the work as physically demanding, psychologically stressful and socially restrictive.376,375
Single-site evidenceSelf-reported- Volunteers and compassionate communities
In Kerala's home-based programmes, local volunteers work alongside doctors and nurses and describe themselves as mediators between families and the programme. A survey of two rural Alappuzha wards found a shortage of trained volunteers and infrequent staff visits among the reported gaps.375,127
Subnational evidenceSelf-reported- Community health workers and home-based care
Palliative units under local self-government bodies have grown since Kerala's 2008 policy and deliver home visits through primary health centres. A statewide survey of 200 providers found none of the government units could prescribe oral morphine and 60% had no full-time trained physician.377,121
Subnational evidence- Charity, religious giving and mutual aid
In one Malappuram programme, the local community supports the service through economic contributions and practical help to patients. This finding comes from a single district programme.375
Single-site evidenceSelf-reported
Kerala
The 2008 state policy was the first in Asia, with roughly 1,000 local self-government units engaged. It sits on the 1996 decentralisation reforms: local governments fund a palliative care nurse's wages, travel, equipment and home-care drugs from their own budgets, with volunteers and community donations in support. Replication elsewhere in India has struggled, most of the regional evidence comes from Kerala's high-literacy setting, and even within Kerala visits and volunteer numbers are uneven.31,123,126,124,125,128,127
Which parts survive without panchayat fiscal autonomy and high literacy, and can a salaried community health worker cadre stand in for the panchayat-funded nurse?
Help answer it:Search PubMedSources cited here
- 3Ju C, Wei L, Man KKC, et al.
Global, regional and national trends in opioid analgesic consumption, 2015 to 2019. Lancet Public Health 2022;7:e335-46. DOI 10.1016/S2468-2667(22)00013-5.
- 11Pallium India,
Guidelines for stocking and dispensing Essential Narcotic Drugs, with International Drug Policy Consortium analysis of the 2014 NDPS amendment.
- 119Bouothmani A, Gutierrez R, Lamrous A, Burza S, Maixenchs M, Richardson K.
Access to opioids for palliative care in humanitarian settings: two case studies of Medecins Sans Frontieres experience in India and Bangladesh. BMC Palliative Care 2025;24(1):90. DOI 10.1186/s12904-025-01673-x. Interviews on a project in Patna, Bihar, 2020 to 2022: limited availability, burdensome regulatory processes, dispensing confined to hospital pharmacies in several states, and lack of prescriber training. Full text read.
- 121Lijimol AS, Krishnan A, Rajagopal MR, Gopal BK, Booth CM.
Improving access and quality of palliative care in Kerala: a cross-sectional study of providers in routine practice. Indian Journal of Palliative Care 2020;26(4):500-505. DOI 10.4103/IJPC.IJPC_17_20. Telephone survey of government and non-government palliative care providers in Kerala: trained physicians, pain documentation, and ability to prescribe oral morphine. Abstract read.
- 158Jacob A, Mathew A.
End-of-life care and opioid use in India: challenges and opportunities. Journal of Global Oncology 2017;3(6):683-686. DOI 10.1200/JGO.2016.008490. States that morphine use fell from 716 kg in 1985 to 18 kg by 1997 (INCB consumption data compiled by the Pain and Policy Studies Group) and that total consumption was 278 kg in 2014; after the 2014 amendment a single licence suffices to procure and dispense morphine. Full text read.
- 50Narcotic Drugs and Psychotropic Substances (Third Amendment) Rules, 2015.
G.S.R. 359(E), Ministry of Finance, Department of Revenue, Gazette of India, 5 May 2015, made under the 2014 amendment. Defines a registered medical practitioner for essential narcotic drugs as a practitioner registered under existing medical or dental registration law who has additionally completed training in pain relief and palliative care, or in opioid substitution therapy. Rules 52A and 52F place possession, dispensing and sale with the recognised medical institution.
- 51Oral morphine use in South India: a population-based study.
PMC5735973. Describes the rules in operation: morphine is dispensed by an approved provider affiliated with a recognised medical institution, physicians may prescribe oral morphine only after completing ten days of hands-on training in pain relief and palliative care, and each institution reports annual consumption to the Office of the Drugs Controller.
- 124Banerjee D.
Culture, communication and community in palliative cancer care: a view from India. ecancermedicalscience 2022;16:ed120. DOI 10.3332/ecancer.2022.ed120. Kerala's network built on the 1996 decentralisation reforms, and a 2008 count of palliative care delivery points nationally, most of them in Kerala. Full text read.
- 117Mitra S, Sarkar AK.
Assessment of training need for National Program for Palliative Care and digital legacy planning among medical officers of an eastern state of India. Indian Journal of Palliative Care 2026;32(1):60-64. DOI 10.25259/IJPC_86_2025. The national programme launched in 2012 and trains district medical officers through a cascade model; West Bengal began phased rollout only in 2017 to 2018; substantial unmet training need after a training day. Full text read.
- 122Panda SK, Panda D, Behera RR, Panda SC, Munda A, Sahu PR.
Assessment of functioning of health and wellness centers of Western Odisha: a cross-sectional study. Cureus 2023;15(4):e37665. DOI 10.7759/cureus.37665. Palliative care services inadequate at the primary care centres studied. Full text read.
- 118Atreya S, Butola S, Bhatnagar S, Kumar D, Muckaden M, Kuraikose J, et al.
Integration of palliative care into primary care: a collaborative effort between the Indian Association of Palliative Care and the Indian Association of Preventive and Social Medicine. Indian Journal of Community Medicine 2024;49(Suppl 2):S234-S239. DOI 10.4103/ijcm.ijcm_858_24. Position paper: poor allocation and use of government funds for palliative care, and little insurance cover for home and outpatient palliative care. Full text read.
- 120Gore S, Mhamane S, Jadhav S, Padvi N, Mhatre A, Joshi P, et al.
Implementation challenges of government-funded health schemes for cancer treatment at Tata Memorial Centre. Journal of Cancer Policy 2025;43:100564. DOI 10.1016/j.jcpo.2025.100564. Abstract read. Low beneficiary awareness of the national insurance scheme and a call to add supportive and palliative care to benefit packages.
- 540Vallath N, Rajagopal MR, Perera S, et al.
Access to pain relief and essential opioids in the WHO South-East Asia Region: challenges in implementing drug reforms. WHO South East Asia J Public Health 2018;7(2):67-72. Regional review of opioid access in the WHO South-East Asia Region, covering India's NDPS Act and its 2014 amendment and noting progress in Bangladesh, India, Nepal and Sri Lanka; authors include palliative care advocates. Abstract read.
- 541Rajagopal MR
Access to palliative care: insights into ground realities post-2014 amendment to NDPS Act. Indian J Med Ethics 2016;1(1):25-30. Commentary on palliative care access in India after the 2014 NDPS amendment; author is a leading palliative care advocate. Abstract read.
- 542Rao R
The journey of opioid substitution therapy in India: Achievements and challenges. Indian J Psychiatry 2017;59(1):39-45. Narrative review of three decades of opioid substitution therapy in India, including its place in the National AIDS Control Programme. Abstract read.
- 543Singh S, Prasad S, Bhatnagar S, et al.
A Cross-Sectional Web-Based Survey of Medical Practitioners in India to Assess their Knowledge, Attitude, Prescription Practices, and Barriers toward Opioid Analgesic Prescriptions. Indian J Palliat Care 2019;25(4):567-574. Web survey of 308 doctors at three tertiary hospitals in New Delhi on opioid prescribing barriers; low response rate (10.4%). Abstract read.
- 544Raj R, Parveen S, Wani SM, et al.
Perspectives of opioid users on overdose recognition, naloxone administration, and attitudes. Ind Psychiatry J 2026;35(1):99-104. Cross-sectional study of 501 people with opioid use disorder at one deaddiction center in Srinagar on overdose and naloxone knowledge; single site. Abstract read.
- 545Mathew B, Lam WWT, Tiwari S, et al.
Expanding Psycho-Oncology Services in India: Perspectives From Physicians in Cancer Care Centres. Psychooncology 2025;34(9):e70271. Qualitative interviews with 20 cancer physicians in India on integrating psycho-oncology services. Abstract read.
- 546Parvathi R, Gopika GB, Basheer MTB, et al.
The double burden of stress and caregiving among family caregivers of palliative care patients: Findings from a cross-sectional study in Kerala, India. Arch Psychiatr Nurs 2026;61:152102. Cross-sectional study of caregiver burden among 200 informal caregivers of palliative care patients in one Kerala district. Abstract read.
- 547Nair MS, Augustine A, Nair G
Impact of Interventions From a Secondary Home-Based Palliative Care Unit on Caregiver Burden in Kerala, India. Cureus 2025;17(4):e82481. Mixed-methods evaluation of one secondary home-based palliative care unit in Kerala described by authors as best performing; single unit, small sample (36 caregivers). Abstract read.
- 548Varkey BPA, Ghoshal A, Salins N, et al.
Mapping end-of-life care in India: a scoping review to identify gaps in policy, practice, and psychosocial support. BMC Palliat Care 2025;24(1):189. Scoping review of end-of-life care in India from 1990 to 2024 covering policy, practice and psychosocial support. Abstract read.
- 549Verma V, Rao KS, Ghoshal A, et al.
Assessing the palliative care needs of children with cancer and their families in tertiary care centres in India: A multicentre observational study. Palliat Care Soc Pract 2026;20:26323524261430380. Multicentre cross-sectional study of palliative care needs of 150 children with cancer at three Indian tertiary cancer centres using the PaPaS scale. Abstract read.
- 550Suresh V, Mittal A, Venketeswaran MV, et al.
Developing a culturally relevant bereavement needs assessment tool (CANCOPE-PI) for caregivers of children with cancer in India: a participatory research approach. Res Involv Engagem 2026;12(1). Participatory development of a bereavement needs assessment tool for caregivers of children who died of cancer at one south Indian cancer center. Abstract read.
- 281Reddy M, Rao S, N S
Hospice referral patterns in India during COVID-19: A retrospective study on advanced cancer patients. BMC Palliat Care 2026;25(1). Retrospective review of 740 admissions to Karunashraya, a 73-bed free nonprofit hospice in Bangalore, showing median admission-to-death of 8 to 10 days; single site, pandemic period, author affiliated with the hospice (self-evaluation). Full text read.
- 283Salins N, Bhatnagar S, Simha S, et al.
Palliative Care in India: Past, Present, and Future. Indian J Surg Oncol 2022;13(Suppl 1):83-90. Narrative history tracing Indian palliative care from the 1980s hospice movement to specialist practice; written by leaders of Indian palliative care organizations (including Karunashraya and Pallium India), so an insider and advocacy view. Abstract read.
- 282Nair M, Ghoshal A
Hospice Care in India-A Pediatrician's Perspective. South Asian J Cancer 2023;12(3):303-308. Perspective article on pediatric hospice care in India covering scarce child-specific hospices, funding gaps and underuse; opinion and advocacy, not primary data. Full text read.
- 126Kochuvilayil A, Varma RP.
Understanding caregiver burden and quality of life in Kerala's primary palliative care program: a mixed methods study from caregivers and providers' perspectives. International Journal for Equity in Health 2024;23(1):92. DOI 10.1186/s12939-024-02155-x. Local governments fund the palliative care nurse's wages, travel, equipment and home-care drugs from their annual budgets, with community donations as top-up; older caregivers carry a heavy burden without systematic support. Full text read.
- 125Chaudhary SR, Thomas A.
Palliative care models in primary health care system of India: a scoping review. BMC Palliative Care 2025;24(1):221. DOI 10.1186/s12904-025-01859-3. Replication of Kerala's local government-led governance elsewhere in India has faced hurdles of administrative capacity, political will and community participation. Full text read.
- 127John A, Varughese CS, Vijayan V, Thomas N, Viswan L, Varghese CG, et al.
Voices from homes: a mixed methods study on gaps in palliative care for patients and their families in rural Alappuzha, Kerala. International Journal for Quality in Health Care 2025;37(3). DOI 10.1093/intqhc/mzaf079. Infrequent visits, volunteer shortages and weak intersectoral coordination in two rural wards. Full text read.
- 375Philip RR, Venables E, Manima A, et al.
"Small small interventions, big big roles": a qualitative study of patient, care-giver and health-care worker experiences of a palliative care programme in Kerala, India. BMC Palliat Care 2019;18(1):16. Focus groups and interviews on a home-based programme in Malappuram district, describing volunteer roles, mostly female family caregivers and local economic support; one co-author is affiliated with the programme studied. Abstract read.
- 376Philip RR, Philip S, Tripathy JP, et al.
Twenty years of home-based palliative care in Malappuram, Kerala, India: a descriptive study of patients and their care-givers. BMC Palliat Care 2018;17(1):26. Register and case-record review of the oldest community-based clinic in Kerala (1996 to 2016) showing caregiver profile and visit frequency; single clinic, one co-author affiliated with the programme. Abstract read.
- 377Nair M, Augustine A
Understanding Long-Term Outcomes of Public Health Strategy in Palliative Care at Micro Level: Impact of Home-Based Palliative Care Services under Local Self-Government Institutions in Kerala, India. Indian J Palliat Care 2022;28(1):7-12. Assessment of one award-winning local government palliative unit with 25 patients and caregivers; single selected unit. Abstract read.
- 31Palliative care policy and practice in Kerala, India.
PMC12149619. Kerala's 2008 policy, the first in Asia; roughly 1,000 local self-government units engaged.
- 123Kumar SK.
Kerala, India: a regional community-based palliative care model. Journal of Pain and Symptom Management 2007;33(5):623-627. DOI 10.1016/j.jpainsymman.2007.02.005. Abstract read. The Neighbourhood Network in Palliative Care as a community-owned network of units in north Kerala.
- 128Singh T, Harding R.
Palliative care in South Asia: a systematic review of the evidence for care models, interventions, and outcomes. BMC Research Notes 2015;8:172. DOI 10.1186/s13104-015-1102-3. Most South Asian evidence comes from in and around Kerala, a state with among the highest literacy in India. Full text read.