Building Care into the System: Lessons from India’s Palliative Network
Adarsh Varghese’s journey traces how listening, local trust, and policy that treats care as a right, builds healthcare systems
View as PDF
SDG 3: Good Health and Well-being
Institutions: Ministry of Health and Family Welfare
In India’s medical colleges, Adarsh Varghese realised early that success often meant endurance – surviving long shifts, exam pressure, and bureaucracy – rather than improving patient care. That’s when he decided to step away from clinical training to shift the system that prized stamina over compassion.
Today, from his desk at Pallium India in Thiruvananthapuram, he works to make relief and dignity part of everyday health care.
Palliative care – relief for people living with serious or chronic illness, including pain management and psychosocial support – was long treated in India as an end-of-life service. Pallium India helped redefine it as a public right: care that begins early and restores quality of life for patients and families.
Its model rests on three layers – outpatient, inpatient, and home-based care – linking care with communities through trained local teams. As Head of the Facilitation Division, Adarsh helps states weave this approach into primary-health programmes, training doctors, nurses, and administrators to see relief and dignity as core services, not optional charity.
Founded in 2003, Pallium India was among the first organisations to demonstrate Kerala’s community-based palliative-care model and to advocate its inclusion in state policy. Its Trivandrum Institute of Palliative Sciences, a WHO Collaborating Centre, now trains hundreds of professionals each year.
In 2023–24 alone, Pallium’s teams reached over 5,000 patients directly, made 37,000 patient contacts, and completed 14,000 home visits. Across India, it supports 950 verified centres – small but steady progress in a country where fewer than 4 percent of people needing palliative care receive it.
“You can’t build humane systems by focusing only on diseases,” Adarsh reflects. “You have to see how people live, and what happens when care fails.”
Before joining Pallium, he worked with the National Health Mission (NHM) and the World Health Organization (WHO) on Covid-19 response, disease surveillance, elderly and palliative care, NCDs, tobacco control, immunisation and broader health policy. With degrees in medicine, public health, and tropical medicine, he moves easily between the clinic and the corridors of policy, seeing how intent becomes implementation.
Beyond the Clinic: System Values and Access
His years in government taught him that public systems fail less for lack of money than for lack of ownership – a lesson that now shapes how he thinks about care and accountability.
“What they need is confidence, not constant suspicion, to act,” he says – a principle that, for him, links management with medicine.
To Adarsh, the ethics of care depend on what a system rewards.
“If the system values empathy, people practise it,” he stresses. “If it rewards speed, quality is the first casualty.”
That trade-off is clearest in pain management, where intent and implementation still diverge. India manufactures morphine in abundance, yet fewer than 4 percent of patients in severe pain receive it. The gap lies less in supply than in regulation. Until 2014, every hospital needed multiple state permissions – to procure, store, and dispense morphine – signed separately by drug controllers and district authorities. That year, after sustained advocacy by Pallium India and allied experts, the Narcotic Drugs and Psychotropic Substances Act was amended to create a single national rule. Recognised medical institutions can now obtain one consolidated license and authorise trained doctors to prescribe essential narcotic drugs.
In practice, though, access still depends on the state. Some controllers delay registration or rely on paper ledgers to track stock; others have digitised systems and regular audits. Kerala includes morphine procurement in district budgets and maintains active supply lines, while many states treat pain relief as a policy promise rather than a service. For Adarsh, this is unfinished work rather than failure – a reform still waiting for routine execution.
“Pain relief needs visibility,” he says. “When it’s tracked like immunisation, it will stay on the agenda.”
Two Indias, One System
Across states, he has seen how geography shapes both opportunity and motivation. In Kerala, health workers collect data to understand; elsewhere, they often collect it to report. The spreadsheets, he jokes, can look healthier than the patients.
He recalls his earlier posting in a north Indian state, where colleagues told him how nearly 2000 “Additional Primary Health Centres” came into being decades ago because of a clerical mistake that no one ever corrected. A planning note that merely suggested adding more PHCs was misread as creating a new category altogether. The state went on to formalise it, staff the centres, and the term eventually became policy. For Adarsh, this isn’t an error so much as a parable about how systems persist: in public health, even paperwork can outlive purpose.
“Systems remember everything,” he reflects. “The task is to help them remember the right things.”
Hiring as Health Policy
Fixing system memory begins with people: those who keep a programme alive when plans or technologies fall short. Adarsh argues that better outcomes begin with people, not procurement.
“We keep designing around technology and budgets,” he remarks, “but the simplest reform is to hire.”
Across India’s primary-health network, persistent vacancies in nursing, data, and management roles have left services running on paper more than in practice. Under the National Health Mission, most states can already fill these gaps through the Human Resources for Health budget head – yet slow approvals and short-term contracts keep posts unfilled. He believes that converting even a fraction of contractual roles into regular district-level positions would restore both continuity and morale.
Palliative care, too, needs people before policy. The National Programme for Palliative Care (NPCC) already provides for doctors, nurses and multipurpose workers, at district hospitals, with budget lines under the Ministry of Health. But in practice, many of these positions remain vacant or underutilised. What India now needs, Adarsh argues, are community-based nurses and field workers -- people who can bridge home-care teams and outpatient clinics. Strengthening that last mile, he says, would turn scattered services into a single system of relief.
He also calls for clearer lines of authority. Too often, those who understand a programme cannot decide, while those who decide do not stay long enough to learn. Every rupee, he says, carries a judgment: with the cost of one sleep-apnoea machine, hundreds can be treated for hypertension. Impact, not indulgence, is the measure of reform.
Kerala’s Everyday Model
Kerala shows what sustained participation can build. Volunteers still visit homes with morphine packets and groceries; local governments fund their work. For Adarsh, this is what happens when care becomes part of governance.
Pallium’s telehealth service alone connected with 2,000 people last year, and its training programmes reached more than 800 professionals online and in classrooms. These small but steady efforts, he says, prove that once compassion enters procedure, it begins to sustain itself.
“A few words in a policy circular – home-based care, ‘continuity of support’ – can change what communities expect. That’s when policy starts listening back.”
Integration, Continuity, and The Next Steps
Drawing on his years managing non-communicable diseases, Adarsh now sees palliative care as part of the same continuum – prevention, treatment, and relief belong in one frame. When systems connect them, patients stop falling through the cracks.
“This integration,” he argues, “is the natural next phase for public health – one that turns episodic care into continuity.”
The challenge now, he adds, is to make proven models routine. Palliative care already sits within Kerala’s budgets; the next step is to embed it in Ayushman Bharat Health and Wellness Centres, build trained health-management cadres across districts, blocks and panchayats, and ensure a reliable nationwide supply of pain-relief medicines. He argues for one more step: facility autonomy.
“District hospitals have limited authority for small operational decisions–staffing, local purchases, patient transport–which needs to step up. That’s where policy becomes practice.”
His timelines are pragmatic. Within two years, he believes, every state can have palliative nodes inside primary care. Within five, if home visits and pain relief are included in national reporting systems such as the Health Management Information System, budgets will begin to follow data – and access will no longer depend on where one lives.
Each milestone, he adds, moves India closer to a listening health system.
“We do need new ideas,” he adds. “But even more, we need to sustain the ones that already work.”
Toward Listening Systems
Adarsh often describes healthcare as a conversation. India, he says, has built hospitals; now it must build systems that listen.
Outside his window, staff from Pallium’s institute set off on home visits – the same route thousands have taken over two decades. He watches them go, a quiet reminder that reform moves person by person.
His own journey – from student to system-builder – mirrors Pallium India’s path: turning compassion into structure.
“Public health will always be a work in progress,” he says. “The next step is simple – keep listening, and act on what we hear.”
View as PDF
Adarsh Varghese is Head of Facilitation Division at Pallium India. All the details are based on his account and have been approved for publication. This piece was prepared with assistance from Ms. Yashita Jain, a member of the editorial team at The Policy Edge.