Increasing Access to Pain Relief in Developing Countries—An EA Perspective

In a nut­shell:

  • The suffer­ing ex­pe­rienced by pa­tients with­out ac­cess to pain re­lief is very wide­spread and very se­vere.

  • When ad­dress­ing ac­cess to pain re­lief di­rectly, we can ad­dress reg­u­la­tory im­ped­i­ments and at­ti­tude/​knowl­edge im­ped­i­ments, though tractabil­ity is ques­tion­able. Ad­dress­ing both reg­u­la­tory and at­ti­tude/​knowl­edge im­ped­i­ments is re­quired for suc­cess. The sub­ject is highly poli­ti­cised, be­ing in­tri­cately tied to poli­cies and at­ti­tudes on nar­cotic drugs. A difficult poli­ti­cal land­scape make in­ter­na­tional solu­tions ap­pear less fea­si­ble than na­tional ones.

  • Devel­op­ment of novel painkil­lers is an­other av­enue, but one that is un­likely to be an area for EA fo­cus.

  • Ac­tors work­ing on this cause in­clude large pri­vate philan­thropists, pub­lic donors, in­ter­na­tional or­gani­sa­tions and non-state ac­tors, academia, and pop­u­lar me­dia.

  • The cause of in­creas­ing ac­cess to pain re­lief in de­vel­op­ing coun­tries is thus large in scale, low-mod­er­ate in tractabil­ity, and low-mod­er­ate in ne­glect­ed­ness. It is a ter­mi­nal cause, hav­ing few long term in­di­rect/​flow-through effects. Mea­sure­ment of the im­pact of in­ter­ven­tions to in­crease ac­cess is difficult. Fund­ing train­ing pro­grammes for lo­cal cham­pi­ons to work on this is­sue may be a promis­ing av­enue.

About the au­thor: I am a pub­lic health con­sul­tant con­tracted to the World Health Or­gani­sa­tion. My work aims to in­crease ac­cess to pain re­lief and pal­li­a­tive care through de­vel­op­ing clini­cal guidelines for can­cer pain re­lief and eval­u­at­ing mod­els of pal­li­a­tive care de­liv­ery. The opinions and as­ser­tions made here are my own and do not rep­re­sent the be­liefs of the World Health Or­gani­sa­tion or its staff.

Fram­ing the is­sues: Pain and ac­cess to pain re­lief

It is worth clar­ify­ing that by in­creas­ing ac­cess to pain re­lief, we pri­mar­ily mean in­creas­ing ac­cess to opi­oid anal­gesics. Ac­cord­ing to the World Health Or­gani­sa­tion, they are es­sen­tial medicines for treat­ing mod­er­ate-se­vere phys­i­cal pain. Other anal­gesics ex­ist (e.g. ke­tamine, fre­quently used as an anal­gesic in de­vel­op­ing set­tings and en­joys fewer in­ter­na­tional re­stric­tions), but only strong opi­oid painkil­lers ad­e­quately treat the mod­er­ate-se­vere pain com­mon in many med­i­cal ill­nesses.

Pain is a com­plex phe­nomenon, and the men­tal/​phys­i­cal dis­tinc­tion is an in­com­plete pic­ture. The ex­pe­rience and mechanisms of the var­i­ous flavours of suffer­ing are in­ter­de­pen­dent. It is well known that phys­i­cal pain, es­pe­cially chronic pain, can cause de­pres­sion. It is also well known that de­pres­sion, stress, and anx­iety can heighten the per­cep­tion of phys­i­cal pain. In­deed, psy­cho­so­matic pain is ‘phys­i­cal’ pain caused by men­tal states alone. The founder of the pal­li­a­tive care move­ment, Dame Cicely Saun­ders, pro­posed the idea of ‘to­tal pain’. A sim­ple de­scrip­tive, non-mechanis­tic model, it recog­nises that phys­i­cal, psy­cholog­i­cal, so­cial, and spiritual suffer­ing con­tribute to the pa­tient’s over­all nega­tive ex­pe­rience in de­pen­dent ways.

Ac­cess to pain re­lief med­i­ca­tions re­quires hav­ing both the med­i­ca­tions and the abil­ity to de­liver them. Pal­li­a­tive care is the con­text for much pain re­lief ad­minis­tra­tion. In­creas­ing ac­cess to pain re­lief in de­vel­op­ing coun­tries will benefit mul­ti­ple ar­eas of med­i­cal prac­tice—surgery, ob­stet­rics, and some emer­gency medicine to name a few. But it is pal­li­a­tive care that stands to benefit the most, pain re­lief med­i­ca­tion be­ing its pri­mary in­stru­ment. It is im­por­tant to note that pal­li­a­tive care is not only for the dy­ing, nor is its fo­cus solely phys­i­cal pain re­duc­tion; it serves to alle­vi­ate the worst of suffer­ing for those with life-threat­en­ing ill­nesses. In­ter­na­tional pal­li­a­tive care de­vel­op­ment is there­fore al­most syn­ony­mous with in­creas­ing ac­cess to pain re­lief med­i­ca­tions, so I ask read­ers to per­mit some con­fla­tion of the terms.

The prob­lem—Wide­spread tor­ture by omission

Trig­ger warn­ings: can­cer, suicide, tor­ture

Dis­cus­sions on ex­treme hu­man suffer­ing fre­quently evoke ex­am­ples of tor­ture and over­look un­treated med­i­cal suffer­ing. This is availa­bil­ity bias. This is by no means to dis­miss the trauma suffered by tor­ture vic­tims, but un­alle­vi­ated med­i­cal suffer­ing is com­pa­rably se­vere and sig­nifi­cantly more com­mon. Com­mon life threat­en­ing dis­eases that re­quire pal­li­a­tive care in­clude can­cer, car­dio­vas­cu­lar dis­ease, HIV, chronic lung dis­ease, and di­a­betes. I can­not find good es­ti­mates, but it is rea­son­able to as­sert that the num­ber of peo­ple tor­tured ev­ery year is dwar­fed by the mil­lions dy­ing in un­met need of pal­li­a­tive care (ref). Without giv­ing an ex­haus­tive illus­tra­tion, metastatic can­cers alone slowly but surely splin­ter limb bones, de­stroy ver­te­brae, tear con­tigu­ous tis­sue, necrose in breasts, cause se­vere and un­remit­ting head pain, and more. When they are ca­pa­ble, some pa­tients take their own lives or at­tempt to (ref). The ex­pe­riences of pa­tients with­out ac­cess to ad­e­quate pain re­lief, “con­sti­tutes cruel, in­hu­man or de­grad­ing treat­ment or pun­ish­ment”, ac­cord­ing to the UN Spe­cial Rap­por­teur on tor­ture and other such con­di­tions (ref).

It may be un­known to EAs from the An­glo­sphere and Western Europe that al­most nowhere else in the world is it easy to get ad­e­quate pain re­lief. Rea­sons for this lack of ac­cess are dis­cussed be­low. In 2011, it was es­ti­mated that 5.5 billion (83%) peo­ple live in coun­tries with low or non-ex­is­tent ac­cess to ad­e­quate pain man­age­ment (ref). The In­ter­na­tional Nar­cotics Con­trol Board (INCB) es­ti­mates that 92% of all mor­phine is con­sumed in Amer­ica, Canada, New Zealand, Aus­tralia, and parts of west­ern Europe— only 17% of the world’s pop­u­la­tion (ref ; 2014 es­ti­mates). There­fore, if an in­di­vi­d­ual out­side these bor­ders is to die of a com­mon life-threat­en­ing dis­ease (i.e. the ma­jor­ity of deaths), they run the real risk of an ex­pe­rience tan­ta­mount to tor­ture by omis­sion.

Causes of the problem

The causes of lack of ac­cess to anal­ge­sia and pal­li­a­tion are many and com­plex. They can be bro­ken into three cat­e­gories:

  1. Reg­u­la­tory im­ped­i­ments,

  2. At­ti­tude and knowl­edge im­ped­i­ments,

  3. Eco­nomic and pro­cure­ment im­ped­i­ments.

Be­cause (3) in­cludes in­suffi­cient med­i­cal in­fras­truc­ture, limited re­sources for the pur­chase of medicines, and bar­ri­ers due to sup­ply sys­tem ca­pac­ity, this cat­e­gory is not typ­i­cally ad­dressed di­rectly in efforts to in­crease ac­cess to anal­gesics (ref). Fur­ther­more, pain re­lief med­i­ca­tions such as mor­phine can be pur­chased at pen­nies per dose. I will there­fore fo­cus on (1) and (2).

More de­tailed ex­plo­ra­tions of the causes can be found in the refer­ences.

Reg­u­la­tory impediments

Opi­oid med­i­ca­tions are con­trol­led sub­stances un­der the var­i­ous in­ter­na­tional Con­ven­tions on Nar­cotic Drugs. Un­der the Con­ven­tions, coun­tries must es­ti­mate their re­quire­ments for con­trol­led medicines and sub­mit their es­ti­mates to the INCB, who will li­cence cer­tain quan­tities of the med­i­ca­tion to be pro­duced or im­ported by that coun­try. The rea­sons for these con­trols are ob­vi­ous, and these reg­u­la­tions do not pose much of an im­ped­i­ment to ac­cess.

Coun­tries are at leisure to place fur­ther con­trols on con­trol­led sub­stances. This is where sig­nifi­cant ac­cess difficul­ties be­gin. Ac­cord­ing to the Con­ven­tions (and there­fore bind­ing un­der in­ter­na­tional law), states have a “dual obli­ga­tion” to en­sure that these sub­stances are available for med­i­cal pur­poses and to pro­tect pop­u­la­tions against abuse and de­pen­dence. The poli­ti­cally mo­ti­vated (ref) global War on Drugs is blamed for skew­ing states’ pri­ori­ties away from ac­cess for med­i­cal pur­poses and to­wards mea­sures to con­trol illicit use.

Such mea­sures of­ten make it ei­ther very difficult or im­pos­si­ble for pa­tients to get the med­i­ca­tions. In Ar­me­nia for ex­am­ple, in or­der to get strong painkil­lers (ref):

  1. First, be a can­cer pa­tient. No other pa­tient qual­ifies for opi­oid anal­ge­sia.

  2. The di­ag­no­sis must be con­firmed through biopsy (tak­ing a small sam­ple from the tu­mour). Only three hos­pi­tals in Ar­me­nia offer this pro­ce­dure. Note that some pa­tients may be im­mo­bile.

  3. The on­col­o­gist must try sev­eral weaker painkil­lers be­fore ask­ing a panel to ap­prove a pre­scrip­tion for mor­phine.

  4. A panel of 5 spe­cial­ists must ex­am­ine the pa­tient at home and ap­prove the mor­phine pre­scrip­tion.

  5. Each pre­scrip­tion re­quires four stamps and three sig­na­tures of ap­proval.

  6. The pa­tient or rel­a­tive must travel to one of the few clinics or spe­cial­ised phar­ma­cies that car­ries mor­phine.

  7. The pa­tient then re­ceives enough in­jectable mor­phine (an un­nec­es­sar­ily in­va­sive pro­ce­dure when oral mor­phine is effec­tive and cheaply available) to re­lieve se­vere pain for only a few hours.

  8. The pre­scribed amount is so small that pa­tients or rel­a­tives must re­fill the pre­scrip­tion ev­ery 1-2 days.


Ar­me­nia is not an ex­cep­tional ex­am­ple; many coun­tries have com­pa­rably re­stric­tive reg­u­la­tions. In ad­di­tion to pa­tient difficul­ties, doc­tors in some coun­tries work un­der fear of pros­e­cu­tion or even jail when pre­scribing opi­oid painkil­lers (ex­am­ple).

At­ti­tude and knowl­edge impediments

If reg­u­la­tory bar­ri­ers are not enough, at­ti­tudes of pa­tients and doc­tors cre­ate fur­ther im­ped­i­ments. A widely held be­lief in coun­tries where opi­oid use is low is that the use of these medicines sig­nifies the end of cu­ra­tive treat­ment for the pa­tient; its use is seen as giv­ing up. Fear of ad­dic­tion and other ad­verse effects also in­hibits use. Opio­pho­bia—the fear of us­ing opi­oid med­i­ca­tions—of­ten has deep so­cial and cul­tural roots (ref) and is pro­mul­gated by pa­tients, doc­tors, and poli­cy­mak­ers al­ike. When prop­erly used, the in­ci­dence of ad­dic­tion and de­pen­dence is low, but fear re­mains in­or­di­nately high. Be­cause opi­oids are so rarely used in most coun­tries, most doc­tors don’t know how to use them even if they had the in­cli­na­tion. In most of the world, opi­oid use is there­fore not part of nor­mal med­i­cal prac­tice.

At­ti­tudes and fears un­der­pin the poli­ti­cal will to change reg­u­la­tions and modes of clini­cal prac­tice. This bar­rier is be­com­ing in­creas­ingly sig­nifi­cant with the opi­oid abuse epi­demic plagu­ing the USA. There are good rea­sons to be­lieve that this is, in part, the fault of ir­re­spon­si­ble mar­ket­ing by phar­ma­ceu­ti­cal com­pa­nies (John Oliver does an en­ter­tain­ing ex­posé) and linked with some of the less de­sir­able idiosyn­crasies of the US health sys­tem. Nev­er­the­less, policy mak­ers in de­vel­op­ing coun­tries are able to point to the sig­nifi­cant is­sues fac­ing the USA and some other coun­tries in or­der to jus­tify the main­te­nance or de­vel­op­ment of poli­cies that re­strict ac­cess to con­trol­led sub­stances be­yond what is rea­son­ably war­ranted.

What are pos­si­ble solu­tions?

Chang­ing regulations

Un­der in­ter­na­tional law, states are already bound to provide ad­e­quate ac­cess to pain re­lief. The law is ig­nored, be it due to re­source con­straints or com­pet­ing na­tional pri­ori­ties. Effec­tive in­ter­na­tional en­force­ment of the law is highly un­likely when it ap­pears that most coun­tries are break­ing it.

The poli­cies of in­ter­na­tional or­gani­sa­tions are gen­er­ally in ac­cord that states re­strict too much ac­cess con­trol­led med­i­ca­tions at the ex­pense of med­i­cal use (e.g. ref). The de­vel­op­ment of fur­ther gen­eral-level in­ter­na­tional poli­cies is un­likely to con­tribute heav­ily to a solu­tion.

The world drug prob­lem is a com­plex catas­tro­phe with many facets. Im­prove­ment in one area (ac­cess to pain med­i­ca­tions) de­mands im­prove­ments in oth­ers for satis­fac­tory solu­tions (e.g. ad­dic­tion and de­pen­dence treat­ment and re­ha­bil­i­ta­tion pro­grammes, med­i­ca­tion se­cu­rity in­fras­truc­ture, coun­ter­mea­sures for di­ver­sion of pre­scribed med­i­ca­tions, ad­e­quate train­ing for med­i­cal staff and car­ers, etc). On an in­ter­na­tional level, high-level poli­cies need trans­lated into spe­cific, ac­tion­able ones. This in­evitably re­quires in­ter­na­tional con­sen­sus. While health typ­i­cally en­joys rel­a­tive free­dom from politick­ing com­pared with other key ar­eas of in­ter­na­tional de­vel­op­ment, ac­cess to con­trol­led medicines is an ex­cep­tion. I have wit­nessed the de­rail­ment of World Health Assem­bly draft­ing ses­sions for im­por­tant policy mea­sures on the pub­lic health di­men­sions of the world drug prob­lem by a sin­gle un­co­op­er­a­tive coun­try. This came de­spite the same coun­try agree­ing to the high pro­file Out­come Doc­u­ment of the UN Gen­eral Assem­bly Spe­cial Ses­sion on the World Drug Prob­lem (ref) just two months ear­lier, which pro­moted the high-level prin­ci­ples that the World Health Assem­bly doc­u­ment at­tempted to con­vert into ac­tion.

While it is hard to gen­er­al­ise for all coun­tries, scope for change at a na­tional or state level seems more promis­ing. Typ­i­cally, lo­cal cham­pi­ons of the cause find some suc­cess af­ter years of effort. In­dia is a good case study for how ad­vo­cacy on a na­tional level in this area can lead to in­sti­tu­tion­al­ised change. Much state-level progress is still re­quired be­fore the ma­jor­ity of pa­tients can benefit in In­dia, how­ever. An EA seek­ing to change reg­u­la­tions would tar­get larger coun­tries with cen­tral­ised health sys­tem gov­er­nance where some poli­ti­cal will makes the prob­lem tractable. In a brief ad­vo­cacy pub­li­ca­tion (the Preventable Pain Pan­demic), I tar­geted Mex­ico and In­dia for their size and ex­tant poli­ti­cal mo­men­tum. Where there is lit­tle poli­ti­cal will and re­ac­tionary poli­cies on con­trol­led medicines (e.g. in some post-so­viet coun­tries), change seems much less tractable.

Education

Ed­u­ca­tion of med­i­cal staff on ad­minis­tra­tion of opi­oid med­i­ca­tions is re­quired be­fore pa­tients can ex­pe­rience in­creased ac­cess. Lob­by­ing for the in­clu­sion of pal­li­a­tive medicine and ad­minis­tra­tion of opi­oid med­i­ca­tions in un­der­grad­u­ate med­i­cal and nurs­ing cur­ricula seems a promis­ing long term strat­egy. Guidelines on the proper ad­minis­tra­tion of opi­oids are es­sen­tial to jus­tify re­lax­ing re­stric­tions. But it’s not only doc­tors and nurses that need ed­u­ca­tion—the at­ti­tudes of pa­tients, car­ers, and policy mak­ers also de­ter­mine prac­tice. Their at­ti­tudes tend to de­pend on those of the gen­eral pop­u­la­tion. A size­able pro­por­tion of the pop­u­la­tion needs to be ed­u­cated on ap­pro­pri­ate at­ti­tudes to pain re­lief med­i­ca­tion. While mass ed­u­ca­tion pro­grammes have worked in ar­eas such as sex­ual health and HIV, it is not ob­vi­ous whether ini­ti­a­tives in this area can pro­duce the re­quired at­ti­tude changes to gen­er­ate poli­ti­cal will on this is­sue.

With limited re­sources, it is pos­si­ble that es­tab­lish­ing lo­cal cen­tres of good prac­tice through tar­geted ed­u­ca­tion and reg­u­la­tory change could gal­vanise change on a na­tional level. In­deed, pal­li­a­tive care or­gani­sa­tions in the state of Ker­ala, In­dia, served this func­tion and catalysed na­tional progress in ac­cess to anal­gesics. Thus, ini­tial tar­geted in­vest­ments may mo­bil­ise ac­tivity and fund­ing na­tion­ally, but over­all tractabil­ity is un­clear.

Other approaches

An ap­proach that by­passes poli­tics would have a much greater chance of suc­cess. The de­vel­op­ment of novel pain kil­lers that are sig­nifi­cantly less ad­dic­tive, less dan­ger­ous, and less prone to abuse would make pain re­lief ad­minis­tra­tion more palat­able to pa­tients, med­i­cal staff, and poli­cy­mak­ers. Some head­way has been made in this re­gard (ex­am­ple—brought to my at­ten­tion by Chris Leong), but it is un­cer­tain if this should be a fo­cus area for EAs for the fol­low­ing rea­sons:

  • For-profit in­cen­tives are enough to mo­ti­vate re­search in this area.

  • If suc­cess­ful, it would take some time be­fore the new med­i­ca­tion is af­ford­able in de­vel­op­ing coun­tries, dur­ing which the at­ti­tu­di­nal and reg­u­la­tory land­scape may have changed sig­nifi­cantly in de­vel­op­ing coun­tries in favour of in­creas­ing ac­cess to ex­ist­ing painkil­lers.

  • The med­i­ca­tions de­vel­oped, even if they have markedly lower ad­verse effects, are likely to be­long to the opi­oid class and there­fore sub­ject to the same reg­u­la­tory bar­ri­ers as older mem­bers of the class (al­though they may spur reg­u­la­tory change if suffi­ciently safe).

Who else is work­ing on it?

A range of or­gani­sa­tions ex­ist that aim to in­crease ac­cess to pain re­lief med­i­ca­tions.

Open So­ciety Foun­da­tions (ref) pro­vides grants globally for work in ac­cess to pain re­lief and pal­li­a­tive care de­vel­op­ment. I can­not find figures, but I fre­quently come across work that they have funded in this do­main. Public donors in­clude PEPFAR, DFID, GIZ, the EU, and sev­eral oth­ers.

Direct work is car­ried out by a range of ac­tors. High-level poli­cies and guidelines are de­vel­oped by or­gani­sa­tions such as the World Health Or­gani­sa­tion, the UN Office on Drugs and Crime (UNODC), and global and re­gional pal­li­a­tive care as­so­ci­a­tions. Na­tional pal­li­a­tive care as­so­ci­a­tions, where they ex­ist, of­ten do much to pro­mote the cause in their coun­try. Valuable work is also performed by Hu­man Rights Watch, who have helped to pop­u­larise ac­cess to pain re­lief as a hu­man rights is­sue and ex­pose ex­am­ples of vi­o­la­tions (ref).

Notable aca­demic work in this area is car­ried out by the Pain and Policy Stud­ies Group of Univer­sity of Wis­con­sin-Madi­son (link). Among other ac­tivi­ties, they mon­i­tor global opi­oid con­sump­tion data and run ‘In­ter­na­tional Pain Policy Fel­low­ships’ (link), which train na­tional cham­pi­ons of the cause to iden­tify and over­come bar­ri­ers to the use of opi­oids in their coun­tries. The pro­gramme has had nu­mer­ous in-coun­try suc­cesses. If the Pain and Policy Stud­ies Group (PPSG) can be con­vinced to re­ceive char­i­ta­ble fund­ing for this ven­ture, it might provide a vi­able fu­ture op­tion for EAs in­ter­ested in this cause area, but data are very few and the im­pact of this pro­gramme is hard to mea­sure.

Pop­u­lar me­dia lends some at­ten­tion to the cause (ex­am­ple—a mov­ing Al Jazeera doc­u­men­tary). The Economist In­tel­li­gence Unit ran a study on the qual­ity of death through­out the world, a com­po­nent of which in­volved eval­u­at­ing ac­cess to pain re­lief med­i­ca­tions (ref).

Sub­stan­tial work on the ground is car­ried out by nu­mer­ous na­tional and lo­cal civil so­ciety and med­i­cal or­gani­sa­tions that are too many and too het­eroge­nous to list here. While these groups are es­sen­tial to the end goal of in­creas­ing ac­cess to pain re­lief, and while many are fund­ing con­strained, my in­tu­ition says an EA should prob­a­bly aim to donate to or work on up­stream bot­tle­necks to max­imise im­pact.

Is­sues for fur­ther investigation

Over­all im­pact:

The im­pact of in­creas­ing ac­cess to pain med­i­ca­tions is un­clear. The prob­lem is large in quan­tity, and se­vere in qual­ity. Nega­tive util­i­tar­i­ans or EAs with a fo­cus on ex­treme suffer­ing will es­pe­cially value ac­cess to anal­ge­sia. But it is not ob­vi­ous whether suffer­ing alle­vi­ated by in­creas­ing hu­man ac­cess to pain re­lief is greater than can be achieved by other global health in­ter­ven­tions or EA cause ar­eas such as an­i­mal char­i­ties. In­creas­ing ac­cess to these med­i­ca­tions prob­a­bly has ex­tremely small long term in­di­rect effects rel­a­tive to other health or de­vel­op­ment in­ter­ven­tions (though there is some ev­i­dence that pal­li­a­tive care is a cost effec­tive health in­ter­ven­tion by re­duc­ing hos­pi­tal­i­sa­tions, thus en­abling money to be spent el­se­where in the health sys­tem). There is nev­er­the­less some­thing sig­nifi­cant to be said for up­hold­ing a min­i­mum amount of hu­man dig­nity, cur­rently de­nied to those with­out ac­cess to pain re­lief. And be­cause the dead can­not ad­vo­cate their past plight, there is at least one rea­son to be­lieve that the cause may be ne­glected com­pared with other global health causes.

We should in­clude the down­side risks of in­creas­ing ac­cess to anal­gesics in our im­pact con­sid­er­a­tions. While the ma­jor­ity of ad­verse effects may be avoid­able un­der a well de­signed ac­cess frame­work, a small num­ber of cases of ad­dic­tion, de­pen­dence, side effects, di­ver­sion, abuse, and over­dose are al­most in­evitable with ex­ist­ing painkil­lers. This does not jus­tify the stringency of cur­rent reg­u­la­tions in most coun­tries, but the les­sons of the USA and other opi­oid-af­flicted coun­tries can­not be over­looked when de­sign­ing and im­ple­ment­ing in­ter­ven­tions to in­crease ac­cess to anal­ge­sia in the de­vel­op­ing world.

Fund­ing op­por­tu­ni­ties for EAs:

I am not aware of good op­por­tu­ni­ties for dona­tions from EAs who wish to donate to this cause. As men­tioned above, the PPSG In­ter­na­tional Pain and Policy Fel­low­ship seems like an es­pe­cially im­pact­ful pro­gramme, po­ten­tially. More de­tailed in­ves­ti­ga­tion would be needed be­fore a recom­men­da­tion can be made to donate there. At pre­sent, they do not ad­ver­tise the pos­si­bil­ity for in­di­vi­d­ual dona­tions. Iden­ti­fy­ing ad­vo­cacy or­gani­sa­tions in large coun­tries with some poli­ti­cal will (prefer­ably with cen­tral­ised health sys­tem gov­er­nance) may provide a high im­pact in­vest­ment op­por­tu­nity but, again, mea­sure­ment is a difficult is­sue.