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A Life or “Good Death” Situation? A Worldwide Ecological Study of the National Contexts of Countries That Have and Have Not Implemented Palliative Care
Address correspondence to: Joseph Clark, University of Hull, The Wolfson Palliative Care Research Centre, Cottingham Road, Allam Medical Building, Hull, United Kingdom.
Palliative care advocates argue that service implementation is feasible in all settings. Yet, services have developed patchily in low- and middle-income settings. Beyond Human Development Index indicators, there has been limited engagement with the broader development challenges facing nations tasked with implementing palliative care.
Objective
The objective of this study was to describe how indicators of national development relate to levels of palliative care services in 207 countries around the world.
Methods
We conducted a ecological study to identify relationships between potential predictor variables and the level of national palliative care development. A total of 28 predictor variables from the following six domains were selected using hypothesized relationships with levels of palliative care development: disease demographics, socioeconomics, health systems, politics, demographics, and economics. The outcome variable was level of national palliative care development on a six-point scale. Spearman's correlation was used to measure the strength of the association.
Results
Twenty-six of 28 variables were statistically significantly associated with levels of palliative care development in 207 countries. Palliative care is more developed in countries with high—percentage of deaths from noncommunicable disease, population proportion aged 65+ years, gross national income, and tourism. Development is lower in countries with high levels of political corruption, infant mortality, deaths by infectious diseases, and weak democracy. Prevalence of undernourishment and levels of private health expenditure were not significantly associated with palliative care development.
Conclusion
Palliative care development is highly consistent with broader national development indicators. It is less in countries where sudden deaths are more likely and benefits from palliative care provision are likely to be very limited. In such countries, resources may be prioritized toward life-prolonging therapies and key aspects of palliative care need only be implemented before fully integrated palliative services. Findings suggest that there may be a “tipping point” in societies, where the relative need for life-prolonging therapies becomes less than the need for integrated palliative care services.
This represents an exponential spread of palliative care practice, since its modern conceptualization. Palliative care advocates argue that service implementation is feasible in all settings.
Yet, services have developed inconsistently in low- and middle-income settings, and inadequate access to palliative care remains a global norm. The authors of the only global mapping study attribute global development to a wide range of qualitative factors (Table 1). They also report that palliative care development is associated with Human Development Ranking.
However, these findings do not inform us about the broader development challenges facing nations who have not implemented palliative care or have done so to a very limited extent.
Table 1Factors Influencing the Development of Palliative Care Services
Worldwide Palliative Care Alliance, 2011.
The Emergence of Palliative Care Champions
Support From Volunteers
A desire to provide better care for the dying
Good patient and family experiences
Freedom from pain being viewed as a human right
Better access to education and training
The growing awareness of new possibilities
Strategic planning and implementation
The practical needs of an aging population
Changes to the laws governing opioids
A changing political climate (within the Council of Europe for example)
Leadership initiatives are having an effect on policymakers
Advocacy has become sharply focused
Improved communications give easier access to information
National governments are now tasked with implementing the World Health Assembly Palliative Care Resolution which states that palliative care should be integrated at all levels of health systems.
This is at the same time when governments make efforts toward achieving the Sustainable Development Goals, with many of these goals already behind schedule.
With limited finances available, policymakers must make decisions regarding where resources should be allocated. It is therefore important to understand the broad development challenges facing countries tasked with implementing palliative care. Only then can sensible recommendations be made regarding how palliative care can be implemented in health systems worldwide.
We aimed to describe how indicators of national development relate to levels of palliative care services in nations around the world.
Methods
We conducted a cross-sectional ecological study to explore relationships between a range of demographic, health, economic, and political variables and levels of palliative care development in 207 countries.
Data Sources
We used the Worldwide Palliative Care Alliance (WPCA) 2011 global rankings as the outcome variable for levels of palliative care development. A global update of the WPCA project was published in 2014; however, this did not include new country rankings. An update to the country rankings is planned for 2019, and future comparative analysis of the 2011 and 2019 data is encouraged.
Predictor variables extracted were drawn from several globally collated macro data sets available in the public domain: the World Bank Development Indicators,
Within such data sets, data are collected on variable years, from heterogeneous sources, and collated by global agencies. All data were extracted in 2014.
Variable Selection
We adapted the WPCA country categorizations of palliative care development into a six-point ordinal scale as the outcome variable (one is lowest and six is highest). Predictor variables were selected using a theoretical approach, based on World Health Organization's guidance on a public health approach to palliative care development
Predictor variables were selected iteratively, based on theoretical hypotheses that they may be relevant to palliative care development. The justifications for variables included are presented as Supplementary Appendix 1 along with explanation of rankings where appropriate; for example, a low Corruption Index Score indicates high levels of corruption. In total, 28 variables from six domains were included (Table 2).
Table 2Variables Selected With a Hypothesized Relationship With Palliative Care Development
Theoretical Domain
Predictor Variable
Burden of disease
Cause of death, by noncommunicable diseases (% of total)
Cause of death, by communicable diseases (% of total)
Country demographics
Population ages 65 yrs and above (% of total)
Mortality rate, infant (per 1000 live births)
Urban population (% of total)
Birth rate, crude (per 1000 people)
Mortality rate, adult, male (per 1000 male adults)
The WPCA study uses United Nations country classifications and provides palliative care rankings for 234 countries. However, the World Bank uses a different country classification approach and publishes data for 207 countries only. As such, countries with a WPCA ranking but no World Bank Data available were removed from the analysis. As shown in Table 3, the proportion classified by each palliative care variable was not unduly altered by using the World Bank compared with the WPCA grouping.
Table 3Distribution of Countries Within Country Classification Groups
Palliative Care Variable
Frequency (%) (n = 234) Using WPCA Classification
Total Removed From Classification Group (%)
Frequency Using World Bank Classification (n = 207)
Difference in Proportion of Countries Represented
1: No known hospice-palliative care activity
75 (32%)
17 (23%)
58 (28%)
−4
2: Capacity building activity
23 (10%)
4 (17%)
19 (9%)
−1
3: Isolated palliative care provision
74 (32%)
6 (8%)
68 (33%)
+1
4: Generalized palliative care provision
17 (7%)
0 (0%)
17 (8%)
+1
5: Countries where hospice-palliative care services are at a stage of preliminary integration into mainstream service provision
25 (11%)
0 (0%)
25 (12%)
+1
6: Countries where hospice-palliative care services are at a stage of advanced integration into mainstream service provision
Available data from macro data sets were imported in to SPSS IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp, Armonk, NY). As predictor variable data are not published annually by global organizations, a five-year period (2007–2011) preceding the outcome variable (2011) was agreed among the research team as a reasonable time frame within which to explore associations between variables. An exception to this rule was made to include disease and health system data from 2000 as this was the only suitable data set usable before 2011. Available data were consolidated and matched to countries.
There were missing data for all variables (Supplementary Appendix 1). Where data were missing for predictor variables, cases were excluded from the analysis. This process was documented, listing the years of data included for each country as well as the total number of countries included within each correlation test.
Following data cleaning, 28 predictor variables and 207 countries with outcome data were included in the analysis.
Analysis
Spearman's correlation was calculated to measure the strength of association between development variables and level of palliative care development.
We explored the possibility of conducting ordinal regression to examine predictor variables together; however, this was not attempted for three reasons. First, we ran collinearity diagnostics in SPSS and found high levels of collinearity, meaning that dependent variables would not independently predict the outcome variable.
Second, there was no “proportional odds” between categories of the independent variable, that is, the degree of difficulty of moving between country groups is not equivalent. Finally, it does not improve the overall narrative of the study to isolate fewer variables of particular statistical importance for palliative care development, when no causal relationships can be inferred. Our findings should therefore be understood as exploratory, and no predictive relationships between variables are inferred.
Results
A total of 26 out of 28 variables were significantly associated with levels of palliative care development (Table 4). Results show that theory-driven hypothesized relationships are highly explanatory of palliative care development. Our study provides data to show that palliative care is underdeveloped in countries that face significant broader development challenges and that palliative care provision increases as these broader challenges reduce or change.
Table 4Associations Between Demographic, Social, Economic, Health, and Political Variables and Levels of Palliative Care Development
The six variables with the strongest relationship to palliative care are presented in Figure 1, and the direction of each relationship between the variables supports the hypothesized reasons for inclusion. Only “prevalence of undernourishment (% of population)” and “health expenditure, private (% of GDP)” were not significantly associated with palliative care development.
Fig. 1Predictor variables with the strongest relationship with palliative care development (n = 6).
Palliative care is more developed in countries with high—percentage of deaths from noncommunicable disease, population proportion aged 65+ years, gross national income, and tourism. Development appears to be responsive to the needs of aging populations, with level of development higher in countries with high life expectancy and percentage of population aged over 65 years. The strong relationship between palliative care development and tourism supports studies which show that tourism can promote health within host low- and middle-income countries as well as the likelihood of high tourism rates in high-income countries.
Higher development in countries with predominantly urban populations supports research identifying the logistical challenges of providing services to rural populations.
Higher levels of development in countries with a high percentage of death rates from noncommunicable diseases perhaps reflect the early development of palliative care as an end-of-life cancer intervention.
Palliative care is less developed in countries with weak democracy and high levels of—political corruption, infant mortality rates, and deaths by infectious disease. This suggests a lack of political will to establish palliative care services in contexts where most people die at a younger age from infectious disease and where deaths are more likely to occur after a short period of illness. Such countries may be focusing resources on tackling infectious diseases (where solutions are less complex than to tackling noncommunicable diseases) at the expense of palliative care.
Countries with no or limited palliative care provision are also associated with low overall health system strength, high mortality rates at younger ages, and high levels of societal inequality. These findings support the overall understanding that countries with limited palliative care services face significant structural problems in the delivery of any form of social welfare. Such countries are also likely to be net receivers of Overseas Development Assistance, which supports suggestions that global funding agencies are not promoting palliative care as a key aspect of international development.
Re-framing global palliative care advocacy for the sustainable development goal era: a qualitative study of the views of international palliative care experts.
Finally, outlier countries were found across all included variables. Most notably, Uganda and Romania both appear as outliers across several variables, with high levels of palliative care development in the context of significant broader development challenges. Another particularly noticeable outlier was “Monaco,” with “no known palliative care activity” in the context of having the highest ratio of hospital beds per 1000 in the world and known wealth and prosperity. These findings encourage renewed attention on how services in Uganda and Romania have developed to a high level in spite of challenging circumstances. However, other outlier countries encourage caution about the validity of some country rankings, given the unexpected and unlikely finding of Monaco as a place without any palliative care at all.
Discussion
This exploratory study provides data to show that international palliative care development is highly consistent with broader national development indicators. Our findings support an overall understanding that countries that have limited palliative care services face significant structural problems in the wider delivery of social welfare, with a particular challenge being high levels of corruption and weak democracy, which have undermined the development of high quality health services. In such circumstances, millions of people continue to die from diseases of poverty (e.g., diarrhea), which are either treatable or preventable in the first place.
In countries where most deaths are still caused by communicable diseases, the dying process is more likely to be relatively brief (while noting that some communicable diseases such as HIV are increasingly of chronic course).
This means that most need for palliative care will occur suddenly, in response to “unexpected” end to life, and not for progressive illness. This limits the benefits that may accrue from the provision of palliative care. In countries where most deaths are caused by noncommunicable diseases, improved life expectancies have come with the associated challenges of increased prevalence of illnesses of old age and chronic complex. In such circumstances, the dying process is likely to be prolonged, with patients living with serious illness and associated problems for a significant period of months to years. This increases the overall need for palliative care and the value proposition which services may represent.
Our analysis suggests that palliative care services are developing to a high level in such circumstances and that development occurs in response to increased longevity of need, relative to other health concerns. It also suggests that there may be a societal “tipping point,” where health care priorities switch from delivery of life-extending therapies (plus basic elements of palliative care) to services aimed at ensuring quality of life as a public health priority—with ongoing appropriate curative services. Societies must plan for when any “switch” must take place and not repeat the mistakes of many health systems in richer countries, where success of acute care provision has often developed into delivery of expensive and futile treatments at the end of life. This has come at the expense of delivery of appropriate supportive and palliative care measures, in particular for those with nonmalignant disease.
By reducing use of expensive “futile” curative treatments in advanced disease, costs may be saved by appropriately directing patients toward palliative care. However, in countries where palliative care services have not developed, it must be acknowledged that rolling out new palliative care services will be an additional cost to already burdened health care systems that are struggling to provide vaccinations for preventable disease and inexpensive curative treatments for otherwise fatal illnesses that are rarely fatal in high-income countries.
Overtreatment of medical problems is a present and growing problem around the world, and great inequalities and inequities exist between (and within) nations in terms of access to appropriate care.
However, undertreatment and lack of access to the most fundamental appropriate health care remains the dominant reality for most people in low- and middle-income countries. Although a key tenet of palliative care is to accept death as a natural process, this does not mean that we should not intervene where the lives of otherwise healthy people may be saved by simple, inexpensive, and appropriate medical treatment.
Within this context, calls for accelerated development of palliative services must be informed by in-depth understanding of national development contexts, local needs, and opportunity costs. It is important that priority palliative interventions are available to those who need them. This raises the need for research to illuminate what the priority issues are for dying patients in all world contexts. While not forgetting holistic approaches to palliative care, development should focus on “key issues” for patients, before fully integrated palliative services. Alongside this, health care systems in low- and middle-income countries must continue to strive to reduce deaths from avoidable and treatable causes.
Limitations
The nonuniformity of methods used to collect national-level data and consequent heterogeneity of data means that the validity of conclusions of this study must be treated with caution. Furthermore, the WPCA rankings themselves are problematic, given that they are commonly based on self-reported data and researcher judgments. Some data were also missing for all variables. This means that some countries were excluded (Table 3), which introduces a small but systematic bias, with richer countries overrepresented. In spite of these limitations, our results are based on “comparable cases,” derived from a single outcome variable. As with all ecological studies, there is an inherent risk of “ecological fallacy.” We acknowledge that by using “country” as the unit of analysis, our results may not reflect the experiences of individuals or inequities within such countries given that health funding and palliative care policies may be at a subnational level. Nevertheless, our observational study illuminates understanding of the broader national problems and challenges facing countries that are yet to implement palliative care to a high level and provokes debate about the future development of palliative care.
Finally, our cross-sectional study offers a snapshot of the global situation in 2014. Since data were collated, there have been numerous global developments, including efforts to implement the 2014 Palliative Care Resolution and the Sustainable Development Goals. In spite of challenges, such policy developments as well as ongoing improvement efforts will have no doubt on improved palliative care development within countries. For example, palliative care has been included as an important part of the National Cancer Control Program in Afghanistan, a country with previously “no known palliative care activity”—immediately altering its country ranking.
There may also have been setbacks to national development in some countries around the world. Publication of new country rankings will facilitate comparative research to improve understanding of how national development contexts interact with palliative care development.
Further work may also investigate how national indicators of development interact with palliative care development to test emerging hypotheses. For example, do high levels of arriving tourists indeed promote palliative care development in nations and what are the consequences of this?
Conclusion
Our findings suggest that there may be a “tipping point,” where the relative need for life-prolonging therapies becomes less than the need for integrated palliative care services. Future research could usefully focus on how to identify any such tipping point in specific national contexts. This would allow appropriate preparation for new challenges of aging populations, associated increases in chronic/degenerative illnesses, and survivorship, when basic interventions to prevent and avoid deaths from avoidable causes have been successfully implemented.
Disclosures and Acknowledgments
This study was funded by the School of Health and Related Research, University of Sheffield. All work was conducted by the authors. The authors declare no conflicts of interest.
The authors are grateful to professors, David Currow and Miriam Johnson, for positive comments on drafts of the final article.
Ethical approval: The study was granted ethical approval from the School of Health and Related Research Ethics Committee at the University of Sheffield.
Appendix
Supplementary Appendix 1Rationale for Variable Inclusion and Included Data Levels
No.
Indicator
Domain
Description
Year of Data
Measure
Records Included
Theoretical Relationship with Palliative Care Development
1
Cause of death, by noncommunicable diseases (NCDs) (% of total)
Burden of disease
Percentage of national population who die due to noncommunicable illness.
Although palliative care is now recommended for both noncommunicable and communicable diseases, inclusion of this variable allows an investigation regarding whether palliative care has developed primarily to meet the needs of cancer patients.
2
Cause of death, by communicable diseases (% of total)
Burden of disease
Percentage of deaths resulting from communicable diseases and maternal, prenatal, and nutrition conditions.
The WHO recommends palliative care for any life-limiting illness. However, as palliative care emerged originally to meet the needs of cancer patients, the inclusion of this indicator allows assessment of whether palliative care services have now developed in countries where people predominantly die for infectious illnesses.
3
Life expectancy at birth, total (yrs)
Socioeconomic
Expected life expectancy for a new born based on assumed continuation of current mortality rates.
Disaggregating life expectancy from the other components of human development score is appropriate in context of the global challenge of aging populations. Inclusion of this variable allows examination of WPCA claims that palliative care has developed “to meet the needs of aging populations.”
4
Age dependency ratio (% of working-age population)
Socioeconomic
Ratio of older dependents, people older than 64 yrs to the working-age population, those ages 15–64 yrs
This indicator is central to discourses around aging and the sustainability of health systems. Its inclusion allows investigation of whether palliative care has developed most highly, in circumstances where fewer people (older or younger) are paying into health systems.
5
Literacy rate, adult total (% of people ages 15 and above)
Socioeconomic
Percentage of adults (15+) who can read, write, and possess basic numeracy.
Literacy rates is one of the social indicators used as a contextual factor for why the Indian state of Kerala has achieved high palliative care coverage.
Such links provide justification for examining any relationship between literacy rates and level of palliative care development. It may be expected that higher literacy rates are indicative of higher levels of palliative care development.
6
Out-of-pocket health expenditure (% of total expenditure on health)
Socioeconomic
Any direct household outlay spent on restoration or enhancement of health.
This variable allows distinction between public and private health systems. Theoretically, lower out-of-pocket expenditure is indicative of high commitment from governments to health care.
Conversely, greater out-of-pocket expenditure is suggestive of a greater role of the private sector in the provision of health care. Understanding palliative care development from a public health approach, it may be expected that out-of-pocket expenditure would be lower in circumstances which have higher levels of palliative care development.
and serves as an estimate of the prevalence of death within a population. Estimating death rates is important in terms of assessing potential need for palliative care services. Competing hypotheses are firstly, that high death rates indicate greater need for palliative care and that palliative care may have developed to meet this need. Alternatively, it could be suggested that higher death rates are indicative of underdeveloped health systems where palliative services may not yet have emerged to meet palliative care need.
8
Prevalence of undernourishment (% of population)
Socioeconomic
Percentage of population below minimum level of dietary energy consumption
The line of enquiry here is that countries where undernourishment remains prevalent are less likely to have developed the infrastructure for palliative care.
9
GINI index
Socioeconomic
Extent to which income distribution or consumption expenditure among individuals or households within a nation deviates from a perfectly equal distribution.
The GINI coefficient is a measurement of the level of income inequality and consumption expenditure within a country. A GINI index of 0 indicates perfect equality, whereas an index of 100 suggests perfect inequality.
One theoretical hypothesis for including the variable is that it can be suggested that income equality (or inequality) is not something that occurs naturally, but which is guided by policies.
One hypothesis is that more equal societies enjoy greater social cohesions, a circumstance that may have facilitated the development of palliative care.
An alternative hypothesis was heard anecdotally by the author that high-income inequality in a country can actually facilitate access to palliative care services, as poorer people seek care as they are unable to seek more expensive curative alternatives.
A theoretical hypothesis is that where large numbers of tourists encounter avoidable suffering—absence of pain relief, for example—that this leads to a response. The work of Ecosphere, a tourism social enterprise, which is helping to introduce palliative care into an isolated Himalayan region in India (Himachal Pradesh) fits with this theory and provides justification to examine any potential broader trends.
11
Internet users (per 100 people)
Socioeconomic
Individual users of the Internet per year (per 100 people)
The WPCA reported growing awareness of new possibilities, better access to education and training, improved communication systems, access to information as well as “broader support networks” as factors driving palliative care development. “Internet use” was deemed to be a reasonable indicator of access to such systems and processes and was therefore included as a facilitator of such factors on that basis. It may therefore be expected that higher Internet use is associated with higher levels of palliative care development.
12
Consumption of morphine equivalent in mg per capita
Health systems
Total opioids distributed to licensed dispensaries (per capita)
Opioid consumption is sometimes referred to as the only indicator collated at global level which is relevant to palliative care provision. Morphine equivalents (MEs) serve as a good indication of the availability and provision of pain relief within a country, although it does not reveal anything about equity of access in a country. Competing hypotheses are that firstly, availability of morphine equivalents has driven service development. Alternatively, it could be that advocacy from palliative care activists has led to greater ME availability. However, it would be expected that the higher the level of consumption, the higher the level of palliative care development.
13
Hospital beds (per 1000 people)
Health systems
Hospital bed available per 1000 people (public and private)
This variable is included as an indicator of countries' health infrastructure. The measure includes beds at public, private, general, and specialized hospitals and rehabilitation centers. It can be suggested that the higher the proportion of beds to people, the greater the chance that some of these are utilized for palliative patients.
14
Health system ranking
Health systems
Overall health system performance ranking measured in terms of improvement in health, health system responsiveness, and distribution of service
In general, high public expenditure on health is consistent with social democratic health systems, whereas low spending is associated with liberal health systems.
The hypothesis here is that the greater the proportion of government resources that are directed toward health, the higher the level of palliative care development.
16
Health expenditure, private (% of GDP)
Political
Private health expenditure includes direct household) spending, private insurance, charitable donations, and payments by private corporations as a percentage of Gross Domestic Product
This variable serves as an indication of political ideology, with higher private spending on health associated with liberal health systems and lower spending, when compared to social democratic models. From a public health perspective, it may be expected that lower private health expenditure would be associated with higher palliative care development.
17
Corruption index
Political
Level of misappropriation of health funding for personal gain
With increased funding, there is increased political pressure for these targets to be met. High levels of corruption have seen the misdirection of finances made available for health care.
Therefore, resources that may have been allocated to palliative care development were not spent on developing palliative services. As there are no global targets relating to palliative care, there is little accountability either. A corruption index score number indicates high levels of corruption
18
Public spending on education, total (% of GDP)
Political
Government spending on education as a percentage of Gross Domestic Product
This indicator has been included for analysis as a further measure of government commitment to social outcomes among its population. Furthermore, the context of Kerala, where educational indicators are high provides more anecdotal evidence of a potential relationship between these two variables.
“The practical needs of an aging population” has been reported as a driver of palliative care development. The needs of people who die before the age of 65 yrs, notwithstanding, including this variable allow us to test the hypothesis that palliative care services have developed to meet the needs of older people (>65).
21
Mortality rate, infant (per 1000 live births)
Demographic
Total deaths of infants under one year of age (per 1000 live births)
With a health systems approach proposed for palliative care development, it might be expected that high infant mortality rates are an indicator of health system weakness. Global prioritization of improving infant mortality rates may suggest that this is being prioritized over and above rollout of palliative care.
22
Urban population (% of total)
Demographic
People living in urban areas as percentage of total population
The geography and demographics of a country can present unique challenges for health systems to deliver quality health care. In terms of the urban:rural distribution of a population, a major issue centers around access to health services. In addition, a systematic review reports that palliative care services have developed mainly in urban areas.
Birth rates have become used as a quasi-indicator of a countries' level of development, with low birth rates prevalent in the countries of high development and higher rates found in lesser developed countries—in particular the world's poorest countries.
The theoretical argument for the inclusion of the variable is that in developmental health systems where countries have not yet tackled issues relating to high infant and maternal mortality, they have not been able to focus on the needs of people at the end of life.
24
Mortality rate, adult, male (per 1000 male adults)
Demographic
Total adult (15–60) male deaths per 1000 adult males
Mortality rates are included as a useful suggestion of the extent to which palliative care services have developed in response to need. In general terms, proponents suggest that most people would benefit from palliative treatment during the final phase of life—whenever that may be. On this basis, it can be suggested that higher mortality rates are indicative of greater level of need within a population and the responsiveness of health systems to palliative care need. Distinction between male and female mortality rates have been drawn to take into consideration potential gender difference.
Generally speaking, growing national populations are associated with low- and middle-income countries and reducing populations, with high-income—and aging—nations.
The variable has been included as it can be said that there is an increased challenge of rolling out palliative care services to an increasing population. Changing population demographics (growing and reducing) present different challenges to policymakers. However, as palliative care is one recommendation from the United Nations as a policy response to global aging, it can be said that we may expect to find greater palliative care development in countries where the population is reducing.
Gross National Income (GNI) per capita is one element of the composite measure of a country's Human Development score. This variable has been included as it may be suggested that the higher the nations income, the greater the financial resources that are available to have funded palliative care development.
28
Net ODA received per capita (current US$)
Economic
Net overseas development assistance divided by midyear population
Overseas Development Assistance (ODA) is the term coined by the Organization for Economic Co-Operation and Development for the transfer of resources from official agencies and governments which “is administered with the promotion of economic development and welfare of developing countries.”
Much ODA is channeled to improving health care services of recipient countries. This variable is of interest, as it may be expected that countries are able to provide ODA to have higher levels of palliative care development, yet, through ODA, opportunities may have arisen for lower income nations fund palliative care.
Re-framing global palliative care advocacy for the sustainable development goal era: a qualitative study of the views of international palliative care experts.
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