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Mapping Levels of Palliative Care Development in 198 Countries: The Situation in 2017

Open AccessPublished:November 21, 2019DOI:https://doi.org/10.1016/j.jpainsymman.2019.11.009

      Abstract

      Context

      Palliative care is gaining ground globally and is endorsed in high-level policy commitments, but service provision, supporting policies, education, and funding are incommensurate with rapidly growing needs.

      Objectives

      The objective of this study was to describe current levels of global palliative care development and report on changes since 2006.

      Methods

      An online survey of experts in 198 countries generated 2017 data on 10 indicators of palliative care provision, fitted to six categories of development. Factor analysis and discriminant analysis showed the validity of the categorization. Spearman correlation analyses assessed the relationship with World Bank Income Level (WBIL), Human Development Index (HDI), and Universal Health Coverage (UHC).

      Results

      Numbers (percentages) of countries in each development category were as follows: 1) no known palliative care activity, 47 (24%); 2) capacity-building, 13 (7%); 3a) isolated provision, 65 (33%); 3b) generalized provision, 22 (11%); 4a) preliminary integration into mainstream provision, 21 (11%); 4b) advanced integration, 30 (15%). Development levels were significantly associated with WBIL (rS = 0.4785), UHC (rS = 0.5558), and HDI (rS = 0.5426) with P < 0.001. Net improvement between 2006 and 2017 saw 32 fewer countries in Categories 1/2, 16 more countries in 3a/3b, and 17 more countries in 4a/4b.

      Conclusion

      Palliative care at the highest level of provision is available for only 14% of the global population and is concentrated in European countries. An 87% global increase in serious health-related suffering amenable to palliative care interventions is predicted by 2060. With an increasing need, palliative care is not reaching the levels required by at least half of the global population.

      Key Words

      Key Message

      With an increasing need, palliative care is not reaching the levels required by at least half of the global population. Our analysis of 198 countries casts doubt on the effectiveness of recent global strategies and emphasizes the urgent need for greater palliative care development and implementation, building on the identified infrastructures.

      Background

      The delivery of palliative care is seen increasingly as a global health issue. In 2014, the World Health Assembly passed a declaration calling upon all governments to integrate the provision of palliative care into their health plans.
      World Health Assembly Resolution 67-19
      Strengthening of palliative care as a component of comprehensive care throughout the life course..
      The Lancet Commission Report on Palliative Care and Pain Relief in 2017 estimated that almost half of the people who die each year encounter “serious health-related suffering” that could benefit from palliative care, 80% of them in low- and middle-income countries.
      • Knaul F.M.
      • Farmer P.E.
      • Krakauer E.L.
      • et al.
      Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report.
      The 2018 Declaration of Astana, focusing on primary care as an aspect of Universal Health Coverage and sustainable development goals, included palliative care across a spectrum of provision that must be accessible to all.
      Declaration of Astana, Global Conference on Primary Health Care 25-26 October 2018.
      Such high-level policy interventions, framed within the wider discourse of global health, are designed to support the worldwide improvement of palliative care and its integration into health systems. There is growing evidence of the enormous need for palliative care that the world is facing.
      • Sleeman K.E.
      • de Brito M.
      • Etkind S.
      • et al.
      The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions.
      The burden of serious health-related suffering will almost double by 2060, with the fastest increases occurring in low-income countries, among older people, and people with dementia. Although it has become common to describe the need for global action to integrate palliative care into health systems as an ethical and economic imperative, palliative care development remains patchy, the field often lacks recognition, there is a dearth of investment, and research evidence to support its global growth is limited.
      • Clark D.
      To Comfort Always: a history of palliative medicine since the nineteenth century.
      Much development at the country level continues to be spearheaded by motivated individuals and nongovernmental organizations, often with limited financial, political, and policy influence. Progress is slow and it is unclear whether high-level policy interventions can escalate the speed and volume of palliative care development around the world.

      Carrasco JM, Inbadas H, Whitelaw A, Clark, D (under review) EArly impact of the 2014 World Health Assembly Resolution on Palliative Care: a qualitative study using semi-structured interviews with key experts. J Palliat Med.

      Two WHO studies have thrown some light on palliative care development globally. A 2015 survey
      • Sharkey L.
      • Loring B.
      • Cowan M.
      • et al.
      National palliative care capacities around the world: results from the World Health Organization Noncommunicable Disease Country Capacity Survey.
      was able to report that 37% of countries had an operational national policy for noncommunicable diseases which included palliative care; palliative care services were financially disadvantaged compared to other noncommunicable disease services; and a large country-income gradient existed for palliative care funding, for oral morphine availability, and the integration of palliative care at the primary levels of the health system. A 2017 survey
      reported that 68% of countries had some form of funding for palliative care and approximately one-third of countries responded that palliative care was generally available in both primary health care facilities (35%) and community or home-based care (37%).
      We report here on a unique global program of work that has been monitoring country-level development in palliative care, across income categories, for more than a decade, beginning in 2006,
      • Wright M.
      • Wood J.
      • Lynch T.
      • Clark D.
      Mapping levels of palliative care development: a global view.
      followed up in 2011,
      • Lynch T.
      • Connor S.
      • Clark D.
      Mapping levels of palliative care development: a global update.
      and now updated for 2017. These original studies have contributed significantly to advocacy, planning, and monitoring of palliative care worldwide and complement related work done for smaller numbers of countries by the Economist Intelligence Unit.
      The Economist Intelligence Unit
      The Quality of Death: Ranking end-of-life care across the world.
      ,
      The Economist Intelligence Unit
      The Quality of Death: Ranking end-of-life care across the world.
      In 2014, the second global study formed a key aspect of the evidence base
      for the 67th World Health Assembly (WHA) Resolution on Palliative Care, which was supported by all member states. Our goal has been to present an unfolding analysis of global palliative care development over time in ways that can inform policy and advocacy.
      The aims of the present study were 1) to allocate each country to one of six categories of palliative care development in 2017 (Table 1) and 2) to track category changes since 2006.
      Table 1Six Levels of Palliative Care Development.
      Category 1: No known palliative care activityA country in this category is one where current research reveals no evidence of any palliative care activity.
      Category 2: Capacity-building palliative care activityA country in this category shows evidence of wide-ranging initiatives designed to create the organizational, workforce, and policy capacity for the development of palliative care services, although no service has been established yet. Developmental activities include attendance at, or organization of, key conferences, personnel undertaking external training in palliative care, lobbying of policy makers and Ministries of Health and emerging plans for service development.
      Category 3a: Isolated palliative care provisionA country in this category is characterized by the development of palliative care activism that is still patchy in scope and not well supported; sources of funding that are often heavily donor dependent; limited availability of morphine; and a small number of palliative care services that are limited in relation to the size of the population.
      Category 3b: Generalized palliative care provisionA country in this category is characterized by the development of palliative care activism in several locations with the growth of local support in those areas; multiple sources of funding; the availability of morphine; several hospice-palliative care services from a range of providers; and the provision of some training and education initiatives by the hospice and palliative care organizations.
      Category 4a: Palliative care services at a preliminary stage of integration to mainstream health care servicesA country in this category is characterized by the development of a critical mass of palliative care activism in a number of locations; a variety of palliative care providers and types of services; awareness of palliative care on the part of health professionals and local communities; a palliative care strategy that has been implemented and is regularly evaluated; the availability of morphine and some other strong pain-relieving drugs; some impact of palliative care on policy; the provision of a substantial number of training and education initiatives by a range of organizations; and the existence of a national palliative care association.
      Category 4b: Palliative care services at an advanced stage of integration to mainstream health care servicesA country in this category is characterized by the development of a critical mass of palliative care activism in a wide range of locations; comprehensive provision of all types of palliative care by multiple service providers; broad awareness of palliative care on the part of health professionals, local communities, and society in general; a palliative care strategy that has been implemented and is regularly updated; unrestricted availability of morphine and most strong pain-relieving drugs; substantial impact of palliative care on policy; the existence of palliative care guidelines; the existence of recognized education centers and academic links with universities with evidence of integration of palliative care into relevant curricula; and the existence of a national palliative care association that has achieved significant impact.

      Methods

      An open-access protocol
      • Baur N.
      • Centeno C.
      • Garralda E.
      • Connor S.
      • Clark D.
      Recalibrating the ‘world map’ of palliative care development.
      contains a full description of our methods, design, use of indicators, data collection, analysis, and how these have been improved over previous iterations of the study, taking into account of published commentary about limitations of the method.
      • Loucka M.
      • Payne S.
      • Brearley S.
      • et al.
      How to measure the international development of palliative care? A critique and discussion of current approaches.
      ,
      • Timm H.
      • Vittrup R.
      Mapping and comparison of palliative care nationally and across nations: Denmark as a case in point.

      Data Sources

      We designed and piloted an online questionnaire to be completed by in-country experts. These were defined as follows:
      • 1.
        Representatives of the national in-country hospice-palliative care association or nearest professional association (e.g., society for palliative medicine, hospice forum). The person should have an established administrative and/or leadership role in the organization making them a reliable source of information.
      • 2.
        Academic experts with known interests and research experience in hospice-palliative care development in-country and/or beyond as evidenced by peer-reviewed publications. The person should have an established academic role in hospice-palliative care research or education making them a reliable source of information.
      • 3.
        Policy specialists (in or outside government) with experience of and/or responsibility for hospice-palliative care delivery in-country. The person should have an established policy role relating to hospice-palliative care making them a reliable source of information.
      We also used two sets of additional data from third-party sources: country populations
      and country-level opioid consumption.

      Obtained by DC from the University of Wisconsin Pain and Policies Study Group through personal communications with Professor James Cleary (now of the Walther Supportive Oncology Program at Indiana University School of Medicine)

      Our study population included 198 territories, comprising the 193 Member States of the United Nations (UN), two observer states, along with Kosovo, Somaliland, and Taiwan, China. We surveyed a total of 560 experts from 179 (90%) countries for which contacts could be found.
      Respondents were identified by global and regional palliative care associations, from named persons in published regional atlases of palliative care, and from the wider literature. For countries where no questionnaire data were obtained or where the questionnaire data were incomplete, we supplemented where possible by systematic review of the available published literature or extraction of data from Regional Palliative Care Atlases published since 2011.
      • Rhee J.Y.
      • Luyirika E.
      • Namisango E.
      • et al.
      APCA Atlas of Palliative Care in Africa.
      • Centeno C.
      • Lynch T.
      • Donea O.
      • Rocafort J.
      • Clark D.
      EAPC Atlas of Palliative Care in Europe 2013.
      • Osman H.
      • Rihan A.
      • Garralda E.
      • et al.
      Atlas of Palliative Care in the Eastern Mediterranean Region.
      • Pastrana T.
      • De Lima L.
      • Wenk R.
      • et al.
      Atlas of Palliative Care in Latin America ALCP.

      Analysis

      We established 10 indicators of palliative care development, drawn from the emerging literature
      • Arias N.
      • Garralda E.
      • De Lima L.
      • Rhee J.Y.
      • Centeno C.
      Global palliative care and cross-national comparison: how is palliative care development assessed?.
      and linked to specific questionnaire items (Table 2). For each indicator, we established an outcome range of six levels, fitted to the palliative care development categories and the definitions adopted. This enabled each country where complete data existed to be assigned a numerical value between zero (Category 1) and five (Category 4b) across each of the 10 indicators. Where data had to be supplemented from documentary sources, we allocated scores to the missing indicators based on research team members' assessment of the sources. The scores were then applied to an analytic algorithm (Fig. 1), using the mode and the median of these indicators. Where mode and median were coincident, this determined the country's overall level of categorization. Where they were not, the mode was moderated either upward or downward by one category based on whether the median value of four specific selected indicators, judged to be the most “consequential” for palliative care development, was higher or lower than the mode. These four consequential indicators were as follows: the availability and consumption of opioids, and the number and geographic distribution of services.
      Table 2Indicators of Palliative Development
      WHO dimensionScoreCategories
      012345
      IndicatorCategory 1

      No known PC activity
      Category 2

      Capacity-building PC activity
      Category 3a

      Isolated PC provision
      Category 3b

      Generalized PC provision
      Category 4a

      PC services at preliminary stage of integration
      Category 4b

      PC services at advanced stage of integration
      Services (Q15)Provision of services
      This indicator relates to the total number of palliative care services operating in a country. These include, but are not limited to, freestanding hospices with or without inpatient beds, hospices that are a part of public or NGO hospitals, home care teams, palliative care support teams in hospitals, palliative care inpatient and outpatient facilities, pediatric palliative care hospices and services. The focus is on services that are providing specialized/specialist palliative care as their primary mission. A palliative care service provider organization may have more than one local service in operation, so the number of palliative care services in a country may be greater than the number of provider organizations. (This definition was included in the questionnaire).
      No evidence/don't knowNo evidence0–0.49 per 100,0000.5–0.99 per 100,0001.0–1.49 per 100,0001.5 and more per 100,000
      (Q17)Geographical spread of servicesNo evidence/don't knowIn progress1–45–67–89–10
      Funding (Q18)Range of available funding sources for palliative careNo evidence/don't knowDirect paymentsDirect payments, donorDonor, institutions & partial NHS (pilot projects)NHS participates in the funding on a regular basisMainly by NHS or health finance system
      Strategy or national plan (Q19 a/e/f/g/k)Existence of national strategy or plan for palliative careNo evidence/don't knowNo referenceReference to PC in national strategies for cancer, AIDS, and/or other noncommunicable diseasesStrategy or national plan specific to PCPC strategy implemented and evaluatedPC strategy implemented and updated OR Desk at Ministry of Health
      Law (Q19 b/c/d)Existence of legal provision to support palliative careNo evidence/don't knowNo referenceEstablishment in progress of any reference (decrees/norms) but not national law—could be regional law (e.g., Germany)Any reference (decrees/norms) but not national law—could be regional law (e.g., Germany)References to PC in national lawsStandalone PC law or recognition of PC as a right in top law or the constitution of the country
      Medicine (Q21/22)Availability of morphine and other strong opioidsNo evidence/don't knowNot availableMorphine occasionally availableMorphine usually availableMorphine always available, other opioids usually availableAny kind of strong opioids always available
      Country consumption of morphine per capita (2015)No evidence/don't know0.0001–0.2399 (Quartile 1)0.2400–1.0387 (Quartile 2)1.0388–3.9857 (Quartile 3)>3.9857 (Quartile 4)>3.9857 (Quartile 4) and any kind of strong opioids always available
      Education (Q23)Training programs for professionals in palliative careNo evidence/don't knowProfessionals receive training abroad, basic courses are available in the countryInformal process of training for palliative care professionals available in the countryEstablishment of official process of palliative medicine specialization in the country in progressOfficial process of palliative medicine specialization available in the countrySubstantial number of professionals certified
      (Q24/25)Education for prequalification doctors/nursesNo evidence/don't knowTeaching by nonprofit sector and/or hospice organizationsTeaching is available at hospitals/medical centers/university hospitals or through Ministry of HealthTeaching is available in the primary care sectorUniversities provide PC trainingUniversities provide PC training and palliative medicine is a recognized medical specialty or subspecialty
      Vitality (Q19 hours/i/j/l/m/n/o)Existence of meetings, associations, journals, conferences, guidelines, collaborations in palliative careNo evidence/don't knowEvidence of PC professional or political meetingsExistence of a national PC association or establishment in progressExistence of at least one of the following: a national journal, palliative care directory, standards or guidelines and national conference AND a national PC associationExistence of at least two of the following: a national journal, palliative care directory, standards or guidelines and national conference AND a national PC associationExistence of at least two of the following: a national journal, palliative care directory, standards or guidelines and national conference AND a national PC association as well as evidence of professional co-operation with other specialties outside PC (national or international)
      a This indicator relates to the total number of palliative care services operating in a country. These include, but are not limited to, freestanding hospices with or without inpatient beds, hospices that are a part of public or NGO hospitals, home care teams, palliative care support teams in hospitals, palliative care inpatient and outpatient facilities, pediatric palliative care hospices and services. The focus is on services that are providing specialized/specialist palliative care as their primary mission. A palliative care service provider organization may have more than one local service in operation, so the number of palliative care services in a country may be greater than the number of provider organizations. (This definition was included in the questionnaire).
      Figure thumbnail gr1
      Fig. 1Scoring algorithm to determine categories of palliative care development.
      By this process, each country was allocated to one of the six predetermined categories of palliative care development. Factor analysis and discriminant analysis were performed to justify the categorization validity.
      Spearman correlation coefficients were computed to discover significant associations between level of palliative care development and World Bank Income Level (WBLI), Human Development Index (HDI), and Universal Health Coverage (UHC).
      For purposes of comparison over time, we combined Categories 3a and 3b, 4a and 4b, from the 2011 and 2017 studies, controlled for new states recognized by the UN since the first world map of palliative care was developed, and excluded jurisdictions (mainly UN-associated territories) not included in the present study.

      Findings

      Completed questionnaires were obtained from 143 (76%) countries; for eight countries (4%), the questionnaire data were incomplete; 28 (14%) countries contacted did not reply and provided no questionnaire data; for 19 (10%) countries, we were unable to identify a contact. Population data were obtained for 198 countries, but opioid consumption data were not available for 45 countries. For the 55 countries with missing or incomplete questionnaire data, we substituted, where possible, with information from documentary sources, and categorized the 198 countries as shown in Fig. 2. Countries where no data were available were placed in Category 1.

      Categorization of Level of Palliative Care Development at 2017

      Table 3 and the map at Fig. 3 show the levels of palliative care development for 198 countries. Only 30 countries (15%) in the world are in the highest level of palliative care development. These countries represent 14% of the world population. A further 21 countries (11%) have high levels of palliative care development, but not across all indicators. They comprise 28% of the world population.
      Table 3Level of Palliative Care Development in 2017 by Country, Population, WHO Region, and World Bank Income Level
      Category

      Number of Countries (%): Total Population (% of World Population)
      WHO RegionCountries
      Category 1: No known palliative care activity

      47 countries (24%);

      235 million people (3.1% of world population)
      AfricaCape Verde, Central African Republic, Chad, Comoros, Congo (Republic), Guinea-Bissau
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Lesotho, Mali, Seychelles, South Sudan
      AmericasAntigua & Barbuda, Cuba, Dominica
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Grenada
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Guyana, Saint Lucia, St Kitts & Nevis
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , St Vincent & the Grenadines
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Suriname
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      Eastern MediterraneanDjibouti, Iraq, Somalia, Somaliland, Syria
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Yemen
      EuropeAndorra, Kosovo
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Monaco, Montenegro, San Marino
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Turkmenistan, Vatican City
      South-East AsiaBhutan, Maldives
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , North Korea, Timor l'Este
      Western PacificBrunei, Kiribati, Laos, Marshall Islands, Micronesia
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Nauru
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Palau
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Solomon Islands
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Tonga, Tuvalu
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      , Vanuatu
      Denotes countries placed in Category 1 because no contacts for survey were identified.
      Category 2: Capacity-building palliative care activity

      13 countries (7%);

      126 million people (1.7% of world population)
      AfricaAngola, Burkina Faso, Burundi, Equatorial Guinea, Eritrea, Gabon, Liberia, Sao Tome e Principe
      AmericasBahamas, Haiti
      Eastern MediterraneanUnited Arab Emirates
      EuropeUzbekistan
      South-East Asia
      Western PacificSamoa
      Category 3a: Isolated palliative care provision

      65 countries (33%);

      3597 million people (47.7% of world population)
      AfricaAlgeria, Benin, Botswana, Cameroon, Congo (DR), Ethiopia, Ghana, Guinea, Madagascar, Mauretania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania, Togo
      AmericasBolivia, Dominican Republic, Ecuador, Guatemala, Honduras, Jamaica, Nicaragua, Paraguay, Peru, Trinidad & Tobago, Venezuela
      Eastern MediterraneanAfghanistan, Bahrain, Egypt, Iran, Kuwait, Lebanon, Libya, Morocco, Pakistan, Palestine, Sudan, Tunisia
      EuropeArmenia, Azerbaijan, Bosnia & Herzegovina, Croatia, Estonia, Greece, Kyrgyzstan, Moldova, Tajikistan, Turkey
      South-East AsiaBangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka
      Western PacificCambodia, Fiji, Malaysia, Papua New Guinea, Philippines, Vietnam
      Category 3b: Generalized palliative care provision

      22 countries (11%);

      426 million people (5.7% of world population)
      AfricaGambia, Kenya, Zambia
      AmericasBelize, Brazil, Colombia, El Salvador, Panama
      Eastern MediterraneanJordan, Oman, Qatar, Saudi Arabia
      EuropeAlbania, Belarus, Bulgaria, Cyprus, Finland, Luxembourg, Macedonia, Malta, Serbia, Slovenia
      South-East Asia
      Western Pacific
      Category 4a: Palliative care at preliminary stage of integration

      21 countries (11%);

      2083 million people (27.6% of world population)
      AfricaCôte d’Ivoire, South Africa, Uganda, Zimbabwe
      AmericaArgentina, Chile, Mexico, Uruguay
      Eastern Mediterranean
      EuropeAustria, Czech Republic, Georgia, Hungary, Kazakhstan, Latvia, Russia, Slovakia, Switzerland, Ukraine
      South-East AsiaThailand
      Western PacificChina, Singapore
      Category 4b: Palliative care at advanced stage of integration

      30 countries (15%);

      1074 million people (14.2% of world population)
      AfricaMalawi, Swaziland
      AmericaBarbados, Canada, Costa Rica, United States of America
      Eastern Mediterranean
      EuropeBelgium, Denmark, France, Germany, Iceland, Ireland, Israel, Italy, Liechtenstein, Lithuania, Mongolia, The Netherlands, Norway, Poland, Portugal, Romania, Spain, Sweden, United Kingdom
      South-East Asia
      Western PacificAustralia, Japan, New Zealand, South Korea, Taiwan
      a Denotes countries placed in Category 1 because no contacts for survey were identified.
      Figure thumbnail gr3
      Fig. 3Global levels of palliative care development.
      Close to one-quarter of countries (47, 24% of the total) have no known palliative care activity. These countries represent 3.1% of the global population.
      Between these extremes, there are 13 countries (7%) that are still building capacity in advance of actual palliative care service provision and 87 countries (44%) where development and delivery are localized to a significant degree and lack sufficient integration with the wider health and social care system to achieve high coverage. These 87 countries of limited palliative care development represent 53% of the global population.
      Table 4 shows the relationship between the level of palliative care development and the United Nations Human Development Index,
      United Nations Development Programme
      UN Human Development Indices and Indicators 2018.
      World Bank Income level,
      World Bank
      Country classifications by income level.
      Universal Health Coverage,
      World Health Organisation
      Universal health coverage.
      and WHO region. There is a strong tendency for countries that are more developed on these measures to have higher levels of palliative care development, with 64% of countries at the highest levels of human development falling in Categories 4a and 4b. There are however outliers at all levels of development, with a small number of highly developed countries having little palliative care provision, and four countries that are at the lowest level of human development but are nevertheless placed in the highest two categories of palliative care provision.
      Table 4Level of Palliative Care Development by Country-Level Indicators
      IndicatorCategory 1Category 2Category 3aCategory 3bCategory 4aCategory 4bTotal
      No.%No.%No.%No.%No.%No.%No.
      Human Development Index level
       Very high352361010171221254358
       High1426362140815592453
       Medium102638215438131339
       Low1129513174513381338
       No Human Development Index99011010
      World Bank Income level
       High813236109151017254260
       Upper-middle16283521379166112455
       Lower-middle112537225036372547
       Low1029515154413261333
       No World Bank Income level2671333
      Universal Health Care Index quintile
       Q5 (high)260026719411215836
       Q4262612347209263935
       Q310261317444105132539
       Q211314111440411131335
       Q1 (low)10266161950251338
       No Universal Health Care Index12801721315
      WHO region
       Africa1021817204336492447
       America92626113151441141135
       Eastern Mediterranean62614125241723
       Europe71312101810181018183256
       South-East Asia4366551911
       Western Pacific1142146232862326
      Total47241376533221121113015198
      Percentages are of row totals.
      We compared for the first time the level of palliative care development with an index of progress toward UHC, as defined by the UN Sustainable Development Goal Target 3.8—that all people receive the essential health services they need, without being exposed to financial hardship. Table 4 shows a close relationship between the level of development of palliative care services and the level of UHC. Over half (58%) of the 36 countries in the top quintile for UHC service coverage are at the highest level of palliative care development. Similarly, only four countries in the highest categories of palliative care development are in the lowest two UHC quintiles or countries with no UHC Index.
      Supplementary Figure 1, Supplementary Figure 2, and 3 contain maps that reveal for each country the level of palliative care development and the WBIL, SDI, and UHC Index, respectively.
      Spearman correlation analyses of palliative care development category against these indicators showed level of development to be significantly associated with WBIL (rS = 0.4785), UHC (rS = 0.5558), and HDI (rS = 0.5426) with P < 0.001, with a moderate size effect in each case.
      Among the WHO geo-health regions, Europe has 32 of 56 countries in the highest level of development, whereas the Eastern Mediterranean and South-East Asia regions have no countries in this category.

      Change Over Time, 2006–2017

      We assessed country-level changes in palliative care development over a period of 11 years (Table 5).
      Table 5Levels of Palliative Care Development for 198 Countries and Extent of Net Change: 2006, 2011, 2017 (Four-Part Typology)
      Country CategoryWorld Map 1 (2006)Change WM1→2World Map 2 (2011)Change WM2→3World Map 3 (2017)Total Change WM1→3
      Number of countries
       Category 151−249−247−4
       Category 238−1721−813−25
       Category 371118258716
       Category 43484295117
       Total194019441984
      % of countries
       Category 126.3−1.025.3−1.623.7−2.6
       Category 219.6−8.810.8−4.26.6−13.0
       Category 336.65.742.31.643.97.3
       Category 417.54.121.64.225.88.3
       Total100100100
      % of world population
       Category 14.20.14.3−1.23.1−1.1
       Category 28.2−5.32.9−1.21.7−6.5
       Category 369.8−14.755.1−1.853.3−16.5
       Category 417.219.937.14.741.824.6
       Other territories0.60.00.6−0.50.1−0.5
       Total100.0100.0100.0
      Countries included in the present study were limited to the 193 UN Member States, two observer states, plus Taiwan, Kosovo, and Somaliland. Earlier surveys did not include Taiwan, Kosovo, and Somaliland, or South Sudan which became a UN Member in 2011.
      The number of countries at the highest level of palliative care development (combined Category 4) has increased by 17 since 2006, representing an additional 24.6% of the world population. As the number of countries in combined Category 3 has also increased (by 16 since 2006), the number of people living in countries at this level has fallen, as larger countries have moved from Category 3 to Category 4.
      The number of countries at the lowest level of palliative care development (Category 1) has only declined slightly, with four fewer countries in this category since 2006. Just 3.1% of the world population live in Category 1 countries.
      In Fig. 4, we show the volume and direction of movement between the four aggregated categories of palliative care development from one survey to the next. In Supplementary Table 1, we provide the underlying data, showing the categorization of each country across the three iterations of the study.
      Figure thumbnail gr4
      Fig. 4Movement of countries between palliative care development levels (four-part typology). *One additional country in Category 4 was not included in WM1 or 2. **Three additional countries in Category 1 were not included in WM1 or 2.
      Between the first, second, and third surveys, there was net upward movement of countries across the four categories. Nine countries that had been in Category 3 in 2006 moved to Category 4 in 2011; 15 countries made this transition between 2011 and 2017. There has also been some downward movement, in particular between 2011 and 2017, with eight countries moving down from Category 4, 10 from Category 3, and five from Category 2 in this period.
      A number of countries appear to have experienced substantial shifts in their level of palliative care development, moving by more than one category. Eight countries in Category 1 in 2011 were in Category 3 in 2017; another eight countries had also made this transition in the opposite direction. One country that had been placed in the lowest category in 2011 was allocated to the highest category in 2017—a small high-income country for which no evidence on the level of palliative care development had previously been identified.
      The number of countries in the world with some form of palliative care service has risen from 105 (2006) to 124 (2011) to 138 (2017). The number of countries with some level of integration of palliative care into mainstream provision increased from 34 (2006), to 42 (2011) to 51 (2017).

      Statistical Analysis of the Categorization

      Factor analysis is a statistical technique to discover different sets of variables explaining the same feature. Each set of variables (in this case, indicators of palliative care development) is summarized in a new variable called a factor. Frequently after an ordinary factor analysis, the groups are not clearly determined and a second step is needed to identify them. This second step is based on rotations of the factors, considered as vectors in the space. There are a number of methods for rotating the factors. In our case, the so-called “varimax rotation” gave the best description of two sets of indicators.
      Factor analysis was performed for application of the 10 indicators, to check their robustness (Fig. 5). The test included 140 countries with complete data for all 10 indicators (including opioid consumption). One factor explained more than 50% of the variability and the load was around 0·7, giving strength to the categorizations.
      Figure thumbnail gr5
      Fig. 5Loadings of the factor analysis with varimax orthogonal rotation. Points relate to indicators listed in .
      After varimax rotation, opioid consumption and available medicines showed up most strongly in the first factor from the four “consequential” indicators (along with “funding” also); the remaining five indicators appeared in the second factor.
      After this, we considered the two obtained factors to check whether the groups identified were coherent with the indicators or not. To do that, we used a machine-supervised learning technique based on Fisher's linear discriminant analysis. Priors proportional to the group sizes were used because this option does not need the assumption of normality in each group. This confirmed the appropriateness of the indicators for making the categorization of palliative care development, with the analysis verifying the classification in 83% of the 140 countries (Table 6).
      Table 6Fisher's Linear Discriminant Analysis for 140 Countries
      True Categories Classified by the AlgorithmMap Categories Classified by the Factorial Analysis
      123a3b4a4b
      1
       3210000
       100%66.67%33.33%0%0%0%0%
      2
       8143000
       100%12.5050.0037.500%0%0%
      3a
       590058100
       100%0%0%98.311.690%0%
      3b
       210031431
       100%0%0%14.2966.6714.294.76
      4a
       260016172
       100%0%0%3.8523.0865.387.69
      4b
       230000221
       100%0%0%0%0%8.70%91.30%
      Total
       1403565212224
       100%2.14%3.57%46.43%15.00%15.71%17.14%
      Priors0.02140.05710.42140.15000.18570.1643
      140 countries with complete data for all 10 indicators (complete questionnaire plus opioid consumption) were included in this supervised classification. Of the total 140 countries, the classification of 116 countries (83%) was verified by the discriminant analysis.
      Entries in bold indicate the numbers and proportions of correctly classified countries in each category.

      Limitations

      We are in no doubt that our approach continues to have significant limitations, despite the improvements we have made to the method of data collection and to the analysis. We describe these limitations and the improvements in detail in the study protocol.
      • Baur N.
      • Centeno C.
      • Garralda E.
      • Connor S.
      • Clark D.
      Recalibrating the ‘world map’ of palliative care development.
      There is a debate in the literature
      • Sharkey L.
      • Loring B.
      • Cowan M.
      • et al.
      National palliative care capacities around the world: results from the World Health Organization Noncommunicable Disease Country Capacity Survey.
      ,
      • Baur N.
      • Centeno C.
      • Garralda E.
      • Connor S.
      • Clark D.
      Recalibrating the ‘world map’ of palliative care development.
      about the merits of using palliative care specialists or government sources to obtain the kind of data we report here. Both have their limitations. The former, although close to the field, often over long periods, may underrepresent or overrepresent the available palliative care provision for perceived strategic reasons; the latter are often less close to the field and can change roles rapidly, leading to a lack of cumulative knowledge. In the present study, we used both sources but privileged the former source where there were two options.
      Data limitations were compounded by language constraints. Questionnaires were only available in three European languages.
      Missing data were a problem we sought to overcome collectively as a research team. On a case-by-case basis, we searched our extensive records of palliative care development publications, published regional atlases of palliative care, gray literature, and Internet sources, to make informed and moderated judgments that would allow the scoring of indicators to be completed. We acknowledge the potential biases of this but argue that the benefits of a fuller and more detailed picture outweigh the limitations.
      It has been observed that although our approach gives an overall level of palliative care development for a country, in many instances, levels of development can vary significantly within country, by region or locality. We sought to address this by including an indicator of geographic coverage, but we acknowledge that more work can be done to establish regional variations in palliative care development, especially in large and populous countries, or where responsibility for palliative care may be devolved to subnational governments.
      We fully acknowledge that rigorously tested indicators of palliative care access and development do not yet exist, that collaborative efforts to develop such reliable indicators and reach consensus upon them should continue,
      • Arias-Casais N.
      • Garralda E.
      • López-Fidalgo J.
      • et al.
      Consensus building on health indicators to assess PC global development with an international group of experts.
      and that the project we report here remains (as we have stated previously) a work in progress and one which we seek continually to improve.

      Discussion

      Palliative care “resolutions” continue to appear from global health organizations, policy makers, and activists,
      • Inbadas H.
      • Zaman S.
      • Whitelaw A.
      • Clark D.
      Palliative care declarations: mapping a new form of intervention.
      but progress toward universal palliative care coverage is hugely constrained. Ours is the only global palliative care development study of its kind. We show that the world population is effectively split down in the middle: between those who live in countries with reasonably robust systems of specialized palliative care delivery, and those who do not. The countries with the highest levels of palliative care development contain 41.8% of the world population and are concentrated in the Global North, though not exclusively, while 80% of the need for palliative care is in low- and middle-income countries. 53.3% of the world's population is in countries with very limited palliative care development mainly in the Global South, though not exclusively. The remainder of the global population (4.8%) is located in countries that have no known palliative care activity or are only at the level of capacity building, and in territories that were not included in the survey (0.1%).
      The Lancet Commission on Palliative Care and Pain Relief highlighted an “access abyss” that separates those in need of palliative care from available services. Our study reveals the fragile and moderate palliative care assets and service infrastructure on which the goals of the Commission will be reliant as it seeks to build greater palliative care capacity within mainstream provision. It is likely that diffusion of the essential package of services called for in the Lancet report will be very difficult to deliver without increased investment in specialized palliative care infrastructure, as a platform from which wider implementation can occur.
      Our comments on change over time are offered with a sense of caution. Improvements made in methods of data collection and analysis for each iteration of the study do inhibit comparisons over the three time periods on which we report. Nevertheless, in presenting these data, we are able to provide a unique insight into the slowly evolving development of palliative care provision globally. At the same time, it is important to acknowledge that assignment to a high level of palliative care development leaves no room for complacency, nor should assignment to a low level lead to resignation and resentment. Indeed, we know, from the wide engagement with the results of our earlier mapping studies, that there is a significant collective will in the global palliative care field to see improvement for all countries and to share knowledge and experience to that end. Similarly, although we remain focused on measuring and mapping the development of specialized palliative care services, there is growing interest in monitoring the development of palliative care delivery within mainstream health and social care provision, across primary and tertiary settings, and in the context of numerous medical specialties. These two approaches are complementary to one another.
      For the first time, we have used the measure of percentage of the global population, rather than number of countries alone, when assessing coverage of the specific levels of palliative care development. Although the two lowest categories contain 60 countries—almost a third of the total—these account for less than 5% of the global population. At the same time, 87 countries are in categories with operational palliative care, but with weak development, and these make up more than a half of the world population.
      With a few exceptions, views about optimal palliative care provision originate in the Global North, where they are frequently seen as a “gold standard” which can somehow be “rolled out” to the Global South, subject only to appropriate resources being made available for implementation.
      • Zaman S.
      • Inbadas H.
      • Whitelaw A.
      • Clark D.
      Common or multiple futures for end of life care around the world? Ideas from the ‘waiting room of history’.
      ,
      • Clark J.
      • Barnes A.
      • Campbell M.
      • Gardiner C.
      A Life or “Good Death” Situation? A Worldwide Ecological Study of the National Contexts of Countries That Have and Have Not Implemented Palliative Care.
      The veracity of this assumption has to be brought into question by the evidence shown here of slow progress in palliative care development in the poorer countries of the world. Although we continue to applaud efforts to ensure that no one should be left behind in the development of robust palliative care systems, our data might also provoke a debate on whether current global health strategies for palliative care are working. Meanwhile, just 30 countries, comprising less than 15% of the global population, have access to the very highest level of palliative care provision.

      Disclosures and Acknowledgments

      The authors thank all those who took the time to complete their questionnaires, without whom there could be no study. Colleagues in regional palliative care associations around the world assisted significantly in their efforts to find key contacts in many countries. The authors are grateful to senior colleagues outside their field for helpful comments on early versions of the paper and to Danny van Steijn, who produced the maps.
      Ethical approval: The study was approved by the University of Glasgow College of Social Sciences Research Ethics Committee.
      This work was supported by an Investigator Award to David Clark [grant number 103319] from the Wellcome Trust, London, United Kingdom. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. None of the authors have any conflicts of interest to declare.

      Supplementary Material

      Supplementary Table 1Country Palliative Care Development Categories Over Three Global Surveys
      Countries2006
      The 2006 World Map used a four-category system of classification; the 2011 and 2017 studies used six categories.
      20112017
      Afghanistan113a
      Albania33b3b
      Algeria223a
      Andorra111
      Angola13a2
      Antigua & Barbuda111
      Argentina43b4a
      Armenia33a3a
      Australia44b4b
      Austria44b4a
      Azerbaijan323a
      Bahamas222
      Bahrain23a3a
      Bangladesh33a3a
      Barbados33a4b
      Belarus33b3b
      Belgium44b4b
      Belize23a3b
      Benin113a
      Bhutan111
      Bolivia223a
      Bosnia & Herzegovina33b3a
      Botswana33a3a
      Brazil33a3b
      Brunei23a1
      Bulgaria33a3b
      Burkina Faso112
      Burundi112
      Cambodia23a3a
      Cameroon33a3a
      Canada44b4b
      Cape Verde111
      Central African Republic111
      Chad111
      Chile44a4a
      China34a4a
      Colombia33a3b
      Comoros111
      Congo (DR)223a
      Congo (Republic)33a1
      Costa Rica44a4b
      Côte d’Ivoire23b4a
      Croatia33b3a
      Cuba33a1
      Cyprus33b3b
      Czech Republic33b4a
      Denmark44a4b
      Djibouti111
      Dominica221
      Dominican Republic33a3a
      Ecuador33a3a
      Egypt33a3a
      El Salvador33a3b
      Equatorial Guinea112
      Eritrea112
      Estonia33a3a
      Ethiopia23a3a
      Fiji223a
      Finland44a3b
      France44b4b
      Gabon112
      Gambia33a3b
      Georgia33b4a
      Germany44b4b
      Ghana23a3a
      Greece33a3a
      Grenada111
      Guatemala33a3a
      Guinea113a
      Guinea-Bissau111
      Guyana33a1
      Haiti222
      Honduras323a
      Hungary44a4a
      Iceland44b4b
      India33b3a
      Indonesia33a3a
      Iran23a3a
      Iraq33a1
      Ireland44b4b
      Israel44a4b
      Italy44b4b
      Jamaica33a3a
      Japan44b4b
      Jordan33b3b
      Kazakhstan33a4a
      Kenya44a3b
      Kiribati111
      Kosovo
      These countries were not included in the 2006 and 2011 surveys.
      N/AN/A1
      Kuwait23a3a
      Kyrgyzstan33a3a
      Laos111
      Latvia33a4a
      Lebanon23a3a
      Lesotho23a1
      Liberia112
      Libya113a
      Liechtenstein114b
      Lithuania33b4b
      Luxembourg34a3b
      Macedonia33a3b
      Madagascar223a
      Malawi34a4b
      Malaysia44a3a
      Maldives111
      Mali13a1
      Malta33b3b
      Marshall Islands111
      Mauritania113a
      Mauritius223a
      Mexico33a4a
      Micronesia111
      Moldova33a3a
      Monaco111
      Mongolia44a4b
      Montenegro121
      Morocco33a3a
      Mozambique23a3a
      Myanmar33a3a
      Namibia23a3a
      Nauru111
      Nepal33b3a
      The Netherlands44a4b
      New Zealand44a4b
      Nicaragua223a
      Niger113a
      Nigeria33a3a
      North Korea111
      Norway44b4b
      Oman223b
      Pakistan33a3a
      Palau111
      Palestine223a
      Panama33a3b
      Papua New Guinea223a
      Paraguay23a3a
      Peru33a3a
      Philippines33a3a
      Poland44b4b
      Portugal33b4b
      Qatar223b
      Romania44b4b
      Russia33a4a
      Rwanda23a3a
      Saint Lucia23a1
      Samoa112
      San Marino111
      Sao Tome e Principe112
      Saudi Arabia33a3b
      Senegal113a
      Serbia34a3b
      Seychelles221
      Sierra Leone33a3a
      Singapore44b4a
      Slovakia34a4a
      Slovenia44a3b
      Solomon Islands111
      Somalia111
      Somaliland
      These countries were not included in the 2006 and 2011 surveys.
      N/AN/A1
      South Africa44a4a
      South Korea33a4b
      South Sudan
      These countries were not included in the 2006 and 2011 surveys.
      N/AN/A1
      Spain44a4b
      Sri Lanka33a3a
      St Kitts & Nevis111
      St Vincent & the Grenadines111
      Sudan23a3a
      Suriname221
      Swaziland33b4b
      Sweden44b4b
      Switzerland44b4a
      Syria111
      Taiwan
      These countries were not included in the 2006 and 2011 surveys.
      N/AN/A4b
      Tajikistan223a
      Tanzania34a3a
      Thailand33a4a
      Timor l'Este111
      Togo113a
      Tonga111
      Trinidad & Tobago33a3a
      Tunisia23a3a
      Turkey23b3a
      Turkmenistan111
      Tuvalu111
      Uganda44b4a
      Ukraine33a4a
      United Arab Emirates33a2
      United Kingdom44b4b
      Uruguay34a4a
      USA44b4b
      Uzbekistan212
      Vanuatu111
      Vatican City221
      Venezuela33a3a
      Vietnam33a3a
      Yemen111
      Zambia34a3b
      Zimbabwe34a4a
      a The 2006 World Map used a four-category system of classification; the 2011 and 2017 studies used six categories.
      b These countries were not included in the 2006 and 2011 surveys.
      Figure thumbnail fx1
      Supplementary Figure 1Levels of palliative care development and World Bank income levels.
      Figure thumbnail fx2
      Supplementary Figure 2Levels of palliative care development and UN Human Development Index Levels.
      Figure thumbnail fx3
      Supplementary Figure 3Levels of palliative care development by WHO Universal Health Coverage Index Quintile.

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