TY - JOUR
AU1 - Aregay,, Atsede
AU2 - O’Connor,, Margaret
AU3 - Stow,, Jill
AU4 - Ayers,, Nicola
AU5 - Lee,, Susan
AB - Abstract Globally, 40 million people need palliative care; about 69% are people over 60 years of age. The highest proportion (78%) of adults are from low- and middle-income countries (LMICs), where palliative care still developing and is primarily limited to urban areas. This integrative review describes strategies used by LMICs to establish palliative care in rural areas. A rigorous integrative review methodology was utilized using four electronic databases (Ovid MEDLINE, Ovid Emcare, Embase classic+Embase and CINAHL). The search terms were: ‘palliative care’, ‘hospice care’, ‘end of life care’, ‘home-based care’, ‘volunteer’, ‘rural’, ‘regional’, ‘remote’ and ‘developing countries’ identified by the United Nations (UN) as ‘Africa’, ‘Sub-Saharan Africa’, ‘low-income’ and ‘middle- income countries’. Thirty papers published in English from 1990 to 2019 were included. Papers were appraised for quality and extracted data subjected to analysis using a public health model (policy, drug availability, education and implementation) as a framework to describe strategies for establishing palliative care in rural areas. The methodological quality of the reviewed papers was low, with 7 of the 30 being simple programme descriptions. Despite the inclusion of palliative care in national health policy in some countries, implementation in the community was often reliant on advocacy and financial support from non-government organizations. Networking to coordinate care and medication availability near-patient homes were essential features of implementation. Training, role play, education and mentorship were strategies used to support health providers and volunteers. Home- and community-based palliative care services for rural LMICs communities may best be delivered using a networked service among health professionals, community volunteers, religious leaders and technology. Palliative care, rural, low- and middle-income countries, integrative review, public health KEY MESSAGES Palliative care is recognized as an international human right. The World Health Organization recommends a Public Health Strategy as a cost-effective intervention for integrating palliative care in health systems. However, there is limited access to palliative care in rural low- and middle-income countries (LMICs). There is little evidence to support models of palliative care in rural areas of LMICs and no guidance in the WHO strategy regarding what sort of outcomes should be assessed as part of the development. LMICs rely on partnerships with non-government organizations in order to fund the provision of palliative care. This may be a risk to sustainability of programmes. Key processes that may support palliative care in rural and remote areas, including networked services to ensure medicines and care are accessible in communities. Training needs to include community members in addition to health professionals. Introduction Palliative care is increasingly recognized as a human right and an essential component of comprehensive care at the end of life (Gwyther et al., 2009; Gómez-Batiste and Connor, 2017). Rural areas are distinct and need to have special consideration in order to provide palliative care (Rainsford et al., 2017). However, people living in rural or remote areas have less access to palliative care services (Spice et al., 2012; Herce et al., 2014; Hannon et al., 2016). Globally, 40 million people need palliative care (Gómez-Batiste and Connor, 2017), with the majority (69%) being older people over 60 years of age (Connor, 2014). The highest proportion of adults (78%) in need of palliative care are from low- and middle-income countries (LMICs) (Connor, 2014), but despite this, the majority have limited access (Lynch et al., 2013). Different strategies to establish palliative care at all levels of the healthcare system have been described (Gómez-Batiste and Connor, 2017). Principally, the World Health Organization (WHO) recommends a public health model to integrate palliative care into existing healthcare systems. This strategy describes cost-effective and evidence-based practices that can reach everyone in need of palliative care (Stjernswärd, 2007). However, in order for a public health model to be effective, palliative care must be integrated by the government into all levels of health care and owned by the community (Stjernswärd, 2007; Callaway et al., 2018). In addition, to effectively integrate into the community, the four components of the WHO public health model need to be addressed: policies; availability of palliative medicine; education; and implementation (Callaway et al., 2018). In all countries, palliative care strategies need to be defined according to the demographic scenario of their setting (Gómez-Batiste and Connor, 2017). For instance, in rural or remote areas with small populations and thus insufficient demand for specific palliative care beds, the palliative care team should develop appropriate intervention strategies involving the community (Gómez-Batiste and Connor, 2017). A range of factors have been found to affect rural palliative care service delivery in previous reviews. Some of these are: limited access to specialized health facilities (Evans et al., 2003; Hannon et al., 2016), geographic isolation; lack of transportation (healthcare provider travelling long distances); time-consuming nature of palliative care; difficulty recruiting healthcare providers and lack of funds (Grant et al., 2011; Spice et al., 2012). Despite these challenges and limitations, those people living in rural environments who require palliative care have a strong desire to remain in their home until the end of their lives (Spice et al., 2012). There is a lack of research studies about palliative care in LMICs and 1.3% of all the publications appear in journals with low or no impact factor (Hannon et al., 2016). Most available publications in LMICs were observational studies, describing programme development, needs assessments and funding and policy issues; only 2% were randomized control trials (Hannon et al., 2016). Further research has been suggested to describe palliative care strategies for diverse rural populations. The lack of homogeneous research describing and evaluating strategies meant a systematic review and meta-analysis was not feasible. Therefore, this review describes the strategies used to establish palliative care in rural LMICs countries. Methods Whittemore and Knafl’s (2005) integrative review guidelines were used to develop the methodology. Five stages are recommended: formulation of the problem (articulated in the background of this review); literature search; data evaluation; data analysis; and presentation of results to combine qualitative and quantitative research and synthesize available literature related to the topic (Whittemore and Knafl, 2005). The four pillars of the described above were used to identify the different palliative care strategies utilized in the papers reviewed (Callaway et al., 2018). Literature search strategy A comprehensive literature search was conducted using four electronic databases (Ovid MEDLINE, Ovid Emcare, Embase classic+Embase and CINAHL). There were insufficient relevant MeSH headings to create an appropriate strategy, and so with assistance from a specialist librarian, search terms were collected from keywords of the articles initially retrieved and included: ‘palliative care’, ‘hospice care’, ‘end of life care’, ‘home-based care’, ‘volunteer’; ‘rural’, ‘regional’, ‘remote’; and a ‘developing countries’ identified by the United Nations (UN) as ‘Africa’, ‘Sub-Saharan Africa’, ‘low-income’ and ‘middle-income countries’ (United Nations, 2016). These terms were combined with Boolean operators ‘OR’ or ‘AND’. One additional paper was found through manual searching of reference lists. Each search was downloaded to a database and duplications removed. In total, 3371 papers were initially identified. Following removal of duplications, two authors checked titles and abstracts for eligibility, as noted above and at this stage 2072 papers were excluded. The remaining papers were retrieved in full text and evaluated to identify those which met the inclusion criteria. Inclusion criteria were published in English; published between 1990 and 2019; and focused on palliative care of adults in rural communities. The search excluded editorials, commentaries, published abstracts and discussion papers that did not focus on specific strategies for the provision of palliative care for adults in rural communities. Data evaluation The quality of each paper was evaluated using the Critical Appraisal Skill Programme (CASP) Guidelines (Lobiondo-Wood and Haber, 2014) for quantitative, qualitative research and descriptions of models. Seven of the reviewed papers were not research papers, but descriptions of local models. A total of 30 papers were reviewed (Figure 1). The results of this evaluation are noted in Table 1. Figure 1 Open in new tabDownload slide Prisma (Liberati et al., 2009) screening process for paper selection. Figure 1 Open in new tabDownload slide Prisma (Liberati et al., 2009) screening process for paper selection. Table 1 Included papers (N = 30), 1990–2019 No. . Authors, year of publication, country . Research focus . Design . Population focus and number of participants . Study quality evaluation . 1 Boit et al. (2014) Western Kenya Description of Kimbilio—a model hospice. Description of service Chronic illnessNone Not applicable 2 Bond and Knopp (2018) North Tanzania Description of community-based palliative care programme. Case study Twenty-six home-based palliative care programmes for chronically ill patients and those diagnosed with incurable diseases. 5/10 3 Campbell and Baernholdt (2016) South Africa Evaluation of palliative care training session. Qualitative A total of 29 community health workers 7/10 4 Campbell (2011) South Africa Experiences of nurses practising home-based palliative care (HBPC). Qualitative Four nurses’ experiences 6/10 5 Campbell and Amin (2014) South Africa Palliative care team experiences related to traditional healers. Qualitative Four nurses and 17 home-based workers 8/10 6 Chandra et al. (2016) Tamil Nadu, India Improvement of community participation in palliative care. Quasi-experiment 145 households with 601 residents 5/9 7 Defilippi and Cameron (2007) South Africa Description of the ICHC model. Service description Hospice Palliative Care Association members Not applicable 8 Dekker et al. (2012) South Africa. Attitudes towards chronic pain and palliative care. Mixed-method A total of 45 patients receiving care and 26 healthcare workers 6/8 9 Devi et al. (2008)Malaysia Improving palliative care through referral to home care and pain relief medication. Service description Pharmacists, doctors, nurses and patients Not applicable 10 Di Sorbo et al. (2010) Zimbabwe Integration of palliative care in rural communities. Service description Households receiving palliative care; Youth, home-based volunteer carers, Health professionals, Physicians, Pastors Not applicable 11 Dongre et al. (2012) India Evaluation of home-based service for village elders. Quasi-Experiment 125 elderly members in Self-Help Groups (SHGs), project village and 80 elderly were members in SHGs, the control village 8/9 12 Downing (2008) Uganda Effectiveness of an HIV/AIDS palliative care educational strategy. A qualitative evaluation of a case study Forty interviews and 20 focus group discussions of healthcare workers 7/10 13 Downing and Kawuma (2008) Uganda Evaluation of a Mobile Training Team (MTT) HIV/AIDS palliative care education programme. A qualitative evaluative case study approach Forty interviews and 20 focus group discussions of healthcare workers 7/10 14 Freire et al. (2018) The Brazilian National Cancer Institute (INCA) in Latin America Information and Communication Technology (ICT) environment of mobile phone to support the palliative cancer care programme. A case study, description of the module of pain and symptom management Patient in their home settings. Appointment with nurses and physicians 5/10 15 Grant et al. (2011) Uganda, Kenya and Malawi Impact of three community-based palliative care interventions. Ethnographic method for rapid evaluation A total of 150 participants 33 patients, 27 family caregivers, 36 staff 25 volunteers, 29 community leaders,12 observations of clinical care 9/10 16 Hartwig et al. (2014). Tanzania Effectiveness of palliative care teams in reducing pain and increasing quality of life in the absence of Morphine. A mixed-method study 145 records of cancer patients across the 13 rural hospitals and 6 nurses in the hospitals 7/10 17 Hennemann-Krause et al. (2015) Brazil Telemedicine as a form of additional support for traditional outpatient care. A prospective, longitudinal, qualitative, descriptive case series 12 advanced cancer patients 10/10 18 Herce et al. (2014) Malawi To evaluate and understand integrated inpatient and home-based care. A situational analysis employing REM Chart review of all adult patients, interviews with 11 caregivers; 7 key stakeholders 8/10 19 Jabbari (2019) Iran Experience of family physicians and key leaders about feasibility of palliative or end-of-life care. Qualitative Two focus groups with 23 physicians 7/10 20 Jack et al. (2011)Uganda Impact of a Community Volunteer Programme. Qualitative Twenty-one patients, 32 volunteers and 11 hospices clinical staff 7/10 21 Jayalakshmi et al. (2017)India Understanding the structure, organization, and delivery of palliative care and conformity to state policy. Qualitative 139 patients in Poovar and 239 patients in Azhur taking palliative care services Interview for healthcare workers (doctors, palliative care nurses) 3/10 22 Kumar (2007)India Sustainable community-owned service offering comprehensive long-term care and palliative care. Service description Community-based palliative care in Northern and mid-Kerala covering the population of more than 12 million Not applicable 23 Lemonica and Barros (2007)Brazil Educational opportunities to enable home-based palliative care service. Service description Integrated education for medical, nursing students and anaesthetic residents. Home care service to patients Not applicable 24 Logie and Harding (2012)Zambia Evaluation of a strategic advocacy programme to enhance the provision of palliative care. A mixed-method evaluation including rapid evaluation Eight palliative care organizations (three urban and five rural) 4/10 25 Munday et al. (2018)North India Evaluation of mobile community teams (home visit) with the support of hospital services. Rapid evaluation method using mixed-method realist approach Five-hospitals, key informant interviews with two Emmanuel Hospitals Association (EHA) project leaders. 32 interviews with EHA palliative care staff and other staff, hospital management at each site. Twelve interviews with patients and carers 6/10 26 Namisango et al. (2016)Rural and urban, Uganda Exploring an electronic database to replace hard-copy documentation-on of medicines. Quasi-Experiment 150 patients with palliative care needs in a rural setting 7/9 27 Nanney et al. (2010) Tanzania Providing a community involved home-based palliative care. Description of service Health (nurses, social workers, clinical officers, chaplains) training; support to home-based community volunteers; Not applicable 28 Potts et al. (2019)India Feasibility and acceptance of a piloted home-based palliative care programme. Qualitative descriptive study Seven palliative care clinical team (nurses, physicians, behavioural counsellor, a study coordinator) and three CHWs 7/10 29 Sedillo et al. (2015) Kenya Palliative care provider self-competence and priorities for future education. A descriptive cross-sectional pilot study survey Five clinical staff, 11 caregivers and 8 support staff 6/8 30 Shabnam et al. (2018)Bangladesh Development, service use and challenges of 24/7 palliative care Telephone Consultation Service (TCS). Mixed-method study 4195 calls from 1164 patients and their caregivers. Six participants (head department, clinical pharmacist, palliative care physicians) 5/10 No. . Authors, year of publication, country . Research focus . Design . Population focus and number of participants . Study quality evaluation . 1 Boit et al. (2014) Western Kenya Description of Kimbilio—a model hospice. Description of service Chronic illnessNone Not applicable 2 Bond and Knopp (2018) North Tanzania Description of community-based palliative care programme. Case study Twenty-six home-based palliative care programmes for chronically ill patients and those diagnosed with incurable diseases. 5/10 3 Campbell and Baernholdt (2016) South Africa Evaluation of palliative care training session. Qualitative A total of 29 community health workers 7/10 4 Campbell (2011) South Africa Experiences of nurses practising home-based palliative care (HBPC). Qualitative Four nurses’ experiences 6/10 5 Campbell and Amin (2014) South Africa Palliative care team experiences related to traditional healers. Qualitative Four nurses and 17 home-based workers 8/10 6 Chandra et al. (2016) Tamil Nadu, India Improvement of community participation in palliative care. Quasi-experiment 145 households with 601 residents 5/9 7 Defilippi and Cameron (2007) South Africa Description of the ICHC model. Service description Hospice Palliative Care Association members Not applicable 8 Dekker et al. (2012) South Africa. Attitudes towards chronic pain and palliative care. Mixed-method A total of 45 patients receiving care and 26 healthcare workers 6/8 9 Devi et al. (2008)Malaysia Improving palliative care through referral to home care and pain relief medication. Service description Pharmacists, doctors, nurses and patients Not applicable 10 Di Sorbo et al. (2010) Zimbabwe Integration of palliative care in rural communities. Service description Households receiving palliative care; Youth, home-based volunteer carers, Health professionals, Physicians, Pastors Not applicable 11 Dongre et al. (2012) India Evaluation of home-based service for village elders. Quasi-Experiment 125 elderly members in Self-Help Groups (SHGs), project village and 80 elderly were members in SHGs, the control village 8/9 12 Downing (2008) Uganda Effectiveness of an HIV/AIDS palliative care educational strategy. A qualitative evaluation of a case study Forty interviews and 20 focus group discussions of healthcare workers 7/10 13 Downing and Kawuma (2008) Uganda Evaluation of a Mobile Training Team (MTT) HIV/AIDS palliative care education programme. A qualitative evaluative case study approach Forty interviews and 20 focus group discussions of healthcare workers 7/10 14 Freire et al. (2018) The Brazilian National Cancer Institute (INCA) in Latin America Information and Communication Technology (ICT) environment of mobile phone to support the palliative cancer care programme. A case study, description of the module of pain and symptom management Patient in their home settings. Appointment with nurses and physicians 5/10 15 Grant et al. (2011) Uganda, Kenya and Malawi Impact of three community-based palliative care interventions. Ethnographic method for rapid evaluation A total of 150 participants 33 patients, 27 family caregivers, 36 staff 25 volunteers, 29 community leaders,12 observations of clinical care 9/10 16 Hartwig et al. (2014). Tanzania Effectiveness of palliative care teams in reducing pain and increasing quality of life in the absence of Morphine. A mixed-method study 145 records of cancer patients across the 13 rural hospitals and 6 nurses in the hospitals 7/10 17 Hennemann-Krause et al. (2015) Brazil Telemedicine as a form of additional support for traditional outpatient care. A prospective, longitudinal, qualitative, descriptive case series 12 advanced cancer patients 10/10 18 Herce et al. (2014) Malawi To evaluate and understand integrated inpatient and home-based care. A situational analysis employing REM Chart review of all adult patients, interviews with 11 caregivers; 7 key stakeholders 8/10 19 Jabbari (2019) Iran Experience of family physicians and key leaders about feasibility of palliative or end-of-life care. Qualitative Two focus groups with 23 physicians 7/10 20 Jack et al. (2011)Uganda Impact of a Community Volunteer Programme. Qualitative Twenty-one patients, 32 volunteers and 11 hospices clinical staff 7/10 21 Jayalakshmi et al. (2017)India Understanding the structure, organization, and delivery of palliative care and conformity to state policy. Qualitative 139 patients in Poovar and 239 patients in Azhur taking palliative care services Interview for healthcare workers (doctors, palliative care nurses) 3/10 22 Kumar (2007)India Sustainable community-owned service offering comprehensive long-term care and palliative care. Service description Community-based palliative care in Northern and mid-Kerala covering the population of more than 12 million Not applicable 23 Lemonica and Barros (2007)Brazil Educational opportunities to enable home-based palliative care service. Service description Integrated education for medical, nursing students and anaesthetic residents. Home care service to patients Not applicable 24 Logie and Harding (2012)Zambia Evaluation of a strategic advocacy programme to enhance the provision of palliative care. A mixed-method evaluation including rapid evaluation Eight palliative care organizations (three urban and five rural) 4/10 25 Munday et al. (2018)North India Evaluation of mobile community teams (home visit) with the support of hospital services. Rapid evaluation method using mixed-method realist approach Five-hospitals, key informant interviews with two Emmanuel Hospitals Association (EHA) project leaders. 32 interviews with EHA palliative care staff and other staff, hospital management at each site. Twelve interviews with patients and carers 6/10 26 Namisango et al. (2016)Rural and urban, Uganda Exploring an electronic database to replace hard-copy documentation-on of medicines. Quasi-Experiment 150 patients with palliative care needs in a rural setting 7/9 27 Nanney et al. (2010) Tanzania Providing a community involved home-based palliative care. Description of service Health (nurses, social workers, clinical officers, chaplains) training; support to home-based community volunteers; Not applicable 28 Potts et al. (2019)India Feasibility and acceptance of a piloted home-based palliative care programme. Qualitative descriptive study Seven palliative care clinical team (nurses, physicians, behavioural counsellor, a study coordinator) and three CHWs 7/10 29 Sedillo et al. (2015) Kenya Palliative care provider self-competence and priorities for future education. A descriptive cross-sectional pilot study survey Five clinical staff, 11 caregivers and 8 support staff 6/8 30 Shabnam et al. (2018)Bangladesh Development, service use and challenges of 24/7 palliative care Telephone Consultation Service (TCS). Mixed-method study 4195 calls from 1164 patients and their caregivers. Six participants (head department, clinical pharmacist, palliative care physicians) 5/10 Open in new tab Table 1 Included papers (N = 30), 1990–2019 No. . Authors, year of publication, country . Research focus . Design . Population focus and number of participants . Study quality evaluation . 1 Boit et al. (2014) Western Kenya Description of Kimbilio—a model hospice. Description of service Chronic illnessNone Not applicable 2 Bond and Knopp (2018) North Tanzania Description of community-based palliative care programme. Case study Twenty-six home-based palliative care programmes for chronically ill patients and those diagnosed with incurable diseases. 5/10 3 Campbell and Baernholdt (2016) South Africa Evaluation of palliative care training session. Qualitative A total of 29 community health workers 7/10 4 Campbell (2011) South Africa Experiences of nurses practising home-based palliative care (HBPC). Qualitative Four nurses’ experiences 6/10 5 Campbell and Amin (2014) South Africa Palliative care team experiences related to traditional healers. Qualitative Four nurses and 17 home-based workers 8/10 6 Chandra et al. (2016) Tamil Nadu, India Improvement of community participation in palliative care. Quasi-experiment 145 households with 601 residents 5/9 7 Defilippi and Cameron (2007) South Africa Description of the ICHC model. Service description Hospice Palliative Care Association members Not applicable 8 Dekker et al. (2012) South Africa. Attitudes towards chronic pain and palliative care. Mixed-method A total of 45 patients receiving care and 26 healthcare workers 6/8 9 Devi et al. (2008)Malaysia Improving palliative care through referral to home care and pain relief medication. Service description Pharmacists, doctors, nurses and patients Not applicable 10 Di Sorbo et al. (2010) Zimbabwe Integration of palliative care in rural communities. Service description Households receiving palliative care; Youth, home-based volunteer carers, Health professionals, Physicians, Pastors Not applicable 11 Dongre et al. (2012) India Evaluation of home-based service for village elders. Quasi-Experiment 125 elderly members in Self-Help Groups (SHGs), project village and 80 elderly were members in SHGs, the control village 8/9 12 Downing (2008) Uganda Effectiveness of an HIV/AIDS palliative care educational strategy. A qualitative evaluation of a case study Forty interviews and 20 focus group discussions of healthcare workers 7/10 13 Downing and Kawuma (2008) Uganda Evaluation of a Mobile Training Team (MTT) HIV/AIDS palliative care education programme. A qualitative evaluative case study approach Forty interviews and 20 focus group discussions of healthcare workers 7/10 14 Freire et al. (2018) The Brazilian National Cancer Institute (INCA) in Latin America Information and Communication Technology (ICT) environment of mobile phone to support the palliative cancer care programme. A case study, description of the module of pain and symptom management Patient in their home settings. Appointment with nurses and physicians 5/10 15 Grant et al. (2011) Uganda, Kenya and Malawi Impact of three community-based palliative care interventions. Ethnographic method for rapid evaluation A total of 150 participants 33 patients, 27 family caregivers, 36 staff 25 volunteers, 29 community leaders,12 observations of clinical care 9/10 16 Hartwig et al. (2014). Tanzania Effectiveness of palliative care teams in reducing pain and increasing quality of life in the absence of Morphine. A mixed-method study 145 records of cancer patients across the 13 rural hospitals and 6 nurses in the hospitals 7/10 17 Hennemann-Krause et al. (2015) Brazil Telemedicine as a form of additional support for traditional outpatient care. A prospective, longitudinal, qualitative, descriptive case series 12 advanced cancer patients 10/10 18 Herce et al. (2014) Malawi To evaluate and understand integrated inpatient and home-based care. A situational analysis employing REM Chart review of all adult patients, interviews with 11 caregivers; 7 key stakeholders 8/10 19 Jabbari (2019) Iran Experience of family physicians and key leaders about feasibility of palliative or end-of-life care. Qualitative Two focus groups with 23 physicians 7/10 20 Jack et al. (2011)Uganda Impact of a Community Volunteer Programme. Qualitative Twenty-one patients, 32 volunteers and 11 hospices clinical staff 7/10 21 Jayalakshmi et al. (2017)India Understanding the structure, organization, and delivery of palliative care and conformity to state policy. Qualitative 139 patients in Poovar and 239 patients in Azhur taking palliative care services Interview for healthcare workers (doctors, palliative care nurses) 3/10 22 Kumar (2007)India Sustainable community-owned service offering comprehensive long-term care and palliative care. Service description Community-based palliative care in Northern and mid-Kerala covering the population of more than 12 million Not applicable 23 Lemonica and Barros (2007)Brazil Educational opportunities to enable home-based palliative care service. Service description Integrated education for medical, nursing students and anaesthetic residents. Home care service to patients Not applicable 24 Logie and Harding (2012)Zambia Evaluation of a strategic advocacy programme to enhance the provision of palliative care. A mixed-method evaluation including rapid evaluation Eight palliative care organizations (three urban and five rural) 4/10 25 Munday et al. (2018)North India Evaluation of mobile community teams (home visit) with the support of hospital services. Rapid evaluation method using mixed-method realist approach Five-hospitals, key informant interviews with two Emmanuel Hospitals Association (EHA) project leaders. 32 interviews with EHA palliative care staff and other staff, hospital management at each site. Twelve interviews with patients and carers 6/10 26 Namisango et al. (2016)Rural and urban, Uganda Exploring an electronic database to replace hard-copy documentation-on of medicines. Quasi-Experiment 150 patients with palliative care needs in a rural setting 7/9 27 Nanney et al. (2010) Tanzania Providing a community involved home-based palliative care. Description of service Health (nurses, social workers, clinical officers, chaplains) training; support to home-based community volunteers; Not applicable 28 Potts et al. (2019)India Feasibility and acceptance of a piloted home-based palliative care programme. Qualitative descriptive study Seven palliative care clinical team (nurses, physicians, behavioural counsellor, a study coordinator) and three CHWs 7/10 29 Sedillo et al. (2015) Kenya Palliative care provider self-competence and priorities for future education. A descriptive cross-sectional pilot study survey Five clinical staff, 11 caregivers and 8 support staff 6/8 30 Shabnam et al. (2018)Bangladesh Development, service use and challenges of 24/7 palliative care Telephone Consultation Service (TCS). Mixed-method study 4195 calls from 1164 patients and their caregivers. Six participants (head department, clinical pharmacist, palliative care physicians) 5/10 No. . Authors, year of publication, country . Research focus . Design . Population focus and number of participants . Study quality evaluation . 1 Boit et al. (2014) Western Kenya Description of Kimbilio—a model hospice. Description of service Chronic illnessNone Not applicable 2 Bond and Knopp (2018) North Tanzania Description of community-based palliative care programme. Case study Twenty-six home-based palliative care programmes for chronically ill patients and those diagnosed with incurable diseases. 5/10 3 Campbell and Baernholdt (2016) South Africa Evaluation of palliative care training session. Qualitative A total of 29 community health workers 7/10 4 Campbell (2011) South Africa Experiences of nurses practising home-based palliative care (HBPC). Qualitative Four nurses’ experiences 6/10 5 Campbell and Amin (2014) South Africa Palliative care team experiences related to traditional healers. Qualitative Four nurses and 17 home-based workers 8/10 6 Chandra et al. (2016) Tamil Nadu, India Improvement of community participation in palliative care. Quasi-experiment 145 households with 601 residents 5/9 7 Defilippi and Cameron (2007) South Africa Description of the ICHC model. Service description Hospice Palliative Care Association members Not applicable 8 Dekker et al. (2012) South Africa. Attitudes towards chronic pain and palliative care. Mixed-method A total of 45 patients receiving care and 26 healthcare workers 6/8 9 Devi et al. (2008)Malaysia Improving palliative care through referral to home care and pain relief medication. Service description Pharmacists, doctors, nurses and patients Not applicable 10 Di Sorbo et al. (2010) Zimbabwe Integration of palliative care in rural communities. Service description Households receiving palliative care; Youth, home-based volunteer carers, Health professionals, Physicians, Pastors Not applicable 11 Dongre et al. (2012) India Evaluation of home-based service for village elders. Quasi-Experiment 125 elderly members in Self-Help Groups (SHGs), project village and 80 elderly were members in SHGs, the control village 8/9 12 Downing (2008) Uganda Effectiveness of an HIV/AIDS palliative care educational strategy. A qualitative evaluation of a case study Forty interviews and 20 focus group discussions of healthcare workers 7/10 13 Downing and Kawuma (2008) Uganda Evaluation of a Mobile Training Team (MTT) HIV/AIDS palliative care education programme. A qualitative evaluative case study approach Forty interviews and 20 focus group discussions of healthcare workers 7/10 14 Freire et al. (2018) The Brazilian National Cancer Institute (INCA) in Latin America Information and Communication Technology (ICT) environment of mobile phone to support the palliative cancer care programme. A case study, description of the module of pain and symptom management Patient in their home settings. Appointment with nurses and physicians 5/10 15 Grant et al. (2011) Uganda, Kenya and Malawi Impact of three community-based palliative care interventions. Ethnographic method for rapid evaluation A total of 150 participants 33 patients, 27 family caregivers, 36 staff 25 volunteers, 29 community leaders,12 observations of clinical care 9/10 16 Hartwig et al. (2014). Tanzania Effectiveness of palliative care teams in reducing pain and increasing quality of life in the absence of Morphine. A mixed-method study 145 records of cancer patients across the 13 rural hospitals and 6 nurses in the hospitals 7/10 17 Hennemann-Krause et al. (2015) Brazil Telemedicine as a form of additional support for traditional outpatient care. A prospective, longitudinal, qualitative, descriptive case series 12 advanced cancer patients 10/10 18 Herce et al. (2014) Malawi To evaluate and understand integrated inpatient and home-based care. A situational analysis employing REM Chart review of all adult patients, interviews with 11 caregivers; 7 key stakeholders 8/10 19 Jabbari (2019) Iran Experience of family physicians and key leaders about feasibility of palliative or end-of-life care. Qualitative Two focus groups with 23 physicians 7/10 20 Jack et al. (2011)Uganda Impact of a Community Volunteer Programme. Qualitative Twenty-one patients, 32 volunteers and 11 hospices clinical staff 7/10 21 Jayalakshmi et al. (2017)India Understanding the structure, organization, and delivery of palliative care and conformity to state policy. Qualitative 139 patients in Poovar and 239 patients in Azhur taking palliative care services Interview for healthcare workers (doctors, palliative care nurses) 3/10 22 Kumar (2007)India Sustainable community-owned service offering comprehensive long-term care and palliative care. Service description Community-based palliative care in Northern and mid-Kerala covering the population of more than 12 million Not applicable 23 Lemonica and Barros (2007)Brazil Educational opportunities to enable home-based palliative care service. Service description Integrated education for medical, nursing students and anaesthetic residents. Home care service to patients Not applicable 24 Logie and Harding (2012)Zambia Evaluation of a strategic advocacy programme to enhance the provision of palliative care. A mixed-method evaluation including rapid evaluation Eight palliative care organizations (three urban and five rural) 4/10 25 Munday et al. (2018)North India Evaluation of mobile community teams (home visit) with the support of hospital services. Rapid evaluation method using mixed-method realist approach Five-hospitals, key informant interviews with two Emmanuel Hospitals Association (EHA) project leaders. 32 interviews with EHA palliative care staff and other staff, hospital management at each site. Twelve interviews with patients and carers 6/10 26 Namisango et al. (2016)Rural and urban, Uganda Exploring an electronic database to replace hard-copy documentation-on of medicines. Quasi-Experiment 150 patients with palliative care needs in a rural setting 7/9 27 Nanney et al. (2010) Tanzania Providing a community involved home-based palliative care. Description of service Health (nurses, social workers, clinical officers, chaplains) training; support to home-based community volunteers; Not applicable 28 Potts et al. (2019)India Feasibility and acceptance of a piloted home-based palliative care programme. Qualitative descriptive study Seven palliative care clinical team (nurses, physicians, behavioural counsellor, a study coordinator) and three CHWs 7/10 29 Sedillo et al. (2015) Kenya Palliative care provider self-competence and priorities for future education. A descriptive cross-sectional pilot study survey Five clinical staff, 11 caregivers and 8 support staff 6/8 30 Shabnam et al. (2018)Bangladesh Development, service use and challenges of 24/7 palliative care Telephone Consultation Service (TCS). Mixed-method study 4195 calls from 1164 patients and their caregivers. Six participants (head department, clinical pharmacist, palliative care physicians) 5/10 Open in new tab Data analysis and interpretation The data were extracted from individual papers and described in tabulated form according to author name, year of publication, setting, research focus, design and methods, population focus, key findings, comments and challenges of the papers. The data extraction was checked by a second reviewer with discrepancies resolved by discussion. The findings were analysed using content analysis (Lobiondo-Wood and Haber, 2014). Content analysis is ‘a systematic coding and categorizing approach use for a large amount of textual information to determine trend and patterns of words used’ (Vaismoradi et al., 2013). In this review, the data were extracted from each paper, then coded and categorized based on their relevance to the four pillars of the WHO public health model for palliative care, as previously described (Figure 2). Figure 2 Open in new tabDownload slide Strategies used by LMICs to establish palliative care, grouped according to the WHO public health model (Stjernsward et al., 2007; Callaway et al., 2018). Figure 2 Open in new tabDownload slide Strategies used by LMICs to establish palliative care, grouped according to the WHO public health model (Stjernsward et al., 2007; Callaway et al., 2018). Presentation of results Thirty papers met the inclusion criteria and were included in the synthesis. Tables 1 and 2 present the characteristics and findings of the included papers: three quasi-experimental (Dongre et al., 2012; Chandra et al., 2016; Namisango et al., 2016); seven qualitative papers (Campbell, 2011; Jack et al., 2011; Campbell and Amin, 2014; Campbell and Baernholdt, 2016; Jayalakshmi and Suhita, 2017; Jabbari et al., 2019; Potts et al., 2019); and seven service descriptions (Defilippi and Cameron, 2007; Kumar, 2007; Lemonica and Barros, 2007; Devi et al., 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Boit et al., 2014). Four papers used case study (Downing, 2008; Downing and Kawuma, 2008; Bond and Knopp, 2018; Freire De Castro Silva et al., 2018) ; one used case series (Hennemann-Krause et al., 2015); five used mixed-method (Dekker et al., 2012; Logie and Harding, 2012; Hartwig et al., 2014; Munday et al., 2018; Shabnam et al., 2018); two used rapid evaluation methodology (REM) (Grant et al., 2011; Herce et al., 2014) and one paper was a quantitative paper (Sedillo et al., 2015). Table 2 Findings, implications and challenges of the included papers Authors, year of publication, country . Findings . Comments and implications . Challenges . Boit et al. (2014) Policy: Kenyan Hospice and Palliative Care Association (KEHPCA) has an advocacy plan and worked closely with the MoH. Drug availability: Morphine included in the essential medicine list and its usage and accessibility is not restricted by law. Education: the staff members trained on how to use Morphine and prevent pain and suffering. Implementation: providing home palliative care service for those who live in a rural area. In 2013, 200 home visits were made. No precise data collection, sampling or ethical review. The strength of interdisciplinary team; showing compassion; spending time with the community; listen to their concerns, and grieving with them. The patients have an economic problem. Inadequate drug supplies, poor access to care in rural areas, health inequalities, and lack of awareness on basic palliative care among healthcare providers and the community. Bond and Knopp (2018) Policy: availability of national palliative care policy with no funding allocated for palliative care services by the government. Drug availability: palliative care team provided paracetamol for mild and diclofenac for moderate and Morphine for severing pains. Education: palliative care incorporated into medical and nursing curricula, and nurses are applying and disseminating their knowledge to other healthcare providers. Implementation: palliative care team provides comprehensive care (physical, psychosocial and spiritual support) with no cost to the clients. Palliative care delivered to those clients diagnosed with a chronically ill and incurable disease who were suffering from pain. Referrals to palliative care centre made by community volunteers or by clients themselves. No precise data collection, sampling or ethical review. Integrate palliative care into the existing healthcare system and to develop a cost-effective, cultural appropriate sustainable palliative care programme. Poverty, lack of funding and limited human resource, fear of opioid usage among healthcare providers and the public. Obtaining a licence to administer Morphine and even having a license, getting access to the medication is challenging. Lack of vehicles and not all palliative care team can operate a motorcycle. The palliative care programme is free of cost and dependant on fund donated organizations. Campbell and Baernholdt (2016) Policy: not applicable Drug availability: not applicable Education: The training sessions composed of six topics: general palliative care, HIV/AIDs, physical care at the end of life, grieving and mourning, and debriefing for CHWs. The evaluation indicated that majority of them (mean score 4.83) learned a new thing, and they should use in their daily work. Implementation: not applicable The evaluation questionnaire source is not clearly stated. Provide training for CHWs and evaluate the palliative care quality delivered by the CHWs. The CHWs and caregivers experienced multiple losses of patients and moral distress. Limited resources. Campbell (2011) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: the nurses indicated that HBPC has many benefits such as the community supports, pain relief, understanding of deep-seated personal issues. HBPC also enables patients to practice their traditional customs and may allow access to traditional medicines, in Zulu, such as the traditional herbs that heal patient wounds. Small-group of nurses participated in the study. Consider the safety issue of nurses who work in home-based palliative care though HBPC have lots of benefits in increasing access to care. The patient and families in rural African homes expect and familiar with the concept of curative care but not palliative care from the HBPC nurses. The safety of nurses is also another challenge. Homes of the Kwa-Zulu poorly ventilated and masks may not be available. Campbell and Amin (2014) Policy: not applicable Drug availability: not applicable Education:not applicable Implementation: benefits and challenges when using traditional healers. They play a significant role in relieving pain and providing psychological care from a cultural perspective, so involving the patients in palliative care training. They were also sharing the work of nurses and CVWs. The findings did not represent the nurses and home-based care workers experience. Nurses and home-based workers discussed the benefits and challenges when using traditional healers. Recommended palliative care training for traditional healers. Traditional healers focused on beliefs/faith of individuals and not based on scientific evidence. Chandra et al. (2016) Policy: not applicable Drug availability: not applicable Education: palliative care awareness increased using education campaign and community volunteers to provide home-based palliative care. Implementation: not applicable Sampling technique—sample size calculation not clearly stated. Community-based care by volunteers is new to the community. Awareness and attitudinal change in palliative care increase through the education campaign. The community expected to get palliative care from experts in hospitals not home-based care from volunteers. Defilippi and Cameron (2007) Policy: not applicable Drug availability: not applicable Education: palliative care training course conducted for community caregivers, nurses and social workers. Bedside training provided for doctors in palliative medicine. Implementation: mentorship a significant role in providing networked service through the integration of palliative home-based care with community caregivers, government hospitals, clinics and NGOs. Description of the palliative care model (no precise data collection, sampling or ethical review) Mentorship helps in strengthening networked service. Dependence on external funding organization which impacts the sustainability of the programme. Dekker et al. (2012) Policy: not applicable Drug availability: pain medication in clinics is limited to Paracetamol, Ibuprofen, Aspirin and diclofenac. Hospital dispensed ∼8.12 g of Morphine per month in the form of 5% tablet, 68% syrup and 27% injection. Education: fifty-eight per cent of healthcare providers had taken palliative care training, including either formal training in school or informal training in the working area. Five of the six physiotherapists, occupational therapists and 9 of the 11 nurses had never trained. Implementation: not applicable Perceived dichotomy between palliative and curative care, and small sample size. Policymakers and healthcare providers to improve pain treatment and access to palliative care. Limited prescription of palliative care medicine. Outside the hospital, access to pain medications was limited. Lack of awareness and unfavourable attitude to palliative care. Devi et al. (2008) Policy: funding for training from hospitals and the government and palliative care unit’s development throughout the country. Drug availability: Morphine prescription policy changed from 2 weeks to 1 month and 3 months for patients in remote areas. Education: health professionals trained, including doctors. Implementation: experience sharing with the palliative care team. Palliative care access in rural areas increased with the active involvement of stakeholders. Palliative care service is networked from hospital to home care. Ninety per cent of the patients indicated that the programme and the service help to relieve their symptoms and the home visit was also helpful. Patients also got the service for free. Description of palliative care model (no precise data collection, sampling or ethical review) Educating and training health professionals, Cost-effective, sustainable home-based palliative care with strong family support and poor health infrastructure. Family fears of Morphine addiction. Di Sorbo et al. (2010) Policy: funding agency supported new palliative care programmes. Drug availability: inadequate supply of Morphine in rural areas and limited availability in cities. NGOs compiled essential medicine list. Education: palliative care training, mentorship to physicians, health professionals, programme officers, volunteers, pastors and youth. Efforts underway with the university to develop a palliative medicine curriculum. Implementation: NGOs support resources to demonstrate home-based palliative care practices. Service for vulnerable youth described, also, assists with the integration of home-based palliative care with local clinics and hospitals. Description of palliative care model (no precise data collection, sampling or ethical review). Recommended for more funding to scale up this model nationally strengthening a network among the community and all funding organizations. Morphine supply limited to cities and not distributed to rural areas. More attention is given to long-term development and sustainability of the programme. Dongre et al. (2012) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: elderly patients received home care from a medical doctor and nurses, and a home visit from the community volunteers, and physiotherapy service in the rural area. The method section broadly described. A need to integrate the palliative care team activity to ensure a continuum of care from home to hospital. Elderly problems are chronic in nature and this produce stress to the patients and families. high prevalence of chronic diseases and risk factors Downing and Kawuma (2008) Policy: not applicable Drug Availability: oral Morphine was available in the districts. Education: health professionals develop new skills, attitudinal change, and confidence in providing care. Training assists the instructor to integrate palliative care into the nursing curriculum. Implementation: health professionals motivated to implement community home-based care services. Endeavoured to integrate the existing healthcare system. Professional qualifications of participants not clearly stated. Evaluating palliative care training and encouraging multidisciplinary teamwork. The participants’ expectation of getting daily expenses of money from the training was not available. Downing (2008) Policy: funding from the joint clinical research centre and MoH and Advocacy at the district or national level. Drug availability: Mobile Training Teams (MTTs) develops drug availability, particularly oral Morphine. Education: MMT 1-year modular training programme. Implementation: MTT bringing about change in practice such as teamwork and attitudinal change of health professionals. Service evaluation broadly described. Specific methods and detailed results not clearly stated. Developing culturally appropriate, affordable palliative care parallel to the four components of public health strategy. The issue of generalizability and validity of the model. Freire et al. (2018) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: the information technology tools used in implementing palliative care and chronic pain management. The palliative care team used mobile devices for communicating with patients in remote areas. The data analysis technique and ethics part of the method is not stated. Support of palliative care team in providing care and to inform pain scale using information system. Internet connection may be a challenge in remote areas. Grant et al. (2011) Policy: not applicable Drug availability: oral Morphine solution used. Education: nurses and community volunteers developed awareness about the illness and changing families and community attitudes towards death and dying. Implementation: volunteers significant in providing health education with links to religious and community leaders. Mobile phone for rapid access in the clinical network. Palliative care team provides home-based palliative care. Palliative care not reaching cancer patients compared to HIV patients. Recommended to enhance awareness of cancer in the community. Volunteer and poverty challenges. Distance and lack of skilled professionals. Hartwig et al. (2014). Policy: not applicable Drug availability: in the absence of Morphine, pain score improved from an average of 3.8/5 (moderately severe pain) to 2.3/5 (moderate pain) and the non-pain symptoms such as psychological, spiritual and family issue improved through palliative care for cancer patients. Education: four of the six nurses were trained to administer Morphine for severe and chronic pain. Three of the nurses have a diploma in palliative care, and the other three have at least 7 years of experience working in palliative hospice. Implementation: the nurse provides holistic palliative care such as emotional, psychosocial support for patients and families; and improved pain management by keeping spiritual well-being. In rural Tanzania, palliative care is implemented, and pain managed in the absence of oral Morphine, but not to the degree that could be achieved if Morphine was available. The possibility of bias and error in translation because of only one interviewer and translator. Lack of pain medications, such as oral Morphine. Psychosocial and spiritual pain such as family conflicts, poverty, the child not going to school this thing add to the physical pain. All the nurse tells the story of more than one patient who had suffered from untreatable pain before death. Hennemann et al. (2015) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation:telemedicine is an essential technology in reducing symptoms, less time spent on transportation, and increased patient and family support. Also maintained quality of home-based palliative care for patients with advanced cancer. Patient and family members need home computer access and literacy. Not applicable for patient and caregivers without computer access. Herce et al. (2014) Policy: Neno Palliative Care Program (NPCP) a joint programme between the NGO and MoH, local and rural government, community and faith-based organizations. The Malawi MoH provides essential health service free of charge. Drug availability: medications prescribed based on the level of pain, starting from mild analgesia to potent opioids. Education: all clinical providers were trained more than a week and these trained volunteer health workers. Implementation: patient-related psychosocial needs linked with socio-economic needs, such as a need for income, receiving food, house repairs. Psychosocial support gained from family members, community churches, neighbours and friends. Most patients preferred home-based (46%) and community- based (30%), hospital-based (24%) palliative care. The key stakeholder's profession or responsibility not clearly stated. Providing comprehensive palliative care integrated with disease-modifying treatment through public-private partnership and by establishing a network community-based and home-based care volunteers. Poverty, transportation, lack of food are the significant challenges of the patients' Lack of consistent funding for palliative care activities, competing for health priorities, as a threat to the sustainability palliative care services. A knowledge gap exists in hospitalized patients. Most caregivers lack training and counselling skills in palliative care. Jabbari (2019)Rural Iran Policy: not applicable drug availability: not applicable Education: not applicable Implementation: there is a structure in the health system which indicates palliative care at each level, should integrate palliative care services with primary health care team including Family Physician (FP), nurses, psychologist, family member, social workers and religious person to provide palliative or end-of-life care. Services provided at no cost and with support from insurance companies. The team members can provide the service in home, charity, special centres and there is a referral system from and to community through the system. The strategy for palliative care should be based around the FP and the other levels of the health system receiving referrals (FP at first level, district hospital second and university hospital third level) using a computerized health information system. Lack of education for health care providers and lack of responsibility among the providers. Cultural and financial problems no sustainable funding. Lack of welcome by the private system and lack of health facilities. Jack et al. (2011) Policy: not applicable Drug availability: not applicable Education: counselling and supporting patients and families in the right way of taking medication. Implementation: CVWs identify the patient address and provide physical, psychological and family care. CVWs used to provide a linked patient with the hospice staff in the remote areas. Sample bias and risk of programme sustainability. The community volunteer used as a bridge among the hospice team and the patients with their families. Lack of transportation and financial issues affect payment to CVWs. Jayalakshmi et al. (2017)Two Local Self-government Institutions (LSGIs) of Kerala, India Policy: not applicable Drug availability: palliative care medications were available in the palliative care unit, health centres and government hospitals. Education: not applicable Implementation: home visits in both places for those patients need urgent service the family members called the nurse. Some of the patients visited once a month, and some once in 2–3 months. The government, palliative care team, was nurse-led while the NGOs were more professional approach in terms of team composition. The description methods did not have a detail description of data analysis, ethical approval. Public–private linkage used for the programme sustainability at community level. Lack of transportation and vehicles, availability of Morphine is also a challenge except in NGO, lack of adequate social welfare, absence of emergency referrals. Lack of institutional structure. No uniform team structure, infrastructure, training of healthcare workers. Kumar (2007)Kerala, India Policy: the NNPC has been engaged with the local governments to prioritize the local health needs. However, more than 90% of the resource of the project was local generated fund. Drug availability: not applicable Education: a structured training programme (16 h of an interactive theory session and 4 days of clinical practice under supervision) including evaluation at the end given to the volunteers. Creating skill and confidence of the local community. Implementation: community volunteers provided a regular home visit and identified the non-medical issues such as financial problems, patients in need of care, and organizing awareness creation activities in the community. The NNPC focused on home care in our patients and closely working with the palliative care facilities in the inpatient units. The earlier structure doctor or nurse-led, replaced with the community, volunteer-led. The solution of the problem should be raised from the community by themselves. Description of NNPC (no clear methodology session). Locally generated funds and the NNPC closely working with the local government for the programme sustainability. Poverty, lack of sanitation, primary health care, primary education and clean drinking water. Lemonica and Barros (2007)Botucatu, Brazil Policy: the government provides essential medications free of charge. Drug availability: the pain medications, including Morphine, were accessible with no cost. Education: palliative care course-integrated to undergraduate and postgraduate curriculums of medical students, nursing education, Anaesthesia residents. It also provides continuing medical education programme speciality training for nurses leading to Masters and Doctoral degree. Implementation: Pain Management and Palliative Care (PMPC) provides home care. Twice a week, the palliative care team visits an average of four patients each day. On-call medical service is available 24 h a day and 7 days a week. Description (data collection, analysis and ethics were not stated). Improved experience of care for dying. Lack of hospital bed to provide inpatient care. Logie and Harding (2012) Policy: advocacy with the MoH-led technical working party and funding organization. Drug availability: multi-sectoral working group established and facilitating oral Morphine provision. Education: expert palliative care training delivered for 1 week. Training for health professionals, diploma students and short courses delivered for all healthcare staff. Implementation: attitudinal change of health professionals towards caring for dying patients; enhanced confidence and assisted with the delivery of home-based care. Lack of transparent methodology (research design, sampling or ethical consideration). Recommends use of WHO public health strategy. Sustainability of the programme because of restricted funding and travel costs. Low consumption of Morphine. Munday et al. (2018)Rural, North India Policy: not applicable Drug availability: the team prescribed the appropriate medication. However, oncologist or anaesthetist was needed in the hospital to prescribe Morphine safely. Education: palliative care team members trained for 10 days twice a year. The doctor took a diploma in palliative medicine and a 6 weeks course. Two nurses took more than a 1-month course—family members trained by the team members on how to care their relatives. Implementation: home visits take place by the palliative care team 5 days a week. Family members have the team phone number to call if the problems severe. All the team have a skill of consultation and being a good listener. The team provides psychological, emotional and spiritual support for both patients and their families. The team is not telling the patient is dying because the community put them in the floor. The community and church leaders were supporting the team members in helping those in need. In the methods section, sample size, number of participants in the quantitative part and ethical approval) were not stated. Provide hospital inpatient palliative care and a home visit for home care service. Lack of funding The number of daily visits varied because of travelled and has poor roads. Time-consuming to get trust by the community. Cultural and language difference is another challenge. The patient and family were below the poverty line. Lack of Morphine. Lack of funding for the services. Namisango et al. (2016) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: compares the effectiveness of electronic application before and after implementation time. The m-health approach showed the need for pharmacies to improve medicine delivery. Also assists patient data security. Identified need for reliable power. Enhance the operational process of pharmacy service in palliative care. Low reporting of patient contact details and lack of mobile phone use. Nanney et al. (2010) Policy: NGO provide fund resources continuum of care for people living with HIV/AIDs. Drug availability: palliative medicine available throughout the country. Education: diploma training for health professionals and volunteers in home-based care by the government-certified trainer. Implementation: palliative care for individuals used home-based palliative care volunteers’ network; quality of palliative care service expansion to vulnerable children by providing a link with community and church leaders. Description of palliative care model (no precise data collection, sampling or ethical review). A continuum of care to provide quality of palliative care. Home-based care volunteers and palliative care team face challenges to help families living in poverty. Potts et al. (2019)Rural, Kolkata, India Policy: not applicable Drug availability: not applicable Education: CHWs were trained for 5 days. The CHWs was also trained in the family and caregivers. Implementation: the CHWs provides primary care such as psychosocial and emotional support and providing comfort to the patients and their families with the guidance of the physicians. However, the CHWs need more training on how to handle patients during an emergency and what to expect during the dying process. CHWs have a good experience in record-keeping and documenting the service provided in each visit. The ethical approval session was not stated, small sample size. CHWs integrated to the health system. Shortage of training days, lack of sufficient pay or incentives for CHWs. Sedillo et al. (2015) Policy: not applicable Drug availability: not applicable Education: self-competence scores differ according to palliative care provider type. findings direct choice of topics for future education. Implementation: not applicable A pilot study with small numbers of self-confidence and education priorities among clinical caregivers and support staff. Educational programme provided palliative care self-competencies in clinical care and patient and family communication. Scope of practice between participants differed. Shabnam et al. (2018) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: The 24/7 TCS started in 2011 to address the needs of palliative care patients and caregivers, only for those who discharge to the rural areas of Bangladesh. The physicians starting from 2012 have reimbursement fee for the service. The service includes all types of everyday problems, from severe symptoms to invitations for funerals. The service is also a bridge that helps to connect the physician and the patients. Calling helps the patient to access information on the availability of bed on ward, to get advice, comfort and to get medicines. Risk of bias and a client may want to take an overdose. The TCS provides a bridge for the patients, caregivers and physicians to reach for those who discharged from the hospital and live outside the capital. Physicians are not trained to consult and provide advice on the telephone. Lack of patient record in the physician's hand. There is also a physical change, so the patients lack familiarity with alternative doctors. Authors, year of publication, country . Findings . Comments and implications . Challenges . Boit et al. (2014) Policy: Kenyan Hospice and Palliative Care Association (KEHPCA) has an advocacy plan and worked closely with the MoH. Drug availability: Morphine included in the essential medicine list and its usage and accessibility is not restricted by law. Education: the staff members trained on how to use Morphine and prevent pain and suffering. Implementation: providing home palliative care service for those who live in a rural area. In 2013, 200 home visits were made. No precise data collection, sampling or ethical review. The strength of interdisciplinary team; showing compassion; spending time with the community; listen to their concerns, and grieving with them. The patients have an economic problem. Inadequate drug supplies, poor access to care in rural areas, health inequalities, and lack of awareness on basic palliative care among healthcare providers and the community. Bond and Knopp (2018) Policy: availability of national palliative care policy with no funding allocated for palliative care services by the government. Drug availability: palliative care team provided paracetamol for mild and diclofenac for moderate and Morphine for severing pains. Education: palliative care incorporated into medical and nursing curricula, and nurses are applying and disseminating their knowledge to other healthcare providers. Implementation: palliative care team provides comprehensive care (physical, psychosocial and spiritual support) with no cost to the clients. Palliative care delivered to those clients diagnosed with a chronically ill and incurable disease who were suffering from pain. Referrals to palliative care centre made by community volunteers or by clients themselves. No precise data collection, sampling or ethical review. Integrate palliative care into the existing healthcare system and to develop a cost-effective, cultural appropriate sustainable palliative care programme. Poverty, lack of funding and limited human resource, fear of opioid usage among healthcare providers and the public. Obtaining a licence to administer Morphine and even having a license, getting access to the medication is challenging. Lack of vehicles and not all palliative care team can operate a motorcycle. The palliative care programme is free of cost and dependant on fund donated organizations. Campbell and Baernholdt (2016) Policy: not applicable Drug availability: not applicable Education: The training sessions composed of six topics: general palliative care, HIV/AIDs, physical care at the end of life, grieving and mourning, and debriefing for CHWs. The evaluation indicated that majority of them (mean score 4.83) learned a new thing, and they should use in their daily work. Implementation: not applicable The evaluation questionnaire source is not clearly stated. Provide training for CHWs and evaluate the palliative care quality delivered by the CHWs. The CHWs and caregivers experienced multiple losses of patients and moral distress. Limited resources. Campbell (2011) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: the nurses indicated that HBPC has many benefits such as the community supports, pain relief, understanding of deep-seated personal issues. HBPC also enables patients to practice their traditional customs and may allow access to traditional medicines, in Zulu, such as the traditional herbs that heal patient wounds. Small-group of nurses participated in the study. Consider the safety issue of nurses who work in home-based palliative care though HBPC have lots of benefits in increasing access to care. The patient and families in rural African homes expect and familiar with the concept of curative care but not palliative care from the HBPC nurses. The safety of nurses is also another challenge. Homes of the Kwa-Zulu poorly ventilated and masks may not be available. Campbell and Amin (2014) Policy: not applicable Drug availability: not applicable Education:not applicable Implementation: benefits and challenges when using traditional healers. They play a significant role in relieving pain and providing psychological care from a cultural perspective, so involving the patients in palliative care training. They were also sharing the work of nurses and CVWs. The findings did not represent the nurses and home-based care workers experience. Nurses and home-based workers discussed the benefits and challenges when using traditional healers. Recommended palliative care training for traditional healers. Traditional healers focused on beliefs/faith of individuals and not based on scientific evidence. Chandra et al. (2016) Policy: not applicable Drug availability: not applicable Education: palliative care awareness increased using education campaign and community volunteers to provide home-based palliative care. Implementation: not applicable Sampling technique—sample size calculation not clearly stated. Community-based care by volunteers is new to the community. Awareness and attitudinal change in palliative care increase through the education campaign. The community expected to get palliative care from experts in hospitals not home-based care from volunteers. Defilippi and Cameron (2007) Policy: not applicable Drug availability: not applicable Education: palliative care training course conducted for community caregivers, nurses and social workers. Bedside training provided for doctors in palliative medicine. Implementation: mentorship a significant role in providing networked service through the integration of palliative home-based care with community caregivers, government hospitals, clinics and NGOs. Description of the palliative care model (no precise data collection, sampling or ethical review) Mentorship helps in strengthening networked service. Dependence on external funding organization which impacts the sustainability of the programme. Dekker et al. (2012) Policy: not applicable Drug availability: pain medication in clinics is limited to Paracetamol, Ibuprofen, Aspirin and diclofenac. Hospital dispensed ∼8.12 g of Morphine per month in the form of 5% tablet, 68% syrup and 27% injection. Education: fifty-eight per cent of healthcare providers had taken palliative care training, including either formal training in school or informal training in the working area. Five of the six physiotherapists, occupational therapists and 9 of the 11 nurses had never trained. Implementation: not applicable Perceived dichotomy between palliative and curative care, and small sample size. Policymakers and healthcare providers to improve pain treatment and access to palliative care. Limited prescription of palliative care medicine. Outside the hospital, access to pain medications was limited. Lack of awareness and unfavourable attitude to palliative care. Devi et al. (2008) Policy: funding for training from hospitals and the government and palliative care unit’s development throughout the country. Drug availability: Morphine prescription policy changed from 2 weeks to 1 month and 3 months for patients in remote areas. Education: health professionals trained, including doctors. Implementation: experience sharing with the palliative care team. Palliative care access in rural areas increased with the active involvement of stakeholders. Palliative care service is networked from hospital to home care. Ninety per cent of the patients indicated that the programme and the service help to relieve their symptoms and the home visit was also helpful. Patients also got the service for free. Description of palliative care model (no precise data collection, sampling or ethical review) Educating and training health professionals, Cost-effective, sustainable home-based palliative care with strong family support and poor health infrastructure. Family fears of Morphine addiction. Di Sorbo et al. (2010) Policy: funding agency supported new palliative care programmes. Drug availability: inadequate supply of Morphine in rural areas and limited availability in cities. NGOs compiled essential medicine list. Education: palliative care training, mentorship to physicians, health professionals, programme officers, volunteers, pastors and youth. Efforts underway with the university to develop a palliative medicine curriculum. Implementation: NGOs support resources to demonstrate home-based palliative care practices. Service for vulnerable youth described, also, assists with the integration of home-based palliative care with local clinics and hospitals. Description of palliative care model (no precise data collection, sampling or ethical review). Recommended for more funding to scale up this model nationally strengthening a network among the community and all funding organizations. Morphine supply limited to cities and not distributed to rural areas. More attention is given to long-term development and sustainability of the programme. Dongre et al. (2012) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: elderly patients received home care from a medical doctor and nurses, and a home visit from the community volunteers, and physiotherapy service in the rural area. The method section broadly described. A need to integrate the palliative care team activity to ensure a continuum of care from home to hospital. Elderly problems are chronic in nature and this produce stress to the patients and families. high prevalence of chronic diseases and risk factors Downing and Kawuma (2008) Policy: not applicable Drug Availability: oral Morphine was available in the districts. Education: health professionals develop new skills, attitudinal change, and confidence in providing care. Training assists the instructor to integrate palliative care into the nursing curriculum. Implementation: health professionals motivated to implement community home-based care services. Endeavoured to integrate the existing healthcare system. Professional qualifications of participants not clearly stated. Evaluating palliative care training and encouraging multidisciplinary teamwork. The participants’ expectation of getting daily expenses of money from the training was not available. Downing (2008) Policy: funding from the joint clinical research centre and MoH and Advocacy at the district or national level. Drug availability: Mobile Training Teams (MTTs) develops drug availability, particularly oral Morphine. Education: MMT 1-year modular training programme. Implementation: MTT bringing about change in practice such as teamwork and attitudinal change of health professionals. Service evaluation broadly described. Specific methods and detailed results not clearly stated. Developing culturally appropriate, affordable palliative care parallel to the four components of public health strategy. The issue of generalizability and validity of the model. Freire et al. (2018) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: the information technology tools used in implementing palliative care and chronic pain management. The palliative care team used mobile devices for communicating with patients in remote areas. The data analysis technique and ethics part of the method is not stated. Support of palliative care team in providing care and to inform pain scale using information system. Internet connection may be a challenge in remote areas. Grant et al. (2011) Policy: not applicable Drug availability: oral Morphine solution used. Education: nurses and community volunteers developed awareness about the illness and changing families and community attitudes towards death and dying. Implementation: volunteers significant in providing health education with links to religious and community leaders. Mobile phone for rapid access in the clinical network. Palliative care team provides home-based palliative care. Palliative care not reaching cancer patients compared to HIV patients. Recommended to enhance awareness of cancer in the community. Volunteer and poverty challenges. Distance and lack of skilled professionals. Hartwig et al. (2014). Policy: not applicable Drug availability: in the absence of Morphine, pain score improved from an average of 3.8/5 (moderately severe pain) to 2.3/5 (moderate pain) and the non-pain symptoms such as psychological, spiritual and family issue improved through palliative care for cancer patients. Education: four of the six nurses were trained to administer Morphine for severe and chronic pain. Three of the nurses have a diploma in palliative care, and the other three have at least 7 years of experience working in palliative hospice. Implementation: the nurse provides holistic palliative care such as emotional, psychosocial support for patients and families; and improved pain management by keeping spiritual well-being. In rural Tanzania, palliative care is implemented, and pain managed in the absence of oral Morphine, but not to the degree that could be achieved if Morphine was available. The possibility of bias and error in translation because of only one interviewer and translator. Lack of pain medications, such as oral Morphine. Psychosocial and spiritual pain such as family conflicts, poverty, the child not going to school this thing add to the physical pain. All the nurse tells the story of more than one patient who had suffered from untreatable pain before death. Hennemann et al. (2015) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation:telemedicine is an essential technology in reducing symptoms, less time spent on transportation, and increased patient and family support. Also maintained quality of home-based palliative care for patients with advanced cancer. Patient and family members need home computer access and literacy. Not applicable for patient and caregivers without computer access. Herce et al. (2014) Policy: Neno Palliative Care Program (NPCP) a joint programme between the NGO and MoH, local and rural government, community and faith-based organizations. The Malawi MoH provides essential health service free of charge. Drug availability: medications prescribed based on the level of pain, starting from mild analgesia to potent opioids. Education: all clinical providers were trained more than a week and these trained volunteer health workers. Implementation: patient-related psychosocial needs linked with socio-economic needs, such as a need for income, receiving food, house repairs. Psychosocial support gained from family members, community churches, neighbours and friends. Most patients preferred home-based (46%) and community- based (30%), hospital-based (24%) palliative care. The key stakeholder's profession or responsibility not clearly stated. Providing comprehensive palliative care integrated with disease-modifying treatment through public-private partnership and by establishing a network community-based and home-based care volunteers. Poverty, transportation, lack of food are the significant challenges of the patients' Lack of consistent funding for palliative care activities, competing for health priorities, as a threat to the sustainability palliative care services. A knowledge gap exists in hospitalized patients. Most caregivers lack training and counselling skills in palliative care. Jabbari (2019)Rural Iran Policy: not applicable drug availability: not applicable Education: not applicable Implementation: there is a structure in the health system which indicates palliative care at each level, should integrate palliative care services with primary health care team including Family Physician (FP), nurses, psychologist, family member, social workers and religious person to provide palliative or end-of-life care. Services provided at no cost and with support from insurance companies. The team members can provide the service in home, charity, special centres and there is a referral system from and to community through the system. The strategy for palliative care should be based around the FP and the other levels of the health system receiving referrals (FP at first level, district hospital second and university hospital third level) using a computerized health information system. Lack of education for health care providers and lack of responsibility among the providers. Cultural and financial problems no sustainable funding. Lack of welcome by the private system and lack of health facilities. Jack et al. (2011) Policy: not applicable Drug availability: not applicable Education: counselling and supporting patients and families in the right way of taking medication. Implementation: CVWs identify the patient address and provide physical, psychological and family care. CVWs used to provide a linked patient with the hospice staff in the remote areas. Sample bias and risk of programme sustainability. The community volunteer used as a bridge among the hospice team and the patients with their families. Lack of transportation and financial issues affect payment to CVWs. Jayalakshmi et al. (2017)Two Local Self-government Institutions (LSGIs) of Kerala, India Policy: not applicable Drug availability: palliative care medications were available in the palliative care unit, health centres and government hospitals. Education: not applicable Implementation: home visits in both places for those patients need urgent service the family members called the nurse. Some of the patients visited once a month, and some once in 2–3 months. The government, palliative care team, was nurse-led while the NGOs were more professional approach in terms of team composition. The description methods did not have a detail description of data analysis, ethical approval. Public–private linkage used for the programme sustainability at community level. Lack of transportation and vehicles, availability of Morphine is also a challenge except in NGO, lack of adequate social welfare, absence of emergency referrals. Lack of institutional structure. No uniform team structure, infrastructure, training of healthcare workers. Kumar (2007)Kerala, India Policy: the NNPC has been engaged with the local governments to prioritize the local health needs. However, more than 90% of the resource of the project was local generated fund. Drug availability: not applicable Education: a structured training programme (16 h of an interactive theory session and 4 days of clinical practice under supervision) including evaluation at the end given to the volunteers. Creating skill and confidence of the local community. Implementation: community volunteers provided a regular home visit and identified the non-medical issues such as financial problems, patients in need of care, and organizing awareness creation activities in the community. The NNPC focused on home care in our patients and closely working with the palliative care facilities in the inpatient units. The earlier structure doctor or nurse-led, replaced with the community, volunteer-led. The solution of the problem should be raised from the community by themselves. Description of NNPC (no clear methodology session). Locally generated funds and the NNPC closely working with the local government for the programme sustainability. Poverty, lack of sanitation, primary health care, primary education and clean drinking water. Lemonica and Barros (2007)Botucatu, Brazil Policy: the government provides essential medications free of charge. Drug availability: the pain medications, including Morphine, were accessible with no cost. Education: palliative care course-integrated to undergraduate and postgraduate curriculums of medical students, nursing education, Anaesthesia residents. It also provides continuing medical education programme speciality training for nurses leading to Masters and Doctoral degree. Implementation: Pain Management and Palliative Care (PMPC) provides home care. Twice a week, the palliative care team visits an average of four patients each day. On-call medical service is available 24 h a day and 7 days a week. Description (data collection, analysis and ethics were not stated). Improved experience of care for dying. Lack of hospital bed to provide inpatient care. Logie and Harding (2012) Policy: advocacy with the MoH-led technical working party and funding organization. Drug availability: multi-sectoral working group established and facilitating oral Morphine provision. Education: expert palliative care training delivered for 1 week. Training for health professionals, diploma students and short courses delivered for all healthcare staff. Implementation: attitudinal change of health professionals towards caring for dying patients; enhanced confidence and assisted with the delivery of home-based care. Lack of transparent methodology (research design, sampling or ethical consideration). Recommends use of WHO public health strategy. Sustainability of the programme because of restricted funding and travel costs. Low consumption of Morphine. Munday et al. (2018)Rural, North India Policy: not applicable Drug availability: the team prescribed the appropriate medication. However, oncologist or anaesthetist was needed in the hospital to prescribe Morphine safely. Education: palliative care team members trained for 10 days twice a year. The doctor took a diploma in palliative medicine and a 6 weeks course. Two nurses took more than a 1-month course—family members trained by the team members on how to care their relatives. Implementation: home visits take place by the palliative care team 5 days a week. Family members have the team phone number to call if the problems severe. All the team have a skill of consultation and being a good listener. The team provides psychological, emotional and spiritual support for both patients and their families. The team is not telling the patient is dying because the community put them in the floor. The community and church leaders were supporting the team members in helping those in need. In the methods section, sample size, number of participants in the quantitative part and ethical approval) were not stated. Provide hospital inpatient palliative care and a home visit for home care service. Lack of funding The number of daily visits varied because of travelled and has poor roads. Time-consuming to get trust by the community. Cultural and language difference is another challenge. The patient and family were below the poverty line. Lack of Morphine. Lack of funding for the services. Namisango et al. (2016) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: compares the effectiveness of electronic application before and after implementation time. The m-health approach showed the need for pharmacies to improve medicine delivery. Also assists patient data security. Identified need for reliable power. Enhance the operational process of pharmacy service in palliative care. Low reporting of patient contact details and lack of mobile phone use. Nanney et al. (2010) Policy: NGO provide fund resources continuum of care for people living with HIV/AIDs. Drug availability: palliative medicine available throughout the country. Education: diploma training for health professionals and volunteers in home-based care by the government-certified trainer. Implementation: palliative care for individuals used home-based palliative care volunteers’ network; quality of palliative care service expansion to vulnerable children by providing a link with community and church leaders. Description of palliative care model (no precise data collection, sampling or ethical review). A continuum of care to provide quality of palliative care. Home-based care volunteers and palliative care team face challenges to help families living in poverty. Potts et al. (2019)Rural, Kolkata, India Policy: not applicable Drug availability: not applicable Education: CHWs were trained for 5 days. The CHWs was also trained in the family and caregivers. Implementation: the CHWs provides primary care such as psychosocial and emotional support and providing comfort to the patients and their families with the guidance of the physicians. However, the CHWs need more training on how to handle patients during an emergency and what to expect during the dying process. CHWs have a good experience in record-keeping and documenting the service provided in each visit. The ethical approval session was not stated, small sample size. CHWs integrated to the health system. Shortage of training days, lack of sufficient pay or incentives for CHWs. Sedillo et al. (2015) Policy: not applicable Drug availability: not applicable Education: self-competence scores differ according to palliative care provider type. findings direct choice of topics for future education. Implementation: not applicable A pilot study with small numbers of self-confidence and education priorities among clinical caregivers and support staff. Educational programme provided palliative care self-competencies in clinical care and patient and family communication. Scope of practice between participants differed. Shabnam et al. (2018) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: The 24/7 TCS started in 2011 to address the needs of palliative care patients and caregivers, only for those who discharge to the rural areas of Bangladesh. The physicians starting from 2012 have reimbursement fee for the service. The service includes all types of everyday problems, from severe symptoms to invitations for funerals. The service is also a bridge that helps to connect the physician and the patients. Calling helps the patient to access information on the availability of bed on ward, to get advice, comfort and to get medicines. Risk of bias and a client may want to take an overdose. The TCS provides a bridge for the patients, caregivers and physicians to reach for those who discharged from the hospital and live outside the capital. Physicians are not trained to consult and provide advice on the telephone. Lack of patient record in the physician's hand. There is also a physical change, so the patients lack familiarity with alternative doctors. Open in new tab Table 2 Findings, implications and challenges of the included papers Authors, year of publication, country . Findings . Comments and implications . Challenges . Boit et al. (2014) Policy: Kenyan Hospice and Palliative Care Association (KEHPCA) has an advocacy plan and worked closely with the MoH. Drug availability: Morphine included in the essential medicine list and its usage and accessibility is not restricted by law. Education: the staff members trained on how to use Morphine and prevent pain and suffering. Implementation: providing home palliative care service for those who live in a rural area. In 2013, 200 home visits were made. No precise data collection, sampling or ethical review. The strength of interdisciplinary team; showing compassion; spending time with the community; listen to their concerns, and grieving with them. The patients have an economic problem. Inadequate drug supplies, poor access to care in rural areas, health inequalities, and lack of awareness on basic palliative care among healthcare providers and the community. Bond and Knopp (2018) Policy: availability of national palliative care policy with no funding allocated for palliative care services by the government. Drug availability: palliative care team provided paracetamol for mild and diclofenac for moderate and Morphine for severing pains. Education: palliative care incorporated into medical and nursing curricula, and nurses are applying and disseminating their knowledge to other healthcare providers. Implementation: palliative care team provides comprehensive care (physical, psychosocial and spiritual support) with no cost to the clients. Palliative care delivered to those clients diagnosed with a chronically ill and incurable disease who were suffering from pain. Referrals to palliative care centre made by community volunteers or by clients themselves. No precise data collection, sampling or ethical review. Integrate palliative care into the existing healthcare system and to develop a cost-effective, cultural appropriate sustainable palliative care programme. Poverty, lack of funding and limited human resource, fear of opioid usage among healthcare providers and the public. Obtaining a licence to administer Morphine and even having a license, getting access to the medication is challenging. Lack of vehicles and not all palliative care team can operate a motorcycle. The palliative care programme is free of cost and dependant on fund donated organizations. Campbell and Baernholdt (2016) Policy: not applicable Drug availability: not applicable Education: The training sessions composed of six topics: general palliative care, HIV/AIDs, physical care at the end of life, grieving and mourning, and debriefing for CHWs. The evaluation indicated that majority of them (mean score 4.83) learned a new thing, and they should use in their daily work. Implementation: not applicable The evaluation questionnaire source is not clearly stated. Provide training for CHWs and evaluate the palliative care quality delivered by the CHWs. The CHWs and caregivers experienced multiple losses of patients and moral distress. Limited resources. Campbell (2011) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: the nurses indicated that HBPC has many benefits such as the community supports, pain relief, understanding of deep-seated personal issues. HBPC also enables patients to practice their traditional customs and may allow access to traditional medicines, in Zulu, such as the traditional herbs that heal patient wounds. Small-group of nurses participated in the study. Consider the safety issue of nurses who work in home-based palliative care though HBPC have lots of benefits in increasing access to care. The patient and families in rural African homes expect and familiar with the concept of curative care but not palliative care from the HBPC nurses. The safety of nurses is also another challenge. Homes of the Kwa-Zulu poorly ventilated and masks may not be available. Campbell and Amin (2014) Policy: not applicable Drug availability: not applicable Education:not applicable Implementation: benefits and challenges when using traditional healers. They play a significant role in relieving pain and providing psychological care from a cultural perspective, so involving the patients in palliative care training. They were also sharing the work of nurses and CVWs. The findings did not represent the nurses and home-based care workers experience. Nurses and home-based workers discussed the benefits and challenges when using traditional healers. Recommended palliative care training for traditional healers. Traditional healers focused on beliefs/faith of individuals and not based on scientific evidence. Chandra et al. (2016) Policy: not applicable Drug availability: not applicable Education: palliative care awareness increased using education campaign and community volunteers to provide home-based palliative care. Implementation: not applicable Sampling technique—sample size calculation not clearly stated. Community-based care by volunteers is new to the community. Awareness and attitudinal change in palliative care increase through the education campaign. The community expected to get palliative care from experts in hospitals not home-based care from volunteers. Defilippi and Cameron (2007) Policy: not applicable Drug availability: not applicable Education: palliative care training course conducted for community caregivers, nurses and social workers. Bedside training provided for doctors in palliative medicine. Implementation: mentorship a significant role in providing networked service through the integration of palliative home-based care with community caregivers, government hospitals, clinics and NGOs. Description of the palliative care model (no precise data collection, sampling or ethical review) Mentorship helps in strengthening networked service. Dependence on external funding organization which impacts the sustainability of the programme. Dekker et al. (2012) Policy: not applicable Drug availability: pain medication in clinics is limited to Paracetamol, Ibuprofen, Aspirin and diclofenac. Hospital dispensed ∼8.12 g of Morphine per month in the form of 5% tablet, 68% syrup and 27% injection. Education: fifty-eight per cent of healthcare providers had taken palliative care training, including either formal training in school or informal training in the working area. Five of the six physiotherapists, occupational therapists and 9 of the 11 nurses had never trained. Implementation: not applicable Perceived dichotomy between palliative and curative care, and small sample size. Policymakers and healthcare providers to improve pain treatment and access to palliative care. Limited prescription of palliative care medicine. Outside the hospital, access to pain medications was limited. Lack of awareness and unfavourable attitude to palliative care. Devi et al. (2008) Policy: funding for training from hospitals and the government and palliative care unit’s development throughout the country. Drug availability: Morphine prescription policy changed from 2 weeks to 1 month and 3 months for patients in remote areas. Education: health professionals trained, including doctors. Implementation: experience sharing with the palliative care team. Palliative care access in rural areas increased with the active involvement of stakeholders. Palliative care service is networked from hospital to home care. Ninety per cent of the patients indicated that the programme and the service help to relieve their symptoms and the home visit was also helpful. Patients also got the service for free. Description of palliative care model (no precise data collection, sampling or ethical review) Educating and training health professionals, Cost-effective, sustainable home-based palliative care with strong family support and poor health infrastructure. Family fears of Morphine addiction. Di Sorbo et al. (2010) Policy: funding agency supported new palliative care programmes. Drug availability: inadequate supply of Morphine in rural areas and limited availability in cities. NGOs compiled essential medicine list. Education: palliative care training, mentorship to physicians, health professionals, programme officers, volunteers, pastors and youth. Efforts underway with the university to develop a palliative medicine curriculum. Implementation: NGOs support resources to demonstrate home-based palliative care practices. Service for vulnerable youth described, also, assists with the integration of home-based palliative care with local clinics and hospitals. Description of palliative care model (no precise data collection, sampling or ethical review). Recommended for more funding to scale up this model nationally strengthening a network among the community and all funding organizations. Morphine supply limited to cities and not distributed to rural areas. More attention is given to long-term development and sustainability of the programme. Dongre et al. (2012) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: elderly patients received home care from a medical doctor and nurses, and a home visit from the community volunteers, and physiotherapy service in the rural area. The method section broadly described. A need to integrate the palliative care team activity to ensure a continuum of care from home to hospital. Elderly problems are chronic in nature and this produce stress to the patients and families. high prevalence of chronic diseases and risk factors Downing and Kawuma (2008) Policy: not applicable Drug Availability: oral Morphine was available in the districts. Education: health professionals develop new skills, attitudinal change, and confidence in providing care. Training assists the instructor to integrate palliative care into the nursing curriculum. Implementation: health professionals motivated to implement community home-based care services. Endeavoured to integrate the existing healthcare system. Professional qualifications of participants not clearly stated. Evaluating palliative care training and encouraging multidisciplinary teamwork. The participants’ expectation of getting daily expenses of money from the training was not available. Downing (2008) Policy: funding from the joint clinical research centre and MoH and Advocacy at the district or national level. Drug availability: Mobile Training Teams (MTTs) develops drug availability, particularly oral Morphine. Education: MMT 1-year modular training programme. Implementation: MTT bringing about change in practice such as teamwork and attitudinal change of health professionals. Service evaluation broadly described. Specific methods and detailed results not clearly stated. Developing culturally appropriate, affordable palliative care parallel to the four components of public health strategy. The issue of generalizability and validity of the model. Freire et al. (2018) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: the information technology tools used in implementing palliative care and chronic pain management. The palliative care team used mobile devices for communicating with patients in remote areas. The data analysis technique and ethics part of the method is not stated. Support of palliative care team in providing care and to inform pain scale using information system. Internet connection may be a challenge in remote areas. Grant et al. (2011) Policy: not applicable Drug availability: oral Morphine solution used. Education: nurses and community volunteers developed awareness about the illness and changing families and community attitudes towards death and dying. Implementation: volunteers significant in providing health education with links to religious and community leaders. Mobile phone for rapid access in the clinical network. Palliative care team provides home-based palliative care. Palliative care not reaching cancer patients compared to HIV patients. Recommended to enhance awareness of cancer in the community. Volunteer and poverty challenges. Distance and lack of skilled professionals. Hartwig et al. (2014). Policy: not applicable Drug availability: in the absence of Morphine, pain score improved from an average of 3.8/5 (moderately severe pain) to 2.3/5 (moderate pain) and the non-pain symptoms such as psychological, spiritual and family issue improved through palliative care for cancer patients. Education: four of the six nurses were trained to administer Morphine for severe and chronic pain. Three of the nurses have a diploma in palliative care, and the other three have at least 7 years of experience working in palliative hospice. Implementation: the nurse provides holistic palliative care such as emotional, psychosocial support for patients and families; and improved pain management by keeping spiritual well-being. In rural Tanzania, palliative care is implemented, and pain managed in the absence of oral Morphine, but not to the degree that could be achieved if Morphine was available. The possibility of bias and error in translation because of only one interviewer and translator. Lack of pain medications, such as oral Morphine. Psychosocial and spiritual pain such as family conflicts, poverty, the child not going to school this thing add to the physical pain. All the nurse tells the story of more than one patient who had suffered from untreatable pain before death. Hennemann et al. (2015) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation:telemedicine is an essential technology in reducing symptoms, less time spent on transportation, and increased patient and family support. Also maintained quality of home-based palliative care for patients with advanced cancer. Patient and family members need home computer access and literacy. Not applicable for patient and caregivers without computer access. Herce et al. (2014) Policy: Neno Palliative Care Program (NPCP) a joint programme between the NGO and MoH, local and rural government, community and faith-based organizations. The Malawi MoH provides essential health service free of charge. Drug availability: medications prescribed based on the level of pain, starting from mild analgesia to potent opioids. Education: all clinical providers were trained more than a week and these trained volunteer health workers. Implementation: patient-related psychosocial needs linked with socio-economic needs, such as a need for income, receiving food, house repairs. Psychosocial support gained from family members, community churches, neighbours and friends. Most patients preferred home-based (46%) and community- based (30%), hospital-based (24%) palliative care. The key stakeholder's profession or responsibility not clearly stated. Providing comprehensive palliative care integrated with disease-modifying treatment through public-private partnership and by establishing a network community-based and home-based care volunteers. Poverty, transportation, lack of food are the significant challenges of the patients' Lack of consistent funding for palliative care activities, competing for health priorities, as a threat to the sustainability palliative care services. A knowledge gap exists in hospitalized patients. Most caregivers lack training and counselling skills in palliative care. Jabbari (2019)Rural Iran Policy: not applicable drug availability: not applicable Education: not applicable Implementation: there is a structure in the health system which indicates palliative care at each level, should integrate palliative care services with primary health care team including Family Physician (FP), nurses, psychologist, family member, social workers and religious person to provide palliative or end-of-life care. Services provided at no cost and with support from insurance companies. The team members can provide the service in home, charity, special centres and there is a referral system from and to community through the system. The strategy for palliative care should be based around the FP and the other levels of the health system receiving referrals (FP at first level, district hospital second and university hospital third level) using a computerized health information system. Lack of education for health care providers and lack of responsibility among the providers. Cultural and financial problems no sustainable funding. Lack of welcome by the private system and lack of health facilities. Jack et al. (2011) Policy: not applicable Drug availability: not applicable Education: counselling and supporting patients and families in the right way of taking medication. Implementation: CVWs identify the patient address and provide physical, psychological and family care. CVWs used to provide a linked patient with the hospice staff in the remote areas. Sample bias and risk of programme sustainability. The community volunteer used as a bridge among the hospice team and the patients with their families. Lack of transportation and financial issues affect payment to CVWs. Jayalakshmi et al. (2017)Two Local Self-government Institutions (LSGIs) of Kerala, India Policy: not applicable Drug availability: palliative care medications were available in the palliative care unit, health centres and government hospitals. Education: not applicable Implementation: home visits in both places for those patients need urgent service the family members called the nurse. Some of the patients visited once a month, and some once in 2–3 months. The government, palliative care team, was nurse-led while the NGOs were more professional approach in terms of team composition. The description methods did not have a detail description of data analysis, ethical approval. Public–private linkage used for the programme sustainability at community level. Lack of transportation and vehicles, availability of Morphine is also a challenge except in NGO, lack of adequate social welfare, absence of emergency referrals. Lack of institutional structure. No uniform team structure, infrastructure, training of healthcare workers. Kumar (2007)Kerala, India Policy: the NNPC has been engaged with the local governments to prioritize the local health needs. However, more than 90% of the resource of the project was local generated fund. Drug availability: not applicable Education: a structured training programme (16 h of an interactive theory session and 4 days of clinical practice under supervision) including evaluation at the end given to the volunteers. Creating skill and confidence of the local community. Implementation: community volunteers provided a regular home visit and identified the non-medical issues such as financial problems, patients in need of care, and organizing awareness creation activities in the community. The NNPC focused on home care in our patients and closely working with the palliative care facilities in the inpatient units. The earlier structure doctor or nurse-led, replaced with the community, volunteer-led. The solution of the problem should be raised from the community by themselves. Description of NNPC (no clear methodology session). Locally generated funds and the NNPC closely working with the local government for the programme sustainability. Poverty, lack of sanitation, primary health care, primary education and clean drinking water. Lemonica and Barros (2007)Botucatu, Brazil Policy: the government provides essential medications free of charge. Drug availability: the pain medications, including Morphine, were accessible with no cost. Education: palliative care course-integrated to undergraduate and postgraduate curriculums of medical students, nursing education, Anaesthesia residents. It also provides continuing medical education programme speciality training for nurses leading to Masters and Doctoral degree. Implementation: Pain Management and Palliative Care (PMPC) provides home care. Twice a week, the palliative care team visits an average of four patients each day. On-call medical service is available 24 h a day and 7 days a week. Description (data collection, analysis and ethics were not stated). Improved experience of care for dying. Lack of hospital bed to provide inpatient care. Logie and Harding (2012) Policy: advocacy with the MoH-led technical working party and funding organization. Drug availability: multi-sectoral working group established and facilitating oral Morphine provision. Education: expert palliative care training delivered for 1 week. Training for health professionals, diploma students and short courses delivered for all healthcare staff. Implementation: attitudinal change of health professionals towards caring for dying patients; enhanced confidence and assisted with the delivery of home-based care. Lack of transparent methodology (research design, sampling or ethical consideration). Recommends use of WHO public health strategy. Sustainability of the programme because of restricted funding and travel costs. Low consumption of Morphine. Munday et al. (2018)Rural, North India Policy: not applicable Drug availability: the team prescribed the appropriate medication. However, oncologist or anaesthetist was needed in the hospital to prescribe Morphine safely. Education: palliative care team members trained for 10 days twice a year. The doctor took a diploma in palliative medicine and a 6 weeks course. Two nurses took more than a 1-month course—family members trained by the team members on how to care their relatives. Implementation: home visits take place by the palliative care team 5 days a week. Family members have the team phone number to call if the problems severe. All the team have a skill of consultation and being a good listener. The team provides psychological, emotional and spiritual support for both patients and their families. The team is not telling the patient is dying because the community put them in the floor. The community and church leaders were supporting the team members in helping those in need. In the methods section, sample size, number of participants in the quantitative part and ethical approval) were not stated. Provide hospital inpatient palliative care and a home visit for home care service. Lack of funding The number of daily visits varied because of travelled and has poor roads. Time-consuming to get trust by the community. Cultural and language difference is another challenge. The patient and family were below the poverty line. Lack of Morphine. Lack of funding for the services. Namisango et al. (2016) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: compares the effectiveness of electronic application before and after implementation time. The m-health approach showed the need for pharmacies to improve medicine delivery. Also assists patient data security. Identified need for reliable power. Enhance the operational process of pharmacy service in palliative care. Low reporting of patient contact details and lack of mobile phone use. Nanney et al. (2010) Policy: NGO provide fund resources continuum of care for people living with HIV/AIDs. Drug availability: palliative medicine available throughout the country. Education: diploma training for health professionals and volunteers in home-based care by the government-certified trainer. Implementation: palliative care for individuals used home-based palliative care volunteers’ network; quality of palliative care service expansion to vulnerable children by providing a link with community and church leaders. Description of palliative care model (no precise data collection, sampling or ethical review). A continuum of care to provide quality of palliative care. Home-based care volunteers and palliative care team face challenges to help families living in poverty. Potts et al. (2019)Rural, Kolkata, India Policy: not applicable Drug availability: not applicable Education: CHWs were trained for 5 days. The CHWs was also trained in the family and caregivers. Implementation: the CHWs provides primary care such as psychosocial and emotional support and providing comfort to the patients and their families with the guidance of the physicians. However, the CHWs need more training on how to handle patients during an emergency and what to expect during the dying process. CHWs have a good experience in record-keeping and documenting the service provided in each visit. The ethical approval session was not stated, small sample size. CHWs integrated to the health system. Shortage of training days, lack of sufficient pay or incentives for CHWs. Sedillo et al. (2015) Policy: not applicable Drug availability: not applicable Education: self-competence scores differ according to palliative care provider type. findings direct choice of topics for future education. Implementation: not applicable A pilot study with small numbers of self-confidence and education priorities among clinical caregivers and support staff. Educational programme provided palliative care self-competencies in clinical care and patient and family communication. Scope of practice between participants differed. Shabnam et al. (2018) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: The 24/7 TCS started in 2011 to address the needs of palliative care patients and caregivers, only for those who discharge to the rural areas of Bangladesh. The physicians starting from 2012 have reimbursement fee for the service. The service includes all types of everyday problems, from severe symptoms to invitations for funerals. The service is also a bridge that helps to connect the physician and the patients. Calling helps the patient to access information on the availability of bed on ward, to get advice, comfort and to get medicines. Risk of bias and a client may want to take an overdose. The TCS provides a bridge for the patients, caregivers and physicians to reach for those who discharged from the hospital and live outside the capital. Physicians are not trained to consult and provide advice on the telephone. Lack of patient record in the physician's hand. There is also a physical change, so the patients lack familiarity with alternative doctors. Authors, year of publication, country . Findings . Comments and implications . Challenges . Boit et al. (2014) Policy: Kenyan Hospice and Palliative Care Association (KEHPCA) has an advocacy plan and worked closely with the MoH. Drug availability: Morphine included in the essential medicine list and its usage and accessibility is not restricted by law. Education: the staff members trained on how to use Morphine and prevent pain and suffering. Implementation: providing home palliative care service for those who live in a rural area. In 2013, 200 home visits were made. No precise data collection, sampling or ethical review. The strength of interdisciplinary team; showing compassion; spending time with the community; listen to their concerns, and grieving with them. The patients have an economic problem. Inadequate drug supplies, poor access to care in rural areas, health inequalities, and lack of awareness on basic palliative care among healthcare providers and the community. Bond and Knopp (2018) Policy: availability of national palliative care policy with no funding allocated for palliative care services by the government. Drug availability: palliative care team provided paracetamol for mild and diclofenac for moderate and Morphine for severing pains. Education: palliative care incorporated into medical and nursing curricula, and nurses are applying and disseminating their knowledge to other healthcare providers. Implementation: palliative care team provides comprehensive care (physical, psychosocial and spiritual support) with no cost to the clients. Palliative care delivered to those clients diagnosed with a chronically ill and incurable disease who were suffering from pain. Referrals to palliative care centre made by community volunteers or by clients themselves. No precise data collection, sampling or ethical review. Integrate palliative care into the existing healthcare system and to develop a cost-effective, cultural appropriate sustainable palliative care programme. Poverty, lack of funding and limited human resource, fear of opioid usage among healthcare providers and the public. Obtaining a licence to administer Morphine and even having a license, getting access to the medication is challenging. Lack of vehicles and not all palliative care team can operate a motorcycle. The palliative care programme is free of cost and dependant on fund donated organizations. Campbell and Baernholdt (2016) Policy: not applicable Drug availability: not applicable Education: The training sessions composed of six topics: general palliative care, HIV/AIDs, physical care at the end of life, grieving and mourning, and debriefing for CHWs. The evaluation indicated that majority of them (mean score 4.83) learned a new thing, and they should use in their daily work. Implementation: not applicable The evaluation questionnaire source is not clearly stated. Provide training for CHWs and evaluate the palliative care quality delivered by the CHWs. The CHWs and caregivers experienced multiple losses of patients and moral distress. Limited resources. Campbell (2011) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: the nurses indicated that HBPC has many benefits such as the community supports, pain relief, understanding of deep-seated personal issues. HBPC also enables patients to practice their traditional customs and may allow access to traditional medicines, in Zulu, such as the traditional herbs that heal patient wounds. Small-group of nurses participated in the study. Consider the safety issue of nurses who work in home-based palliative care though HBPC have lots of benefits in increasing access to care. The patient and families in rural African homes expect and familiar with the concept of curative care but not palliative care from the HBPC nurses. The safety of nurses is also another challenge. Homes of the Kwa-Zulu poorly ventilated and masks may not be available. Campbell and Amin (2014) Policy: not applicable Drug availability: not applicable Education:not applicable Implementation: benefits and challenges when using traditional healers. They play a significant role in relieving pain and providing psychological care from a cultural perspective, so involving the patients in palliative care training. They were also sharing the work of nurses and CVWs. The findings did not represent the nurses and home-based care workers experience. Nurses and home-based workers discussed the benefits and challenges when using traditional healers. Recommended palliative care training for traditional healers. Traditional healers focused on beliefs/faith of individuals and not based on scientific evidence. Chandra et al. (2016) Policy: not applicable Drug availability: not applicable Education: palliative care awareness increased using education campaign and community volunteers to provide home-based palliative care. Implementation: not applicable Sampling technique—sample size calculation not clearly stated. Community-based care by volunteers is new to the community. Awareness and attitudinal change in palliative care increase through the education campaign. The community expected to get palliative care from experts in hospitals not home-based care from volunteers. Defilippi and Cameron (2007) Policy: not applicable Drug availability: not applicable Education: palliative care training course conducted for community caregivers, nurses and social workers. Bedside training provided for doctors in palliative medicine. Implementation: mentorship a significant role in providing networked service through the integration of palliative home-based care with community caregivers, government hospitals, clinics and NGOs. Description of the palliative care model (no precise data collection, sampling or ethical review) Mentorship helps in strengthening networked service. Dependence on external funding organization which impacts the sustainability of the programme. Dekker et al. (2012) Policy: not applicable Drug availability: pain medication in clinics is limited to Paracetamol, Ibuprofen, Aspirin and diclofenac. Hospital dispensed ∼8.12 g of Morphine per month in the form of 5% tablet, 68% syrup and 27% injection. Education: fifty-eight per cent of healthcare providers had taken palliative care training, including either formal training in school or informal training in the working area. Five of the six physiotherapists, occupational therapists and 9 of the 11 nurses had never trained. Implementation: not applicable Perceived dichotomy between palliative and curative care, and small sample size. Policymakers and healthcare providers to improve pain treatment and access to palliative care. Limited prescription of palliative care medicine. Outside the hospital, access to pain medications was limited. Lack of awareness and unfavourable attitude to palliative care. Devi et al. (2008) Policy: funding for training from hospitals and the government and palliative care unit’s development throughout the country. Drug availability: Morphine prescription policy changed from 2 weeks to 1 month and 3 months for patients in remote areas. Education: health professionals trained, including doctors. Implementation: experience sharing with the palliative care team. Palliative care access in rural areas increased with the active involvement of stakeholders. Palliative care service is networked from hospital to home care. Ninety per cent of the patients indicated that the programme and the service help to relieve their symptoms and the home visit was also helpful. Patients also got the service for free. Description of palliative care model (no precise data collection, sampling or ethical review) Educating and training health professionals, Cost-effective, sustainable home-based palliative care with strong family support and poor health infrastructure. Family fears of Morphine addiction. Di Sorbo et al. (2010) Policy: funding agency supported new palliative care programmes. Drug availability: inadequate supply of Morphine in rural areas and limited availability in cities. NGOs compiled essential medicine list. Education: palliative care training, mentorship to physicians, health professionals, programme officers, volunteers, pastors and youth. Efforts underway with the university to develop a palliative medicine curriculum. Implementation: NGOs support resources to demonstrate home-based palliative care practices. Service for vulnerable youth described, also, assists with the integration of home-based palliative care with local clinics and hospitals. Description of palliative care model (no precise data collection, sampling or ethical review). Recommended for more funding to scale up this model nationally strengthening a network among the community and all funding organizations. Morphine supply limited to cities and not distributed to rural areas. More attention is given to long-term development and sustainability of the programme. Dongre et al. (2012) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: elderly patients received home care from a medical doctor and nurses, and a home visit from the community volunteers, and physiotherapy service in the rural area. The method section broadly described. A need to integrate the palliative care team activity to ensure a continuum of care from home to hospital. Elderly problems are chronic in nature and this produce stress to the patients and families. high prevalence of chronic diseases and risk factors Downing and Kawuma (2008) Policy: not applicable Drug Availability: oral Morphine was available in the districts. Education: health professionals develop new skills, attitudinal change, and confidence in providing care. Training assists the instructor to integrate palliative care into the nursing curriculum. Implementation: health professionals motivated to implement community home-based care services. Endeavoured to integrate the existing healthcare system. Professional qualifications of participants not clearly stated. Evaluating palliative care training and encouraging multidisciplinary teamwork. The participants’ expectation of getting daily expenses of money from the training was not available. Downing (2008) Policy: funding from the joint clinical research centre and MoH and Advocacy at the district or national level. Drug availability: Mobile Training Teams (MTTs) develops drug availability, particularly oral Morphine. Education: MMT 1-year modular training programme. Implementation: MTT bringing about change in practice such as teamwork and attitudinal change of health professionals. Service evaluation broadly described. Specific methods and detailed results not clearly stated. Developing culturally appropriate, affordable palliative care parallel to the four components of public health strategy. The issue of generalizability and validity of the model. Freire et al. (2018) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: the information technology tools used in implementing palliative care and chronic pain management. The palliative care team used mobile devices for communicating with patients in remote areas. The data analysis technique and ethics part of the method is not stated. Support of palliative care team in providing care and to inform pain scale using information system. Internet connection may be a challenge in remote areas. Grant et al. (2011) Policy: not applicable Drug availability: oral Morphine solution used. Education: nurses and community volunteers developed awareness about the illness and changing families and community attitudes towards death and dying. Implementation: volunteers significant in providing health education with links to religious and community leaders. Mobile phone for rapid access in the clinical network. Palliative care team provides home-based palliative care. Palliative care not reaching cancer patients compared to HIV patients. Recommended to enhance awareness of cancer in the community. Volunteer and poverty challenges. Distance and lack of skilled professionals. Hartwig et al. (2014). Policy: not applicable Drug availability: in the absence of Morphine, pain score improved from an average of 3.8/5 (moderately severe pain) to 2.3/5 (moderate pain) and the non-pain symptoms such as psychological, spiritual and family issue improved through palliative care for cancer patients. Education: four of the six nurses were trained to administer Morphine for severe and chronic pain. Three of the nurses have a diploma in palliative care, and the other three have at least 7 years of experience working in palliative hospice. Implementation: the nurse provides holistic palliative care such as emotional, psychosocial support for patients and families; and improved pain management by keeping spiritual well-being. In rural Tanzania, palliative care is implemented, and pain managed in the absence of oral Morphine, but not to the degree that could be achieved if Morphine was available. The possibility of bias and error in translation because of only one interviewer and translator. Lack of pain medications, such as oral Morphine. Psychosocial and spiritual pain such as family conflicts, poverty, the child not going to school this thing add to the physical pain. All the nurse tells the story of more than one patient who had suffered from untreatable pain before death. Hennemann et al. (2015) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation:telemedicine is an essential technology in reducing symptoms, less time spent on transportation, and increased patient and family support. Also maintained quality of home-based palliative care for patients with advanced cancer. Patient and family members need home computer access and literacy. Not applicable for patient and caregivers without computer access. Herce et al. (2014) Policy: Neno Palliative Care Program (NPCP) a joint programme between the NGO and MoH, local and rural government, community and faith-based organizations. The Malawi MoH provides essential health service free of charge. Drug availability: medications prescribed based on the level of pain, starting from mild analgesia to potent opioids. Education: all clinical providers were trained more than a week and these trained volunteer health workers. Implementation: patient-related psychosocial needs linked with socio-economic needs, such as a need for income, receiving food, house repairs. Psychosocial support gained from family members, community churches, neighbours and friends. Most patients preferred home-based (46%) and community- based (30%), hospital-based (24%) palliative care. The key stakeholder's profession or responsibility not clearly stated. Providing comprehensive palliative care integrated with disease-modifying treatment through public-private partnership and by establishing a network community-based and home-based care volunteers. Poverty, transportation, lack of food are the significant challenges of the patients' Lack of consistent funding for palliative care activities, competing for health priorities, as a threat to the sustainability palliative care services. A knowledge gap exists in hospitalized patients. Most caregivers lack training and counselling skills in palliative care. Jabbari (2019)Rural Iran Policy: not applicable drug availability: not applicable Education: not applicable Implementation: there is a structure in the health system which indicates palliative care at each level, should integrate palliative care services with primary health care team including Family Physician (FP), nurses, psychologist, family member, social workers and religious person to provide palliative or end-of-life care. Services provided at no cost and with support from insurance companies. The team members can provide the service in home, charity, special centres and there is a referral system from and to community through the system. The strategy for palliative care should be based around the FP and the other levels of the health system receiving referrals (FP at first level, district hospital second and university hospital third level) using a computerized health information system. Lack of education for health care providers and lack of responsibility among the providers. Cultural and financial problems no sustainable funding. Lack of welcome by the private system and lack of health facilities. Jack et al. (2011) Policy: not applicable Drug availability: not applicable Education: counselling and supporting patients and families in the right way of taking medication. Implementation: CVWs identify the patient address and provide physical, psychological and family care. CVWs used to provide a linked patient with the hospice staff in the remote areas. Sample bias and risk of programme sustainability. The community volunteer used as a bridge among the hospice team and the patients with their families. Lack of transportation and financial issues affect payment to CVWs. Jayalakshmi et al. (2017)Two Local Self-government Institutions (LSGIs) of Kerala, India Policy: not applicable Drug availability: palliative care medications were available in the palliative care unit, health centres and government hospitals. Education: not applicable Implementation: home visits in both places for those patients need urgent service the family members called the nurse. Some of the patients visited once a month, and some once in 2–3 months. The government, palliative care team, was nurse-led while the NGOs were more professional approach in terms of team composition. The description methods did not have a detail description of data analysis, ethical approval. Public–private linkage used for the programme sustainability at community level. Lack of transportation and vehicles, availability of Morphine is also a challenge except in NGO, lack of adequate social welfare, absence of emergency referrals. Lack of institutional structure. No uniform team structure, infrastructure, training of healthcare workers. Kumar (2007)Kerala, India Policy: the NNPC has been engaged with the local governments to prioritize the local health needs. However, more than 90% of the resource of the project was local generated fund. Drug availability: not applicable Education: a structured training programme (16 h of an interactive theory session and 4 days of clinical practice under supervision) including evaluation at the end given to the volunteers. Creating skill and confidence of the local community. Implementation: community volunteers provided a regular home visit and identified the non-medical issues such as financial problems, patients in need of care, and organizing awareness creation activities in the community. The NNPC focused on home care in our patients and closely working with the palliative care facilities in the inpatient units. The earlier structure doctor or nurse-led, replaced with the community, volunteer-led. The solution of the problem should be raised from the community by themselves. Description of NNPC (no clear methodology session). Locally generated funds and the NNPC closely working with the local government for the programme sustainability. Poverty, lack of sanitation, primary health care, primary education and clean drinking water. Lemonica and Barros (2007)Botucatu, Brazil Policy: the government provides essential medications free of charge. Drug availability: the pain medications, including Morphine, were accessible with no cost. Education: palliative care course-integrated to undergraduate and postgraduate curriculums of medical students, nursing education, Anaesthesia residents. It also provides continuing medical education programme speciality training for nurses leading to Masters and Doctoral degree. Implementation: Pain Management and Palliative Care (PMPC) provides home care. Twice a week, the palliative care team visits an average of four patients each day. On-call medical service is available 24 h a day and 7 days a week. Description (data collection, analysis and ethics were not stated). Improved experience of care for dying. Lack of hospital bed to provide inpatient care. Logie and Harding (2012) Policy: advocacy with the MoH-led technical working party and funding organization. Drug availability: multi-sectoral working group established and facilitating oral Morphine provision. Education: expert palliative care training delivered for 1 week. Training for health professionals, diploma students and short courses delivered for all healthcare staff. Implementation: attitudinal change of health professionals towards caring for dying patients; enhanced confidence and assisted with the delivery of home-based care. Lack of transparent methodology (research design, sampling or ethical consideration). Recommends use of WHO public health strategy. Sustainability of the programme because of restricted funding and travel costs. Low consumption of Morphine. Munday et al. (2018)Rural, North India Policy: not applicable Drug availability: the team prescribed the appropriate medication. However, oncologist or anaesthetist was needed in the hospital to prescribe Morphine safely. Education: palliative care team members trained for 10 days twice a year. The doctor took a diploma in palliative medicine and a 6 weeks course. Two nurses took more than a 1-month course—family members trained by the team members on how to care their relatives. Implementation: home visits take place by the palliative care team 5 days a week. Family members have the team phone number to call if the problems severe. All the team have a skill of consultation and being a good listener. The team provides psychological, emotional and spiritual support for both patients and their families. The team is not telling the patient is dying because the community put them in the floor. The community and church leaders were supporting the team members in helping those in need. In the methods section, sample size, number of participants in the quantitative part and ethical approval) were not stated. Provide hospital inpatient palliative care and a home visit for home care service. Lack of funding The number of daily visits varied because of travelled and has poor roads. Time-consuming to get trust by the community. Cultural and language difference is another challenge. The patient and family were below the poverty line. Lack of Morphine. Lack of funding for the services. Namisango et al. (2016) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: compares the effectiveness of electronic application before and after implementation time. The m-health approach showed the need for pharmacies to improve medicine delivery. Also assists patient data security. Identified need for reliable power. Enhance the operational process of pharmacy service in palliative care. Low reporting of patient contact details and lack of mobile phone use. Nanney et al. (2010) Policy: NGO provide fund resources continuum of care for people living with HIV/AIDs. Drug availability: palliative medicine available throughout the country. Education: diploma training for health professionals and volunteers in home-based care by the government-certified trainer. Implementation: palliative care for individuals used home-based palliative care volunteers’ network; quality of palliative care service expansion to vulnerable children by providing a link with community and church leaders. Description of palliative care model (no precise data collection, sampling or ethical review). A continuum of care to provide quality of palliative care. Home-based care volunteers and palliative care team face challenges to help families living in poverty. Potts et al. (2019)Rural, Kolkata, India Policy: not applicable Drug availability: not applicable Education: CHWs were trained for 5 days. The CHWs was also trained in the family and caregivers. Implementation: the CHWs provides primary care such as psychosocial and emotional support and providing comfort to the patients and their families with the guidance of the physicians. However, the CHWs need more training on how to handle patients during an emergency and what to expect during the dying process. CHWs have a good experience in record-keeping and documenting the service provided in each visit. The ethical approval session was not stated, small sample size. CHWs integrated to the health system. Shortage of training days, lack of sufficient pay or incentives for CHWs. Sedillo et al. (2015) Policy: not applicable Drug availability: not applicable Education: self-competence scores differ according to palliative care provider type. findings direct choice of topics for future education. Implementation: not applicable A pilot study with small numbers of self-confidence and education priorities among clinical caregivers and support staff. Educational programme provided palliative care self-competencies in clinical care and patient and family communication. Scope of practice between participants differed. Shabnam et al. (2018) Policy: not applicable Drug availability: not applicable Education: not applicable Implementation: The 24/7 TCS started in 2011 to address the needs of palliative care patients and caregivers, only for those who discharge to the rural areas of Bangladesh. The physicians starting from 2012 have reimbursement fee for the service. The service includes all types of everyday problems, from severe symptoms to invitations for funerals. The service is also a bridge that helps to connect the physician and the patients. Calling helps the patient to access information on the availability of bed on ward, to get advice, comfort and to get medicines. Risk of bias and a client may want to take an overdose. The TCS provides a bridge for the patients, caregivers and physicians to reach for those who discharged from the hospital and live outside the capital. Physicians are not trained to consult and provide advice on the telephone. Lack of patient record in the physician's hand. There is also a physical change, so the patients lack familiarity with alternative doctors. Open in new tab The research was mainly conducted in Africa: five papers South Africa (Defilippi and Cameron, 2007; Campbell, 2011; Dekker et al., 2012; Campbell and Amin, 2014; Campbell and Baernholdt, 2016); four papers in Uganda (Downing, 2008; Downing and Kawuma, 2008; Jack et al., 2011; Namisango et al., 2016); two papers in Kenya (Boit et al., 2014; Sedillo et al., 2015); three papers in Tanzania (Nanney et al., 2010; Hartwig et al., 2014; Bond and Knopp, 2018); one in Zimbabwe (Di Sorbo et al., 2010); one in Malawi (Herce et al., 2014); one in Zambia (Logie and Harding, 2012); and one multisite paper in Uganda, Kenya and Malawi (Grant et al., 2011). A further six papers originated from India (Kumar, 2007; Dongre et al., 2012; Chandra et al., 2016; Jayalakshmi and Suhita, 2017; Munday et al., 2018; Potts et al., 2019); three from Brazil (Lemonica and Barros, 2007; Hennemann-Krause et al., 2015; Freire De Castro Silva et al., 2018) and one each from Malaysia (Devi et al., 2008); Iran (Jabbari et al., 2019); and Bangladesh (Shabnam et al., 2018). Several models of palliative care were described including: seven home-based palliative care papers (Lemonica and Barros, 2007; Devi et al., 2008; Di Sorbo et al., 2010; Campbell, 2011; Logie and Harding, 2012; Boit et al., 2014; Jayalakshmi and Suhita, 2017; Jabbari et al., 2019); and four, community-based palliative care papers (Jack et al., 2011; Dongre et al., 2012; Hennemann-Krause et al., 2015; Bond and Knopp, 2018). In five papers, integrated models of community- and home-based care was described (Defilippi and Cameron, 2007; Kumar, 2007; Downing and Kawuma, 2008; Nanney et al., 2010; Jack et al., 2011; Herce et al., 2014; Munday et al., 2018). Results The integrative review results are described using the four pillars of the WHO public health model (Figure 2). Although in some countries palliative care has been included as a part of government policy, translation of health policy and implementation in the community was often reliant on advocacy and the financial support from non-government organizations (NGOs). Policies Policy strategies in the reviewed papers described the availability of palliative care in national health policy or non-government agency advocacy plans for incorporating palliative care in national health plans. Strategies varied widely between countries and included funding to support palliative care delivery both at the community and at healthcare organizational levels. In this review, palliative care policy was described in 10 papers (Kumar, 2007; Lemonica and Barros, 2007; Devi et al., 2008; Downing, 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Logie and Harding, 2012; Boit et al., 2014; Herce et al., 2014; Bond and Knopp, 2018). Although some governments provided policies about the way palliative care will be provided (Bond and Knopp, 2018), the provision of palliative care was largely implemented by NGOs (Di Sorbo et al., 2010; Nanney et al., 2010; Herce et al., 2014). Five papers described government initiatives to develop palliative care in rural settings (Lemonica and Barros, 2007; Devi et al., 2008; Logie and Harding, 2012; Herce et al., 2014; Bond and Knopp, 2018). For instance, in Sarawak, Malaysia, Davi et al. (2008) found that palliative care to be part of the national healthcare policy and health professional practice. In response to the national policy, the Malaysian Ministry of Health (MoH) increased the allocated budget to establish palliative care units throughout the country. This budget was supplemented by a fundraising strategy to ensure families donated to a fund, and significant donations were used to set-up an NGO, the ‘Sarawak Hospice Society’ (Devi et al., 2008). Furthermore, in Botucatu (Brazil), the government allowed free essential medications such as Morphine for patients in need (Lemonica and Barros, 2007). While, in Zambia, MoH and the Palliative Care Association of Zambia provided a fund to enhance palliative care (Logie and Harding, 2012). However, in the Royal District of Marta, North Tanzania a national palliative care policy was developed but with no government budget allocation (Bond and Knopp, 2018). Two papers, the Nankya Model in Uganda and Kimbilio a model hospice in Kenya, had an advocacy plan to establish palliative care at the district and national levels (Downing, 2008; Boit et al., 2014). In the other three papers, NGOs undertook initiatives to establish palliative care. For instance, the Foundation for Hospice in sub-Saharan Africa (FHSSA), established palliative care sites in Zimbabwe (Di Sorbo et al., 2010). The FSSHA (a non-profit U.S. National Hospice and Palliative Care Organization) with other international NGOs received funding to expand the palliative care programme by, e.g. the provision of resources for home-based care kits in different rural sites of Tanzania (Nanney et al., 2010). Furthermore, in Kerala (India), 90% of the palliative care funding, was sourced by the neighbourhood network in palliative care (NNPC) sourced from local governments (Kumar, 2007). However, lack of funding (Logie and Harding, 2012; Boit et al., 2014; Herce et al., 2014; Bond and Knopp, 2018) and dependence on external donors or NGOs were associated with concern about sustainability when government policy was not associated with government funding (Di Sorbo et al., 2010; Nanney et al., 2010; Logie and Harding, 2012). Medication availability The availability of palliative medicines is an umbrella term that includes prescribing, distributing, dispensing and administering of medications, and usually includes a list of essential medicines suggested by WHO. Of importance is the availability of opioids for the management of pain. The availability of medications varied widely and may be dependent upon relevant policy, culture and religious beliefs, and accessibility to medications. Sixteen papers described strategies and challenges in relation to palliative medicines (Lemonica and Barros, 2007; Devi et al., 2008; Downing, 2008; Downing and Kawuma, 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Grant et al., 2011; Jack et al., 2011; Dekker et al., 2012; Logie and Harding, 2012; Boit et al., 2014; Hartwig et al., 2014; Herce et al., 2014; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018; Munday et al., 2018). In rural Malawi and Brazil, Morphine was available free of charge (Lemonica and Barros, 2007; Herce et al., 2014). In rural Malawi, patients have used 53% of the Morphine prescribed (Herce et al., 2014). Whereas, in rural Zimbabwe, the NGO provided a list of essential palliative medicines to the government supply-chain, where Morphine supply was limited and not available outside the main cities (Di Sorbo et al., 2010). Additionally, in rural South Africa, palliative medicines are limited to supply from clinics (Dekker et al., 2012). In rural areas in North Tanzania, a license is required to administer Morphine (Bond and Knopp, 2018). Besides Tanzania, Morphine supply is also a challenge in Uganda, Zambia and South Africa with the training of health professionals to administer oral Morphine found to increase the demand for the drug resulting in the medication being available in all districts (Nanney et al., 2010; Logie and Harding, 2012). In the absence of Morphine in a rural hospital in Tanzania, a nurse provided advocacy for oral Morphine and pain scores improved through non-pharmacological management (Hartwig et al., 2014). In rural Western Kenya, North Tanzania and Kerala, palliative care medications were available without any legal restrictions (Boit et al., 2014; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018). However, in rural North India, a hospital oncologist or anaesthetist was needed to prescribe Morphine (Munday et al., 2018). In contrast, another paper described a networked system of medications from the large hospital to rural clinics (Devi et al., 2008). Doctors in larger hospitals created a prescription which was faxed to the rural clinic nearest to a patient’s home (Devi et al., 2008). The medication was prescribed for 1 month in rural areas and 3 months in more remote areas. The Malaysian medication system was also capable of calculating the consumption level of opioids to enable appropriate supply distribution of essential medications (Devi et al., 2008). In three rural African countries including Uganda, community volunteer workers (CVWs) played a significant role in ensuring the delivery of medication to patients’ homes and advising them to take the right drug at the right time (Grant et al., 2011; Jack et al., 2011). To enhance medication availability, a software application was piloted to replace hard-copy documentation of palliative medication prescription in pharmacies (Namisango et al., 2016). This software application reduced stock expiration, improved time-efficiency and medicine management. However, the availability of Morphine in clinical care was mostly limited to hospitals in cities (Downing, 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Dekker et al., 2012; Logie and Harding, 2012; Hartwig et al., 2014; Munday et al., 2018). Additionally, fear of opioid usage among healthcare providers and the public (Devi et al., 2008; Bond and Knopp, 2018), reduced the accessibility of palliative medicines, and a license was needed to administer Morphine (Boit et al., 2014; Bond and Knopp, 2018). Education The education of health professionals and the public featured in 21 of the reviewed papers in curriculum plans; palliative care courses for healthcare providers; expert training; family caregiver training and support; and mentorship (Defilippi and Cameron, 2007; Kumar, 2007; Lemonica and Barros, 2007; Devi et al., 2008; Downing, 2008; Downing and Kawuma, 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Grant et al., 2011; Jack et al., 2011; Dekker et al., 2012; Logie and Harding, 2012; Boit et al., 2014; Hartwig et al., 2014; Herce et al., 2014; Sedillo et al., 2015; Campbell and Baernholdt, 2016; Chandra et al., 2016; Bond and Knopp, 2018; Munday et al., 2018; Potts et al., 2019). Palliative care was incorporated into the curricula of medical, nursing and other health disciplines in Western Kenya, northern Tanzania and Brazil (Lemonica and Barros, 2007; Boit et al., 2014; Bond and Knopp, 2018). In Zimbabwe, a university planned to develop a curriculum in palliative medicine (Di Sorbo et al., 2010). A Kenyan paper also discussed the future interest of clinical staff to develop competence in particular areas of palliative care, such as paediatric palliative care (Sedillo et al., 2015). Hospice centres in South Africa conducted bedside training for physicians studying either a diploma or degree in palliative medicine (Defilippi and Cameron, 2007). Four papers reported that diploma students completed palliative care studies in different settings in order to enhance their confidence and skills (Defilippi and Cameron, 2007; Nanney et al., 2010; Logie and Harding, 2012; Munday et al., 2018). In 14 papers, palliative care training was described as being delivered to healthcare providers, social workers, home-based care volunteers (HBCVs), community health workers (CHWs) and spiritual leaders (Defilippi and Cameron, 2007; Kumar, 2007; Downing, 2008; Downing and Kawuma, 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Jack et al., 2011; Dekker et al., 2012; Logie and Harding, 2012; Hartwig et al., 2014; Herce et al., 2014; Bond and Knopp, 2018; Munday et al., 2018; Potts et al., 2019). Additionally, in three papers, a mentorship and supervision approach was significant in developing the scope of the provision of hospice care and assisting with accreditation processes (Defilippi and Cameron, 2007; Di Sorbo et al., 2010; Herce et al., 2014). Only one paper discussed the benefit and challenges of traditional healers in palliative care (Campbell and Amin, 2014). Traditional healers are knowledgeable about local, cultural and their community problems, which enable them to solve psychosocial problems (Campbell and Amin, 2014). However, without palliative care training, there was a concern that healers may not understand the importance of holistic care and the role of other palliative care team members. Another two papers described public awareness campaigns using poster exhibitions about home care in capital cities and some rural areas (Devi et al., 2008; Chandra et al., 2016). In these papers, palliative care awareness was achieved through house-to-house visits, printed pamphlets and banners displayed around the village, as well as being a topic on cultural nights (Chandra et al., 2016). An exhibition of posters about home care was undertaken in a rural community (Devi et al., 2008). The main palliative care education challenges included: lack of training for traditional healers, community volunteers, family caregivers and the public (Devi et al., 2008; Campbell and Amin, 2014; Chandra et al., 2016). There was a lack of awareness about palliative care among community and healthcare providers (Grant et al., 2011; Boit et al., 2014; Herce et al., 2014; Jabbari et al., 2019). Educational limitations then led to difficulty in physician and nursing access to mentoring and supervision in rural areas (Di Sorbo et al., 2010). Implementation Strategies for implementing palliative care were described in 26 papers (Defilippi and Cameron, 2007; Kumar, 2007; Lemonica and Barros, 2007; Devi et al., 2008; Downing, 2008; Downing and Kawuma, 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Campbell, 2011; Grant et al., 2011; Jack et al., 2011; Dongre et al., 2012; Logie and Harding, 2012; Boit et al., 2014; Campbell and Amin, 2014; Hartwig et al., 2014; Herce et al., 2014; Hennemann-Krause et al., 2015; Namisango et al., 2016; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018; Freire De Castro Silva et al., 2018; Munday et al., 2018; Shabnam et al., 2018; Jabbari et al., 2019; Potts et al., 2019). In LMICs, NGOs provide resources for expanding new palliative care programmes, to assist the continuity of care, as well as for integrating palliative care into the national health plans (Defilippi and Cameron, 2007; Di Sorbo et al., 2010; Nanney et al., 2010; Herce et al., 2014). Some papers described networking and the importance of teamwork in implementation. The Continuum of Care for People Living with HIV/AIDS in Tanzania (CHAT) model provided a network among home-based community volunteers (HBCVs), and the clinical palliative care team (Nanney et al., 2010); CVWs served as a bridge to link patients with the hospice staff (Jack et al., 2011). In rural Western Kenya, the hospice team closely networked with the community and the palliative care team who worked in a referral and teaching hospital (Boit et al., 2014); and in Sarawak (Malaysia), a palliative care team provided a service networked between the hospital and trained staff in a rural clinic (Devi et al., 2008). In South Africa and rural Malawi, the integrated community-based home care (ICHC) model had strengthened the links of health institutions at local, regional and national levels and hospice members were used for the main national palliative care resources (Defilippi and Cameron, 2007; Herce et al., 2014). Ten papers discussed the importance of teamwork in facilitating changes in community attitudes about palliative care (Kumar, 2007; Lemonica and Barros, 2007; Downing, 2008; Downing and Kawuma, 2008; Nanney et al., 2010; Grant et al., 2011; Boit et al., 2014; Hartwig et al., 2014; Bond and Knopp, 2018; Munday et al., 2018). Five papers focused on the use of technology to deliver palliative care services. Hennemann-Krause et al. (2015) evaluated the use of telemedicine for patients and family members with computer knowledge and skills, to self-assess symptom scores compared to in-person with a clinician. The use of telemedicine played a significant role in reducing travel time and increased both patient and their family member’s satisfaction. Cell phones were used by CVWs to link the patient and nurse for advice and support (Grant et al., 2011; Jack et al., 2011); a freestanding mobile clinical system was also used (Jack et al., 2011). For those with difficulty travelling to a clinic in Malaysia, the assessment was undertaken by telephone (Devi et al., 2008). In Bangladesh, telephone consultations provided a bridge between the physician and the patient, to access information from the hospital on bed availability, receiving general advice, medicines and comfort (Shabnam et al., 2018). The role of traditional healers was identified by participants as assisting with implementation in rural home-based care services (Campbell and Amin, 2014). A description of a palliative care programme in South Africa discussed the benefit of traditional healers in not only relieving pain and providing psychological care, but also guiding the cultural context for palliative care, and sharing the work of nurses and CVWs (Campbell and Amin, 2014). Caregivers in home-based palliative settings in rural South Africa also enabled patients to access traditional medicines, such as herbs for wound care (Campbell, 2011). In Sarawak, massage is a traditional acceptable practice for pain reduction (Devi et al., 2008). Service delivery challenges included: patients presenting late with advanced disease (Grant et al., 2011); community dependence on traditional healers (Campbell and Amin, 2014); lack of integration of palliative care with other care needs along the continuum of care (Grant et al., 2011); poverty (Boit et al., 2014; Hartwig et al., 2014; Herce et al., 2014; Bond and Knopp, 2018; Munday et al., 2018); and of the safety issues of nurses visiting homes (Campbell, 2011). Additionally, lack of hospital beds (Lemonica and Barros, 2007); cultural and language differences (Munday et al., 2018; Jabbari et al., 2019); access to technology (Hennemann-Krause et al., 2015; Shabnam et al., 2018); and limited transport access to get services (Campbell, 2011; Grant et al., 2011; Jack et al., 2011; Logie and Harding, 2012; Jayalakshmi and Suhita, 2017) were all current challenges. Strategies used to resolve challenges in LMICs The specific strategies used in the papers to resolve the challenges of delivering palliative care were extracted using the framework provided by the WHO public health strategy for palliative care: (Table 3). The challenges to the delivery of palliative care in rural LMICs are summarized in Figure 3. Figure 3 Open in new tabDownload slide Challenges of providing palliative care in rural LMICs, based on the four pillars of WHO public health model. Figure 3 Open in new tabDownload slide Challenges of providing palliative care in rural LMICs, based on the four pillars of WHO public health model. Table 3 Strategies to address the challenges of palliative care provision in rural areas of LMICs Challenges . Strategies to address challenges in providing palliative care in rural LMICs . Policy Policy not linked to practice or funding Availability of national palliative care policy for palliative care (Bond and Knopp, 2018); Collaboration between policymakers and NGOs (Devi et al., 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Logie and Harding, 2012; Boit et al., 2014; Herce et al., 2014). Advocacy plans at national, local and district levels (Downing, 2008; Boit et al., 2014); and Local and international grants, developing income-generating programmes, and fundraising events (Logie and Harding, 2012; Boit et al., 2014; Bond and Knopp, 2018). The hospice applied to receive reimbursement through the national insurance programme (Boit et al., 2014). Medication availability Lack of accredited staff, availability of medicines and validity of orders Staff education and training in Morphine administration (Nanney et al., 2010; Boit et al., 2014). Expand the length of time of prescription validity (Devi et al., 2008). Preparation of an oral Morphine solution from powder in the hospitals (Grant et al., 2011). Permission for qualified health professionals to administer medication in the absence of doctors (Grant et al., 2011). Mobile phones empowered to get rapid access to clinical and social support (Devi et al., 2008; Grant et al., 2011). Morphine available free of charge (Herce et al., 2014; Bond and Knopp, 2018); the nurse provides advocacy for oral Morphine (Hartwig et al., 2014). Morphine included in the essential medicine list, and its accessibility was not restricted by law (Boit et al., 2014). Education and training Lack of training of staff and understanding of palliative care in the community Increased awareness of palliative care through community activities like visiting houses in a village, brochures and printed pamphlet campaigns for the community (Chandra et al., 2016). Using posters that describe home-based palliative care (Devi et al., 2008). Specific training to target particular audiences (healthcare professionals, community health workers, volunteers, spiritual leaders and families (Defilippi and Cameron, 2007; Devi et al., 2008; Downing, 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Herce et al., 2014; Bond and Knopp, 2018; Munday et al., 2018; Potts et al., 2019). Supervision and mentorship to palliative care providers (Defilippi and Cameron, 2007; Di Sorbo et al., 2010; Herce et al., 2014). Palliative care incorporated in undergraduate and postgraduate of medical, nursing, dental, anaesthesia and pharmacy curricula (Lemonica and Barros, 2007; Boit et al., 2014; Bond and Knopp, 2018). The CHWs were very engaged in the training sessions, participated in the role play and shared stories (Campbell and Baernholdt, 2016). Implementation Service access in remote communities Palliative care integrated across the continuum of care, as in successful models of care for those with HIV (Grant et al., 2011; Logie and Harding, 2012), networked activity with the community and palliative care team (Kumar, 2007; Devi et al., 2008; Boit et al., 2014). Mobile palliative care clinics in out-reach activities (Logie and Harding, 2012). Technology such as mobile phones to enable rapid access; facilitate communication; integration of electronic medical record to support access to the existing system and collect data for research (Grant et al., 2011; Freire De Castro Silva et al., 2018); TCS (Shabnam et al., 2018). Community volunteers motivated and supported; and. An overall public health approach to provide an equitable provision of palliative care (Grant et al., 2011). The palliative care team members participated in-home visit (Kumar, 2007; Lemonica and Barros, 2007; Dongre et al., 2012; Herce et al., 2014; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018; Munday et al., 2018), compassionate care (Boit et al., 2014; Hartwig et al., 2014), with no cost (Kumar, 2007; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018) funeral and grieving with the community, listening to their needs, respecting their values, spend time in the community (Boit et al., 2014; Hartwig et al., 2014). Community- and home-based palliative care programme is the most cost-effective in low resource settings (Kumar, 2007; Lemonica and Barros, 2007; Downing and Kawuma, 2008; Dongre et al., 2012; Herce et al., 2014; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018; Potts et al., 2019). HBPC helped nurses to work independently, allow the patient to use traditional medicines patient to die peacefully without the decision of others (Campbell, 2011; Campbell and Amin, 2014). Establishing palliative medicine, clinics, educating families and healthcare providers, key persons should be involved, and the patients want to die at home, due to this, palliative care should be widely accessible and integrated to both inpatient and outpatient services (Herce et al., 2014; Jabbari et al., 2019). Challenges . Strategies to address challenges in providing palliative care in rural LMICs . Policy Policy not linked to practice or funding Availability of national palliative care policy for palliative care (Bond and Knopp, 2018); Collaboration between policymakers and NGOs (Devi et al., 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Logie and Harding, 2012; Boit et al., 2014; Herce et al., 2014). Advocacy plans at national, local and district levels (Downing, 2008; Boit et al., 2014); and Local and international grants, developing income-generating programmes, and fundraising events (Logie and Harding, 2012; Boit et al., 2014; Bond and Knopp, 2018). The hospice applied to receive reimbursement through the national insurance programme (Boit et al., 2014). Medication availability Lack of accredited staff, availability of medicines and validity of orders Staff education and training in Morphine administration (Nanney et al., 2010; Boit et al., 2014). Expand the length of time of prescription validity (Devi et al., 2008). Preparation of an oral Morphine solution from powder in the hospitals (Grant et al., 2011). Permission for qualified health professionals to administer medication in the absence of doctors (Grant et al., 2011). Mobile phones empowered to get rapid access to clinical and social support (Devi et al., 2008; Grant et al., 2011). Morphine available free of charge (Herce et al., 2014; Bond and Knopp, 2018); the nurse provides advocacy for oral Morphine (Hartwig et al., 2014). Morphine included in the essential medicine list, and its accessibility was not restricted by law (Boit et al., 2014). Education and training Lack of training of staff and understanding of palliative care in the community Increased awareness of palliative care through community activities like visiting houses in a village, brochures and printed pamphlet campaigns for the community (Chandra et al., 2016). Using posters that describe home-based palliative care (Devi et al., 2008). Specific training to target particular audiences (healthcare professionals, community health workers, volunteers, spiritual leaders and families (Defilippi and Cameron, 2007; Devi et al., 2008; Downing, 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Herce et al., 2014; Bond and Knopp, 2018; Munday et al., 2018; Potts et al., 2019). Supervision and mentorship to palliative care providers (Defilippi and Cameron, 2007; Di Sorbo et al., 2010; Herce et al., 2014). Palliative care incorporated in undergraduate and postgraduate of medical, nursing, dental, anaesthesia and pharmacy curricula (Lemonica and Barros, 2007; Boit et al., 2014; Bond and Knopp, 2018). The CHWs were very engaged in the training sessions, participated in the role play and shared stories (Campbell and Baernholdt, 2016). Implementation Service access in remote communities Palliative care integrated across the continuum of care, as in successful models of care for those with HIV (Grant et al., 2011; Logie and Harding, 2012), networked activity with the community and palliative care team (Kumar, 2007; Devi et al., 2008; Boit et al., 2014). Mobile palliative care clinics in out-reach activities (Logie and Harding, 2012). Technology such as mobile phones to enable rapid access; facilitate communication; integration of electronic medical record to support access to the existing system and collect data for research (Grant et al., 2011; Freire De Castro Silva et al., 2018); TCS (Shabnam et al., 2018). Community volunteers motivated and supported; and. An overall public health approach to provide an equitable provision of palliative care (Grant et al., 2011). The palliative care team members participated in-home visit (Kumar, 2007; Lemonica and Barros, 2007; Dongre et al., 2012; Herce et al., 2014; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018; Munday et al., 2018), compassionate care (Boit et al., 2014; Hartwig et al., 2014), with no cost (Kumar, 2007; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018) funeral and grieving with the community, listening to their needs, respecting their values, spend time in the community (Boit et al., 2014; Hartwig et al., 2014). Community- and home-based palliative care programme is the most cost-effective in low resource settings (Kumar, 2007; Lemonica and Barros, 2007; Downing and Kawuma, 2008; Dongre et al., 2012; Herce et al., 2014; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018; Potts et al., 2019). HBPC helped nurses to work independently, allow the patient to use traditional medicines patient to die peacefully without the decision of others (Campbell, 2011; Campbell and Amin, 2014). Establishing palliative medicine, clinics, educating families and healthcare providers, key persons should be involved, and the patients want to die at home, due to this, palliative care should be widely accessible and integrated to both inpatient and outpatient services (Herce et al., 2014; Jabbari et al., 2019). Open in new tab Table 3 Strategies to address the challenges of palliative care provision in rural areas of LMICs Challenges . Strategies to address challenges in providing palliative care in rural LMICs . Policy Policy not linked to practice or funding Availability of national palliative care policy for palliative care (Bond and Knopp, 2018); Collaboration between policymakers and NGOs (Devi et al., 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Logie and Harding, 2012; Boit et al., 2014; Herce et al., 2014). Advocacy plans at national, local and district levels (Downing, 2008; Boit et al., 2014); and Local and international grants, developing income-generating programmes, and fundraising events (Logie and Harding, 2012; Boit et al., 2014; Bond and Knopp, 2018). The hospice applied to receive reimbursement through the national insurance programme (Boit et al., 2014). Medication availability Lack of accredited staff, availability of medicines and validity of orders Staff education and training in Morphine administration (Nanney et al., 2010; Boit et al., 2014). Expand the length of time of prescription validity (Devi et al., 2008). Preparation of an oral Morphine solution from powder in the hospitals (Grant et al., 2011). Permission for qualified health professionals to administer medication in the absence of doctors (Grant et al., 2011). Mobile phones empowered to get rapid access to clinical and social support (Devi et al., 2008; Grant et al., 2011). Morphine available free of charge (Herce et al., 2014; Bond and Knopp, 2018); the nurse provides advocacy for oral Morphine (Hartwig et al., 2014). Morphine included in the essential medicine list, and its accessibility was not restricted by law (Boit et al., 2014). Education and training Lack of training of staff and understanding of palliative care in the community Increased awareness of palliative care through community activities like visiting houses in a village, brochures and printed pamphlet campaigns for the community (Chandra et al., 2016). Using posters that describe home-based palliative care (Devi et al., 2008). Specific training to target particular audiences (healthcare professionals, community health workers, volunteers, spiritual leaders and families (Defilippi and Cameron, 2007; Devi et al., 2008; Downing, 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Herce et al., 2014; Bond and Knopp, 2018; Munday et al., 2018; Potts et al., 2019). Supervision and mentorship to palliative care providers (Defilippi and Cameron, 2007; Di Sorbo et al., 2010; Herce et al., 2014). Palliative care incorporated in undergraduate and postgraduate of medical, nursing, dental, anaesthesia and pharmacy curricula (Lemonica and Barros, 2007; Boit et al., 2014; Bond and Knopp, 2018). The CHWs were very engaged in the training sessions, participated in the role play and shared stories (Campbell and Baernholdt, 2016). Implementation Service access in remote communities Palliative care integrated across the continuum of care, as in successful models of care for those with HIV (Grant et al., 2011; Logie and Harding, 2012), networked activity with the community and palliative care team (Kumar, 2007; Devi et al., 2008; Boit et al., 2014). Mobile palliative care clinics in out-reach activities (Logie and Harding, 2012). Technology such as mobile phones to enable rapid access; facilitate communication; integration of electronic medical record to support access to the existing system and collect data for research (Grant et al., 2011; Freire De Castro Silva et al., 2018); TCS (Shabnam et al., 2018). Community volunteers motivated and supported; and. An overall public health approach to provide an equitable provision of palliative care (Grant et al., 2011). The palliative care team members participated in-home visit (Kumar, 2007; Lemonica and Barros, 2007; Dongre et al., 2012; Herce et al., 2014; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018; Munday et al., 2018), compassionate care (Boit et al., 2014; Hartwig et al., 2014), with no cost (Kumar, 2007; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018) funeral and grieving with the community, listening to their needs, respecting their values, spend time in the community (Boit et al., 2014; Hartwig et al., 2014). Community- and home-based palliative care programme is the most cost-effective in low resource settings (Kumar, 2007; Lemonica and Barros, 2007; Downing and Kawuma, 2008; Dongre et al., 2012; Herce et al., 2014; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018; Potts et al., 2019). HBPC helped nurses to work independently, allow the patient to use traditional medicines patient to die peacefully without the decision of others (Campbell, 2011; Campbell and Amin, 2014). Establishing palliative medicine, clinics, educating families and healthcare providers, key persons should be involved, and the patients want to die at home, due to this, palliative care should be widely accessible and integrated to both inpatient and outpatient services (Herce et al., 2014; Jabbari et al., 2019). Challenges . Strategies to address challenges in providing palliative care in rural LMICs . Policy Policy not linked to practice or funding Availability of national palliative care policy for palliative care (Bond and Knopp, 2018); Collaboration between policymakers and NGOs (Devi et al., 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Logie and Harding, 2012; Boit et al., 2014; Herce et al., 2014). Advocacy plans at national, local and district levels (Downing, 2008; Boit et al., 2014); and Local and international grants, developing income-generating programmes, and fundraising events (Logie and Harding, 2012; Boit et al., 2014; Bond and Knopp, 2018). The hospice applied to receive reimbursement through the national insurance programme (Boit et al., 2014). Medication availability Lack of accredited staff, availability of medicines and validity of orders Staff education and training in Morphine administration (Nanney et al., 2010; Boit et al., 2014). Expand the length of time of prescription validity (Devi et al., 2008). Preparation of an oral Morphine solution from powder in the hospitals (Grant et al., 2011). Permission for qualified health professionals to administer medication in the absence of doctors (Grant et al., 2011). Mobile phones empowered to get rapid access to clinical and social support (Devi et al., 2008; Grant et al., 2011). Morphine available free of charge (Herce et al., 2014; Bond and Knopp, 2018); the nurse provides advocacy for oral Morphine (Hartwig et al., 2014). Morphine included in the essential medicine list, and its accessibility was not restricted by law (Boit et al., 2014). Education and training Lack of training of staff and understanding of palliative care in the community Increased awareness of palliative care through community activities like visiting houses in a village, brochures and printed pamphlet campaigns for the community (Chandra et al., 2016). Using posters that describe home-based palliative care (Devi et al., 2008). Specific training to target particular audiences (healthcare professionals, community health workers, volunteers, spiritual leaders and families (Defilippi and Cameron, 2007; Devi et al., 2008; Downing, 2008; Di Sorbo et al., 2010; Nanney et al., 2010; Herce et al., 2014; Bond and Knopp, 2018; Munday et al., 2018; Potts et al., 2019). Supervision and mentorship to palliative care providers (Defilippi and Cameron, 2007; Di Sorbo et al., 2010; Herce et al., 2014). Palliative care incorporated in undergraduate and postgraduate of medical, nursing, dental, anaesthesia and pharmacy curricula (Lemonica and Barros, 2007; Boit et al., 2014; Bond and Knopp, 2018). The CHWs were very engaged in the training sessions, participated in the role play and shared stories (Campbell and Baernholdt, 2016). Implementation Service access in remote communities Palliative care integrated across the continuum of care, as in successful models of care for those with HIV (Grant et al., 2011; Logie and Harding, 2012), networked activity with the community and palliative care team (Kumar, 2007; Devi et al., 2008; Boit et al., 2014). Mobile palliative care clinics in out-reach activities (Logie and Harding, 2012). Technology such as mobile phones to enable rapid access; facilitate communication; integration of electronic medical record to support access to the existing system and collect data for research (Grant et al., 2011; Freire De Castro Silva et al., 2018); TCS (Shabnam et al., 2018). Community volunteers motivated and supported; and. An overall public health approach to provide an equitable provision of palliative care (Grant et al., 2011). The palliative care team members participated in-home visit (Kumar, 2007; Lemonica and Barros, 2007; Dongre et al., 2012; Herce et al., 2014; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018; Munday et al., 2018), compassionate care (Boit et al., 2014; Hartwig et al., 2014), with no cost (Kumar, 2007; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018) funeral and grieving with the community, listening to their needs, respecting their values, spend time in the community (Boit et al., 2014; Hartwig et al., 2014). Community- and home-based palliative care programme is the most cost-effective in low resource settings (Kumar, 2007; Lemonica and Barros, 2007; Downing and Kawuma, 2008; Dongre et al., 2012; Herce et al., 2014; Jayalakshmi and Suhita, 2017; Bond and Knopp, 2018; Potts et al., 2019). HBPC helped nurses to work independently, allow the patient to use traditional medicines patient to die peacefully without the decision of others (Campbell, 2011; Campbell and Amin, 2014). Establishing palliative medicine, clinics, educating families and healthcare providers, key persons should be involved, and the patients want to die at home, due to this, palliative care should be widely accessible and integrated to both inpatient and outpatient services (Herce et al., 2014; Jabbari et al., 2019). Open in new tab Discussion The purpose of this review was to describe the strategies that LMICs have used to establish palliative care in rural settings. The available literature on the implementation of palliative care models was located and summarized. The WHO public health model was used to frame the review with the local models found in the papers. The key findings of this review were the essential nature of collaboration’ the availability of Morphine; education; and using networking and home visits, to improve palliative care. This discussion describes the review findings and makes comparison with studies published about rural palliative care delivery in more developed countries where the public health model of palliative care has been utilized. Most descriptions of palliative care acknowledged the importance of collaboration between the government and the NGO, working in local and international grants, developing income-generating activities, fundraising events and an advocacy plan at national, local and district levels. In developed countries like Norway, and Spain, and in Mongolia, the regional government offered full coverage, with the public healthcare system taking responsibility for developing palliative care documents and implementing palliative care at all levels (primary, secondary and tertiary levels) (Davaasuren et al., 2007; Herrera et al., 2007; Kaasa et al., 2007). However, in the Eastern Mediterranean, there is a scarcity of funding for palliative care (Fadhil et al., 2017). The World Health Assembly 67 (2014) suggested that palliative care be included in the definition of universal health coverage. They emphasized the need for health services to provide integrated palliative care in an equitable manner across all levels of health care with the emphasis on primary, home-and community-based care. The reviewed papers addressed the availability of Morphine in the use of an essential list of medicines. The premise of this list is that opioids should be easily accessible where the patients primary care is delivered; Morphine should be affordable, and oral Morphine solution should be formulated when possible (Callaway et al., 2018). However, in the findings of this review, in Middle-Eastern countries and in Nepal, though the essential medicine list was used and injectable opioids were available, oral Morphine was less available, accessible and was often unaffordable for the people living a long way from major cities (Silbermann et al., 2012; Paudel et al., 2015). Indeed, in two papers, an oncologist or anaesthetist was required to prescribe the Morphine, expanding the length of time patients waited for a prescription. In contrast, in Mongolia, all doctors have the ability to prescribe opioids and generic, cost-effective medications, including Morphine, have been made available and accessible for all patients (Davaasuren et al., 2007). This indicates that although a country adopts the essential medicines list, unless underpinning principles are enabled, access to essential medicines will still be constrained. This review highlights that implementation of palliative care in rural areas must encompass education at community level, as well as education and training of health professionals and care workers. In Nepal, Spain and Mongolia, bedside training was given to healthcare professionals, and a palliative care training curriculum was developed by the palliative care association of the country (Davaasuren et al., 2007; Herrera et al., 2007; Paudel et al., 2015). A systematic approach to education in rural areas was the feature of an education programme in Canada. This programme developed a curriculum on palliative care education for the rural staff, patients and families, including course evaluation instruments (Spice et al., 2012). As part of this programme, in-service training was delivered to staff and an online-education module on palliative care topics for interdisciplinary staff working in rural areas. In three papers of the review, palliative care was integrated into undergraduate and postgraduate courses of different health disciplines. Similarly, in Mongolia, palliative care has been incorporated in undergraduate curricula of nurses, doctors and social workers (Davaasuren et al., 2007). In contrast, in Norway, palliative care is not integrated in health professional curriculum and in the Middle-East there is an acknowledged lack of palliative care training for health professionals (Kaasa et al., 2007; Silbermann et al., 2012). A number of papers in this integrative review emphasized the importance of service networks between hospitals and rural clinics to deliver continuity of palliative care using community volunteers in rural areas. For instance, the use of technology expanded opportunities for education and utilization of volunteers; linkages between rural and urban settings were of benefit; and confidence in using a mobile phone specialist consultation team assisted skill levels. All enhanced the implementation of palliative care in rural areas. Similarly, in Norway and rural Spain, the palliative care programme networked across all the structures and levels of healthcare systems (Herrera et al., 2007; Kaasa et al., 2007). However, the success of networking is dependent on the flow of information between primary and specialist care services and the capacity of staff and users of the services to access information. (Evans et al., 2003). Home- and community-based palliative care was delivered through frequent home visits and included educating family and caregivers. Services were supported with community volunteers and healthcare providers and the staff participated in funerals in rural areas (Downing et al., 2010; Ddungu, 2011). In Spain, home visiting is a feature of community-based palliative care (Herrera et al., 2007; Kaasa et al., 2007). In addition, a review of studies conducted in LMICs indicated that community-based volunteer programmes were a crucial component of palliative care in the rural or remote areas; however, the strategies of the programmes were not clearly described (Hannon et al., 2016). We expected to see more evidence in the reviewed strategies for the provision of palliative care about the priority of palliative care at a policy level, the development of guidelines and incorporation of palliative care into national documents. However, this was rarely discussed as part of palliative care service development in rural areas of LIMCs. The lack of attention to the policy component of the WHO Public Health Model, may contribute to issues of sustainability. There was also a paucity of evaluative outcomes described in the reviewed papers (Hannon et al., 2016). The previous and the updated version of WHO Public Health Model does not feature standards for evaluation or research as part of the model and a revision of this aspect in the model may strengthen the capacity of services to demonstrate the outcomes of their programmes for future funding and support (Stjernswärd et al., 2007; Callaway et al., 2018). Though the findings have successfully summarized the strategies and challenges of palliative care in rural LMICs, there are limitations to the study and therefore to the weight of its findings. The review is limited to those published journal papers and reviews identified in the search. The use of other search terms (such as resource-poor countries and using grey literature) may have produced more papers. Most publications were simple descriptions of palliative care models. The findings are limited because at least 12 of the 30 papers had poor to no transparent methodology. Most of the studies contain bespoke strategies designed to fit the particular contexts for which they were developed. With a lack of repetition of evaluations and the poor quality of some studies, there is insufficient evidence supporting any particular strategy. Furthermore, the review undertaken to make comparisons for the discussion also found limited published papers that focused on rural settings and the public health model. The lack of strong evidence for strategies in rural areas of LMICs makes a strong case for further research to evaluate the strength of interventions in low resource setting. Conclusion This paper has described the strategies and challenges used to establish palliative care in rural areas of LMICs. The four pillars of the WHO public health model were used to frame the findings. The findings indicated that most of the palliative care models are dependent on NGOs for funding and palliative care was not integrated into existing healthcare systems. Medications such as Morphine are limited in most rural areas. There was little discussion for the integration of palliative care in undergraduate and postgraduate courses, despite this being a feature in more developed programmes in middle- to high-income countries. The home- and community-based models are dominant in rural areas. Consistently, recommendations were for the delivery of palliative care using teams including local community members like traditional healers, volunteer workers, family caregivers and religious, and community leaders. Networked service, technology such as computer software and mobile phones have also been used to bridge communication between patients and palliative care team in rural areas. A commonality across strategies for the development and implementation of palliative care in LMICs was a collaborative approach between government, health services, professionals and community. This may be an important feature of successful service development that should be investigated. Repeated evaluation of replicated models is essential for understanding the success of specific rural palliative care strategies. Further research on the public health model is required to strengthen the understanding of a successful model of palliative care in rural areas of LMICs. Conflict of interest statement. None declared. Ethical approval. No ethical approval was required for this study. Acknowledgements The authors acknowledge the specialist librarian Mrs Paula Todd, for her assistance on searching data and EndNote. AA is supported by a Monash University International Postgraduate Research Award. References Boit JM , Ototo R , Ali Z , Malloy P. 2014 . 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Sixty-seventh World Health Assembly, Geneva, 24. © The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Strategies used to establish palliative care in rural low- and middle-income countries: an integrative review
JF - Health Policy and Planning
DO - 10.1093/heapol/czaa051
DA - 2019-12-21
UR - https://www.deepdyve.com/lp/oxford-university-press/strategies-used-to-establish-palliative-care-in-rural-low-and-middle-zA2FVJGs2d
DP - DeepDyve
ER -