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Table 2 Summary of aims and key findings of the included reviews

From: Challenges on the provision of palliative care for patients with cancer in low- and middle-income countries: a systematic review of reviews

Author (Year),
Implementation Year(s), Country/Region
Review aimSetting/
Population
Findings
BarriersPossible facilitators/recommendations for improvement
Donkor, Luckett, Aranda and Phillips [39],
1990–2017
Australia
Systematic review, included 18 studies
To identify the facilitators and barriers to the implementation of cancer treatments and PC.LMICs
Cancer
Health system:
• Drug importation process
Policy:
• Lack of financial support
• Limited political commitment
• Restrictive pharmacovigilance laws and regulations
• Fragmented health system
Organisation/ structure:
• Limited physical infrastructure
Personal:
• Education
• Community sharing
Health system:
• Creating a learning environment
• Information management system
Policy:
• Payment support
• Stakeholder sharing
• Political commitment
• Positive relationships with international organisations
• Strategy aligned with national policy
Soto-Perez-de-Celis [46]
2017
USA
To identify the existing deficiencies and providing a framework for the improvement of PC.Latin America
Cancer
Personal:
• Cultural barriers
Health System:
• Lack of opportunities for clinical training
Policy:
• Inadequate or inappropriate legislation
• Lack of comprehensive national PC plans
• Unreliable reporting of data
Organisation/ Structure:
• Insufficient infrastructure
Personal:
• Improve education
• Enhance cultural aspects
• Individualized care for patient’s preferences and beliefs
Health System:
• Increase the availability of pain medication
• Training to all HCPs
• Enhance, expand access to medication
Policy:
• Design comprehensive PC plans
• Integrate end-of-life care into national health care laws
• Enhance research
Organisation/ Structure:
• Improve infrastructure
Fadhil et al. [40]
2017
Egypt
To identify barriers to the development of PC.Eastern Mediterranean Region
Cancer
Personal:
• Poor awareness of policy makers about PC
• Poor awareness of HCPs about PC
• Poor public awareness
Health System:
• Little partnership working
• Insufficient PC education for HCPs
• Gaps in access to essential pain-relief medicines.
Policy:
• Scarcity of national plans and policies
• Complicated political situations
• Weak health-care systems
• Absence of PC in national policies
Ali [47]
2016
Kenya
To assess the integration of PC services into the public healthcare systemKenya
cancer
Health system:
• Training HCPs
• A higher diploma in PC 
Policy:
• The government budget for PC services
• Include PC in local health strategies and plans.
• National PC guidelines
Hannon et al. [33]
2015
Canada
To overcome barriers that continue to affect the availability of PC in LMICs.LMICs
cancer
Personal:
• Negative attitudes about PC and death and dying
Health System:
• Limited access to opioid medication
• Lack of training of HCPs and volunteers
Policy:
• Lack of investment in health systems
Personal:
• Education of HCPs
• Shifts in societal norms to PC
• Shifts in HCPs norms to PC
Health System:
• Changes in legislation restricting access to opioid medications
• Training of health professionals;
Policy:
• A health policy that supports the integration of PC
• Investment in systems of health care delivery
• Development of rigorous data and research
• International partnerships
Rochmawati et al. [48]
1990–2015
Indonesia
Systematic review, includes 9 studies
To identify facilitators and barriers to the provision of PC.Indonesia
Cancer, HIV/AIDS
Personal:
• Knowledge deficit and misunderstanding of HCPs
Health System:
• Difficult access to narcotic drugs
Organisation/ Structure:
• Geography
Personal:
• Family and community support
Policy:
• Policy and organisation support
Health System:
• Volunteering
Abdel-Razeq et al. [32]
2014
Jordan
To discuss challenges and offer suggestions for the improvement of cancer management.Jordan
Cancer
Personal:
• Negative HCPs attitudes
• Negative public attitudes
Health System:
• Lack of specialized human resources
• Lack of adequate training of responsible staff
• Interrupted opioids supply and availability
• Shortage of trained female nurses
• Few specialized ancillary support personnel
Policy:
• Not available outcome data at a national level
Personal:
• Increase HCPs knowledge
Health System:
• Structured training programs for HCPs
Policy:
• Integration of both clinical care and clinical research
Zeinah et al. [34]
2012
Qatar
To outline current PC at Middle Eastern countries.
To address major challenges hindering the development of PC.
Middle East countries
Cancer
Personal:
• Lack of education and awareness
Health System:
• Shortage of specialized PC teams
Policy:
• Political issues
• Scarcity of resources
• Shortage or lack of funding
• Lack or deficiency governmental support
Organisation/ Structure:
• No application of service (including opioid use and expertise)
Personal:
• Raising awareness of the public on opiophobia;
• Raising awareness of the HCPs on opiophobia.
Health System:
• Informal training to medical oncologists in PC.
• Providing formal education to HCPs
Policy:
• Adequate funding for training programs.
Basu et al. [35]
2013
USA
To provide an overview of the progress in providing PC in low- and medium-resource countries.
To present the development of PC in Ethiopia.
LMICs
Cancer
Personal:
• Negative cultural attitudes and beliefs of patients
• Negative cultural attitudes of physicians
Health System:
• Lack of a trained workforce;
• Lack of availability of opioids or restricting in their use
Policy:
• Lack of funding
Silbermann et al. [49]
2012
Israel
To address the accomplishments and challenges of palliative cancer care in Middle Eastern countries.Middle East countries
Cancer
Personal:
• Families’ feeling of alienation and isolation
• Families’ fear of neglect by the primary physician
Health System:
• Lack of relevant training of HCPs
• Poor accessibility to essential PC drugs
• Delay in referrals
Policy:
• Lack of health policies and plans
Personal:
• Education of physicians and nurses about PC principles
• A community-based orientation
Health System:
• Introduce PC principles into the curricula
• Develop postgraduate training programs for physicians and nurses.
Policy:
• Public policy
Elcigil [50]
2011
Turkey
To assess the status of PC in Turkey.Turkey
Cancer
Personal:
• Lack of PC education
• Lack of public awareness
• Limited knowledge of opioid analgesics
Health System:
• Lack of training programs
• Shortage of nursing staff
• Lack of certification for PC Nursing
Policy:
• Very limited research
Personal:
• Increase public awareness channels
Health System:
• Disseminate information on certification of PC nurses to agencies.
Policy:
• Establish interdisciplinary research on PC concepts
• Increase funding for research
• Evidence-based curriculum to strengthen the teaching of PC concepts
Shawawra and Khleif [51]
2011
Palestine
To conduct a needs assessment survey within facilities that provide care for oncology patients in the West Bank.Palestine
Cancer
Personal:
• Lack of community awareness on PC
Health System:
• No presence of educational resources for PC,
• No training programs in PC,
Policy:
• An absence of organisational strategic planning,
• No standards for PC service
• An absence of national standards on PC.
Personal:
• The need for public awareness.
Health System:
• The need for training of HCPs
• Introduce PC principles into the curricula
Policy:
• Networking between the national non-governmental organization's and the Ministry of Health .
• National policy and standards on PC and opioids legislations.
• Baseline data and research.
• Interdisciplinary teamwork.
Bingley and Clark [52]
2008
UK
To review PC development in six Middle East countriesMiddle East countries
Cancer
Personal:
• Opioid phobia in the public
• Opioid phobia in professionals
• Lack of public awareness of PC
• Lack of professional level awareness
Health System:
• Inadequate professional training programs
Policy:
• Lack of funds
• Lack of government support.
Personal:
• Public education programs;
• Raising awareness about the need for PC
Health System:
• Increasing national and international training
• Improving opioid legislation
Policy:
• Improving health care policies;
• Negotiating for a secure government or health insurance funding provision
McDermott [53]
2007
UK
To identify strengths and weaknesses in the state of development across the subcontinent.India
Cancer
Personal:
• Limited knowledge of patients about PC
Health System:
• Unavailability of opioid
• Shortage of workforce
Policy:
• Limited national PC policy
• Insufficient funding for services
• Absence of social security system
Organisation/ Structure:
• Poverty;
• Population density
• Geography
Personal:
• Increase public awareness of PC
Health System:
• Improve drug availability and expertise
Policy:
• Include PC in medical and nursing curricula
• Design and implement a national PC policy
  1. LMICs Low- and Middle-Income Countries; UK United Kingdom; USA United State America; PC Palliative Care; HCPs Health care Providers