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

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 system

Kenya

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 countries

Middle 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