Background Fewer than 1 in 20 people on the African continent in need of palliative care receive it. Malawi is a low-income country in sub-Saharan Africa that has yet to achieve advanced palliative care integration accompanied by unrestricted access to pain and symptom relieving palliative medicines. This paper studied the impact of Malawi’s Waterloo Coalition Initiative (WCI) – a local project promoting palliative care integration through service development, staff training, and increased service access. Methods Interdisciplinary health professionals at 13 hospitals in southern Malawi were provided robust palliative care training over a 10-month period. We used a cross-sectional evaluation to measure palliative care integration based on 11 consensus-based indicators over a one-year period. Results 92% of hospitals made significant progress in all 11 indicators. Specifically, there was a 69% increase in the number of dedicated palliative care rooms/clinics, a total of 253 staff trained across all hospitals (a 220% increase in the region), substantive increases in the number of patients receiving or assessed for palliative care, and the number of hospitals that maintained access to morphine or other opioid analgesics while increasing the proportion of referrals to hospice or other palliative care programs. Conclusion Palliative care is a component of universal health coverage and Sustainable Development Goal 3. The WCI has made tremendous strides in establishing and integrating palliative care services in Malawi with notable progress across 11 project indicators, demonstrating that increased palliative care access is possible in severely resource-constrained settings through sustained models of partnership at the local level.

Worldwide 56·8 million people need palliative care (PC), and Africa shows the highest demand. This study updates the 2017 review of African PC development, using a scoping review methodology based on Arksey and O'Malley's framework and the PRISMA-ScR checklist. The review was conducted across PUBMED, CINAHL, Embase, government websites, and the African PC Association Atlas, from 2017 to 2023, charting its progress using the new WHO framework for PC Development, which, in addition to Services, Education, Medicines, and Policies, two new dimensions were incorporated: Research and Empowerment of people and Communities. Of the 4.420 records, 118 met the inclusion criteria. Findings showed increased adult specialised services (n = 675), and 15 of 54 countries have paediatric services. Nonetheless, the ratio of services per population mostly remains under 0,10 per 100.000 inhabitants. PC education was included in undergraduate curricula in 29 countries; despite the rise in morphine availability (28 countries), median consumption remains under 3 mg/per capita/year, and 14 countries presented stand-alone policies. Publications on PC development increased, and 26 countries have National PC Associations. Notwithstanding progress since 2017, significant hurdles remain, highlighting the need for ongoing research and policy development to ensure equitable access to palliative care in Africa.

Background: Service provision is a key domain to assess national-level palliative care development. Three editions of the European Association for Palliative Care (EAPC) Atlas of Palliative Care monitored the changes in service provision across Europe since 2005. Aim: To study European trends of specialized service provision at home care teams, hospital support teams, and inpatient palliative care services between 2005 and 2019. Design: Secondary analysis was conducted drawing from databases on the number of specialized services in 2005, 2012, and 2019. Ratios of services per 100,000 inhabitants and increase rates on number of services for three periods were calculated. Analysis of variance (ANOVA) analyses were conducted to determine significant changes and chi-square to identify countries accounting for the variance. Income-level and sub-regional ANOVA analysis were undertaken. Setting: 51 countries. Results: Forty-two countries (82%) increased the number of specialized services between 2005 and 2019 with changes for home care teams (104% increase-rate), inpatient services (82%), and hospital support teams (48%). High-income countries showed significant increase in all types of services ( p < 0.001), while low-to-middle-income countries showed significant increase only for inpatient services. Central–Eastern European countries showed significant improvement in home care teams and inpatient services, while Western countries showed significant improvement in hospital support and home care teams. Home care was the most prominent service in Western Europe. Conclusion: Specialized service provision increased throughout Europe, yet ratios per 100,000 inhabitants fell below the EAPC recommendations. Western Europe ratios’ achieved half of the suggested services, while Central–Eastern countries achieved only a fourth. High-income countries and Western European countries account for the major increase. Central–Eastern Europe and low-to-middle-income countries reported little increase on specialized service provision.

CONTEXT:Approximately 170,000 children in need of palliative care die every year in Europe without access to it. This field remains an evolving specialty with unexplored development.OBJECTIVES:To conduct the first regional assessment of pediatric palliative care (PPC) development and provision using data from the European Association for Palliative Care atlas of palliative care 2019.METHODS:Two surveys were conducted. The first one included a single question regarding PPC service provision and was addressed by European Association for Palliative Care atlas informants. The second one included 10 specific indicators derived from an open-ended interview and rating process; a specific network of informants was enabled and used as respondents. Data were analyzed and presented in the map of the figure.RESULTS:Data on PPC service provision were gathered from 51 of 54 (94%) European countries. Additional data were collected in 34 of 54 (62%) countries. A total of 680 PPC services were identified including 133 hospices, 385 home care services, and 162 hospital services. Nineteen countries had specific standards and norms for the provision of PPC. Twenty-two countries had a national association, and 14 countries offered education for either pediatric doctors or nurses. In seven countries, specific neonatal palliative care referral services were identified.CONCLUSION:PPC provision is flourishing across the region; however, development is less accentuated in low-to-middle-income countries. Efforts need to be devoted to the conceptualization and definition of the models of care used to respond to the unmet need of PPC in Europe. The question whether specialized services are required or not should be further explored. Strategies to regulate and cover patients in need should be adapted to each national health system.

Background: Indicators assessing national-level palliative care (PC) development used for cross-national comparison depict progress on this field. There is current interest on its inclusion in global monitoring frameworks. Objective: Identify and conceptualize those most frequently used for international PC development reporting. Design: Systematic review. Data Sources: PubMed, CINAHL, Google Scholar, and Google targeting national-level development indicators used for cross-national comparison. Additional search requesting experts' suggestions on key studies and "snow-balling" on reference section of all included studies. Identified indicators were listed and categorized in dimensions: services, use of medicines, policy, and education. Results: Fifty-four studies were included. Development has been evaluated using 480 different formulations of 165 indicators, 38 were highly reported. Thirty-two fell into proposed dimensions, 11 for use of medicines, 9 for policy, 7 for services, and 5 for education. Six into complementary dimensions: research, professional activity, and international cooperation. Six were the most frequently used indicators: number of PC services per population (40 reports), existence of PC national plan, strategy, or program (25), existence of palliative medicine specialization (22), availability and allocation of funds for PC (13), medical schools, including PC, in undergraduate curricula (13), and total use of opioids-morphine equivalents (11). Conclusion: There is a clear pattern for national-level PC development evaluation repeatedly using a small number of indicators. Indicators addressing generalistic provision, integration into health systems, and specific fields such as pediatric lack. This study invites international discussion on a global consensus on PC-development assessment.

Background: Indicators assessing national-level palliative care (PC) development used for cross-national comparison depict progress on this field. There is current interest on its inclusion in global monitoring frameworks. Objective: Identify and conceptualize those most frequently used for international PC development reporting. Design: Systematic review. Data Sources: PubMed, CINAHL, Google Scholar, and Google targeting national-level development indicators used for cross-national comparison. Additional search requesting experts' suggestions on key studies and "snow-balling" on reference section of all included studies. Identified indicators were listed and categorized in dimensions: services, use of medicines, policy, and education. Results: Fifty-four studies were included. Development has been evaluated using 480 different formulations of 165 indicators, 38 were highly reported. Thirty-two fell into proposed dimensions, 11 for use of medicines, 9 for policy, 7 for services, and 5 for education. Six into complementary dimensions: research, professional activity, and international cooperation. Six were the most frequently used indicators: number of PC services per population (40 reports), existence of PC national plan, strategy, or program (25), existence of palliative medicine specialization (22), availability and allocation of funds for PC (13), medical schools, including PC, in undergraduate curricula (13), and total use of opioids-morphine equivalents (11). Conclusion: There is a clear pattern for national-level PC development evaluation repeatedly using a small number of indicators. Indicators addressing generalistic provision, integration into health systems, and specific fields such as pediatric lack. This study invites international discussion on a global consensus on PC-development assessment.

Context. International consensus on indicators is necessary to standardize the global assessment of palliative care (PC) development. Objectives. To identify the best indicators to assess current national-level PC development. Methods. Experts in PC development were invited to rate 45 indicators organized by domains of the World Health Organization Public Health Strategy in a two-round RAND/UCLA-modified Delphi process. In the first round, experts rated indicators by relevance, measurability, and feasibility (1-9). Ratings were used to calculate a global score (1-9). Indicators scoring >7 proceeded to the second round for fine-tuning of global scores. Median, confidence interval, Content Validity Index, and Disagreement Index were calculated. Indicators scoring a lower limit 95% confidence interval of >7 and a Content Validity Index of >= 0.30 were selected. Results. 24 experts representing five continents and several organizations completed the study. 25 indicators showed a high content validity and level of agreement. Policy indicators (n = 8) included the existence of designated staff in the National Ministry of Health and the inclusion of PC services in the basic health package and in the primary care level list of services. Education indicators (n = 4) focused on processes of official specialization for physicians, inclusion of teaching at the undergraduate level, and PC professorship. Use of medicines indicators (n = 4) consisted of opioid consumption, availability, and prescription requirements. Services indicators (n = 6) included number and type of services for adults and children. Additional indicators for professional activity (n = 3) were identified. Conclusion. The first list including 25 of the best indicators to evaluate PC development at a national level has been identified. (C) 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Background: Although there are global studies on palliative care development, none report region-specific indicators of development for each country in Africa. We aimed to develop and deploy a set of indicators to measure the current state of palliative care development in Africa according to WHO's Public Health Strategy for integrating palliative care, including policies, availability and access to medicines, education, and service provision. Methods: Qualitative interviews were conducted with 16 country experts between March and August, 2016. From those interviews, 367 indicators were derived, 130 after exclusion criteria and content analysis were performed. The country experts rated the indicators for validity and feasibility, a 14-member international committee of experts participated in a two-round modified UCLA-RAND Delphi consensus, and the coauthors ranked the indicators during November–December 2016. The final 19 indicators were further defined and sent to 66 key country informants from 51 African countries during January–March 2017. Findings: Surveys were received from 48 countries. Uganda, South Africa, and Kenya have the highest number of specialised hospice and palliative care services (71% of identified palliative care services); 19% (9/48) have no identified hospice and palliative care services. 22% (12/48) indicated having stand-alone palliative care policies, and 42% (20/48) reported having a dedicated person for palliative care in the Ministry. Zambia, Uganda, South Africa, Kenya, Ghana, and Egypt reported some official form of physician accreditation. Opioid consumption per capita was low (75% of countries had <1 mg consumption per head per year) compared to the global average (62 mg), with the highest consumption in Mauritius, South Africa, Namibia, and Morocco. 54% (26/48) reported having a national palliative care association. These data were used to build the African Palliative Care Association (APCA) Atlas of Palliative Care in Africa, the first comparative, quantitative, African-specific report on national palliative care development in African countries. Interpretation: There is limited palliative care development in Africa, but there is also a significant improvement in the number of countries with hospice and palliative care services, compared to previous reports. Improvements in advocacy were identified, with more than half of countries reporting a national palliative care association. Governments need to take the steps to improve education, increase the number of services, and ensure safe access to opioids. Funding: Arnhold Institute of Global Health at the Icahn School of Medicine at Mount Sinai, the African Palliative Care Association, the International Association for Hospice and Palliative Care, and the Institute for Culture and Society at the University of Navarra.

Background: The Pontifical Academy for Life (PAV) is an academic institution of the Holy See (Vatican), which aims to develop and promote Catholic teachings on questions of biomedical ethics. Palliative care (PC) experts from around the world professing different faiths were invited by the PAV to develop strategic recommendations for the global development of PC (PAL-LIFE group). Design: Thirteen experts in PC advocacy participated in an online Delphi process. In four iterative rounds, participants were asked to identify the most significant stakeholder groups and then propose for each, strategic recommendations to advance PC. Each round incorporated the feedback from previous rounds until consensus was achieved on the most important recommendations. In a last step, the ad hoc group was asked to rank the stakeholders' groups by order of importance on a 13-point scale and to propose suggestions for implementation. A cluster analysis provided a classification of the stakeholders in different levels of importance for PC development. Results: Thirteen stakeholder groups and 43 recommendations resulted from the first round, and, of those, 13 recommendations were chosen as the most important (1 for each stakeholder group). Five groups had higher scores. The recommendation chosen for these top 5 groups were as follows: (1) Policy makers: Ensure universal access to PC; (2) Academia: Offer mandatory PC courses to undergraduates; (3) Healthcare workers: PC professionals should receive adequate certification; (4) Hospitals and healthcare centers: Every healthcare center should ensure access to PC medicines; and (5) PC associations: National Associations should be effective advocates and work with their governments in the process of implementing international policy framework. A recommendation for each of the remaining eight groups is also presented. Discussion: This white paper represents a position statement of the PAV developed through a consensus process in regard to advocacy strategies for the advancement of PC in the world.

Resumen Contexto: La Academia Pontificia de la Vida (PAV) es una institución académica de la Santa Sede (Vaticano) cuyo objetivo es promover una visión católica de la ética biomédica. La PAV invitó a una serie de expertos en Cuidados Paliativos (CP) de todo el mundo, de todas las creencias, a desarrollar recomendaciones estratégicas para el desarrollo global de CP ("Grupo PAL-LIFE"). Diseño: Trece expertos internacionales reconocidos por su actividad promotora global de CP participaron en un estudio Delphi on-line. En un proceso de cuatro rondas, se pidió a los participantes que identificasen los grupos de interés o instituciones claves para la promoción de CP y que propusieran, para cada uno de ellos, recomendaciones estratégicas para el desarrollo de CP. Cada ronda incorporaba los comentarios de las rondas previas hasta lograr el consenso en las recomendaciones más importantes. En una última fase, al grupo de expertos se le solicitó la jerarquización por importancia de los grupos clave en una escala de 1 a 13. También se solicitaron sugerencias concretas para la implementación de las recomendaciones. Mediante análisis clúster se ordenaron los grupos de interés en dos niveles de importancia para el desarrollo de CP. Resultados: Trece recomendaciones fueron seleccionadas como las más importantes (una por cada grupo clave). Las recomendaciones para los grupos mejor puntuados fueron: (1) Responsables Políticos: garantizar el acceso universal a los CP; (2) Academia: ofrecer cursos obligatorios de CP en el pregrado; (3) Profesionales sanitarios: promover una certificación adecuada; (4) Hospitales e Instituciones sanitarias: asegurar el acceso a medicamentos de CP; y (5) Asociaciones de CP: ser promotoras eficaces y trabajar con los gobiernos en la implementación de las recomendaciones internacionales sobre CP. También se presentan recomendaciones para los ocho grupos clave restantes. Discusión: Este documento representa la posición oficial de la PAV en lo que respecta a estrategias de promoción para el desarrollo de los CP en el mundo.

ContextFactors contributing to and impeding palliative care (PC) development in Africa can provide insights into current strategies for advancing PC.ObjectivesTo identify key factors affecting PC development in African countries from in-country PC experts' perspectives.MethodsAbout 16 PC experts from seven African countries undertook semistructured interviews on PC development in their respective countries. An interpretive description approach was adopted, with data analyzed using constant comparison.ResultsEmerged themes included drivers, strengths, challenges, and aspirations for PC development in Africa. Drivers included advocates and pioneering organizations, HIV/AIDS, culture of caregiving, and the World Health Assembly PC resolution. Strengths included community health workers, the special role of nurses, diversity of services, and short training courses. Challenges included lack of PC education; lack of standardization in implementation; limited availability of and/or accessibility to morphine; poverty and disease burden; and lack of funding for PC. Aspirations included integration of PC, specialization in PC, nurse prescribing, and strong partnerships with Ministries of Health. Factors already highlighted in the literature were only briefly discussed.ConclusionThe key factors underpinning PC development in the seven countries contributed to the beginnings of PC in Africa, fueled by advocates who built on existing strengths to maximize opportunities. However, the current approach is at high risk in terms of its sustainability, and strategies for maximizing existing resources and growing infrastructure support are needed moving forward.

Given that the fundamental goal of palliative care is “the prevention and relief of suffering,” it is imperative that palliative care clinical and educational programs in high-income countries (HICs) partner with colleagues in low- and middle-income countries (LMICs) to assist them to expand and facilitate access to palliative care training of all levels and for all types of palliative care providers. Outside of Europe, North America, and Australia, access to high-quality palliative care (PC) services is rare.1Knaul FM, Farmer PE, Krakauer EL, et al. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report. Lancet [Epub ahead of print].Google Scholar Although there has been growth in palliative care development worldwide, only 8.5% of countries have achieved advanced integration of PC into service provision.2Lynch T. Connor S. Clark D. Mapping levels of palliative care development: a global update.J Pain Symptom Manage. 2013; 45: 1094-1106Abstract Full Text Full Text PDF PubMed Scopus (333) Google Scholar PC training of all levels recommended by the World Health Organization (WHO), basic, intermediate, and specialist, is difficult or impossible to access in LMICs.3Assembly W.H. WHA resolution 67.19: Strengthening of palliative care as a component of comprehensive care throughout the life course. WHO, Geneva, Switzerland2014Google Scholar As a result, growth of palliative care services is slow in LMICs, and unnecessary suffering on an enormous scale persists.1Knaul FM, Farmer PE, Krakauer EL, et al. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report. Lancet [Epub ahead of print].Google Scholar Meanwhile, training programs in Europe, North America, and Australia graduate hundreds of palliative medicine specialists each year, many of whom become palliative care educators. Previous efforts by institutions in HICs to provide PC training for colleagues in LMICs, although limited by the lack of interest by global health funders, have yielded remarkable results. In the early 2000s, the International Palliative Medicine Fellowship Program at San Diego Hospice in California, U.S., trained 26 physicians from LMICs, including current palliative care leaders in Vietnam, Mongolia, Uganda, Rwanda, Tanzania, Egypt, Jordan, and Peru.4Allain T.D. Reflection on the death of San Diego Hospice and the Institute for Palliative Medicine.J Palliat Med. 2013; 16: 602Crossref PubMed Scopus (1) Google Scholar The International Pain Policy Fellowship, based at the University of Wisconsin, U.S., provided training and technical assistance to four cohorts of clinicians and government officials from LMICs to assist them to overcome barriers to making opioids accessible safely for medical uses,5Bosnjak S. Maurer M.A. Ryan K.M. Leon M.X. Madiye G. Improving the availability and accessibility of opioids for the treatment of pain: the International Pain Policy Fellowship.Support Care Cancer. 2011; 19: 1239-1247Crossref PubMed Scopus (44) Google Scholar with numerous publications documenting its successes6Leon M. Florez S. De Lima L. Ryan K. Integrating palliative care in public health: the Colombian experience following an international pain policy fellowship.Palliat Med. 2011; 25: 365-369Crossref PubMed Scopus (12) Google Scholar, 7Paudel B.D. Ryan K.M. Brown M.S. et al.Opioid availability and palliative care in Nepal: influence of an international pain policy fellowship.J Pain Symptom Manage. 2015; 49: 110-116Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 8Krakauer E.L. Nguyen T.P. Husain S.A. et al.Toward safe accessibility of opioid pain medicines in Vietnam and other developing countries: a balanced policy method.J Pain Symptom Manage. 2015; 49: 916-922Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar; and the End-of-Life Nursing Education Consortium has trained thousands of nurses and other professionals, many from LMICs.9Ferrell B. Malloy P. Virani R. The End of Life Nursing Education Nursing Consortium project.Ann Palliat Med. 2015; 4: 61-69PubMed Google Scholar Other successful partnerships include the University of Iowa in India,10Broderick A. Pallium India Wordpress: Ann Broderick.2015https://annbroderick1.wordpress.com/Google Scholar Memorial Sloan Kettering Cancer Center in Uganda,11Foley KM. Global Palliative Care. In: JY R, editor. 2017.Google Scholar and Indiana University in Kenya,12Pensack-Rinehart R. ASCO-AMPATH Oncology Institute Host MCMC in Eldoret, Kenya, February 14-17, 2012. [press release]. ASCO, Alexandria, VA2012Google Scholar but these successes have not always resulted in sustainable funding. One unique collaboration between Hospice Africa Uganda and Makerere University in Kampala has entailed palliative care specialists from HICs providing ongoing training and training-of-trainers in an LMIC. With support from the University of Edinburgh and several governmental and nongovernmental funders, Hospice Africa Uganda has trained clinicians from throughout sub-Saharan Africa and provides various levels of training for physicians and nurses in both English and French. But it, too, has struggled to find adequate funding for its programs.13Rhee J.Y. Luyirika E. Namisango E. et al.APCA Atlas of Palliative Care in Africa. IAHPC Press, 2017Google Scholar Furthermore, programs such as the Master's Program in Palliative Medicine in South Africa14Gwyther L. Rawlinson F. Palliative medicine teaching program at the University of Cape Town: integrating palliative care principles into practice.J Pain Symptom Manage. 2007; 33: 558-562Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar have shown that training African colleagues in Africa can be less expensive than in an HIC, and trainees learn in their own clinical environment. In the past 25 years, the number of palliative care specialist training programs has grown rapidly in HICs. Although there are a few palliative medicine specialist training programs in the U.S. offering informal opportunities to gain experience in teaching, practicing, or doing research in an LMIC as well as partnerships between palliative medicine educational institutions in HICs and LMICs,10Broderick A. Pallium India Wordpress: Ann Broderick.2015https://annbroderick1.wordpress.com/Google Scholar, 12Pensack-Rinehart R. ASCO-AMPATH Oncology Institute Host MCMC in Eldoret, Kenya, February 14-17, 2012. [press release]. ASCO, Alexandria, VA2012Google Scholar, 15Ferris F.D. Moore S.Y. Callaway M.V. Foley K.M. Leadership development initiative: growing global leaders… Advancing palliative care.J Pain Symptom Manage. 2018; 55: S146-S156Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar we know of no official training programs in global palliative care for palliative medicine specialist trainees in HICs. Specialist training programs in palliative medicine in HICs could help to reduce the enormous disparity in access to palliative care by offering training in global palliative medicine for specialist trainees and practicing palliative care specialists who wish to devote all or part of their careers to providing training and technical assistance in palliative care in LMICs. To establish a global palliative care training track, a palliative care specialist training program in an HIC must have at least one faculty member with experience in teaching and working in an LMIC to develop the curriculum and supervise trainees. The program should establish a partnership with at least one medical school in an LMIC that already offers palliative care training and intends to provide required palliative care training for medical and nursing undergraduates and for medical postgraduates in fields such as oncology, hematology, geriatrics, and critical care. A goal of the collaboration can be to develop a palliative care specialist training program. The global palliative care faculty member(s) should become familiar with the partner institution, the local clinical situation, and the local culture. The global palliative care training track would entail an additional year of training beyond the usual duration of palliative medicine specialist training. Before traveling abroad, the trainee should have basic training in global health in general and in global palliative care in particular and should begin studying the language and culture of the overseas partner. During the first few months abroad, the trainee's classroom and bedside teaching should be supervised directly by a global palliative care faculty member and by one or more local faculty members. The trainee would initially observe teaching by ex-patriot and local faculty members and then take on a gradually increasing share of mentored teaching responsibilities. The trainee also should plan a small research project with ex-patriot and local faculty members who would contribute to developing a clinical palliative care research program at the partner institution. In total, trainees should spend at least six to nine months working at the partner institution. They also should visit other palliative care services or hospices in the country or region and, if possible, participate in a regional palliative care conference. As a result, the trainee should acquire the clinical and pedagogical knowledge and skills, the cultural sensitivity, and the humility to provide long-term, effective, locally relevant palliative care training and technical assistance in LMICs. Potential funders for a year-long global palliative care training program may include foundations that fund health-related projects in the region of the partner institution, businesses with corporate social responsibility programs that operate in the region, or private individuals with an interest in the region or in palliative care for the underserved. The disparity in access to palliative care services between rich and poor countries is one of the largest disparities in global health, and this disparity persists in part due to low access to palliative care training in LMICs.1Knaul FM, Farmer PE, Krakauer EL, et al. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report. Lancet [Epub ahead of print].Google Scholar Awareness of disparities such as this is fueling the rapidly growing interest in global health among medical graduates. It is time for palliative care specialist training programs in HICs to respond to this need by partnering with local institutions in LMICs to advance training in global palliative care. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest.

Context. To date, there is no study comparing palliative care (PC) development among African countries. Objectives. To analyze comparatively PC development in African countries based on region-specific indicators. Methods. Data were obtained from the African PC Association Atlas of PC in Africa, and a comparative analysis was conducted. Nineteen indicators were developed and defined through qualitative interviews with African PC experts and a two-round modified Delphi consensus process with international experts on global PC indicators. Indicators were grouped by the World Health Organization public health strategy for PC dimensions. These indicators were then sent as a survey to key informants in 52 of 54 African countries. Through an expert weighting process and ratings from the modified Delphi, weights were assigned to each indicator. Results. Surveys were received from 89% (48 of 54) of African countries. The top three countries in overall PC development were, in order, Uganda, South Africa, and Kenya. Variability existed by dimension. The top three countries in specialized services were Uganda, South Africa, and Nigeria; in policies, it was Botswana followed by parity among Ethiopia, Rwanda, and Swaziland; in medicines, it was Swaziland, South Africa, then Malawi; and in education, it was equivalent between Uganda and Kenya, then Ghana and Zambia. Conclusion. Uganda, South Africa, and Kenya are the highest performing countries and were the only ones with composite scores greater than 0.5 (50%). However, not one country universally supersedes all others across all four PC dimensions. The breakdown of rankings by dimension highlights where even high-performing African countries can focus their efforts to further PC development. (C) 2018 The Authors. Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine.

Despite the fact that Italy and Spain are culturally similar, there are important differences in palliative care services development. For example, Italy has a greater proportion of hospice teams compared with Spain, while Spain has a greater proportion of hospital support teams.1 Noting these differences, we decided to compare a major palliative care service model from each country: the Seragnoli Hospice Foundation (FHS), Italy, and the Palliative Care Support Team (PCST) at the Clinica Universidad de Navarra (CUN), Spain, where an oncologist from FHS recently completed a 4-week rotation. We compare the institutions according to symptom assessment and management, psychological and spiritual care, caregiver support and impact on the rest of the hospital. Initially, the differences between the two teams, such as culture and practice, were more noticeable, but by the end of the rotation the shared values were what stood out. FHS is a private non-profit foundation in Italy composed of three hospices that care for advanced and terminal patients, each with a …

Since the last comprehensive review on the development of national palliative care in Africa was undertaken 12 years ago, in 2005, we did a scoping review of peer-reviewed, published articles on palliative care development between 2005-16 for each African country. The scoping review was conducted by assessing the medical literature and including local expert recommendations of suggested articles. We did a basic quality assessment of the articles using the journals' impact factor, journal quartile, and the number of citations as suitable metrics for quality consideration. Articles published in English, Spanish, Portuguese, and French that mentioned at least one dimension of WHO's palliative care public health strategy (implementation of services, education, policies, or medicine availability) and vitality (activity by professionals or advocates) were included. Of the 518 articles found, 49 met the inclusion criteria. Information on 26 (48%) of 54 African countries was found. Most services were concentrated in Kenya, South Africa, and Uganda, and 14 (26%) countries showed an increase in services during this timeframe. Stand-alone palliative care policies exist in Malawi, Mozambique, Rwanda, Swaziland, Tanzania, and Zimbabwe. Postgraduate diplomas in palliative care are available in Kenya, South Africa, Uganda, and Tanzania. Restricted access to opioids, prescriber restriction laws, and a low prevalence of morphine use remain common barriers to adequate palliative care provision. Although information on palliative care is unevenly distributed, the available information showed an increased development of palliative care services in a subset of African countries. Despite this growth, however, there is still minimal to no identified palliative care development in most African countries.

Rhee, John Y. MPH; Callaghan, Katharine A. BA; Stahl, Amanda BS; Brown, Martin T. BS; Allen, Philip BS; McInerney, Grace BS; Dumitru, Ana-Maria G. BS Author Information

BACKGROUND Indicators specific to the African context are important to measure palliative care (PC) development accurately. OBJECTIVE To describe the process used to develop a set of PC macroindicators for Africa. DESIGN Open-ended interviews on national PC development were conducted with five African Country Experts. Indicators were rated (1-4) by 14 Country Experts for validity and feasibility. An additional 11 interviews were conducted to ensure indicator saturation. Indicators scoring ≥3 proceeded to a modified two-round RAND/UCLA Delphi with global experts on PC development (International Committee). Finally, indicators were ranked by the project team. SETTING/SUBJECTS Sixteen country experts from 7 African countries and 14 International Committee members. RESULTS One hundred three indicators were rated by Country Experts, and 58 proceeded to the Delphi. Thirty-eight indicators were rated as important by the International Committee, and the project team ranked 19 of these as most important. Service indicators (n = 6) included the number of types of services most important in Africa (e.g., hospices, home based) and coverage. Policy indicators (n = 4) included the existence of PC in national policies, guidelines, and budget and a responsible person. Education indicators (n = 3) consisted of inclusion of PC in medical and nursing curricula and recognition as a specialty. Medicine indicators (n = 4) focused on morphine availability, consumption, and prescribing barriers. Vitality indicators (n = 2) reflected the existence of a national association and its activity. CONCLUSION The process to develop African-specific PC indicators resulted in 19 indicators that were used to measure PC development as a comparative baseline for development in African countries.

Physician-assisted suicide and euthanasia (PAS/E) has been increasingly discussed and debated in the public arena, including in professional medical organizations. However, the medical student perspective on the debate has essentially been absent. We present a medical student perspective on the PAS/E debate as future doctors and those about to enter the profession. We argue that PAS/E is not in line with the core principles of medicine and that the focus should be rather on providing high-quality end-of-life and palliative care.