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Regional Office, Cairo, Egypt. (I Fadhil PhD, G Lyons MPH); and. International Observatory on. End of Life Care, Faculty of. Health and Medicine, Lancaster.
Policy Review

Barriers to, and opportunities for, palliative care development in the Eastern Mediterranean Region Ibtihal Fadhil, Gemma Lyons, Sheila Payne

The 22 countries of WHO’s Eastern Mediterranean Region are experiencing an increase in the burden of non-communicable diseases (NCDs), including cancer. Of the six WHO regions, the Eastern Mediterranean Region is projected to have the greatest increase in cancer incidence in the next 15 years. Furthermore, most cancers are diagnosed at a late stage, resulting in a lower cancer survival rate than in the European Region and the Region of the Americas. With increasing numbers of deaths from cancer, palliative care should be available to relieve suffering in patients with advanced disease and at the end of life. However, in the Eastern Mediterranean Region, the palliative care available is variable and inconsistent. Several barriers exist to the development and expansion of palliative care delivery in this region, including the absence of palliative care in national policies, little partnership working, insufficient palliative care education for health-care professionals and volunteers, poor public awareness, and gaps in access to essential pain-relief medicines. In this Review, we explore data and evidence from published literature, WHO meeting reports, cancer control mission reports, and the WHO global NCD country capacity survey to identify the status of palliative care in the Eastern Mediterranean Region, including the challenges and opportunities for development.

Introduction Palliative care aims to improve the quality of life of patients and their families through the prevention and relief of suffering associated with life-threatening illness. This approach involves early identification, assessment, and treatment of pain and other related physical, psychosocial, and spiritual issues.1 In this Policy Review, we focus on end-of-life care rather than supportive care throughout the patients’ illness and treatment. Palliative care for chronic life-limiting health problems is an unmet need in most parts of the world; however, there is increased recognition and awareness of the need for palliative care for non-communicable diseases (NCDs), especially for cancer. At the global level, WHO explicitly recognises that palliative care is part of the comprehensive services required for NCDs through the Global Action Plan for the Prevention and Control of NCDs 2013–2020.2 Furthermore, the 2014 World Health Assembly Resolution (67.19)3 recognises that palliative care, when indicated, is fundamental to improving the quality of life, wellbeing, comfort, and human dignity for individuals, as an effective person-centred health service that values the needs of patients to receive adequate, personally sensitive, and culturally sensitive information about their health status, and their central role in making decisions about the treatment received. Additionally, palliative care is encompassed in the definition of universal health coverage4 and the WHO global strategy on people-centered and integrated health services offers a framework for the strengthening of palliative care programmes across diseases.5 Cancer is the fourth most common cause of death in the Eastern Mediterranean Region, after cardiovascular disease;6 however, the cancer burden in this region is increasing progressively and the incidence is projected to be the highest of all six WHO regions by 2030.6,7 www.thelancet.com/oncology Vol 18 March 2017

Lancet Oncol 2017; 18: e176–84 WHO, Eastern Mediterranean Regional Office, Cairo, Egypt (I Fadhil PhD, G Lyons MPH); and International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK (Prof S Payne PhD) Correspondence to: Dr I Fadhil, WHO, Eastern Mediterranean Regional Office, Cairo 11371, Egypt [email protected]

In the past 15 years, some countries in the region (eg, Jordan, Morocco, and Saudi Arabia) have improved early detection of cancer, especially breast cancer;8 however in most countries, patients with cancer seek treatment at an advanced stage and thus cure is unlikely, even with the best available treatments. Accordingly, palliative care is essential and is usually the only viable option for those patients. Yet, in the Eastern Mediterranean Region, palliative care needs are largely unaddressed in many countries. When present, palliative care services are generally at an early stage of development and are not integrated within the national health-care systems. Many challenges exist within the areas of governance, human resources, training, and availability of medication for palliative care. Improved access to essential palliative care services is one of the regional strategic health-care interventions included in the regional framework for action.9 This framework is a roadmap that enables countries in the Eastern Mediterranean Region to implement the UN Political Declaration on Prevention and Control of NCDs.10 The framework provides strategic interventions and indicators to assess the progression of countries by 2018, in the areas of governance, prevention and reduction of risk factors, surveillance, monitoring and evaluation, and health care.9 The regional strategic direction for cancer control and prevention in the Eastern Mediterranean Region focuses on three key areas: capacity building of the providers, improvement in accessibility of pain management, and provision of home-based or community-based palliative care services.11 Palliative care is also an integral part of the new initiative for scaling up cancer care in the Eastern Mediterranean Region.12 We did this Review to explore the relevant aspects of palliative care in the Eastern Mediterranean Region, to identify potential barriers to development, and to make recommendations for future action. We compiled evidence e176

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Lebanon Occupied Syria Palestinian territory Iraq

Tunisia Morocco Algeria

Iran

Afghanistan

Jordan Libya

Kuwait Pakistan Bahrain Saudi Arabia Qatar United Arab Emirates

Egypt

Oman Sudan

Yemen

Djibouti

Eritrea South Sudan

Ethiopia Somalia

Projected increase in cancer incidence (%) 50

100

150

200

Figure 1: Projected percentage increase in cancer incidence in the Eastern Mediterranean Region between 2012 and 2030 Green shading indicates countries of the WHO African Region.

Breast

Incidence

Mortality

41·9

18·6

Prostate

9·7

6·2

Lung

7·9

7·1

Colorectal

7·4

4·9

Liver

7·1

6·8

Table 1: Age-standardised incidence and mortality per 100 000 individuals for the five most common cancers in the Eastern Mediterranean Region7

Patients with breast cancer (%)

Patients with cervical cancer (%)

USA

Saudi Arabia

Egypt

USA

Saudi Egypt Arabia

Localised stage

65%

29%

26%

58%

36%

36%

Advanced stage

30%

55%

58%

33%

51%

53%

Advanced stage with metastasis

5%

16%

17%

9%

14%

11%

Table 2: Stage of diagnosis in breast and cervical cancer, as reported by population-based registries11

from multiple sources, including WHO regional reports, cancer plans and strategy documents, desk review of studies and research into palliative care in the Eastern Mediterranean Region, and data extracted from the 2015 NCD country capacity survey (CCS),13 conducted by WHO, which was completed by 21 of 22 countries in the region.

Cancer burden Cancer incidence in the Eastern Mediterranean Region has been projected to increase substantially during the next 15 years (figure 1). In this region, more than 555 318 new cancer cases and 367 441 deaths were reported in 2012.7 However, by 2030, projection models indicate that 961 000 new cases and 652 000 deaths7 will occur annually, thus increasing the need for palliative care provisions. e177

The most common cancers in the region are breast, colorectal, lung, liver, and bladder cancer. Combined, these five cancers account for 40% of cancer cases in the region.7 Breast cancer alone accounts for around 100  000 new cancer cases per year in the Eastern Mediterranean Region—three-times more than any other cancer. Furthermore, breast cancer has the highest mortality rate, causing more than 42 000 deaths per year, followed by lung cancer (29 000) and liver cancer (28 000). However, when the rates are age standardised, prostate cancer has the second highest incidence, and bladder cancer the sixth. Table 1 shows the age-standardised incidence and mortality rates for these cancers. In the Eastern Mediterranean Region, most cancer cases are diagnosed at an advanced stage (table 2), whereby cure is improbable even with the best treatments; accordingly, the need for palliative care in the region is substantial.7 As would be expected from the late stage of diagnosis, cancer survival is low in the region compared with developed regions, such as the Americas and Europe.7 In the Eastern Mediterranean Region, the risk of cancer developing before age 75 years is 12·9%, whereas the risk is twice as high in the Americas, at 24·5%. Despite this substantial difference in the risk of cancer developing, the risk of premature death from cancer is similar between these regions, at 9·1% in the Eastern Mediterranean and 10·6% in the Americas (figure 2).7

Palliative care In most countries in the Eastern Mediterranean Region, palliative care services are in the early stages of development. Some countries have more developed services than others; however, generally the level of palliative care is basic. On the basis of a mapping exercise in 2006,14 the Worldwide Palliative Care Alliance categorised countries by level of palliative care develop­ ment again in 2011,15 using the four categories from the original study, although two of these categories were further subdivided into a and b categories (figure 3). The categories range from 1 (countries with no known activity) to 4 (countries approaching integration). Compared with the global distribution of palliative care, a greater proportion of countries in the Eastern Mediterranean Region are at an early stage of develop­ment of palliative care provisions (figure 3). Whereas six countries in the region have no known services, most fall into the 3a category with localised provision of hospice and palliative care (table 3).15,16 A notable increase in palliative care provision occurred between 2006 and 2011, with five countries in the region moving from category 2 (capacity building) to category 3 (isolated provision) during that period. The Quality of Death Index confirms the scarcity of palliative care services in the Eastern Mediterranean Region. The first version of the index,17 published in 2010, did not include any countries in the Eastern Mediterranean Region; however, the second version in 201518 included six countries from the region (Egypt, www.thelancet.com/oncology Vol 18 March 2017

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100 90

70 60

Availability of palliative care services Primary care practitioners in the Eastern Mediterranean Region are well placed to provide palliative care services to their communities;20 however, few such services are available. The CCS collected country data for whether at least 50% of the population has access to public palliative care services through primary care.13 Only Saudi Arabia and Syria reported to have primary care-based palliative care services available to at least 50% of patients with NCDs within the public health system. The survey also investigated access to home-based care. Saudia Arabia, Syria, and Qatar reported that home-based palliative care www.thelancet.com/oncology Vol 18 March 2017

50 40 30 20 10 0

Europe

Americas

Western Pacific

Eastern Mediterranean

Africa region

Southeast Asia

Figure 2: Risk of premature cancer and cancer death before age 75 years by WHO region in 20127 100

Policies and plans

1

90 Proportion of countries in each group (%)

Access to palliative care services is a major challenge in the Eastern Mediterranean Region, where only an estimated 5% of adults who are in need of palliative care actually receive it.19 One of the key strategic interventions in the regional framework for action is to improve access to palliative care services, including an operational national palliative care plan. The 2015 WHO NCD CCS investigated the inclusion of palliative care as part of a national NCD action plan;13 ten countries reported having included it (table 4). Of these countries, eight reported including palliative care as part of their national NCD action plan. Kuwait and Tunisia reported to have included palliative care, even though their national NCD plans are still under development and not yet endorsed. Both these countries have a standalone palliative care policy or plan. Furthermore, funding for palliative care is scarce in the Eastern Mediterranean Region. In the CCS, only 12 countries in the region were reported to have funding available for palliative care (table 4). All the low-income countries in the region reported having no funding available for palliative care services, although three of the six countries did have funding available for other NCD-related services, such as early detection and health care.

Risk of cancer development Risk of cancer death

80

Risk (%)

Iraq, Iran, Jordan, Morocco, and Saudi Arabia). The index compared 80 countries worldwide on the basis of 20 qualitative and quantitative indicators across five domains: palliative care and health-care environment, human resources, affordability of care, quality of care, and community engagement. One high-income country was included (Saudi Arabia), which ranked lowest on the index of the 35 high-income countries compared, with an indicator of 30·8%. Overall, Saudi Arabia ranked 60th of 80 countries. Morocco and Egypt, included as low-income countries, both scored higher than Saudi Arabia, with indicators of 33·8% and 32·9%, respectively. Iraq, included as a middle-income country, had the lowest Quality of Death score of all 80 countries included, with an indicator of 12·5%. The report found that palliative care can be improved through national policies, training of health-care staff, subsidies for care, and access to opioids and psychological support.

25

80 70

20

17 12

60

Group 4b Group 4a Group 3b Group 3a Group 2 Group 1

74

50 40 30

3

20 10 0

6

EMR

23

75

Worldwide

Figure 3: Palliative Care Alliance category distribution in the Eastern Mediterranean Region and worldwide15 The numbers on the bars represent the number of countries in each category. Group 1 countries have no known activity, group 2 countries are capacity building, group 3a countries have isolated provision, group 3b countries have generalised provision, group 4a countries have preliminary integration, and group 4b countries have advanced integration. EMR=Eastern Mediterranean Region.

was available to cover at least half the population. However, in view of the ongoing conflict in Syria, availability of palliative care services is likely to be low. Home-based care has strong potential for implemen­ tation in the Eastern Mediterranean Region because of the structure of the community and the strong family bonds.21 Furthermore, Middle Eastern culture, which places a strong emphasis on family and social bonds, is conducive to the establishment of home-based palliative care services. However, this model of care requires a supportive environment and a strong link between health-care systems and home-based support. Medical and nursing services (ie, primary care general practitioners and community nurses) that can access the patient at home or be easily consulted by telephone are essential. This approach also requires training and development of health-care professionals, caregivers, and volunteers.22 e178

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Inclusion of palliative care in national NCD Action Plan

Funding for palliative care

Afghanistan

No

No

Countries Category 1 (no known activity)

Afghanistan, Djibouti, Libya, Somalia, Syria, Yemen

Category 2 (capacity building)

Oman, occupied Palestinian territory, Qatar

Bahrain

Yes

Yes

Catergory 3a (isolated provision)

Bahrain,* Egypt, Iran,* Iraq, Kuwait,* Lebanon,* Morocco, Pakistan, Saudi Arabia, Sudan,* Tunisia, United Arab Emirates

Egypt

No

No

Iran

Yes

No

Category 3b (generalised provision)

Jordan

Iraq

Yes

No

Jordan

No

No

Category 4a None (preliminary integration)

Kuwait

Yes

Yes

Category 4b (advanced integration)

Lebanon

Yes

Yes

Libya

No

Yes

Morocco

Yes

Yes

Occupied Palestinian territory No

Yes

Oman

No

Yes

Pakistan

No

No

Qatar

Yes

Yes

Saudi Arabia

Yes

Yes

Somalia

No

No

Sudan

No

No

Syria

No

Yes

Tunisia

Yes

Yes

United Arab Emirates

Yes

Yes

Yemen

No

No

None

*Countries that moved from category 2 to category 3a between 2006 and 2011.

Table 3: Worldwide Palliative Care Alliance categorisation of palliative care development for countries in the Eastern Mediterranean Region, 201115

Access to palliative care services within secondary level care varies between countries in the Eastern Mediterranean Region. The panel outlines examples of hospital-based and clinic-based services in the region.

Partnerships and networks In most countries in the Eastern Mediterranean Region, non-governmental organisations (NGOs) provide a range of important services. NGOs provide financial support to the families of patients with cancer, endorse training programmes, and support cancer centres by providing equipment and medications. These organisations often have a key role in palliative care services, in view of the little government funding available. The long-established institutions in the region are usually operated by voluntary, not-for-profit, charitable associations, with financial support from the Ministry of Health and donations from the community.23,30 For example, Pakistan has 20 cancer care centres: 17 private and three governmental. Treatment is mainly supported by local charity organisations. A few hospices exist, which are supported by private NGOs.31 Meanwhile, in Jordan, in addition to existing hospitals, palliative care services are offered by several non-profit civil society organisations, including the Al-Malath Foundation for Humanistic Care.24,25 This foundation is a non-govern­ mental volunteer organisation established in 1993, and has a hospice with a team of volunteer nurses who provide social, spiritual, psychological, and nursing care for patients during their end-of-life period. The Palliative Care Jordanian Society is an NGO established in 2010, and focuses on increasing the culture of palliative care through training, education, advocacy, and networking. In Lebanon, the Lebanese Center for Palliative Care (Balsam; Beirut, Lebanon) is a NGO that provides holistic support to patients with life-threatening illnesses by providing medical services and psychological, social, practical, and spiritual support within the family and e179

NCD=non-communicable diseases.

Table 4: Inclusion of palliative care in the national non-communicable disease action plan and funding availability in countries of the Eastern Mediterranean Region13

home environment.32,33 Capacity building in palliative care is also provided to ensure effective delivery of in-hospital and community palliative care. In occupied Palestinian territory, initiation of palliative care services has been proposed by the Al-Sadeel Society, an NGO which is currently the first and only official palliative care society in the Palestinian National Authority. The organisation delivers an educational and awareness programme at Beit Jala Governmental Hospital. Moreover, in cooperation with the Middle East Cancer Consortium, the organisation has supported several physicians in training abroad.34,35

Human resources and training programmes Variability exists across the Eastern Mediterranean Region in availability of human resources with palliative care expertise (physicians, nurses, medical assistants, care workers, and volunteers), and access to appropriate training programmes. Since 2000, several short courses have been delivered in the region by various international organisations (eg, the Middle East Cancer Consortium, the US National Cancer Institute, The Oncology Nursing Society in the USA, The American Society of Clinical Oncology [ASCO], Education www.thelancet.com/oncology Vol 18 March 2017

Policy Review

in Palliative and End-of-Life Care, and the Institute for Palliative Medicine at the San Diego Hospice). These courses are being delivered to scale up the number of well trained palliative care professionals in the region. Furthermore, WHO’s Eastern Mediterranean Regional Office has been delivering an annual training of trainers workshop on palliative care since 2010, targeting various health-care providers. The programme is delivered jointly with regional partners, such as the Gulf Federation for Cancer Control. The most recent workshop was held in Kuwait in November, 2015.27 The programme is a generalist orientation in which health professionals are exposed to a broad range of palliative care concepts and principles. The focus is on use of the WHO protocol for integration of palliative care in primary health care, to expand the services and empower primary health-care staff. At the country level, a proposal for a national palliative care programme in Saudi Arabia was developed in 2004, which included systematic training programmes for health-care staff.36 The country has successfully accredited palliative care in their medical specialist training and has developed a well structured 1 year palliative care fellowship.31 The structured fellowship programme will be extended to 2 years in early 2017 and is accredited by the Saudi Medical Council as a speciality. A 3-month certificate in palliative care has also been developed, in addition to ongoing symposia and local short courses, and a 2·5 year Masters programme in Spiritual Care accredited by Durham University, UK.31 In Jordan, a 3-month diploma in palliative care management and spiritual care communication has been accredited by the Ministry of Higher Education. The King Hussain Cancer Centre (Amman, Jordan) provides a 9-month diploma in palliative care in partnership with Jordan University, Yale University, and the United States Agency for International Development; furthermore, a series of in-house short courses are available.37,38 However, palliative care is not yet integrated into medical and nursing curricula in Saudi Arabia.39 However, despite these developments in training, most countries in the Eastern Mediterranean Region still face shortages of a well trained workforce, and often an unequal distribution of human resources, and the absence of a multidisciplinary approach to palliative care. For example, one challenge is that the existing health education systems do not support palliative care as a priority area. Training in palliative care is not mandatory in most countries as part of graduate or undergraduate professional education. Few medical and nursing schools have incorporated palliative care into their curricula, and most existing residency programmes in oncology, medicine, family medicine, and paediatrics do not include palliative care in their core curriculum; therefore, medical residents and fellows are rarely examined on this topic. In some Eastern Mediterranean Region countries, palliative care services are available despite an absence of specialist trained staff. In occupied Palestinian www.thelancet.com/oncology Vol 18 March 2017

Panel: Examples of hospital-based or clinic-based palliative care services in the Eastern Mediterranean Region In Bahrain, palliative care is offered in the main hospital (Salmynia Medical Complex, Manama, Bahrain), which has a team of oncologists, palliative care specialists, a medical officer, residents, and nurses. The hospital has two weekly follow-up clinics, one weekly pain clinic, and a hotline for home-care problems.23 However, since 2010, little further progress has been made because of staff shortages and scarcity of funding. In Jordan, palliative care is offered at two hospitals in the city of Amman: the King Hussein Cancer Centre and Al Basheer Hospital. The King Hussein Cancer Centre is a comprehensive cancer centre, whereas the oncology unit at Al Basheer Hospital provides support service to several hundred patients annually.24,25 A 2016 study26 has shown the improvement in symptoms experienced through delivery of outpatient palliative care services in Jordan. In Egypt, pain clinics are established at most cancer care centres; however, no complete multidisciplinary palliative care team is functioning. In 2008, a centre was established at Kasr AlAiny Hospital of Cairo University.27 In Oman, palliative care is still in the early stages of development. The medical oncology department at the main hospital in Muscat is currently providing the essential palliative care services for patients who are terminally ill, but such services are mainly given on a day-care basis.27,28 Saudi Arabia has been developing palliative care services since 1992, and has expanded to the whole state.23 More than 15 cancer centres and well established palliative care units with integrated home-based care exist, providing services for 500 patients annually.23 The units are composed of multidisciplinary teams incorporating various professionals, such as physicians, nurses, social workers, dieticians, physical therapists, home-care health nurses, health educators, pharmacists, and religious authorities.29 However, more work is needed to raise awareness of palliative care, and to improve pain management legislation.23

territory, for example, although two oncology centres have palliative care services, there are no specialised trained palliative care doctors or health-care staff.

Pain management Pain management is an essential aspect of palliative care; it alleviates the suffering of patients at progressive stages of illness, subsequently improving their quality of life.40 To this end, the WHO model list of essential medicines41 describes 14 palliative care medications, and access to opiate pain relief is one of the 25 indicators in the global monitoring framework for NCDs;42 however, several challenges affect the availability and access to these medicines in the Eastern Mediterranean Region.43 Pain relief is mostly achieved through the admin­ istration of opioids, which are available throughout the region; however, government legislation is in place for the prescription of generic or proprietary opioid medication.44 The global data indicate that opioid consumption is quite low in in the Eastern Mediterranean Region compared with the rest of the world (table 5).45,46 Of countries in which morphine was available in 2014, the mean consumption was 0·384 mg per person, whereas the global average for the same time period was 16 times higher at 6·24 mg per person. A substantial, but less pronounced, difference was recorded in global methadone consumption, which was more than double e180

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Ratio of global to Global consumption Eastern Mediterranean (mg per person)* Region consumption (mg Eastern Mediterranean Region consumption per person)* Fentanyl

0·213

0·009

24:1

Hydromorphone

0·801

0·001

793:1

Methadone

4·610

1·210

4:1

Morphine

6·240

0·384

16:1

Oxycodone

11·900

0·077

153:1

0·847

0·814

1:1

62·000

6·250

10:1

Pethidine Total morphine equivalence *Data shown are mean values.

Table 5: Consumption of opioids in the Eastern Mediterranean Region and globally, in 201445,46

that of the Eastern Mediterranean Region (table 5). However, the mean is heavily skewed by Iran, where the mean methadone consumption was 9·3 mg per person. Overall, the total morphine equivalence in the Eastern Mediterranean Region was six-times lower than the global mean. Several challenges exist that affect the adequate availability of and access to pain relief medications— namely, inadequate or overly strict legislation, unbalanced policies within and between countries in the region, restrictions on available forms of medication (especially oral opioids), a scarcity of supply and distribution systems, restrictions on who can prescribe these drugs, insufficient knowledge regarding the use of controlled medicines, and in­appropriate attitudes towards controlled medicines.45,46 To overcome some of these challenges, WHO has been working jointly with member states and other partners since 2010, to review and modify national legislations related to the availability and affordability of opioids for pain management. A series of training workshops and country assessments were done to enable countries to assess the local situation, including analysis of legislation and policies, updating national essential medicines lists, training in data reporting, and supporting health institutions to establish adequate curricula for pain management.27

Discussion Palliative care in most of the Eastern Mediterranean Region remains at an early stage of development, with insufficient strategic planning by governments for palliative care services. Barriers exist not only because of a scarcity of resources across much of the region, but also because of the complicated political situations and weak health-care systems coupled with the conflict affecting some countries in the region. More than half of all countries in the region are in a state of emergency, including three countries in complex emergencies with active conflicts and ten countries facing protracted crises. Eight of these countries currently have UN humanitarian strategic response plans (Afghanistan, e181

Iraq, Libya, occupied Palestinian territory, Somalia, Sudan, Syria, and Yemen). These situations are having an impact on health-care systems, affecting health-care access including palliative care and medication supply.47,48 The scarcity of national plans and policies has been identified. Countries in the Eastern Mediterranean Region should strive to develop national palliative care plans integrated within their NCD strategy in line with the local context and health-care needs. Although funding might not be available at present, policy makers could work with national and international partners to secure future funding and improve capacity. Palliative care is provided by a mixture of NGOs, charitable religious associations, and private and government hospitals. At the system level, partnership working between these organisations can help facilitate sharing of resources, provide standardised training, and increase capacity within countries. Furthermore, collaboration between countries will strengthen palliative care provision at the regional level. In this Policy Review, we have highlighted examples of where mixed models of statutory, for-profit, and philanthropic funding have enabled countries to develop and sustain palliative care services. In the Eastern Mediterranean Region, the majority of the population has little or no understanding of palliative care services.23 Additionally, poor awareness among policy makers, health-care professionals, and the public about what palliative care is, and the benefits this approach can offer to patients and health-care systems, is a key challenge that needs to be addressed. Moreover, several misconceptions about palliative care—eg, pain is associated with death and pain medication leads to addiction—combined with social and cultural barriers such as beliefs about death and dying, are another problem in the region.27 For example, the culture of the Eastern Mediterranean Region has long-standing fatalistic beliefs about death.21 Therefore, there is little public demand for these services and individuals might be reluctant to accept palliative care when it is offered. Information should be made available through government or community portals to raise public understanding of the benefits of palliative care. Patients with serious and life-limiting cancers need to be aware that they can receive access to high-quality and compassionate palliative care wherever they are living. Globally, the issue of professional education and accreditation of palliative medicine is an important topic.49,50 Since 2000, the number of palliative care training courses in the Eastern Mediterranean Region has increased; however, numbers of specialist palliative-care professionals and volunteers remain low. Therefore, countries in the region should provide health-care professionals with accredited training in palliative care, both as part of undergraduate and www.thelancet.com/oncology Vol 18 March 2017

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graduate education. Furthermore, a module on advancing palliative care was included in the new edition of the European Society for Medical Oncology– ASCO Global Curriculum in Medical Oncology in 2016, which could be very useful for the development of training in the Eastern Mediterranean Region.51 Additionally, training of community volunteers should be encouraged to increase capacity in the provision of practical and psychosocial support for patients receiving palliative care. This strategy has proven successful in other low-income and middle-income countries worldwide, such as India, Thailand, and Uganda.52 To improve pain management, countries can review legislation on availability and affordability of opioids. This review process can be implemented at the national level through a situational analysis of legislation and policies. For example, in Lebanon, legislation has been reviewed through the development of a national committee.53 Additionally, countries should update national essential medicines lists and support health institutions when establishing adequate curricula for pain management, using the WHO country checklist.54,55 WHO has developed a list of essential medicines, which includes opioids and medicines for other common symptoms of palliative care. A national committee that integrates palliative care into national health policies is fundamental for countries to improve access to palliative care. The requirement for such a committee is coupled with the need for countries to have funding mechanisms in place for palliative care. A financing allocation can be done by use of a resource-stratification approach to the cancer care pathway, with incorporation of supportive and palliative care.56 More advocacy activity is needed to sensitise policy makers and decision makers to promote investment and secure the resources required for palliative care, both in the Eastern Mediterranean Region and in low-income and middle-income countries worldwide.57 This Policy Review has several limitations. Notably, little research and published literature exists about palliative care in most of the Eastern Mediterranean Region. Furthermore, the data that are available, such as the CCS, provide a very narrow insight into the overall picture of palliative care provision, because it is limited to three closed questions on the topic regarding the availability of funding for palliative care, the sources of funding for palliative care, and the availability of palliative care (primary health care or home-based) for patients with NCDs within the public health system. A potential bias could exist because we focused on publications in English; thus, future reviews should include material published in French and Farsi languages. Furthermore, information gathered from meeting reports is not scientifically rigorous; however, such information does provide a contextual and realworld insight into service availability, partnerships, training, and barriers to pain relief. Overall, this Review www.thelancet.com/oncology Vol 18 March 2017

Search strategy and selection criteria We envisioned this Policy Review as a scoping review and presented it as a narrative review of the evidence using systematic procedures, but we do not claim it to be a systematic review. To identify papers of relevance, we searched Google, CINAHL, and MEDLINE with the terms “supportive care”, “palliative care”, “end-of-life care”, “cancer”, “cancer trends”, “epidemiology”, “public health”, and “Eastern Mediterranean” (and with the names of the 22 countries within the region), within their titles, abstracts, or keywords. Additionally, we searched various websites: WHO, World Wide Hospice and Palliative Care Alliance, Lien Foundation, International Association of Hospice and Palliative Care, Pain and Policy Studies Database, and European Association for Palliative Care (in which blogs from the Eastern Mediterranean region have been published). We derived the opioid and morphine mapping data from WHO based on data published by the International Narcotics Control Board, which is the independent and quasi-judicial control organ monitoring the implementation of the UN drug control conventions. Because the Review was intended to be wide ranging, the inclusion criteria included qualitative, quantitative, and mixed method research, including WHO data monitoring reports, policy documents, and international and country-specific reports written in English and Arabic between Jan 1, 2000, and Aug 31, 2016. We excluded papers written in languages other than English or Arabic, those published before Jan 1, 2000, and those not involving patients with cancer.

provides a synthesis of the available information, including data gathered through WHO meeting reports, which begins to build a picture of the status of palliative care in the Eastern Mediterranean Region. Investigators of future studies should aim to collect primary data from both service providers (physicians and nurses) and service users (patients and family members). Additionally, population-level retro­spective surveys of bereaved family members are used for national quality improvement initiatives of end-of-life care in four countries (Ireland, Italy, the UK, and the USA)—these could also be considered in the Eastern Mediterranean Region. At the end of life, patients with cancer receiving palliative care experience a high level of distress. Therefore, greater attention to development of palliative care services is needed in the Eastern Mediterranean Region. This Review found little published scientific evidence of palliative care services in the region. There is a need to leverage more national data and establish comparable evidence bases to drive policy. Indicators of palliative care programme growth, educational initiatives, and capacity building exist in some countries, but questions remain about their sustainability. Overall, this Review has identified an urgent need to expand access to palliative care services in the Eastern Mediterranean Region and encourage the engagement of hospitals in quality improvement initiatives. Contributors IF wrote the manuscript, with contributions from GL. SP provided references. All authors reviewed and commented on revisions of the paper. Declaration of interests We declare no competing interests.

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