1094 Journal of Pain and Symptom Management Vol. 45 No. 6 June 2013

Special Article

Mapping Levels of Palliative CareDevelopment: A Global UpdateThomas Lynch, PhD, Stephen Connor, PhD, and David Clark, PhDInternational Observatory on End of Life Care (T.L.), Lancaster University, Lancaster; Worldwide

Palliative Care Alliance (S.C.), London; and School of Interdisciplinary Studies (D.C.), University of

Glasgow, Glasgow, United Kingdom

Abstract

Our purpose is to categorize palliative care development, country by country, throughout theworld, showing changes over time. We adopt a multi-method approach. Development iscategorized using a six-part typology: Group 1 (no known hospice-palliative care activity)and Group 2 (capacity-building activity) are the same as developed during a previous study(2006), but Groups 3 and 4 have been subdivided to produce two additional levels ofcategorization: 3a) Isolated palliative care provision, 3b) Generalized palliative careprovision, 4a) Countries where hospice-palliative care services are at a stage of preliminaryintegration into mainstream service provision, and 4b) Countries where hospice-palliativecare services are at a stage of advanced integration into mainstream service provision. In2011, 136 of the world’s 234 countries (58%) had at least one palliative care servicedanincrease of 21 (þ9%) from 2006, with the most significant gains having been made inAfrica. Advanced integration of palliative care has been achieved in only 20 countries(8.5%). Total countries in each category are as follows: Group 1, 75 (32%); Group 2, 23(10%); Group 3a, 74 (31.6%); Group 3b, 17 (7.3%); Group 4a, 25 (10.7%); andGroup 4b, 20 (8.5%). Ratio of services to population among Group 4a/4b countries rangesfrom 1:34,000 (in Austria) to 1:8.5 million (in China); among Group 3a/3b countries,from 1:1000 (in Niue) to 1:90 million (in Pakistan). Although more than half of the world’scountries have a palliative care service, many countries still have no provision, and majorincreases are needed before palliative care is generally accessible worldwide. J PainSymptom Manage 2013;45:1094e1106. � 2013 U.S. Cancer Pain Relief Committee.Published by Elsevier Inc. All rights reserved.

Key Words

Palliative care, hospice, map, global development

1

Introduction

Interest in the comparative analysis of pallia-tive care development has been evident,

Address correspondence to: Thomas Lynch, PhD, Inter-national Observatory on End of Life Care, Institutefor Health Research, Alexandra Square, LancasterUniversity, Lancaster LA1 4YT, United Kingdom.E-mail: t.lynch@lancaster.ac.uk

Accepted for publication: May 18, 2012.

� 2013 U.S. Cancer Pain Relief Committee.Published by Elsevier Inc. All rights reserved.

particularly in Europe, since the late 1990s.The first study to review palliative care usingcomparative methods was reported in 2000,and it focused on seven countries in WesternEurope.2 In 2003, a study commissioned bythe Open Society Foundation InternationalPalliative Care Initiative (IPCI) successfullymapped the development of palliative careacross 28 former communist countries in East-ern Europe and Central Asia.3 As a direct

0885-3924/$ - see front matterhttp://dx.doi.org/10.1016/j.jpainsymman.2012.05.011

Vol. 45 No. 6 June 2013 1095Mapping Levels of Palliative Care Development: A Global Update

result of the IPCI project, the InternationalObservatory on End of Life Care (IOELC)was established by D. C. at Lancaster Universityin the U.K. The IOELC used comparativemethods in its reviews of hospice-palliativecare activity and devised a common templateto present its research-based reports on coun-tries; this resulted in major reviews of palliativecare development in Africa (26 countries), theMiddle East (six countries), and South EastAsia (three countries) as well as a study cover-ing the whole of India. The European Associa-tion for Palliative Care (EAPC) Task Force onthe Development of Palliative Care in Europebegan in 2003 under the leadership of Profes-sor Carlos Centeno, and has substantially con-tributed to the agenda of documenting theprogress of palliative care across countriesand regions.4 Jaspers and Schindler5 reviewedhospice and palliative care provision in Ger-many compared with those in ten other Euro-pean countries, and Gronemeyer et al.6

undertook a comparative review of palliativecare provision in 16 countries across Easternand Western Europe.

Emerging from this series of studies was anambitious attempt in 2006 to measure andclassify the development of palliative care in ev-ery country in the world. The IOELC built ona basic description that had been produced ear-lier by the Hospice Information Service but at-tempted to build more depth into the analysisby developing a four-part typology depictingthe levels of hospice-palliative care develop-ment across the globe: no known hospice-palliative care activity (Group 1 countries);capacity building activity (Group 2 countries);localized hospice-palliative care provision(Group 3 countries); and countries wherehospice-palliative care services were reachinga measure of integration with the mainstreamhealth care system (Group 4 countries). By pre-senting a ‘‘worldmap’’ of hospice-palliative caredevelopment, the study sought to contribute tothe debate about the growth and recognition ofpalliative care services and, in particular,whether or not the four-part typology reflectedsequential levels of palliative care develop-ment.7 This mapping project was commis-sioned by the Worldwide Palliative CareAlliance, with funding from Help the Hospicesin the U.K., and the National Hospice and Palli-ative Care Organization in the U.S.

Since 2006, there have been further compar-ative studies on palliative care development.For example, in 2008, the work of the EAPCTask Force on the Development of PalliativeCare in Europe was extended in a collaborativestudy that specifically focused on the 27 mem-ber states of the European Union.8 This studywas important in moving beyond a descriptivecomparison of the data to sketch out the be-ginnings of a more detailed method for rank-ing the 27 countries by the level of theirpalliative care development. A study commis-sioned by the Lien Foundation in Singaporeand carried out by the Economist IntelligenceUnit was published in 2010. This too attemp-ted a ranking of palliative care development,this time in 40 countries of the world, andwith a more complex set of indicators.9 In2011, a report from Human Rights Watchalso documented the state of pain and pallia-tive care services in 40 countries.10

MethodsAlthough the 2006 study has been heavily

cited in the literature and adopted as a toolfor international palliative care advocacy, it be-came clear that the rankings might benefitfrom refinement and the method of categori-zation also could be made more robust. To up-date the original findings and also address thedefinitional and methodological concerns, the2006 mapping exercise was repeated in 2011,with some new criteria in the ranking. Withinthe typology, changes have been made in thecriteria for the level of palliative care develop-ment in Groups 3 and 4, and these have beensubdivided to produce two additional levels ofcategorization (Groups 3a, 3b, 4a, and 4b).

Location and Extraction of Relevant DataData on palliative care development were

initially collected from the following sources:published articles in peer reviewed and profes-sional journals, books and monographs, pallia-tive care directories, palliative care and relatedwebsites, data provided by the EAPC TaskForce for the Development of Palliative Carein Europe, IOELC reviews and databases, aswell as gray literature and conference presenta-tions (Fig. 1). We explored questions of pallia-tive care coverage, public awareness, education

1096 Vol. 45 No. 6 June 2013Lynch et al.

and training, opioid availability, and reim-bursement. We also focused on service typesand settings, the impact of palliative care onpolicy, links with academic institutions, andthe relationship between palliative care ser-vices and other mainstream service providers.Critical points included whether there was evi-dence of government support, the implemen-tation of strategic plans, published research,and palliative care elements in medical aswell as nursing curricula and accreditedcourses.

In-country ‘‘key experts’’ in palliative carewere particularly important sources of datafor the study. Palliative care ‘‘champions’’with extensive knowledge of both nationaland international development were identifiedin a variety of ways: within the sources citedabove, from their participation in the previousstudy in 2006, from information provided by66 national palliative care associations, andfrom international palliative care sources (In-ternational Association for Hospice and Pallia-tive Care, Help the Hospices, and WorldwidePalliative Care Alliance). In countries wherea champion was identified, they were re-quested to 1) provide information on the num-ber and different types of palliative careservices in their country, and 2) indicate whichcategory within the new typology most accu-rately reflected the current status of palliativecare in their country. Eighty-five palliativecare champions were identified, and they pro-vided information about the status of palliativecare in their respective countries. Where no

Palliative care

“champion”

identified

(n=85)

Palliative care

“champion”

unable to be

identified

(n=149)

Initial data

collection

process

Req

in

pa

ca

Reg

care

prov

on

ca

No re

care

retu

Fig. 1. Method of locating and

palliative care champion could be identified,regional palliative care associations (e.g., AsiaPacific Hospice Palliative Care Network and Af-rican Palliative Care Association) acted as‘‘proxies’’ and provided valuable informationon behalf of a further 77 countries.In countries where a palliative care cham-

pion could not be identified and where the in-formation from a regional palliative careassociation was not available, data collectedfrom the initial sources identified above (par-ticularly from the previous study in 2006)were revisited to determine to which categorythe country in question should be allocated;knowledge gained by the authors while work-ing on other hospice and palliative care-related projects (e.g., work undertaken withthe Open Society Foundation IPCI) also wasused to achieve this objective. In total, the sta-tus of palliative care development in 72 coun-tries was calculated in this manner. In caseswhere categorization of a particular countrywas unclear (approximately 14 in total), theauthors undertook a consultative process witheach other. The initial categorization wasmade by T. L. based on the available evidence;S. C. and D. C. then conferred on cases thatwere particularly difficult to categorize, usingtheir extensive and detailed knowledge ofmany of the countries in the study, in somecases based on visits made to those countriesin recent years. The country in questionwas then allocated to one of the following cat-egories based on its perceived level of palliativecare development:

uest to provide

formation on

lliative care

services/

tegorization

ional palliative

association to

ide information

palliative care

services/

tegorization

gional palliative

association –

rn to initial data

(n=72)

Information on

palliative care

services/categorization

provided by “champion”

(n=85)

Information on

palliative care

services/categorization

provided by regional

palliative care

association

(n=77)

extracting relevant data.

Vol. 45 No. 6 June 2013 1097Mapping Levels of Palliative Care Development: A Global Update

Group 1 Countries: No Known Hospice-PalliativeCare Activity. Although we have been unableto identify any palliative care activity in thisgroup of countries, we acknowledge theremay be instances where, despite our best ef-forts, current work has been unrecognized.

Group 2 Countries: Capacity Building Activity. Inthis group of countries, there is evidence ofwide-ranging initiatives designed to create theorganizational, workforce, and policy capacityfor the development of hospice-palliative careservices although no service has yet been estab-lished. The developmental activities includeattendance at, or organization of, key confer-ences; personnel undertaking external train-ing in palliative care; lobbying of policymakers and Ministries of Health; and incipientservice development.

Group 3 Countries

Group 3a: Isolated Palliative Care Provision. Thisgroup of countries is characterized by thedevelopment of palliative care activism that ispatchy in scope and not well-supported; sourceof funding that is often heavily donor-dependent; limited availability of morphine;anda small numberofhospice-palliative care ser-vices that are often home-based in nature andlimited in relation to the size of the population.

Group 3b: Generalized Palliative Care Provision.This groupof countries is characterizedby thede-velopment of palliative care activism in several lo-cations with the growth of local support in thoseareas;multiple sourcesof funding; theavailabilityof morphine; several hospice-palliative care ser-vices from a community of providers who are in-dependent of the health care system; and theprovision of some training and education initia-tives by the hospice organizations.

Group 4 Countries

Group 4a: Countries Where Hospice-Palliative CareServices Are at a Stage of Preliminary Integrationinto Mainstream Service Provision. This groupof countries is characterized by the develop-ment of a critical mass of palliative care activ-ism in a number of locations; a variety ofpalliative care providers and types of services;awareness of palliative care on the part of

health professionals and local communities;the availability of morphine and some otherstrong pain-relieving drugs; limited impact ofpalliative care on policy; the provision of a sub-stantial number of training and education ini-tiatives by a range of organizations; andexistence of (or at least an interest in the con-cept of) a national palliative care association.

Group 4b: Countries Where Hospice-Palliative CareServices Are at a Stage of Advanced Integrationinto Mainstream Service Provision. This groupof countries is characterized by the develop-ment of a critical mass of palliative care activismin a wide range of locations; comprehensiveprovision of all types of palliative care by multi-ple service providers; broad awareness of pallia-tive care on the part of health professionals,local communities, and society in general; unre-stricted availability of morphine and moststrong pain-relieving drugs; substantial impactof palliative care on policy, in particular on pub-lic health policy; the development of recog-nized education centers; academic linksforged with universities; and the existence ofa national palliative care association.

Finally, global hospice-palliative care devel-opment was categorized using the revised typol-ogy, country by country, throughout the world;this development is depicted in a series ofworld and regional maps. The maps presentedhere make use of the United Nations (U.N.) listof 234 ‘‘countries or areas,’’ which are groupedinto 21 regions (such as Central America) andthen allocated to eight ‘‘major areas’’ desig-nated as ‘‘continents’’ (Sub-Saharan Africa;Middle East, North Africa, and Greater Arabia;North America; Central America and the Carib-bean; South America; Asia; Europe; and Aus-tralia and Oceania). Significantly, the U.N. listincludes small territories such as the AlandIslands, Isle of Man, and the Holy See (the Vat-ican). The size of these countries ranges from17 million square kilometers (Russia), to 0.44square kilometers (the Vatican). The mostpopulated country is China, with around 1.35billion people whereas the least populated isPitcairn Island, with about 50 people.

Other Development IndicatorsTo gain a broader view of the development

of a country, data also were collected regarding

1098 Vol. 45 No. 6 June 2013Lynch et al.

human development. The U.N. Human Devel-opment Index11 (HDI) measures a country’sachievements in the three aspects of longevity,knowledge, and standard of living, which high-light the development in human rather thaneconomic terms (The HDI was created to re-emphasize that people and their lives shouldbe the ultimate criteria for assessing the devel-opment of a country, not economic growth).Figures relating to population size were takenfrom the World Health Organization web-site12 (192 countries at that time) and supple-mented by estimated figures from the WorldFact Book13 (42 countries), which are suppliedby the U.S. Census Bureau and are based onstatistics from population censuses and vitalstatistics registration systems.

ResultsIn 2006, 115 of the world’s 234 countries

(49%) had established one or more hospice-palliative care services; in 2011, 136 of theworld’s 234 countries (58%) had one ormore hospice-palliative care services establish-eddan increase of 21 countries (þ9%). In2006, 156 countries (67%) were actively en-gaged in either delivering a hospice-palliativecare service or developing the frameworkwithin which such a service could be delivered;in 2011, there had been a slight increase in thisnumber to 159 countries (68%)dan increaseof 1%. Table 1 lists the countries in each ofthe six categories showing changes from2006, and Fig. 2 displays these countries ina map of the world.

Palliative Care and Human DevelopmentIn most regions of the world, a strong associ-

ation exists between palliative care and humandevelopment. Thirty (67%) of the 45 countriesin Groups 4a/4b (preliminary/advanced palli-ative care integration) have a very high level ofdevelopment as measured by the U.N. HDI,and five countries (11%) have a high level ofhuman development. Only six countries(13%) in Groups 4a/4b have a low level of hu-man development, yet this is a significant in-crease from the figure for 2006, whichsuggested that only one (3%) country fromGroup 4 was in the low development group.All six countries from Groups 4a/4b with low

levels of human development are from Africa,suggesting that, in contrast to other regions ofthe world, the level of palliative care develop-ment in this particular area may not be con-comitant with the overall levels of humandevelopment. In Group 1 (no known palliativecare activity), only two (3%) of the 75 coun-tries have a very high level of human develop-ment and seven (9%) countries have a highlevel of human development. By contrast, 20(27%) countries in Group 1 have a low levelof human development, and 33 (44%) coun-tries in this group have no HDI at all (Table 2).

Ratio of Services to PopulationCountries in Groups 4a/4b have multiple

services; within this group, the ratio of servicesto population does not exceed 1:8.5 million(China). Countries in Groups 3a/3b fre-quently have a single service provision and a ra-tio of services to population that extends to1:90 million (Pakistan) (Table 3).

Regional VariationsA regional analysis of palliative care develop-

ment produces striking variations in the levelsachieved by neighboring countries and in eachcountry’s ratio of services to population. InNorth America, both Canada and the U.S.are in Group 4b, whereas no palliative care ac-tivity could be identified in Greenland. InLatin America, Chile, Costa Rica, PuertoRico, and Uruguay are in Group 4a, whereasseveral other countries in the region provideeither a single or a relatively small number ofpalliative care services (Table 4); several Carib-bean Islands also offer a single palliative careservice.In Western Europe, only small countries,

such as Andorra, Monaco, and the Holy See(Vatican), or U.K. regions such as the FalklandIslands are in Groups 1 or 2; other U.K. re-gions such as Guernsey and the Isle of Manare in Group 3a. Greece is also in Group 3a,with Cyprus, Malta, and Portugal in 3b; the re-mainder of Western European countries are inGroups 4a/4b (Table 5).In Central and Eastern Europe/Common-

wealth of Independent States (CEE/CIS),countries such as Turkmenistan and Uzbeki-stan have no known palliative care capacity;this is in stark contrast to countries such as

Table 1Distribution of Countries and Global Population by Category (2011), N ¼ 234

Group 1 No knownactivity n ¼ 75 (32%)

Afghanistan, American Samoa, Andorra, Anguilla, Antigua and Barbuda, Aruba, Benin,Bhutan, Burkina Faso, Burundi, Cape Verdi, Central African Republic, Chad, Comoros,Cook Islands, Djibouti, Equatorial Guinea, Eritrea, Falkland Islands, Faroe Islands,French Guiana, French Polynesia, Gabon, Greenland, Grenada, Guam, Guinea, Guinea-Bissau, Kiribati, Korea (DPR), Laos, Liberia, Libya, Liechtenstein, Maldives, MarshallIslands, Martinique, Mauritania, Mayotte, Micronesia, Monaco, Montserrat, Nauru, TheNetherlands Antilles, New Caledonia, Niger, Norfolk Island, Northern Mariana Islands,Palau, Pitcairn, Saint Helena, Saint Kits and Nevis, Saint Pierre and Miquelon, SaintVincent and the Grenadines, Samoa, San Marino, Sao Tome and Principe, Senegal,Solomon Islands, Somalia, Svalbard, Syria, Timor-Leste, Togo, Tokelau, Tonga,Turkmenistan, Turks and Caicos Islands, Tuvalu, US Virgin Islands, Uzbekistan (� fromcategory 2), Vanuatu, Wallis and Fortuna, Western Sahara, Yemen.

Group 2 Capacitybuilding n ¼ 23 (10%)

Aland Islands (� from category 3), Algeria, Azerbaijan (� from category 3), Bolivia,British Virgin Islands, Democratic Republic of Congo, Dominica, Fiji, Haiti, Holy See(Vatican), Honduras (� from category 3), Madagascar, Mauritius, Montenegro (þ fromcategory 1), Nicaragua, Oman, Palestinian Authority, Papua New Guinea, Qatar,Reunion, Seychelles, Suriname, Tajikistan, The Bahamas.

Group 3a Isolatedprovision n ¼ 74 (31.6%)

Angola (þ from category 1), Armenia, Bahrain (þ from category 2), Bangladesh,Barbados, Belize (þ from category 2), Bermuda, Botswana, Brazil, Brunei (þ fromcategory 2), Bulgaria, Cambodia, Cameroon, Cayman Islands, Colombia, Congo, Cuba,Dominican Republic, Ecuador, Egypt, El Salvador, Estonia, Ethiopia (þ from category2), Ghana (þ from category 2), Gibraltar, Greece, Guadeloupe, Guatemala, Guernsey,Guyana, Indonesia, Iran (þ from category 2), Iraq, Isle of Man, Jamaica, Jersey,Kazakhstan, Korea (South), Kuwait (þ from category 2), Kyrgyzstan, Latvia, Lebanon(þ from category 2), Lesotho (þ from category 2), Macedonia, Mali (þ from category1), Mexico, Moldova, Morocco, Mozambique (þ from category 2), Myanmar, Namibia(þ from category 2), Nigeria, Niue (þ from category 1), Pakistan, Panama, Paraguay (þfrom category 2), Peru, Philippines, Reunion, Russia, Rwanda (þ from category 2),Saint Lucia (þ from category 2), Saudi Arabia, Sierra Leone, Sri Lanka, Sudan (þ fromcategory 2), Gambia, Thailand, Trinidad and Tobago, Tunisia, Ukraine, United ArabEmirates, Venezuela, Vietnam.

Group 3b Generalizedprovision n ¼ 17 (7.3%)

Albania, Argentina (� from category 4), Belarus, Bosnia and Herzegovina, Cote D’ivoire(þ from category 2), Croatia, Cyprus, Czech Republic, Georgia, India, Jordan,Lithuania, Malta, Nepal, Portugal, Swaziland, Turkey (þ from category 2).

Group 4a Preliminaryintegration n ¼ 25 (10.7%)

Chile, China (þ from category 3), Costa Rica, Denmark, Finland, Hungary, Israel, Kenya,Luxembourg (þ from category 3), Macau (þ from category 3), Malawi (þ fromcategory 3), Malaysia, Mongolia, The Netherlands, New Zealand, Puerto Rico (þ fromcategory 2), Serbia (þ from category 3), Slovakia (þ from category 3), Slovenia, SouthAfrica, Spain, Tanzania (þ from category 3), Uruguay (þ from category 3), Zambia (þfrom category 3), Zimbabwe (þ from category 3).

Group 4b Advancedintegration n ¼ 20 (8.5%)

Australia, Austria, Belgium, Canada, France, Germany, Hong Kong, Iceland, Ireland, Italy,Japan, Norway, Poland, Romania, Singapore, Sweden, Switzerland, Uganda, U.K., U.S.

Vol. 45 No. 6 June 2013 1099Mapping Levels of Palliative Care Development: A Global Update

Poland and Romania that are in Group 4b(Table 6).

In Western Asia, only Israel is in Group 4a(preliminary integration); a number of othercountries in the region offer limited palliativecare provision and are in Groups 3a/3b(Table 7).

In Africa, no palliative care service could beidentified in 28 of the continent’s countries;this contrasts with the categorization of Ugandain Group 4b and several other countries in theregion that are categorized in Group 4a(Table 8). A good example of progress in Africais provided by Cote’ D’Ivoire, which movedfrom Group 2 in 2006 to Group 3b in 2011.There are now 26 hospice-palliative care ser-vices in Cote D’Ivoire (22 government

hospitals/health facilities, three mission hospi-tals, and one private hospital). The African Pal-liative Care Association (APCA) and otherpartners have worked in Cote D’Ivoire to de-velop palliative care; a palliative care infrastruc-ture has been developed and palliative careservices provided. Despite remaining in thesame group as 2006 (Group 3), Nigeria is re-ported as ‘‘making progress’’ in the develop-ment of palliative care. The seven palliativecare services in Nigeria include two private hos-pices and five government-owned, tertiaryhealth, hospital palliative care services. Thereare five formally qualified physicians and fourformally qualified nurse specialists practicingpalliative care in the country. ‘‘Much progress’’is reported from Kenya, where 44 services

Fig. 2. WPCA Palliative Care Development All Levels (n ¼ 234). The boundaries and names shown and the des-ignations used on this map do not imply the expression of any opinion whatsoever on the part of the WPCA con-cerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation ofits frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yetbe full agreement. WPCA ¼ Worldwide Palliative Care Alliance.

1100 Vol. 45 No. 6 June 2013Lynch et al.

currently exist, including the recent integrationof palliative care into ten government hospitals.There are several medical institutions deliver-ing educational courses on palliative care, andthe discipline is gradually being integratedinto the curricula of medical, nursing, phar-macy, and dental schools across the country(e.g., the Nursing Council of Kenya). Inaddition, the National Cancer Control Strategycontains explicit reference to palliative care.Some African countries with only a single

Table 2Human Development and Levels of Pallia

Group Total Countries (N ) Very High, n (%) High, n (%

1 75 2 (3) 7 (9)2 23 1 (4) 7 (30)3a 74 8 (11) 23 (31)3b 17 7 (41) 5 (29)4a 25 12 (48) 4 (16)4b 20 18 (90) 1 (5)Total 234 48 (100) 47 (100)

HDI ¼ Human Development Index.

palliative care service are beginning to developeducation and training initiatives; for example,the organization ‘‘Pallia Familli,’’ which pro-vides home-based palliative care in Kinshasa,has organized several palliative care trainingand education initiatives in conjunction withthe Congolese Federation for Palliative Care.Even countries such as Senegal that remain cat-egorized as having ‘‘no known palliative carecapacity,’’ are reported as displaying ‘‘someaspects of capacity-building.’’ The impact of

tive Care Development, by Group

) Medium, n (%) Low, n (%) No HDI, n (%)

13 (17) 20 (27) 33 (44)8 (35) 4 (17) 3 (13)

20 (27) 14 (19) 9 (12)3 (18) 2 (12) 0 (0)3 (12) 5 (20) 1 (4)0 (0) 1 (5) 0 (0)

47 (100) 46 (100) 46 (100)

Table 3Ratio of Palliative Care Services to Population

Group Lowest Services (n) Ratio 1:000s Highest Services (n) Ratio 1:000s

3a Niue 1 1 Pakistan 2 90,4043b Lithuania 65 51 Turkey 14 53444a The Netherlands 295 56 China 159 85114b Austria 247 34 Uganda 34 962

Vol. 45 No. 6 June 2013 1101Mapping Levels of Palliative Care Development: A Global Update

unpredictable and volatile political situationson the development of palliative care in the re-gion is evident in countries such as Zimbabwe,which has moved erratically between differentgroups since the initial process of categoriza-tion commenced.

In the Asia Pacific and Oceania regions, Aus-tralia, Hong Kong, and Singapore haveachieved advanced palliative care integration(Group 4b), although many other countriesin the region offer either a limited numberof palliative care services or no services at all(Table 9). It should also be noted that approx-imately one-fifth of the world’s population isfound in China, and one-sixth in India.

Table 4Indicative Ratio of Hospice-Palliative Care

Services to Populations Within the Americas andthe Caribbean

Country Services (n) PopulationRatio1:000s

Bermuda 2 68,679 34United States 6568 314,659,000 48Cayman Islands 1 51,384 51Canada 500 33,573,000 67Costa Rica 42 4,579,000 109Puerto Rico 35 3,989,133 114Uruguay 24 3,361,000 140St. Lucia 1 172,000 172Barbados 1 256,000 256Belize 1 307,000 307Argentina 90 40,276,000 448Guadeloupe 1 452,772 453Guyana 1 762,000 762Chile 21 16,970,000 808Trinidad and

Tobago1 1,339,000 1339

Jamaica 2 2,719,000 1359Guatemala 5 14,027,000 2805Panama 1 3,454,000 3454Cuba 3 11,204,000 3734Ecuador 3 13,625,000 4541El Salvador 1 6,163,000 6163Paraguay 1 6,349,000 6349Colombia 7 45,660,000 6522Mexico 14 109,610,000 7829Brazil 22 193,734,000 8800Peru 3 29,165,000 9722Dominican

Republic1 10,090,000 10,090

Venezuela 1 28,583,000 28,583

In 2006, there was no known palliative careactivity in 78 of the world’s 234 countries(33%); by 2011, this figure had decreased bythree countries (�1%) to 75. The number ofcountries that were demonstrating capacity-building potential in 2006 was 41 (18%); by2011, this number had decreased by a totalof 18 countries to 23 (�8%). Countries withlocalized hospice-palliative care provision in2006 totaled 80 (34%); in 2011, the combinednumber of countries in Groups 3a and 3b to-taled 91 (39%)dan increase of 11 countries(þ5%). Finally, the division of Group 4 indi-cates that although 25 countries (10.7%) arenow approaching integration with mainstreamhealth service providers, only 20 countries(8.5%) have actually achieved this. In 2011,the total number of countries in Group 4 was45 (19%), as opposed to 35 (15%) in2006dan increase of 10 countries (þ4%)(Tables 10e12).

Table 5Indicative Ratio of Hospice-Palliative CareServices to Populations in Western Europe

Country Services (n) Population Ratio 1:000s

Gibraltar 2 28,956 14Isle of Man 4 84,655 21Guernsey 2 65,068 33Austria 247 8,364,000 34Iceland 8 323,000 40Jersey 2 94,161 47UK 1295 61,565,000 48Germany 1690 82,167,000 49Belgium 210 10,647,000 51Norway 88 4,812,000 55The Netherlands 295 16,592,000 56Sweden 140 9,249,000 66Ireland 57 4,515,000 79Spain 502 44,904,000 89Switzerland 81 7,568,000 93Luxembourg 5 486,000 97Denmark 45 5,470,000 122France 471 62,343,000 132Italy 376 59,870,000 159Cyprus 5 871,000 174Malta 2 409,000 204Finland 26 5,326,000 205Greece 32 11,161,000 349Portugal 20 10,707,000 535Turkey 14 74,816,000 5,344

Table 6Indicative Ratio of Hospice-Palliative Care

Services to Populations in Central and EasternEurope/Commonwealth of Independent States

Country Services (n) PopulationRatio1:000s

Lithuania 65 3,287,000 51Poland 432 38,074,000 88Hungary 78 9,993,000 128Latvia 16 2,249,000 141Bulgaria 41 7,545,000 184Slovenia 8 2,020,000 252Republic of

Macedonia7 2,042,000 292

Mongolia 7 2,671,000 382Romania 55 21,275,000 387Belarus 21 9,634,000 459Czech Rep 22 10,369,000 471Slovakia 11 5,406,000 491Albania 6 3,155,000 526Georgia 7 4,260,000 608Moldova 5 3,604,000 721Russia 165 140,874,000 854Croatia 5 4,416,000 883BosniaHerzegovina 4 3,767,000 942Ukraine 38 45,708,000 1202Estonia 1 1,340,000 1340Kyrgyzstan 3 5,482,000 1827Serbia 5 9,850,000 1970Kazakhstan 6 15,637,000 2606Armenia 1 3,083,000 3083

Table 8Indicative Ratio of Hospice-Palliative Care

Services to Populations in Africa

Country Services (n) Population Ratio 1:000s

Swaziland 5 1,185,000 237South Africa 210 50,110,000 239Botswana 4 1,950,000 490Namibia 3 2,171,000 724Reunion Island 1 800,000 800Cote d’Ivoire 26 21,075,000 811Kenya 44 39,802,000 905Uganda 34 32,710,000 962Zimbabwe 13 12,523,000 963Zambia 13 12,935,000 995Malawi 9 15,263,000 1696Gambia 1 1,705,000 1705Lesotho 1 2,067,000 2067Tanzania 20 43,739,000 2187Congo 1 3,683,000 3683Ghana 5 23,837,000 4767Rwanda 2 9,998,000 4999Tunisia 2 10,272,000 5136Sierra Leone 1 5,696,000 5696Cameroon 3 19,522,000 6507Mali 1 13,010,000 13,010Angola 1 18,498,000 18,498Sudan 2 42,272,000 21,136Nigeria 7 154,729,000 22,104Mozambique 1 22,894,000 22,894Egypt 3 82,999,000 27,666Morocco 1 31,993,000 31,993Ethiopia 2 82,825,000 41,412

Table 9Indicative Ratio of Hospice-Palliative Care

Services to Populations in the Asia Pacific andOceania Regions

Country Services (n) Population Ratio 1:000s

Niue 1 1000 1Australia 320 21,293,000 67New Zealand 48 4,266,000 89Japan 686 127,156,000 185Singapore 23 4,737,000 206

1102 Vol. 45 No. 6 June 2013Lynch et al.

DiscussionSince 2008, there has been an increase in

the number of countries of the world thathave established one or more hospice-palliative care services (þ9%), although onlya slight increase has occurred in the total num-ber of countries actively engaged in either de-livering a hospice-palliative care service ordeveloping the framework within which sucha service can be delivered (þ1%). Since2006, a total of 21 countries (9%) have movedfrom Groups 1/2 (no known activity/capacitybuilding) into Groups 3/4 (some form of

Table 7Indicative Ratio of Hospice-Palliative CareServices to Populations in Western Asian

Countries

Country Services (n) Population Ratio 1:000s

Israel 17 7,170,000 422Bahrain 1 791,000 791Kuwait 2 2,985,000 1492Jordan 4 6,316,000 1579Lebanon 2 4,224,000 2112UA Emirates 2 4,599,000 2299Saudi Arabia 3 25,721,000 8573Iraq 1 30,747,000 30,747Iran 1 74,196,000 74,196

palliative care provision). It should be ac-knowledged, however, that, within the contextof these results, there are many instances in

Korea (South) 97 23,906,000 246Malaysia 110 27,468,000 250Macau 2 573,003 286Brunei 1 400,000 400Hong Kong 15 7,122,508 475Philippines 108 91,983,000 852India 284 1,198,003,000 4218Nepal 6 29,331,000 4889Thailand 13 67,764,000 5212Cambodia 2 14,805,000 7402China 159 1,353,311,000 8511Myanmar 3 50,020,000 16,673Sri Lanka 1 20,238,000 20,238Indonesia 10 229,965,000 22,996Bangladesh 7 162,221,000 23,174Vietnam 3 88,069,000 29,356Pakistan 2 180,808,000 90,404

Table 10Gross Changes in the Number of Countries in

Each Category

Group 2006 2011 Change (n) Change (%)

1 78 (33%) 75 (32%) �3 �12 41 (18%) 23 (10%) �18 �83 80 (34%) 91 (39%) þ11 þ54 35 (15%) 45 (19%) þ10 þ4

Vol. 45 No. 6 June 2013 1103Mapping Levels of Palliative Care Development: A Global Update

which palliative care remains inaccessible tothe majority of a country’s population.

A regional analysis of palliative care develop-ment between 2006 and 2011 indicates thatthe most notable regions involved in thechange from Groups 1/2 (no known activity/capacity building) to Group 3a (isolated provi-sion) are Africa (þ9 countries), the MiddleEast (þ5 countries), and the Americas/Carib-bean (þ3 countries). In the Middle East,a good example of progress is provided by Leb-anon, which moved from Group 2 to Group3a. In Africa, much progress has been initiatedby the APCA, ably supported by funders suchas the Open Society Foundation IPCI, amongothers. Angola moved from Group 1 to Group3a because the APCA conducted an explor-atory study there and initiated some palliativecare contacts that resulted in a service beingestablished. Ghana also moved from Group 1to Group 3a because a national palliative careassociation was formed and several palliativecare services have since been established.Ethiopia, Namibia, Rwanda, and Sudan allmoved from Group 2 to Group 3a becausea palliative care infrastructure had been devel-oped and isolated palliative care services wereprovided, albeit at a low level. Cote d’Ivoiremoved from Group 2 to Group 3b for the

Table 11Changes in Palliative Care Directio

Group Coun

1 Uzbekistan (� from category 2)2 Montenegro (þ from category 1)/Aland Islands (� fr

Azerbaijan (� from category 3) Honduras (� from ca3a Angola (þ from category 1) Bahrain (þ from category

Ethiopia (þ from category 2) Ghana (þ from categoLebanon (þ from category 2) Lesotho (þ from catcategory 2) Namibia (þ from category 2) Niue (þ f(þ from category 2) Saint Lucia (þ from category 2

3b Cote D’ivoire (þ from category 2), Turkey (þ from ca4a China (þ from category 3) Luxembourg (þ from categ

3) Puerto Rico (þ from category 2) Serbia (þ fromcategory 3) Uruguay (þ from category 3) Zambia (

4b

same reason, although the progress has beenreported as ‘‘slightly greater’’ than in othercountries of the region.

Progress from Group 3 to Group 4a againshowed Africa as the most prominent region(þ4 countries). Malawi, Tanzania, Zambia,and Zimbabwe changed category because ofthe work done by the APCA and other partnersto develop and scale up palliative care in thosecountries; the APCA suggests that these coun-tries have made ‘‘tremendous progress’’ inrecent years and envisage them being recatego-rized toGroup 4b (advanced integration) in thenear future.OtherAfrican countries believed tobe close to moving from Group 3 to Group 4include Botswana, Cameroon, Morocco, andNigeria. However, the impact of funding with-drawal by The Diana, Princess of Wales Memo-rial Fund from Africa in 2012 on thecontinued development of palliative care inthe region is as yet unknown.

Progress is also reported in a number ofCEE/CIS countries after prolonged supportfrom international funders such as IPCI; for ex-ample, two countries moved from Group 3 toGroup 4a. Slovakia was recategorized becauseseveral hospice beds are now available in hospi-tals and teaching hospitals, palliative care wasbeing implemented in postgraduate educationfor physicians and undergraduate educationfor nurses, there was good availability of mor-phine, and a National Association of PalliativeCare has been established. Serbia wasrecategorized as a result of the impact of itsthree-year National Strategy for Palliative CareDevelopment, which would substantially in-crease the number of hospital/home-based pal-liative care teams and palliative care units

n by Country 2006e2011

try (þ/�)

om category 3)tegory 3)2) Belize (þ from category 2) Brunei (þ from category 2)ry 2) Iran (þ from category 2) Kuwait (þ from category 2)egory 2) Mali (þ from category 1) Mozambique (þ fromrom category 1) Paraguay (þ from category 2) Rwanda) Sudan (þ from category 2)tegory 2), Argentina (� from category 4)ory 3) Macau (þ from category 3) Malawi (þ from categorycategory 3) Slovakia (þ from category 3) Tanzania (þ fromþ from category 3) Zimbabwe (þ from category 3)

Table 12Changes in Palliative Care Direction by Region 2006e2011

Group Region (þ/�)

1 1 � CEE/CIS (� from group 2)2 1 � CEE/CIS (þ from group 1)/1 � Europe (� from group 3)

1 � CEE/CIS (� from group 3) 1 � Americas/Caribbean (� from group 3)3a 2 � Africa (þ from group 1) 7 � Africa (þ from group 2) 5 � Middle East (þ from group 2) 1 � Asia Pacific/

Oceania (þ from group 1) 3 � Americas/Caribbean (þ from group 2)3b 1 � Africa (þ from group 2) 1 � Europe (þ from group 2)/1 � Americas/Caribbean (� from group 4)4a 2 � Asia Pacific/Oceania (þ from group 3) 1 � Europe (þ from group 3) 4 � Africa (þ from group 3) 1 �

Americas/Caribbean (þ from group 2) 1 � Americas/Caribbean (þ from group 3) 2 � CEE/CIS (þ fromgroup 3)

4b

1104 Vol. 45 No. 6 June 2013Lynch et al.

throughout the country, provide education andtraining initiatives for both health professionalsand the families of patients, improve the avail-ability of oral morphine and other forms of opi-oids, and ultimately result in the integration ofpalliative care into the Serbian health caresystem.

InWesternEurope, the respondent fromLux-embourg recategorized the country fromGroup3 toGroup4a becauseof an increase in thenum-ber of hospice and palliative care units and thesubstantial development of palliative care edu-cation and training initiatives in the country;progress also has resulted from the introductionof a new law in 2009 regarding palliative care.

In the Americas/Caribbean, Uruguay was re-categorized from Group 3 to Group 4a for sev-eral reasons: the number of hospice/palliativecare services had increased, palliative care isnow recognized in the National Health Pro-gram, a Diploma in Palliative Care had beenintroduced into the State University alongwith undergraduate palliative care programsin other universities, the national associationwas ‘‘developing rapidly,’’ and the availabilityof opioids was described as ‘‘good.’’ In con-trast, although Argentina had made ‘‘major ad-vances in palliative care over the last 20 years,’’there was still only localized hospice-palliativecare provision; ‘‘great disparity’’ still existedin the palliative care that was provided, accord-ing to geography and differing levels of com-plexity; and areas still existed where palliativecare was inaccessible. As a result, Argentinawas recategorized from Group 4 to Group 3b.

LimitationsThis study has certain limitations. As with

the 2006 study, despite our best efforts in at-tempting to ascertain the status of palliative

care development, there remained an absenceof data for some countries. Also, the way inwhich services are counted proved problem-atic. Two systems operate in tandem. Servicesin five of the six continents tend to be countedby provider, irrespective of the number of ser-vices. In Europe, they are usually counted bytype (e.g., home care, day care, inpatient units,or hospital teams). Although this allows a de-gree of comparability for services in the coun-tries of Europe as well as within and across theother five continents, it also inhibits any com-parable worldwide analysis. In addition, listingservices by provider is by no means foolproofand could be a source of bias, as a countrywith few but large-scale provider organizationswould show a lower ratio of services per capitacompared with a country having several smallproviders. Differences in the way in which ser-vices are counted may be an artifact of the waysin which relevant studies have worked and theprocedures of the ‘‘counting’’ organizations.We attempted to address these issues by listingthe number of providers and services in thesame category of data under the heading‘‘services/providers,’’ and attempting to gleanclarification from key persons and local pallia-tive care experts.A major problem was that of standar-

dization and definition in how services arecharacterized. Terms such as ‘‘hospice,’’ ‘‘inpa-tient unit,’’ or ‘‘mobile team’’ do not have a uni-versal currency, and globally, there weredifficulties in comparing ‘‘like with like.’’ Wealso note the diversity of provision and the dif-ferent ‘‘histories’’ of palliative care in specificjurisdictions and acknowledge the absence ofagreed upon standards and quality measuresglobally. In addition, most data regarding pal-liative care development originate from

Vol. 45 No. 6 June 2013 1105Mapping Levels of Palliative Care Development: A Global Update

palliative care activists in each respective coun-try, and this is acknowledged as a potentialsource of bias or inaccuracy.

Respondents were selected from data pro-vided by a variety of sources, for example, the2006 study, the EAPC Task Force for the Devel-opment of Palliative Care in Europe, IOELCreviews and databases, and information fromwork that we had undertaken on other relatedprojects. Respondents in 2011 were asked tograde the level of palliative care developmentin their respective country. A limitation wasthat respondents often experienced difficultyin choosing between the divided Groups 3aor 3b and 4a or 4b. Some respondents sug-gested that their country ‘‘did not fit into anycategory,’’ that their country was ‘‘somewhereon the border’’ between two categories, orthat ‘‘strengths and limitations’’ existed withineach subcategory. This situation was reflectedin several countries in the CEE/CIS, where na-tional palliative care associations had beenformed but because of financial problemsand political changes that resulted in inconsis-tent public health policy, the progress of palli-ative care remained ‘‘very slow.’’ Respondentsfrom the Americas/Caribbean also experi-enced some difficulty in determining betweenthe newly divided categories, for example, therespondent from Panama stressed that hercountry was ‘‘not 3a at all, but cannot be cate-gorized as 3b either.’’ In the Asia Pacific andOceania region, the respondent from Nepalexperienced some difficulty in choosing be-tween Groups 3a and 3b, whereas the respon-dent from Australia found differentiatingbetween Groups 4a and 4b somewhat problem-atic. Several Western European countries (e.g.,Austria, Denmark, The Netherlands, andSpain) also had difficulty in categorizingthemselves in either Group 4a or Group 4b,suggesting that they often ‘‘scored differentlyfor the different items’’ and, therefore, were‘‘somewhere in between.’’ In the African re-gion, the respondent from South Africa pro-posed another subcategory within Group 4 tofurther refine the typology.

ConclusionWe have demonstrated that it is possible to

map and measure levels of palliative care de-velopment, country by country, throughout

the world. Our purpose is to facilitate cross-national comparative analysis and stimulateadvocacy, policy making, and service develop-ment. To provide a more refined view of exist-ing levels of palliative care development, themapping exercise from 2006 was updated,new data were collected, and the typologywas amended. The strong association betweenthe categorization of palliative care develop-ment and human development provides an in-dication that the typology has an element ofvalidity and reliability. Limitations to the studyincluded the absence of data for some coun-tries, problems in the counting and categoriza-tion of services, self-reporting by key personswho may have been subject to bias or inaccur-acy, and respondents’ difficulty in choosing be-tween the newly divided categories.

In 2011, 136 of the world’s 234 countries(58%) had one or more hospice-palliativecare services established, an increase of 21countries (þ9%) from 2006. A regional analy-sis of palliative care development between2006 and 2011 indicates that the most signifi-cant gains have been made in Africa. Althoughthere are indications of interest in palliativecare on the part of national governments andpolicy makers, advanced integration of pallia-tive care with wider health services has beenachieved in only 20 countries globally(8.5%). Despite increasing calls for palliativecare to be recognized as a human right, thereremains much to be done before palliativecare is accessible equitably and globally.

Disclosures and AcknowledgmentsThis study was commissioned by the World-

wide Palliative Care Alliance and was under-taken independently in consultation with thefunding body. There are no potential conflictsof interest in the research reported or thedevelopment of the submission.

During the course of this study, advice wassought from a number of organizations and in-dividuals involved in palliative care worldwide.The authors are greatly indebted to all whocontributed and provided valuable advice, in-formation, and assistance. Special acknowledg-ment is given to the International Observatoryon End of Life Care for continued support andassistance throughout the duration of thisproject.

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References1. Clark D, Centeno C. Palliative care in Europe:an emerging approach to comparative analysis.Clin Med 2006;6:197e201.

2. Clark D, ten Have H, Janssens R. Commonthreads? Palliative care service developments inseven European countries. Palliat Med 2000;14:479e490.

3. Clark D, Wright M. Transitions in end of lifecare. Hospice and related developments in EasternEurope and Central Asia. Buckingham: Open Uni-versity Press, 2003.

4. Centeno C, Clark D, Lynch T, et al. EAPC atlasof palliative care in Europe. Houston: IAHPCPress, 2007.

5. Jaspers B, Schindler J. Status of Palliative Careand Hospice Care in Germany compared to selectedother States: Belgium, France, Great Britain, Nether-lands, Norway, Austria, Poland, Sweden, Switzerlandand Spain. [in German] In: Client: Study Commis-sion of the Bundestag ‘‘Ethics and Law in ModernMedicine’’, 2004. Available from http://www.dgpalliativmedizin.de/pdf/Gutachten%20Jaspers-Schindler%20Endfassung%2050209.pdf. AccessedFebruary 10, 2010.

6. Gronemeyer R, Fink M, Globish M, SchumannF. Project on hospice and palliative care in Europe:Helping people at the end of their lives. Berlin: LitVerlag (English edition), 2005.

7. Wright M, Wood J, Lynch T, Clark D. Mappinglevels of palliative care development: a global view.J Pain Symptom Manage 2008;35:469e485.

8. Martin-Moreno J, Harris M, Gorgojo L, et al.Palliative care in the European Union. EuropeanParliament Economic and Scientific Policy Depart-ment, 2008. Available from http://www.europarl.europa.eu/activities/committees/studies/download.do?file¼21421. Accessed January 11, 2011.

9. Economist Intelligence Unit. The quality ofdeath: ranking end-of-life care across the world. Areport commissioned by the Lien Foundation.2010. Available from http://www.eiu.com/site_info.asp?info_name¼qualityofdeath_lienfoundation&page¼noads. Accessed July 2, 2012.

10. Human Rights Watch. Global state of pain treat-ment. Available from http://www.hrw.org/reports/2011/06/01/global-state-pain-treatment-0. AccessedNovember 16, 2011.

11. United Nations. International human develop-ment indicators. Available from http://hdr.undp.org/en/statistics/. Accessed November 24, 2011.

12. WorldHealthOrganization. Countries. Availablefrom http://www.who.int/countries/en/. AccessedNovember 12, 2011.

13. Central Intelligence Agency. The world factbook. Available from https://www.cia.gov/library/publications/the-world-factbook. Accessed November16, 2011.