Mapping Palliative Care Availability and Accessibility: A First Step to Eradicating Access Deserts in the Low- and Middle-Income Settings

Abstract

Objective:

Palliative care is unavailable and/or inaccessible for the majority of people in low- and middle-income countries (LMIC). This study aims to determine the availability and accessibility of palliative care services in Malaysia, a middle-income country that has made good progress toward universal health coverage (UHC).

Method:

Publicly available data, and databases of registered palliative care services were obtained from governmental and non-governmental sources. Google Maps and Rome2Rio web-based applications were used to assess geographical disparities by estimating the median distance, travel time, and travel costs from every Malaysian district to the closest palliative care service.

Results:

Substantial variations in availability, components, and accessibility (distance, time, and cost to access care) of palliative care services were observed. In the highly developed Central Region of Peninsular Malaysia, specialty care was available within 4 km whereas in the less-developed East Coast of Peninsular Malaysia, patients had to travel approximately 46 km. In the predominantly rural East Malaysia, basic palliative care services were 82 km away and, in some instances, where land connectivity was scarce, it took 2.5 h to access care via boat. The corresponding median travel costs were USD2 (RM9) and USD23 (RM114) in Peninsular Malaysia and East Malaysia.

Conclusion:

The stark urban–rural divide in the availability and accessibility of palliative care services even in a setting that has made good progress toward UHC highlights the urgent need for decentralization of palliative care in the LMICs. This may be achieved by capacity building and task shifting in primary care and community settings.

Introduction

Palliative care is a fundamental component of universal health coverage (UHC) and yet 80% to 90% of the global palliative care needs remain unmet. Globally, 32% of countries lack hospice and palliative care activity, whereas 32% offers isolated services. Less than 10% of countries worldwide have advanced, integrated palliative care provision.^1,2 Strikingly, the majority of the unmet need for palliative care is in the low- and middle-income countries (LMIC).^3,4 Southeast Asia has an overall population of 679.69 million people living in the region.⁵ Malaysia occupies a central position within Southeast Asia consisting of 2 land masses separated by South China Sea and a total land area of 330 289 square kilometers. Malaysia, an upper middle-income country with a population of 33.4 million people⁵ occupies a central position within Southeast Asia consisting of 2 land masses separated by South China Sea and a total land area of 330 289 square kilometers. The nation has made good progress toward UHC and has a high human development index, where highly subsidized healthcare is made available through a nationwide network of public hospitals and primary care clinics. The Global Atlas of Palliative Care,⁶ however, reports that Malaysia has isolated palliative care access, characterized by services that are patchy in scope and poorly supported. Most community-based palliative care in the country is donor-dependent, with limited morphine availability.^3,7

Between 2014 and 2030, Malaysia’s population with serious health-related suffering (SHS) amenable to palliative care is expected to increase by 240%,⁸ amplifying the urgent need for increased access to holistic palliative care services, including pain and symptom management. Community-based access is particularly important for patients living in rural or geographically isolated regions. Equitable access to palliative care medicines including opioids is critical in optimizing quality of life following SHS and ensuring a dignified death.^9,10

Palliative care in Malaysia is delivered via several mechanisms namely hospital-based palliative care, domiciliary palliative care (offered as part of UHC by the public primary care clinics), and community-based services (offered free of charge by nongovernmental organizations [NGOs]).¹¹ The bulk of palliative care patients managed in the community settings are based on referrals from the hospitals.¹² There is presently a lack of empirical data that illustrates palliative care accessibility in Malaysia, in conjunction with an in-depth description of available services. This study aimed to fill the gap.

Method

Data Collection

Data collection took place between August 2021 and March 2022. Ethical approval was obtained from the Medical Research and Ethics Committee, Ministry of Health Malaysia (ID NMRR-21-1263-60284).

All clinical cate services outside the public health system are mandated to be registered with the Ministry of Health (Act 586: Private Healthcare Facilities And Services Act 1998).¹³ Data on registered palliative care services available in the public and private health sectors were sourced from databases of the National Palliative Care Services, and the Family Health Development Division of Ministry of Health Malaysia.¹⁴ Data on community-based palliative care service were obtained from the records of the Malaysian Hospice Council.¹⁵ Details of the providers, locations, and components of palliative care services, as well as the qualifications of service providers, were extracted and mapped to all the districts or territories in Malaysia. Geographical disparities in access to formal palliative care services were also assessed by estimating the distance, time taken to access care, and travel costs requited for Malaysians with SHS to obtain care.

Study Setting

Malaysia comprises 2 noncontiguous regions: West (Peninsular) Malaysia and East Malaysia (located in Borneo Island). Peninsular Malaysia is more developed and accounts for a majority of the population and economy, whereas East Malaysia is predominantly rural (Table 1). In the present study, accessibility to palliative care services was determined for all 157 districts in East, and Peninsular Malaysia, as well as the small state of Perils, and the Federal Territories of Kuala Lumpur, Putrajaya, and Labuan. We also examined accessibility by geographical regions.

Table 1.

Population, Median Monthly Income and Poverty Rate by Regions, Malaysia.

Region	State	Classification	Population (in 100,000)a	Elderly population aged > 65 years (%)b	Median monthly household income (USD)a	Poverty rate (%)a
Central		Highly developed
	Selangor		6538.1	6.0	1720	1.7
	FT Kuala Lumpur		1773.7	8.3	2142	0.4
	FT Putrajaya		110.0	2.1	2295	0.2
East Coast		Mainly rural
	Pahang		1678.6	8.0	950	8.8
	Kelantan		1906.7	6.9	709	21.2
	Terengganu		1259.2	6.0	1128	12
North		Mainly urban
	Penang		1773.6	9.6	1289	3.3
	Kedah		2185.2	8.7	902	12.7
	Perak		2510.3	11.5	885	11.4
South	Perlis	Developed	254.9	9.8	952	9.9
	Negeri Sembilan		1128.8	9.0	1055	6.6
	Melaka		932.7	9.0	1283	6.1
	Johor		3781.1	7.9	1340	5.9
East Malaysia		Largely rural Less industrialized
	Sabah		3908.5	4.1	889	26.3
	Sarawak		2816.5	8.5	902	12.9
	FT Labuan		99.6	5.3	1443	5.2

^aAs of year 2020, Department of Statistics Malaysia (DOSM) official website¹⁶

^bAs of year 2020 My Demography Dashboard, DOSM.¹⁷

Statistical Analysis

The route planner under the “get directions” function in Google Maps web platform was utilized to determine the median distance, time taken to access care either by patients or by the healthcare workers to reach out to the community, and cost of public transportation between a district to the closest health facility offering palliative care. Distance and the time taken to travel both by car and via public transportation were calculated for morning (8 am) and late afternoon (3 pm) to capture differences in traveling time between light-traffic and rush hour periods. The geographical center of the districts was entered as the starting points and health facility entrances as end points. In Perlis and the Federal Territories, the center of the state or territory was used to map accessibility to the nearest palliative care services. The cost for traveling one-way via public transportation was calculated from each district to the nearest facility, using Google Maps (https://g.co/kgs/JehfLc), and the Rome2Rio (https://g.co/kgs/Y8c2cT) web-based applications.

Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Distance, time taken to access care, and travel costs were summarized using medians for each state. Exact distance, time, and cost were generated for the state of Perlis and the Federal Territories of Kuala Lumpur, Putrajaya, and Labuan.

Results

Availability of Palliative Care Services in Malaysia

As of December 2021, there were 34 public tertiary hospitals offering palliative care services under Ministry of Health Malaysia (Table 2). Of these, 4 comprised inpatient palliative care units with resident palliative care physicians; 9 with weekly or biweekly visiting palliative care physicians; 6 with services delivered by designated medical officers with basic palliative care training or medical officers rotating from internal medicine departments; and 11 with palliative care delivered by a specialist from a clinical department outside of palliative care. Four public teaching hospitals offered palliative care services (Table 2), 2 of which were in Kuala Lumpur, and 1 in Selangor and in Negeri Sembilan, respectively. Inpatient palliative care services were nonetheless only available in one teaching hospital. In the private sector, only 5 private hospitals had a resident palliative care physician. It is noteworthy that the great majority of the teaching and private hospitals offering palliative care services in the nation was concentrated in Klang Valley, a large urban agglomeration in the Central Region of Peninsular Malaysia.

Table 2.

Availability of Palliative Care Services in Malaysia as of December 2021.

State	Number of districts	Total facilities N = 124 n (%)	Specialty care: MOH hospital N = 17 n (%)	Specialty care: Public university hospital N = 4 n (%)	Speciality care: Private hospital N = 5 n (%)	Care led by nonpalliative care physicians: MOH hospital N = 17 n (%)	Domiciliary care: Public N = 50 n(%)	Community-based care: NGO N = 29 n (%)
Selangor	9	43 (34.6)	4 (24)	2 (50)	3 (60)	0	27 (54)	5 (17)
FT Kuala Lumpur	1	6 (4.8)	2 (12)	1 (25)	2 (40)	0	0	1 (3)
FT Putrajaya	1	2 (1.6)	1 (6)	0	0	0	0	1 (1)
Johor	10	7 (5.6)	0	0	0	5 (29)	0	2 (7)
Kedah	12	13 (10.4)	2 (12)	0	0	0	10 (20)	1 (3)
Kelantan	10	4 (3.2)	0	0	0	2 (12)	0	2 (7)
Melaka	3	2 (1.6)	0	0	0	1 (6)	0	1 (3)
Negeri Sembilan	7	2 (1.6)	1 (6)	1 (25)	0	0	0	1 (3)
Pahang	11	3 (2.4)	0	0	0	2 (12)	0	1 (3)
Penang	5	7 (5.6)	2 (12)	0	0	1 (6)	1 (2)	3 (10)
Perak	12	19 (15.3)	4 (24)	0	0	0	12 (24)	3 (10)
Perlis	0	0	0	0	0	0	0	0
Terengganu	8	2 (1.6)	0	0	0	1 (6)	0	1 (3)
FT Labuan	1	0	0	0	0	0	0	0
Sabah	27	7 (5.6)	1 (6)	0	0	2 (12)	0	4 (13)
Sarawak	40	7 (5.6)	0	0	0	3 (18)	0	4 (13)

Abbreviations: MOH, Ministry of Health; NGO, nongovernmental organization.

Thirty-one percent (n = 50) of the 160 public primary care clinics (Klinik Kesihatan) in Malaysia offered domiciliary palliative care services (Table 2), concentrated in 4 states: Kedah, Penang, Perak (Northern Region), and Selangor (Central Region). Patients managed by domiciliary palliative care teams were those considered stable and bedridden and referred from palliative care units of public hospitals. Home visits were conducted by an interprofessional team of doctors, nurses, medical assistants, and occasionally dieticians, physiotherapists, and/or occupational therapists, supervised by a family health physician. The team provided basic wound care, health services, education, and psychosocial support for patients and their caregivers (Table 3). Patients who lived in Putrajaya (and within a 35 km radius) received palliative care through the home nursing unit of the National Cancer Institute.

Table 3.

Component of Palliative Care Services Provided in Various Settings in Malaysia.

Component of care	Hospital-based care	Domiciliary palliative carea	Community-based palliative caseb
Pain management
Symptom control
Opioid availability
Other essential palliative care drugsc
After-hours care
End of life care
Advance care planning
Trained staff
Respite care
Psychospiritual support
In-patient care
Home care
Loan of medical equipment

^aHome-based palliative care service provided by a multidisciplinary group from the public health clinic (Klinik Kesihatan) led by a doctor

^bHome-based palliative care service provided by NGOs consisting of multidisciplinary healthcare workers and volunteers led by a doctor

^cList of essential palliative care medications as per World Health Organization recommendations.

Available

Partially available

Not available

Beyond the public and private health institutions, there were a total of 29 registered teams offering community-based palliative care across Malaysia (Table 2), which were free and provided by NGOs. Twenty-five teams were registered under the Malaysian Hospice Council, whereas 4 were under other organizations. These teams were operating in most parts of Malaysia, except for Perlis and Labuan.

Across the various layers of healthcare settings, the range of service provision varied based on staff competency and training as well as availability of medication and equipment (Table 3). Within the hospital settings, types of services largely depended on availability of inpatient units, resident palliative care physicians, or other clinical specialists. Services provided by the domiciliary team meanwhile tended to be very basic and did not cover all the domains of services as per WHO recommendation including end-of-life care and psychospiritual care. Pain management was also restricted in terms of availability of opioids. The competency and knowledge of the staff who were involved varied across the various states as not all healthcare professionals received formal training (data not shown).

Accessibility to Palliative Care Services in Malaysia

Median distance to the nearest palliative care facility in the Central Region of Peninsular Malaysia was 3.7 km. The median cost of traveling via public transport in this region was also the cheapest for patients, costing about RM 4.50 (USD 1.00) one-way (Table 4). Traveling time (one-way), averaged between 8 am and 3 pm, was 17 min via car and about 28 min via public transport.

Table 4.

Distance, Time Taken to Access Care, and Cost of Travel to the Nearest Facility With Palliative Cares Service in Malaysia.^a

Region	State	No of districts	Distance (km)	One way time taken to access careb (minutes)		One way time taken to access carec (minutes)		One way travel costc (RM (USD))
				8 am	3 pm	8 am	3 pm
Central		11	3.7	16	16	23	23	4.45 (1.00)
	Selangor	9	3.3	14	16	23	23	4.45 (1.00)
	FT Kuala Lumpur	1	6.8	18	14	21	21	1.90 (0.50)
	FT Putrajaya	1	4.8	22	22	33	33	0.50 (0.10)
East Coast		32	45.7	70	80	90	80	34.30 (7.00)
	Pahang	10	79.3	80	100	143	94	14.00 (3.00)
	Kelantan	12	35.7	52	62	45	55	78.00 (17.00)
	Terengganu	10	27.4	52	40	65	60	16.30 (4.00)
North		18	13.05	23	25	35	32	6.80 (1.00)
	Penang	5	13.0	28	28	38	37	2.00 (0.50)
	Kedah	12	12.3	18	20	25	17	6.80 (2.00)
	Perak	1	16.1	27	25	33	35	7.90 (2.00)
	Perlis	0	47.1	75	85	181	181	31.00 (7.00)
South		14	29.0	60	60	81	81	6.80 (1.00)
	Negeri Sembilan	1	37.6	65	60	127	102	5.90 (1.00)
	Melaka	3	23.6	55	55	74	68	5.20 (1.00)
	Johor	10	36.3	62	50	79	79	11.00 (2.00)
East Malaysia		19	82.3	110	110	111	82	104.00 (22.00)
	Sabah	7	83.3	110	100	112	101	54.00 (12.00)
	Sarawak	11	81.3	115	130	110	74	132.00 (29.00)
	FT Labuan	1	169.0	270	280	357	357	60.00 (13.00)

Abbreviation: FT, Federal Territory

^aMedian value is shown for all states which has more than 3 districts, whereas exact value is shown for states with less than 3 districts (all federal territories and state of Perlis).

^bCar.

^cPublic transport.

In Pahang (East Coast Region)—one of the largest states in Peninsular Malaysia with a population of 1.681 million—there were only 3 facilities offering palliative care (Figure 1). Here, the median distance to the nearest facility was 79 km, and the average time taken to travel was about 78 min by car and 121 min via public transport, costing approximately RM 14.00 (USD 3.00) one way. People from the Bera district of Pahang needed to travel about 150 km, which took approximately 5 h and 20 min to travel via public transport. For the rest of the population in Pahang, it costs around RM 67 (USD 15.00) (Table 4). Residents of the other 2 states of the East Coast region—Terengganu and Kelantan had to travel to the neighboring state of Pahang to receive specialist palliative care consultation and services, incurring substantial costs.

Figure 1.

Distribution of palliative care facilities, by Malaysian states.

Patients on Penang Island (Penang state; largely urban and located in the Northern Region of Peninsular Malaysia) relied mainly on specialist care at Hospital Pulau Pinang, a Ministry of Health-owned facility, and 2 community-based NGO-operated palliative care services. Domiciliary palliative care from public sector was not available on the island (Table 2). Patients on mainland Penang, on the other hand, only had access to domiciliary palliative care in one primary care clinic (Table 2) and rely on 2 public hospitals for access to specialist palliative care. Palliative care services were not available in the state of Perlis (Table 2), and patients needed to travel about 50 km to the state of Kedah (Table 4). The corresponding time taken to access care was estimated to be about 80 min via car and 101 min via public transportation between 8 am and 3 pm. Such a journey costs about RM 31.00 (USD 7.00) one way (Table 4).

As for the rural states in East Malaysia (Sarawak, Sabah, Federal Territory of Labuan), the overall median traveling distance to the nearest facility offering palliative care service was 82 km. Median time taken to access care was 128 min via car and 132 min via public transportation (Table 4). Of note, the residents of the Federal Territory of Labuan, which is an island off the state of Sabah in East Malaysia, had to travel about 169 km to access palliative care, taking about 4 h and 30 min to travel via ferry, costing them about RM 60 (USD 13.00) one way. In Sarawak, which is the biggest state in Malaysia, specialist palliative care was only available in 3 districts. Community-based palliative care was scarce, provided by NGOs only in 2 of the 40 districts in the state. In the rural districts of Daro and Matu in Sarawak, land connectivity was limited. Here, patients needed to travel for about 2 h and 30 min via boat or boat ambulance to the nearest facility offering palliative care. In the rural state of Sabah, a resident typically needed to travel 116 min (public transport) to access palliative care, costing around RM 54 (USD 11.00) one-way.

In sum, palliative care accessibility was least burdensome in the Central Region, where services were within 4 km in at least half of the districts, taking between 14 and 23 min to travel via car and public transportation, respectively. In comparison, the corresponding median distance that needed to be traveled by patients residing in East Malaysia was 20 times further (82 km). The journey also took 5 times longer (between 128 and 132 min). Even within Peninsular Malaysia, disparities in access were noticeable (Table 4). Most specialist and community-based care were concentrated in the Central Region. Median costs for traveling via public transportation from East Coast of Peninsular Malaysia were about 7.5 times more than those from the Central Region (RM 34.30 [USD 7.50] vs RM 4.45 [USD 1.00], one way).

Discussion

We used a pragmatic approach to map the availability and accessibility of palliative care services in Malaysia, an upper-middle-income country that has achieved much progress toward UHC. Substantial disparities were found not only in the availability and components of palliative care services but also in terms of distance, travel time, and travel cost to access care: Patients in the more developed regions could access specialist palliative care within a reasonable distance, while the rural areas were direly isolated from even basic palliative care with long time, and distance taken to access care, and incurring high travel costs.

Although palliative care access has expanded remarkably over the past decade in Malaysia,¹⁸ the present results corroborate the notion that services remain heavily dependent on public tertiary hospitals.^18,19 The COVID-19 pandemic has exposed the fragility of hospital-based palliative care delivery model that failed in the face of lockdowns and palliative care work-force redeployment.²⁰ COVID-19 is just one example of the urgent need for decentralized palliative care delivery and decongestion of tertiary care services through task shifting and capacity building in primary care settings in Malaysia as well as in the other LMICs.¹⁸

The current study findings emphatically demonstrate the burden (distance, time, and cost) imposed by isolated palliative care services on the general population dealing with SHS. Substantial empirical within-country differences in service availability, distance, time taken to access care, and cost all complicate equitable access to palliative care even in the context of Malaysia’s heavily subsidized public healthcare system. These disparities were especially evident between the Central Region (eg, urban/developed) and East Malaysia and the East Coast of Peninsular Malaysia (eg, rural or isolated). This urban-rural divide in accessibility to palliative care is striking considering that Malaysia’s population is rapidly aging,¹⁴ and that about 70% of patients will die with palliative care needs by 2030.²¹

Our results show that palliative care services in primary care and community settings remain underdeveloped in most of Malaysia. They are mainly provided by the Ministry of Health Malaysia and a handful of NGOs and remain unevenly distributed, with most services limited to urban areas. As palliative care is not present near home in most parts of the country, it is conceivable that many patients in rural areas are constrained to their homes with unrelieved suffering in advanced illness and at the end of life. Even in instances where domiciliary care or community-based palliative care is available, there are formidable systemic barriers. Firstly, there are no national minimum standards to guide public or private community-based palliative care in Malaysia,^18,19,22 making it difficult to gauge the quality of services that are being delivered. Although the Ministry of Health delivers domiciliary palliative care in some districts, the present scope of services appears quite basic. Prior evidence also suggests that most doctors working in community settings have no access to palliative medicines (eg, opioids),²² and the healthcare workers’ and volunteers’ skills vary greatly given the absence of standardized training.^18,22 However, promising models do exist locally and can be replicated with better fiscal and advocacy support from the public health system and the government at a scale. For instance, Hospis Malaysia in Kuala Lumpur is a charitable organization providing palliative care services for an estimated 2000 patients per year.²³ Although the organization has demonstrated consistent delivery of services for more than 3 decades, national expansion of such a model will be challenging in the face of its current financing mechanism, which is largely dependent on private donors.¹⁸

While this study showed that specialist palliative care services were available in close proximity to patients residing in urban areas, this does not preclude other access barriers namely the long waiting times for inpatient and outpatient services in Malaysian public hospitals.²⁴ Furthermore, there is presently an absence of identifiable pathways for patients requiring palliative care to receive immediate medical attention in the emergency departments. Lack of primary-care or community-based palliative care services may also increase the burden of health systems with potentially avoidable hospitalizations, unnecessary intensive medical management, and hospital deaths,²⁵ as have been demonstrated in the United States where pain-related emergency department visits increased 51% between 2007 and 2017 in the setting of decreased opioid prescription and, thus, poorer quality pain management.²⁶

Like Malaysia, many other LMICs are facing similar problems when it comes to equitable access to palliative care despite the fact that they are facing exponential growth in the burden of noncommunicable diseases.²⁷ The disparity is alarming where about half of the poorest populations live in countries, which only receive around 1 % of the global morphine distribution.²⁸ Despite being declared as a basic human rights by WHO, only about 14% out of the 40 million people who need palliative care are receiving it and they are mainly from higher income countries.²⁹

Therefore, decentralization of palliative care delivery should be a key strategy and a top priority for policymakers in the LMICs. Strengthening community-based palliative care services provided by both the public sector and NGOs will be central to tracking palliative care development in the future.³⁰ The health system to this end must strive for innovative approaches to increasing palliative care training and access to medicines and equipment in primary care and community settings.

One such example is the Extension for Community Healthcare Outcomes (ECHO) project, a telementoring initiative that has been initiated in several LMICs and demonstrated to boost the confidence, knowledge, and skills of the healthcare workers in primary care and community settings in providing palliative care services.^31–34 The ECHO Primary Palliative Care Project in Malaysia that was initiated in March 2022 for instance is delivered via a web-based videoconferencing platform, connecting palliative care experts with health care workers to provide core palliative care knowledge and skills, as well as to share experiences using case discussions and didactic talks.³⁵

Another example is the collaboration between American Society of Clinical Oncology (ASCO) and Sarawak General Hospital.³⁶ A train the trainer program, International Development and Education Award, palliative care e-course, and translation of ASCO’s educational materials, ensuring that language is not an obstacle to acquiring palliative care knowledge.³⁶ Similar outcomes have been reported in other countries such as Brazil, Mexico, Greece, Canada, Romania, Saudi Arabia, and United Arab Emirates where combined knowledge and competence increased from 46% prior to the course to 84% after course completion.³⁷

Nonetheless, progress cannot be made without governmental commitment to finance standardized training in generalist level palliative care for all healthcare professionals. The LMICs can learn valuable lessons from Thailand, an upper middle-income country in Southeast Asia, which has demonstrated Ministry of Health policy support that has led to budgetary allocations for palliative care services and expanded community partnerships across the country.^18,21 Apart from that, a national health policy on palliative care was introduced, with the goal of establishing a palliative care unit in each regional general hospital and about 300 community hospitals by the year 2016 and with full-time trained nurses to serve as the unit’s care coordinator.³⁸

Given the identified lack of community-based palliative care services even in settings with progressive universalism such as in the present study, there is also an urgent need for public advocacy that is separate from the health system, where citizens can take responsibility for improved palliative care access. Compassionate community models worldwide provide a citizen-oriented approach to providing practical support in death, dying, and grieving throughout neighborhoods, work-places, faith communities, and other social networks.³⁹

To the best of our knowledge, this is the only study that provides data on distance, travel time, and travel costs to access palliative care alongside an in-depth analysis of service availability in an LMIC setting. Our findings provide the much-needed empirical evidence to urge the health policymakers and government to develop public health level strategies and allocate funding to enable the decentralization of palliative care in the nation. It is recommended that other LMICs also undertake a similar exercise to assess the availability and accessibility of palliative care services in their respective settings.

Limitations

An inherent limitation of the current study nonetheless is that data on quality of palliative care was not available. Furthermore, only registered facilities were captured, hence potentially missing the informal providers of palliative care services such as faith-based organizations. While this study identifies accessibility to palliative care service, the scope of services provided in various types of facilities is not stated. Data on type of integration that exists among services are not available, and it can be useful to further explore the equity of palliative care services in Malaysia.

Conclusion

Our findings highlight the urgent need for capacity building and task shifting, which will facilitate the decentralization of palliative care in Malaysia, and other LMICs alike. Palliative care services are considered an ethical shared responsibility of the entire health system and should be comprehensively provided regardless of patient’s location.⁴⁰ Political will and public–private partnerships between agencies and sectors may aid in overcoming some of the barriers to equitable access (eg, resource limitations, lack of training, and access to medications).⁴¹