Table 2.

Summary of aims and key findings of the included reviews

Author (Year), Implementation Year(s), Country/Region	Review aim	Setting/ Population	Findings
			Barriers	Possible facilitators/recommendations for improvement
Donkor, Luckett, Aranda and Phillips [39], 1990–2017 Australia Systematic review, included 18 studies	To identify the facilitators and barriers to the implementation of cancer treatments and PC.	LMICs Cancer	Health system: • Drug importation process Policy: • Lack of financial support • Limited political commitment • Restrictive pharmacovigilance laws and regulations • Fragmented health system Organisation/ structure: • Limited physical infrastructure	Personal: • Education • Community sharing Health system: • Creating a learning environment • Information management system Policy: • Payment support • Stakeholder sharing • Political commitment • Positive relationships with international organisations • Strategy aligned with national policy
Soto-Perez-de-Celis [46] 2017 USA	To identify the existing deficiencies and providing a framework for the improvement of PC.	Latin America Cancer	Personal: • Cultural barriers Health System: • Lack of opportunities for clinical training Policy: • Inadequate or inappropriate legislation • Lack of comprehensive national PC plans • Unreliable reporting of data Organisation/ Structure: • Insufficient infrastructure	Personal: • Improve education • Enhance cultural aspects • Individualized care for patient’s preferences and beliefs Health System: • Increase the availability of pain medication • Training to all HCPs • Enhance, expand access to medication Policy: • Design comprehensive PC plans • Integrate end-of-life care into national health care laws • Enhance research Organisation/ Structure: • Improve infrastructure
Fadhil et al. [40] 2017 Egypt	To identify barriers to the development of PC.	Eastern Mediterranean Region Cancer	Personal: • Poor awareness of policy makers about PC • Poor awareness of HCPs about PC • Poor public awareness Health System: • Little partnership working • Insufficient PC education for HCPs • Gaps in access to essential pain-relief medicines. Policy: • Scarcity of national plans and policies • Complicated political situations • Weak health-care systems • Absence of PC in national policies	–
Ali [47] 2016 Kenya	To assess the integration of PC services into the public healthcare system	Kenya cancer	–	Health system: • Training HCPs • A higher diploma in PC  Policy: • The government budget for PC services • Include PC in local health strategies and plans. • National PC guidelines
Hannon et al. [33] 2015 Canada	To overcome barriers that continue to affect the availability of PC in LMICs.	LMICs cancer	Personal: • Negative attitudes about PC and death and dying Health System: • Limited access to opioid medication • Lack of training of HCPs and volunteers Policy: • Lack of investment in health systems	Personal: • Education of HCPs • Shifts in societal norms to PC • Shifts in HCPs norms to PC Health System: • Changes in legislation restricting access to opioid medications • Training of health professionals; Policy: • A health policy that supports the integration of PC • Investment in systems of health care delivery • Development of rigorous data and research • International partnerships
Rochmawati et al. [48] 1990–2015 Indonesia Systematic review, includes 9 studies	To identify facilitators and barriers to the provision of PC.	Indonesia Cancer, HIV/AIDS	Personal: • Knowledge deficit and misunderstanding of HCPs Health System: • Difficult access to narcotic drugs Organisation/ Structure: • Geography	Personal: • Family and community support Policy: • Policy and organisation support Health System: • Volunteering
Abdel-Razeq et al. [32] 2014 Jordan	To discuss challenges and offer suggestions for the improvement of cancer management.	Jordan Cancer	Personal: • Negative HCPs attitudes • Negative public attitudes Health System: • Lack of specialized human resources • Lack of adequate training of responsible staff • Interrupted opioids supply and availability • Shortage of trained female nurses • Few specialized ancillary support personnel Policy: • Not available outcome data at a national level	Personal: • Increase HCPs knowledge Health System: • Structured training programs for HCPs Policy: • Integration of both clinical care and clinical research
Zeinah et al. [34] 2012 Qatar	To outline current PC at Middle Eastern countries. To address major challenges hindering the development of PC.	Middle East countries Cancer	Personal: • Lack of education and awareness Health System: • Shortage of specialized PC teams Policy: • Political issues • Scarcity of resources • Shortage or lack of funding • Lack or deficiency governmental support Organisation/ Structure: • No application of service (including opioid use and expertise)	Personal: • Raising awareness of the public on opiophobia; • Raising awareness of the HCPs on opiophobia. Health System: • Informal training to medical oncologists in PC. • Providing formal education to HCPs Policy: • Adequate funding for training programs.
Basu et al. [35] 2013 USA	To provide an overview of the progress in providing PC in low- and medium-resource countries. To present the development of PC in Ethiopia.	LMICs Cancer	Personal: • Negative cultural attitudes and beliefs of patients • Negative cultural attitudes of physicians Health System: • Lack of a trained workforce; • Lack of availability of opioids or restricting in their use Policy: • Lack of funding	–
Silbermann et al. [49] 2012 Israel	To address the accomplishments and challenges of palliative cancer care in Middle Eastern countries.	Middle East countries Cancer	Personal: • Families’ feeling of alienation and isolation • Families’ fear of neglect by the primary physician Health System: • Lack of relevant training of HCPs • Poor accessibility to essential PC drugs • Delay in referrals Policy: • Lack of health policies and plans	Personal: • Education of physicians and nurses about PC principles • A community-based orientation Health System: • Introduce PC principles into the curricula • Develop postgraduate training programs for physicians and nurses. Policy: • Public policy
Elcigil [50] 2011 Turkey	To assess the status of PC in Turkey.	Turkey Cancer	Personal: • Lack of PC education • Lack of public awareness • Limited knowledge of opioid analgesics Health System: • Lack of training programs • Shortage of nursing staff • Lack of certification for PC Nursing Policy: • Very limited research	Personal: • Increase public awareness channels Health System: • Disseminate information on certification of PC nurses to agencies. Policy: • Establish interdisciplinary research on PC concepts • Increase funding for research • Evidence-based curriculum to strengthen the teaching of PC concepts
Shawawra and Khleif [51] 2011 Palestine	To conduct a needs assessment survey within facilities that provide care for oncology patients in the West Bank.	Palestine Cancer	Personal: • Lack of community awareness on PC Health System: • No presence of educational resources for PC, • No training programs in PC, Policy: • An absence of organisational strategic planning, • No standards for PC service • An absence of national standards on PC.	Personal: • The need for public awareness. Health System: • The need for training of HCPs • Introduce PC principles into the curricula Policy: • Networking between the national non-governmental organization's and the Ministry of Health . • National policy and standards on PC and opioids legislations. • Baseline data and research. • Interdisciplinary teamwork.
Bingley and Clark [52] 2008 UK	To review PC development in six Middle East countries	Middle East countries Cancer	Personal: • Opioid phobia in the public • Opioid phobia in professionals • Lack of public awareness of PC • Lack of professional level awareness Health System: • Inadequate professional training programs Policy: • Lack of funds • Lack of government support.	Personal: • Public education programs; • Raising awareness about the need for PC Health System: • Increasing national and international training • Improving opioid legislation Policy: • Improving health care policies; • Negotiating for a secure government or health insurance funding provision
McDermott [53] 2007 UK	To identify strengths and weaknesses in the state of development across the subcontinent.	India Cancer	Personal: • Limited knowledge of patients about PC Health System: • Unavailability of opioid • Shortage of workforce Policy: • Limited national PC policy • Insufficient funding for services • Absence of social security system Organisation/ Structure: • Poverty; • Population density • Geography	Personal: • Increase public awareness of PC Health System: • Improve drug availability and expertise Policy: • Include PC in medical and nursing curricula • Design and implement a national PC policy

LMICs Low- and Middle-Income Countries; UK United Kingdom; USA United State America; PC Palliative Care; HCPs Health care Providers