Primary palliative care in low- and middle- income countries: A systematic review and thematic synthesis of the evidence for models and outcomes.

What is already known about this topic?

• ••  Serious health-related suffering is predicted to more than double in low- and middle-income countries (LMICs) by 2060.
• ••  Primary care is ‘widely regarded as the most inclusive, equitable and cost-effective way to achieve universal health coverage’ and should include palliative care and symptom management according to the World Health Organization.

• ••  Much of the primary palliative care literature centres around health systems in high-income countries and falls short of

  considering the unique strengths and challenges of health systems in LMICs.

   

What does this paper add?

• ••  This systematic review and thematic synthesis provides us with a framework of models of primary palliative care, a process model for how these models operate within the larger health systems of LMICs, appropriate outcomes to meas- ure to determine service quality and efficacy and barriers and facilitators to implementing primary palliative care in this context.
• ••  Primary palliative care is delivered in various ways in LMICs, including in primary care clinics by multidisciplinary health- care teams and occasionally palliative care specialists, in people’s homes by healthcare professionals and volunteers and in tertiary healthcare facilities by generalists. These models are shaped by historical events, government policies, resource availability, cultural norms and community networks.

• ••  Primary palliative care literature focussed on LMICs is limited, particularly in the central and South Americas and parts of Africa. Published literature likely does reflect all primary palliative care services that are delivered in LMICs.

   

  Implications for practice, theory or policy

  • ••  The lack of a clear definition of what primary palliative care means in LMICs can limit uptake and availability.

  • ••  Future research should focus on how to sustainably staff and fund primary palliative care services, how to effectively train and mentor staff to deliver these services to meet the growing need, how to best conduct holistic assessment and

    achieve goal-concordant care LMICs and how to enable patients with life limiting illness to remain at home.