A comparative study of the status of supportive-palliative care provision in Iran and selected countries: Strengths and weaknesses

BACKGROUND: Terminally, illnesses such as cancer, AIDS, dementia, and advanced heart disease will require special supportive and palliative care, although a few numbers of these patients are provided with these services. The aim of the present study was to perform a comparative study of supportive-palliative care provision in selected countries. MATERIALS AND METHODS: This research was a descriptive comparative study that its research population was the frameworks of palliative and supportive care provision in Egypt, Turkey, America, Australia, Canada, the Netherlands, and China. These frameworks were compared across six dimensions of service receivers, financing, providers, service provider centers, type of services provided, and training. Data collection tool has included the checklist and information sources, documents, evidence, articles, books, and journals collected through the Internet and organizations related to the health information of selected countries and by the library search. Data were investigated and analyzed using the data collection tool and checklists. FINDINGS: The findings showed that the developed countries having decentralized trusteeship structure had a more favorable status in palliative and supportive care provision. The type of services provided was a combination of mental, psychological, social, spiritual, financial, and physical and communication services. Provider centers included hospital, the elderly, and cancer and charity centers. CONCLUSION: Regarding the investigation and recognition of the status of supportive-palliative care provision, it was observed that the provision of these services was a concern of the selected countries, but they did not have a defined model or pattern to provide these services. Therefore, it is suggested that each country takes a step to redesign and define frameworks and structures in the evolution of supportive-palliative cares in accordance with the particular conditions, indigenous culture, religion, and other effective cases of that country and pays special attention to the role and position of supportive-palliative cares.


Introduction
S ince illness is considered as an inseparable part of human life, hence observing the patient's rights is also a respected point. Every patient has the right to receive appropriate health services, coupled with preserving human dignity, fairly, and according to cultural and religious criteria, respectfully, up-to-date, without gender and ethnic discrimination, and at all stages, including prevention, diagnosis, treatment, and rehabilitation. [1] In the past few decades, the provision of health-care services to patients has shifted from a traditional, passive, and inefficient system to a more active and dynamic system. [2] On the other hand, at present, issues such as aging of the population and the pattern change of diseases toward chronic diseases have made the necessity of intensive care provision unavoidable. [3] Global health estimates indicate that currently, the highest factor of mortality among the elderly in the world is, respectively, heart diseases, cancer and diabetes, a situation that is both different in various ages and in high, middle, and low-income countries. [4] Undoubtedly, terminally diseases such as cancer, AIDS, dementia, and advanced heart disease will require special supportive and palliative care. However, according to the declaration of the World Health Organization, only 14% of people subject to special care have these services. [5] Palliative care is a set of measures conducted aiming to promote the life quality of patients and their families to remove the problems and issues due to incurable and life-threatening diseases through early diagnosis, complete evaluation, and treatment of pain and other psychological-mental and physiological problems. [6] Supportive care also means optimizing care for the comfort and social support of the patients and their families at all stages of the disease. [6] In numerous studies, the deployment of a comprehensive system and the provision of special care for incurable patients on the verge of death have been emphasized. [7,8] Hospice care rather than care in hospitals is very effective in reducing hospital services consumption, reducing hospital admissions rate, especially in the intensive units, and consequently reducing hospital costs for these individuals and health systems. Hospices have not currently been developed in Iran. Iran lacks a comprehensive model of care for incurable patients on the verge of death and does not have a proper forecast of facilities, trained workforce, and organizational structures for these services. [9,10] In Iran, such patients are cared in hospital centers. However, the providers of such services not only do not receive the necessary training in this area but mainly due to the lack of receiving adequate training, do not provide appropriate care for these patients. In the absence of structures such as hospices, services to cancer patients or other patients at the end-of-life stages are not performed in hospital centers, or no services are provided at all. The quality of such services in hospitals whether in terms of employees' attitude and knowledge or in terms of the appropriateness of hospital structure and facilities for patients requiring end-of-life care is not appropriate. Therefore, the end-of-life special care system for patients on the verge of death must be developed within the health system of Iran. [11] So far, various studies have been conducted in the field of palliative and supportive care. Kelley et al. in a study conducted aiming to determine the factors in caring incurable patients, determined seven basic areas of regional medical resourcing, personal physician executive models, local executive models, patient access to financial resources for treatment, patient's preferences and patient relatives' preferences for care, and the possibility of the patient's benefiting from the treatment, and concluded in such a way that physician's executive models can influence treatment method, and that the patient's characteristics in terms of gender, age, race, and economic status can affect in the interaction on the physician's executive models, and ultimately the evidence indicate interaction between race and the type of treatment. [12] Furthermore, Luzny et al. in their study mentioned five basic areas of pain relief, independence, nutrition support, skin protection to cope with bedsore, and spiritual and social support in palliative care. [13] Nowadays, in respect of meeting the need of incurable patients, the deployment and development of the care system of incurable patients on the verge of death in the country is important. Therefore, the compilation and provision of care services package, including outlining organizational structure such as trusteeship, facilities, equipment and workforce, explanation of service provision processes, exact determination of insurance systems and payment systems to service providers, determination of management methods and the determination of monitoring, measurement and evaluation indicators of services is considered a necessity. The present research aims to more recognize the existing models in the field of palliative care provision in selected countries. This review can be used as a source for policymakers, researchers, physicians, and other people to provide more appropriate services to incurable patients. It can also be used to understand the routes of complex problems and to support the compilation of innovative policies and programs.

Study design and setting
This study was a comparative study in which the health services system of different countries were studied in depth and comprehensively.
The sources of information were the documents, evidence, and articles published by the organizations related to the health information of the selected countries which were collected by the library research method. The applied sites were Health Information, Canadian Health Information, Databases of (Web of Science, PubMed, Scopus, Science Direct, and Google Scholar), and websites of the Ministry of Health of the selected countries and so on. Unknown sites were not used. The investigated articles were also reviewed from the time interval of 2000 onwards. In order to recognize the palliative cares status better in the countries under study, demographic, economic and health outcome indicators, type of political, economic and health services provision structure among the countries were also investigated.

Data collection tool and technique
The data collection tool consisted of predesigned tables in which the data was completed and filled. By careful per reviewing, data such as population size, health share as GDP percentage, life expectancy, and other data were summarized in checklists. The full list of variables is reported in Tables 1 and 2.

Study participants and sampling
In order to conduct this research, supportive-palliative cares provision model and frameworks in Iran, Egypt, Turkey, USA, Australia, Canada, Netherlands, and China in six dimensions of service recipients, financing, providers, service provider centers, types of services provided, and education were compared.

Ethical consideration
The draft of this study was approved by the Ethics Committee of Iran University of Medical Sciences (code number: 1397596).

Results
The findings of this study have been presented in three sections as follows: (1) Data related to demographic, economic, and health outcomes indicators among selected countries, (2) Type of political, economic, and health services provision structure among these countries, and (3) Status and structure of palliative cares among selected countries.

Demographic, economic, and health outcomes
The findings of the present study showed that among the selected countries, China is the most populated country with a population of 1.386 billion people and the Netherlands with a population of 17.08 million people is the least populated country [ Table 1].
Among the countries investigated, in terms of "budget allocation" to the health sector, America had allocated the highest (17.1) and Turkey had allocated the lowest (5.4) percentage of their GDP 1 to the health sector. In terms of "life expectancy" among the countries investigated, Australia and Canada had the highest ratio of life expectancy. Egypt and Turkey also had the lowest life expectancy ratio and the highest mortality ratio of 15-60 years old in the population of 1000 people. It is worth mentioning that Iran also has the highest mortality ratio among children under 5 years old after Egypt. Among the countries investigated in terms of "health cost per capita," America had the highest and China had the lowest health cost per capita ratio. In terms of "public sector share of health," Canada had the highest public sector share of health among the selected countries. In terms of the "human development index," the Netherlands and Canada had the highest and Egypt had the lowest human development index [ Table 1].

The type of political, economic, and health services provision structure
In this section, a comparison of countries based on the structural layer has been firstly performed on the role of private and public providers, the trusteeship structure, organizing service provision, and payment system of the selected countries.
Among the countries investigated, the private sector in America and the Netherlands allocates the first role in providing health services to itself and the government has a minimal share in providing services. The payment system in America is also as Medicare, Medicaid, and Diagnostic-Related Groups (DRGs), but in the Netherlands, it is as performance reward, per capita, budget and salary, and the government has a control or supervision role, while in the investigated countries, the providers are the combination of public and the private sectors, and the government generally has a 1 Gross Domestic Product GDP=Gross domestic product more prominent role than the private sector, and the payment system in these countries is as performance reward, salary, per capita, and budgetary.
Trusteeship in the health system of America, Australia, Canada, and the Netherlands is decentralized and organizing service provision is, respectively, as 1-state, 2-state/regional/local, 3-provincial, and 4-provincial/ urban, while the trusteeship structure of other investigated countries is as decentralized or often decentralized, and organizing services provision in them is as provincial and city-wide. It should be mentioned that in most liberal countries, health is not proposed as a right and the trusteeship structures are as decentralized form [ Table 2].

The status and structure of palliative care
In this section of the study, the comparison of selected countries has been performed according to the service receivers, financing, providers, provider centers, type of services, and training.

Service receivers
The findings of the present study showed that cancer patients are among the groups that in all the investigated countries, palliative care has been provided to them.
In Egypt and countries such as America, Australia, the Netherlands, and Canada, which are more exposed to aging and the life expectancy ratio in these countries is higher, the phenomenon of aging is more prevalent, and as a result, palliative care for these groups is also provided more than other groups. The incurable diseases are also more subject to receiving palliative care in countries such as America, Australia, and the Netherlands. On the other hand, China is the only country that has subjected dying or on the verge of death patients to palliative care provision.

Financing
In comparing and investigating the palliative care financing situation in the countries investigated, it was shown that public and private sectors together have a prominent role in all countries, and they are not funded exclusively by the public or private sector in any country. Australia, America, and Egypt are also among the countries that palliative care is funded by charitable people.

Providers
The findings of the present study showed that family physicians, various specialists, and nurses are among the groups that provide services in the field of palliative care in all countries. Furthermore, the results obtained from comparing and investigating countries show that oncologists have a more prominent role in providing palliative care services in countries such as America, Australia, and Canada and have more activity than other people in this area. Turkey was also one of the few countries among the investigated countries in which rehabilitation specialists such as physiotherapists, nutritionists, and social workers play a role in providing palliative care services.

Provider centers
Regarding palliative care centers or locations in the countries investigated, it was observed that hospitals in all countries are the main reference of providing care. America and the Netherlands are among the countries in which the elderly centers also perform the activity as a palliative care provider. In China, Canada, and Australia, in addition to hospitals, private centers also have a role as palliative care providers. In the Netherlands in addition to hospitals, the elderly homes, nursing homes, oncology clinic, and children's medical homes also perform the activity to provide palliative care. Among the countries studied, Egypt and Turkey are the only countries that palliative care is provided solely in the hospitals.

Type of services
On the other hand, regarding the services provided in palliative care among the countries investigated, it was

Trainings in palliative care
Concerning the role and importance of palliative care training, it was also observed that there is no formal and academic training in any of the countries investigated, and it was identified as the main challenges among all countries [ Table 3].

Discussion
The results of demographic, economic indicators, and health outcomes among the selected countries showed that America allocates the highest budget and Turkey also allocates the lowest budget to the health sector. Life expectancy had the highest ratio in Australia and Canada, and Turkey and Egypt also had the lowest ratio of life expectancy and the highest mortality. In terms of health cost per capita, China had the lowest ratio and America had the highest ratio. Furthermore, the findings of the present study concerning the type of political, economic structure, and health care provision showed that the private sector allocates the first role in providing health services to itself in America and the Netherlands. America's payment system is a combination of Medicare, Medicaid, and DRGs, and in the Netherlands, it is also as performance reward, per capita, budget, and salary, and the government has a controlling or supervising role. In other countries as compared, the two private and public sectors together have contributed to the provision of health services, and the payment system is as performance reward, salary, per capita, and budget in these countries. Trusteeship in the health systems of America, Australia, Canada, and the Netherlands is decentralized and organizing the provision of services is 1-state, 2-state/regional/local, 3-provincial, and 4-provincial/urban, respectively. It should be mentioned that in most liberal countries, health is not proposed as a right and the trusteeship structure is as decentralized. [14][15][16][17] Iran's economic structure as a developing country is a combination and classification of the political structure in this provincial country. Health system trusteeship is often centralized and health services have been organized at the provincial and county levels. The structure of Iran is closer to social countries. In fact, countries like Iran, which have abundant natural resources, have often designed their structure in a public and centralized manner. [17,18] Liberal countries, on the other hand, emphasize individualism and minimal government interference in structures, and all of these characteristics have been formed in the health system of these countries. For example, America, considering the minimal intervention of the government and attention to individual freedom, has based its health system on the treatment and mostly on private sectors. [19,20] Finally, the findings obtained from the investigation and comparison of selected countries concerning the provision and structure of palliative care showed that cancer patients and the elderly are the largest group of patients that in all countries benefit from palliative and supportive services. China is also the only country that in addition to the elderly and cancer patients provides palliative care for dying patients. Funding in the selected countries in the field of palliative and supportive care is a combination of public and private sectors and charity. The palliative and supportive care provider forces in the selected countries were a combination of family physicians and specialists, rehabilitation specialists, and social workers. The results indicated that in developed countries, the majority of the group of providers was oncologists, medical professionals, and experienced nurses. Among the countries selected, Turkey was one of the few countries that physiotherapists and social workers had more roles. The main reference of palliative and supportive care provider centers in all countries was hospital. It can be concluded that liberal and developed countries are among those countries where palliative care is not confined to the hospital, and even palliative care is provided in specialized centers such as the elderly and charity centers, and so on. Turkey and Egypt were also identified as developing countries that the palliative and supportive care provision centers were limited to the hospital. The type of services were almost similar to each other in all countries, and service types such as mental, psychological, social, spiritual, financial, physical, and communication were provided. The results of the present research regarding palliative and supportive care trainings in selected countries showed that, in none of the countries, training was formal and academic and it was identified as the main challenges among all countries. [14][15][16][17] As it was observed and investigated, the lack of academic training and not defining the specific structure and instruction regarding supportive-palliative cares were the main reasons for not providing these services officially in the selected countries. There is no special trained staff and force in the field of supportive-palliative cares in any of the selected countries and this is also another reason of not providing these services officially in the health-care service provider centers.
Demographic composition, type of financing, and the type of health-care provider centers are other incentives of the countries and health-care provider centers in supportive-palliative cares provision because the private and even charitable sectors refuse to provide these services when they are not funded, and the patients who are eligible for these services will be deprived of the cares. Therefore, it is essential to regard specific financial source for these cares, and encouraging incentives should be considered for charitable and private providers so that the provision of these cares play a more highlighted role than before.

Conclusion
Iran does not have a defined and specific framework for palliative and supportive care provision, and most of the patients for whom this care is provided informally are cancer patients. Financing is in a combined form, and physicians and nurses are among the main groups of providers. Service provider centers include the public, private, and charitable sectors, but the private sector has a more prominent role than other sectors. The services provided are mostly related to the physical, emotional, social work, and spiritual services of the patients. Iran, with its specific structures in various fields, is, in fact, a unique type of developing countries. However, it has not been able to create its own structures and frameworks in the field of palliative and supportive care as it deserves, fitting its native status. Thus, the proportion between economic, social structures such as health and other related cases has been reduced, and this point can be observed at various levels that it has changed the health system to a multiple cooperative with a discrete and piecewise structure. The countries with different payment systems and semi-centralized structure in health and having proper economic conditions and social supports have a more favorable status than other countries in respect of health. In order to reduce the gaps and to perform better in the field of palliative and supportive care provision to specific patient groups, each country needs to consider reviewing the structures and define palliative and supportive care frameworks. Therefore, it is suggested that Iran also take a step to redesign and define the frameworks and structures in the development of palliative and supportive care, and pay particular attention to the role and position of palliative and supportive care.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.