Palliative care development as a solution to mitigate the human crisis of cancer in low- and middle-income countries: a theory of change approach

Abstract Background The burden of cancer is rising in low- and middle-income countries (LMICs), where social determinants, limited access to treatment, and inadequate palliative care amplify suffering. With most unmet palliative care needs concentrated in LMICs, strengthening palliative care in these settings is a moral and health systems imperative. This study aimed to develop a roadmap for palliative care development in LMICs. Methods A theory of change framework was used to explore palliative care development in LMICs as it enabled mapping of complex, interacting elements and their impact on meaningful change. Stakeholders were recruited through purposive and snowball sampling via the research team’s professional networks, and included physicians, nurses, public health experts, and community participants. Eight virtual workshops addressed key elements of the theory of change framework: impact, outcomes, preconditions, interventions, and assumptions. Data from workshop transcripts, online chats, and facilitator meetings were analysed iteratively using consensus-driven theory-informed approach to map the causal pathway. Results Twenty-one stakeholders from three continents participated in eight facilitated workshops. Stakeholders emphasised integration of palliative care into health systems as central to its development and essential for mitigating cancer-related suffering. The desired outcome was comprehensive, sustainable, and culturally relevant palliative care. Fourteen preconditions, 21 interventions, and 12 assumptions were identified and mapped onto the causal pathway. Conclusion The theory of change approach facilitated the creation of contextually grounded stakeholder-informed roadmap for palliative care development in LMICs, achievable through integration within existing health systems. Future efforts should concentrate on testing the implementation, feasibility and impact of this roadmap across diverse LMICs.