The research, conducted by an international team led by Seema Rajesh Rao of Manipal Academy of Higher Education in India alongside collaborators from the United Kingdom, the United States and Canada, was undertaken as part of the Lancet Oncology Commission on the human crisis of cancer. Its starting point is grim arithmetic. The Lancet Commission on Palliative Care and Pain Relief has estimated that more than 90 percent of patients dying from cancer experience serious health-related suffering, a term encompassing severe physical, psychological and social distress. The global burden of this suffering is projected to double by 2060, and while it may slow or plateau in wealthy nations by mid-century, the end of life in many poorer countries remains marked by unrelieved pain. Catastrophic out-of-pocket spending on cancer treatment deepens the damage, pushing families into poverty, reducing workforce participation and amplifying caregiver burden.

To chart a way forward, the team turned to a methodology borrowed from social policy and evaluation science: the theory of change framework. Rather than prescribing solutions from the top down, theory of change works backwards from a desired long-term goal, mapping the intermediate outcomes, preconditions, interventions and assumptions that must line up for that goal to be achieved. It is a technique designed for complex social problems, where simple cause-and-effect logic fails. The researchers convened 21 stakeholders from 12 countries across Asia, Africa and South America—physicians, nurses, public health experts and community participants, all with hands-on experience building or delivering palliative care in their regions. Over three months, the group took part in eight facilitated virtual workshops, each lasting more than two hours and devoted to a specific component of the causal pathway: impact, long-term outcomes, interventions, preconditions and assumptions.

The workshops were deliberately participatory. Facilitators presented evidence from a framework synthesis of palliative care in low-resource settings, existing models from around the world, and worked examples of theory of change maps, but the content itself was generated and refined by the stakeholders. Transcripts, chat logs, facilitator notes and email contributions were analysed iteratively and by consensus, with concepts sorted into the framework’s components and their relationships mapped into a causal diagram. The final product was a roadmap containing 14 preconditions, 21 interventions and 12 assumptions, all arranged along a pathway leading from concrete actions to a single, agreed impact: the development of comprehensive, sustainable and culturally relevant palliative care capable of easing cancer-related suffering in low- and middle-income countries.

One finding stood above all others: integration. The stakeholders concluded that palliative care cannot be built as a parallel, standalone service in settings where specialist teams are scarce and budgets are thin. Instead, it must be embedded within existing health systems, with core palliative care competencies distributed across primary care, oncology and other frontline services, while specialist teams support complex cases and provide systems leadership. This tiered model echoes evidence from high-income countries, where landmark randomised trials such as those led by Jennifer Temel and Camilla Zimmermann showed that early palliative care integrated alongside oncology treatment improves quality of life and, in some cases, even survival. But the study’s authors are careful to note that evidence from wealthy nations cannot simply be transplanted, because patient demographics, healthcare delivery models and societal values differ profoundly.

The systems thinking lens the researchers applied to their findings reveals why piecemeal interventions so often fail. Viewed as a complex adaptive system, palliative care development in poorer countries depends on a dense web of interacting factors: health beliefs, socioeconomic conditions, workforce capacity, medication access and health policy. Consider opioid access, one of the most glaring inequities in global cancer care. Restrictive opioid policies breed fear of opioids among clinicians and caregivers, which suppresses prescribing and consumption. With fewer people using these medicines, the access problem loses political salience, weakening the impetus for reform. The result is a self-reinforcing feedback loop in which restrictive policies perpetuate themselves. The study argues that meaningful change requires identifying and reconfiguring such feedback loops rather than tinkering with isolated components—a conclusion with implications far beyond pain management.

The roadmap’s architects also distinguished three attributes that any successful model must embody. Comprehensiveness means multidimensional, patient- and family-centred care enabled by timely referrals and seamless collaboration among oncology, palliative and primary care teams, together with equitable access to essential medicines, caregiver support and attention to the quality of death and dying. From a systems perspective, comprehensiveness is an emergent property: it arises only when policies, funding mechanisms, workforce capacity, referral systems and supply chains are structurally and functionally aligned. Sustainability, meanwhile, was described as the foundational backbone of the entire enterprise. Without robust national policies, budget allocations, effective governance and political and legal commitment at the macro level, interventions at the clinic and community levels remain vulnerable to collapse. Cultural relevance formed the third pillar, recognising that care must resonate with local values, health beliefs and community practices to be accepted at all.

Culture, in fact, emerged as an embedded determinant influencing system behaviour at every level. How people experience illness, make decisions, communicate prognosis, express grief and assign responsibility for caregiving is shaped by social norms and community practices. In many low- and middle-income countries, families and clinicians collude to withhold diagnoses from patients, a practice that obstructs advance care planning and early referral. Opiophobia is prevalent among both providers and the public, and beliefs in traditional or alternative medicine shape health-seeking behaviour. The study’s authors contend that for palliative care interventions to endure, they must be informed by local customs, delivered in culturally sensitive ways, championed by communities themselves and structured around local resource constraints. Notably, the resulting roadmap aligns closely with the World Health Organization’s six essential components of palliative care development—service integration, policy, education, medication availability, research and community empowerment—but extends that model by showing how the elements interact dynamically within real health and social systems.

The study is not without limitations. The virtual format may have dulled the quality of interaction, attendance was inconsistent, and South Asia was overrepresented relative to Eastern Europe and the Pacific. English proficiency was an inclusion criterion, introducing potential selection bias, and the sheer heterogeneity of low- and middle-income countries limits how far the findings can be generalised. Yet the participatory design, spanning three continents and multiple disciplines, produced a roadmap that its authors describe as contextually grounded, acceptable and actionable. The team situates its ceiling of accountability—the point beyond which external forces dominate—between long-term outcomes and ultimate impact, acknowledging that national policies, armed conflict, forced displacement, humanitarian emergencies, natural disasters and economic shocks all lie beyond the reach of any single intervention. The next step, the researchers say, is to test the roadmap’s feasibility, acceptability and impact across diverse settings. If it works, the payoff could be immense: a future in which a cancer diagnosis in the world’s poorest countries no longer condemns patients to a death defined by preventable pain.

Subject of Research: Palliative care development and health system integration to reduce cancer-related suffering in low- and middle-income countries

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

Article References: Rao, S. R., Atreya, S., Mathew, M., Rao, A. P., Walshe, C., Preston, N., Simha, S., Sullivan, R., Rosa, W. E., Rodin, G., & Salins, N. (2026). Palliative care development as a solution to mitigate the human crisis of cancer in low- and middle-income countries: a theory of change approach. Supportive Care in Cancer, 34(11), Article 1080. https://doi.org/10.1007/s00520-026-11306-5

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11306-5

Keywords: palliative care, cancer, low- and middle-income countries, theory of change, health systems, serious health-related suffering, opioid access, systems thinking, global health equity, Lancet Oncology Commission, cultural relevance, health policy

The research was conducted by a team affiliated with the Lancet Oncology Commission on the Human Crisis in Cancer, an initiative launched to quantify and correct the growing imbalance between biomedical investment and the human dimensions of oncology. Using data from the 2023 global review by the International Cancer Control Partnership, the researchers screened a standardized questionnaire of 95 items and identified 20 questions relevant to five Commission domains: compassionate care models, human-centred metrics, equitable access to psychosocial and palliative services, workforce and education reform, and value-aligned governance. Those items were then mapped into six analytical themes spanning sociocultural factors, systems of care, medical education, economic protection, mental health and palliative care.

The single most striking finding concerns who gets a seat at the table. Although 93 percent of the plans reported that stakeholders were involved in their development, only 12 percent identified people living with cancer as stakeholders. Governmental, professional and institutional actors dominate cancer planning almost everywhere, meaning the very documents that set national priorities rarely reflect the priorities of the people they are meant to serve. The authors point to power imbalances, funding and time constraints, and simple lack of awareness as likely barriers, and note that World Health Organization guidance explicitly calls for engaging patient groups in national cancer control planning.

The income gradient in the data is stark. On average, human-centred themes appeared in 44 percent of plans from upper-middle and high-income countries but only 32 percent of plans from lower-middle and low-income countries. Medical education was the exception that proved the rule: 96 percent of countries with dedicated cancer plans included workforce development or provider training, with no significant difference between income groups. But the content of that training was overwhelmingly biomedical. Oncologists, pathologists and surgical specialists featured prominently, while psychosocial support training appeared in just 16 percent of plans, community health worker training in 12 percent, and patient navigator training in a mere 4 percent.

Economic protection emerged as perhaps the most neglected theme of all. Only 13 percent of plans included strategies to shield patients from catastrophic health expenditure — typically defined as spending more than 30 percent of household income on cancer-related costs — and the figure was essentially flat across income levels, with high-income countries actually among the least likely to include such provisions. Universal health coverage strategies appeared in just 26 percent of plans overall. Given that financial toxicity is a well-established driver of cancer inequity, treatment abandonment and poorer outcomes, the authors argue that this neglect represents a fundamental misalignment between policy and patient need.

Mental health provisions fared little better. While 72 percent of countries with cancer plans included strategies to support families or caregivers of patients in active treatment, only 3 percent of all plans referenced essential medicines for treating psychological distress such as anxiety, depression and delirium — the least frequently included item in the entire analysis. Post-treatment survivorship care appeared in 80 percent of high-income country plans but only 25 percent of low-income country plans, a difference that was highly statistically significant. This gap is particularly concerning given the documented burden of depression among cancer patients, which is highest on the African continent at a pooled prevalence of 35 percent, compared with 25 percent in North America, and given established links between psychological distress, quality of life, treatment adherence and survival.

Palliative care was the strongest-performing human-centred theme, appearing in an average of 65 percent of plans, with pain management strategies present in 62 percent and no significant income-based differences. Yet even here the picture is incomplete: patient navigation — the practice of guiding patients through screening, treatment, financial assistance and supportive services — was included in 42 percent of plans overall but dropped to around 11 percent in lower-income settings, precisely where late-stage presentation is most common and navigation may deliver the greatest benefit. In many African countries, up to 80 percent of patients present with locally advanced or metastatic disease at diagnosis, making supportive and navigational infrastructure not a luxury but a necessity.

The authors are careful to spell out what their analysis can and cannot show. Roughly 18 percent of WHO Member States lacked publicly available plans, and the study measured policy intent rather than implementation, funding or patient outcomes. A plan’s silence on psychosocial care does not prove the absence of services, since mental health or financial protection may be addressed through separate national health or universal coverage policies. Countries were weighted equally regardless of population, so the figures describe the proportion of countries rather than the proportion of people covered. In conflict-affected states, a plan can look comprehensive on paper while the health system it describes barely functions. Still, the consistency of the gaps across regions and income levels suggests a genuine structural blind spot rather than a documentation artifact.

The study’s conclusions align with the Commission’s broader call to rehumanize cancer care. Its recommendations include embedding scalable patient navigation — particularly financial navigation — into national plans, strengthening structural supports for caregivers, guaranteeing access to essential psychotropic medicines, reforming workforce training to include psychosocial competencies, and shifting governance toward value-aligned, equity-oriented models. The authors also propose that future iterations of the assessment instrument move beyond binary yes-or-no questions to capture whether commitments are actually costed, assigned to an agency, implemented and monitored, with equity-stratified indicators and patient-reported experience measures built in.

What makes the findings resonate beyond oncology is what they reveal about how health systems value intangible goods. Machines, drugs and screening programs are easy to cost, procure and count; compassion, dignity and psychological safety are not. The analysis suggests that unless national strategies explicitly name and resource the human dimensions of cancer care, those dimensions will continue to lose out in budget negotiations and implementation plans — and the patients who bear the heaviest burden of advanced disease, poverty and psychological distress will continue to be the least likely to receive them. The authors’ message to policymakers is blunt: a cancer strategy that plans only for the tumor, and not for the person, is an incomplete strategy.

Subject of Research: Global policy analysis of human-centred cancer care in national cancer strategy plans

Article Title: A cross-sectional global policy analysis of the human gap in 156 national cancer strategy plans

Article References: Lau, E., Shapiro, G. K., Rodin, G., Sullivan, R., Bhoo-Pathy, N., Unger-Saldaña, K., Trapani, D., Salins, N., Skelton, M., & Li, M. (2026). A cross-sectional global policy analysis of the human gap in 156 national cancer strategy plans. eClinicalMedicine, 100, Article 104244. https://doi.org/10.1016/j.eclinm.2026.104244

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104244

Keywords: national cancer control plans, human-centred care, psychosocial support, palliative care, patient navigation, health equity, financial protection, mental health, cancer policy, low-income countries, Lancet Oncology Commission, eClinicalMedicine