Colombia’s 5-year public health strategy for palliative care: Implementation protocol

Abstract

Background:

In recent years, Colombia has evolved from having isolated palliative care services to becoming a leader in the field. The country has enacted pioneering palliative care legislation and established the Colombian Observatory of Palliative Care to support research and advocacy. These efforts have addressed regional needs and barriers, and Colombia has also developed compassionate communities to support those with serious illnesses. In line with global health initiatives, a comprehensive public health action plan has been created, focusing on underserved areas and including new legislation to enhance palliative care education. However, implementing these plans in conflict-affected regions remains a significant challenge. With support from the Ministry of Health, the Observatory will lead the implementation process, starting with stakeholder analysis and collaborative efforts to identify effective solutions.

Objectives:

Through stakeholder focus groups, this study aims to develop a comprehensive methodology for implementing the National Palliative Care Plan in three rural regions of Colombia.

Design and methods:

Through a participatory action research approach, we conducted two distinct workshops. The first workshop is dedicated to analyzing the current context and generating feasible solutions, while the second workshop builds on these solutions to formulate collaborative strategies. Each workshop engages a diverse array of stakeholders, including patients, healthcare professionals, and policymakers, among others, to ensure comprehensive representation. The workshops are organized with presentations, facilitated discussions, and roundtable sessions to address various palliative care domains. Data gathered from these discussions are recorded, transcribed, and subjected to thematic analysis to report the process of building collaborative networks in palliative care. This process will facilitate the development of actionable, sustainable solutions tailored to regional needs and provide a methodological framework that other countries can adapt to implement their palliative care plan.

Conclusion:

There is growing health interest in developing national palliative care plans. However, effective implementation remains challenging, particularly in low- and middle-income countries. This protocol describes the co-creation of a stakeholder-focused methodology for developing palliative care in Colombia.

Introduction

Colombia, an upper-middle-income country in Latin America, was considered to have isolated palliative care provision in 2008. ¹ Since then, it has emerged as a leader in palliative public health advancement. In 2014, the country passed a groundbreaking law to ensure the delivery of palliative care. ² Since 2016, Colombia has hosted the Colombian Observatory of Palliative Care (COPC), a unique regional initiative that annually gathers data, reports findings, and advocates for integrating palliative care into public health. ³ The COPC has conducted innovative policy-focused research to map social barriers and regional development of palliative care, comparing these findings with the level of need experienced by people living and dying with health-related suffering.^4,5 The country has also been a pioneer in developing compassionate communities, which engage local groups in supporting those with serious illnesses and end-of-life challenges, thereby improving the quality of life for patients and their families. ⁶

Furthermore, in response to the 2018 Astana Declaration by the World Health Organization (WHO), which called for empowering communities to make data-driven decisions and ensure comprehensive primary care—including preventive, promotive, curative, rehabilitative, and palliative care—Colombian stakeholders have developed a 5-year public health action plan for palliative care. This plan is specifically designed to address the needs of rural and underserved regions with limited or no palliative care services. ⁷ The national action plan is based on the WHO 2021 palliative care public health model and established Latin American research priorities.^8,9 To further support these efforts, a bill enacted in 2022 aims to enhance palliative care education in Colombia, improving training and resources for healthcare professionals. ¹⁰ Collectively, these initiatives position Colombia as one of the leading countries in legislative and policy support for palliative care. ¹¹ Clelland et al. conducted an assessment of palliative care public policy and found that only 55 (28%) out of 195 countries worldwide had developed a national strategy or plan for palliative care. However, the levels of implementation vary widely, with most plans coming from high-income countries, and there is limited literature on the implementation of these public health strategies in middle- and low-income countries. ¹² This challenge is further compounded by the Colombian context, particularly in war-torn rural regions where guerrilla groups and drug cartels have dominated for over 40 years, severely hindering access to basic healthcare. ¹³ Therefore, with financial support from the Colombian Ministry of Health, the COPC will lead the implementation process. This effort started with a preliminary regional stakeholder analysis ¹⁴ and will be followed by the facilitation of collaborative spaces and methodologies for stakeholders, which are detailed in this protocol. These activities aim to identify realistic regional implementation solutions and report a rigorous methodology on how to build collaborative networks among stakeholders to improve palliative care delivery, which will be reported in a future paper.

Methods and analysis

Patient and public involvement

Given the intricate nature of healthcare as a socio-technical system, advancing toward universality and sustainability necessitates collaborative efforts among diverse stakeholders. Research on systemic change policies underscores the importance of participatory methods, which facilitate stakeholder interactions and enhance foresight processes. ¹⁵ Stakeholder platforms serve as collaborative frameworks that unite various groups affected by or involved in a particular issue or sector. These platforms facilitate dialogue, decision-making, and coordination among stakeholders to create more inclusive, transparent, and effective outcomes. By leveraging the unique strengths and resources of each stakeholder and fostering mutual understanding, this collaborative approach addresses complex, multifaceted issues more effectively. ¹⁶ To ensure a high-quality study design, the reporting of this research adheres to the Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines, which provide a detailed framework for consensus processes in system-level efforts to enhance the quality, safety, and value of healthcare. ¹⁷ The guidelines checklist can be revised as Supplemental File 1.

Aim

To establish practical ways to implement the National Palliative Care Plan in three deprived Colombian rural regions (Amazonas, Orinoquía, and Pacífico) by following four landmarks:

• 1. Performing critical analysis of the current situation and the plan’s objectives.

• 2. Conveying tailored feasible solutions to achieve the plan’s objectives.

• 3. Agreeing on collaborative efforts by the diverse stakeholders of each region.

• 4. Targeting the empowerment and engagement of the communities.

To achieve our goal, we will organize two workshops using Hudson’s proposed model for focus group research in palliative care and stakeholder platform designs. ¹⁸ The initial workshop is scheduled for July 2024 and will focus on addressing the first and second landmarks. The second workshop will take place 8 months later, reviewing the second landmark and continuing with the third and fourth landmarks. Both workshops will be held in Bogota, lasting one entire day, and will accommodate and pay for the expenses of all of the stakeholders invited. Participating stakeholders will be recruited virtually through the Palliative Care Colombian Observatory network and selected based on a prior stakeholder analysis, which assessed their capability, interest, and knowledge of public health while maintaining a diversity approach that considered gender, age, cultural background, belief systems, geographic location, career field, and research interests. ¹⁴ Each workshop is expected to include at least two participants from each of the following groups: patients, scientific associations, healthcare students, universities, government representatives, health insurance companies, researchers, hospital administrators, local authorities, religious representatives, pharmaceutical regulatory agencies, affiliated and independent physicians, and representatives from afro-descendant populations and indigenous communities. M.S.C., L.V., and M.X.L. are experienced qualitative researchers with in-depth knowledge of social determinants unique to Colombia, such as guerrilla conflict, racism, and drug trafficking, among others, that hinder access to palliative care and may be challenging to navigate within group dynamics. They will ensure these topics are appropriately acknowledged and managed if raised by participants.

Phase I: First workshop

The workshop will begin with a brief introduction of all participants. Following this, there will be two opening presentations for the stakeholders. The first presentation will be delivered by the director of the COPC, providing a comprehensive overview of the project and explaining the purpose of the workshop. The second presentation will be given by an invited expert in creating innovative partnerships, who will discuss stakeholder platforms to ensure stakeholders are motivated throughout the session. Participants will receive a badge with their name, where they can indicate their areas of interest in palliative care to stimulate more focused and strategic conversations. Afterward, the stakeholders will be assigned to six roundtables—two tables for each region. These groups will be pre-divided in a diverse and balanced manner, with 7–9 individuals per table. Each table will have a facilitator who will pose thought-provoking questions and record stakeholders’ viewpoints, a timekeeper who will assist the facilitator and also take notes on stakeholder interventions and non-verbal cues, printed support material for each stakeholder on the national palliative care plan, and a voice recorder to capture the entire session. The table facilitators and timekeepers will be selected based on their knowledge of the national palliative care plan, will be trained, and will receive printed instructions on their role before the workshop.

To initiate the discussion, the table facilitator will invite each stakeholder to introduce themselves and will establish fundamental guidelines for respectful and attentive participation. The facilitator will ensure that all stakeholders comprehend the procedures for requesting the word and that participation is equitable among all members. To address the first landmark of conducting a critical analysis of the current situation and the plan’s objectives, the facilitator will ask stakeholders whether the regional context has shifted since the palliative care national public health plan was based on 2019 data and could not be implemented until after the COVID-19 pandemic was controlled, with the plan being published and socialized in 2022. Stakeholders will be encouraged to review the plan’s objectives and identify any progress or challenges that were not previously reported across the six domains of palliative care development: provision of palliative care services, availability of the basic package of palliative medicines, education in palliative care, community empowerment, public policy, and financial support. Following this, stakeholders will discuss how collaborative work mechanisms could bridge the gap between the current regional reality and the previously reviewed goals for palliative care development. The table facilitator will ensure that each of the six domains is addressed in the discussion. Finally, stakeholders will be asked to propose initial actions to implement regional solutions for achieving universal palliative care rural delivery. Table facilitators will remind stakeholders to consider collaborative initiatives for each of the six domains of palliative care development. For each question, stakeholders will have 40 min to discuss, with breaks allowed between questions. The notes taken by the facilitator and timekeeper, along with the voice recordings, will be securely stored and used by a senior researcher (L.M.V.-E.) for two main purposes: first, to prepare a summary of the key themes discussed at each table and region, which will be shared with the research group to inform and enhance the second workshop; and second, to conduct a comprehensive final synthesis, as detailed below. If, as the research team reviews the material, they identify stakeholders recurrently highlight a topic as crucial for palliative care delivery in rural settings, which is underexplored in the current literature, a scoping review may be proposed to support the second workshop. Also, the research team will stay in contact with the stakeholders during the time between workshops.

Phase II: Second workshop

For the second workshop, stakeholders who participated in the first workshop, along with new stakeholders from the same civil society groups previously described, will be invited to join. The workshop will begin with a presentation that highlights the feasible solutions proposed in the previous workshop, focusing on their regional application to achieve the objectives of the national palliative care plan. A second conference will be presented by an international expert, who will discuss various methods for integrating the proposed solutions into primary care, drawing on global experiences. A third conference will address how international examples can be adapted to fit the national context, considering the country’s unique identity, governance, and health system pillars. The first stage of the day will conclude with an extended session dedicated to discussing and synthesizing the second landmark, utilizing the input received in the conferences. This session will focus on developing a collaborative rural network to facilitate the implementation of the most effective solutions for achieving the national plan’s goals. As in the first workshop, discussions will take place at predefined tables but in different rooms, each led by a facilitator and supported by a timekeeper who will record and document stakeholders’ viewpoints. The objective is for stakeholders to develop collaborative rural network solutions for each of the six domains of palliative care development that are characterized by several essential attributes (see Figure 1). These solutions should be sustainable over time, ensuring their long-term viability and relevance. They must also be participatory, reflecting regional identity and inclusivity, engaging a diverse range of stakeholders in the decision-making process. In addition, a well-defined governance framework should be established to facilitate effective decision-making and management. The solutions should possess dynamic adaptability, allowing them to respond effectively to changes in the regional context. Furthermore, they should support continuous and smooth interaction among all network members to maintain cohesion and foster ongoing collaboration. Stakeholders will be reminded to address all these essential attributes throughout the day’s discussions.

Figure 1.

Essential attributes to build up a collaborative rural network to address each domain of palliative care development.

The third and fourth landmarks will be addressed through a co-creative process that facilitates dialogue among stakeholders and invited experts in the second stage of the day. To this end, a conference led by an expert will be followed by discussions among stakeholders at their respective tables. The first conference will be about managing collaborative rural networks and the role of the leader in promoting participation and dynamism, and the second conference will remind the stakeholders to adopt the essential attributes when building rural networks to promote palliative care. After stakeholders have had considerable time to discuss each conference, a lengthy break will be provided for rest, refreshments, and independent discussions. The workshop will conclude with a two-hour plenary session in which representatives from each region will present their views. During this session, stakeholders will keep on discussing the solutions, implementation strategies, and collaborative network designs they believe are best suited to achieving the goals of the national palliative care plan. Lastly, stakeholders will socialize their experience, provide feedback, and propose commitments for the near and mid-term future. The research group will summarize the second workshop results with all the participating stakeholders and the Ministry of Health department.

Phase III: Final synthesis and follow-up

The solutions proposed by the stakeholders are expected to significantly enhance palliative care development in Colombia. However, these solutions may not necessarily be applicable in other contexts. What is most valuable and useful for other countries is the methodology used to build collaborative networks through stakeholders’ insights, facilitating the implementation of public health programs in challenging scenarios typical of low- and middle-income countries. This outcome will be reported by conducting a thematic analysis, for which all the qualitative data retrieved will be transcribed in MS Word. To ensure high-quality reporting and transparency, we will follow the guidance provided by Braun and Clarke using the reflexive thematic analysis reporting guidelines. ¹⁹ A senior researcher (L.M.V.-E.) will identify segments of the text relevant to how low- and middle-income countries can implement their national palliative care plans in deprived rural areas and will assign initial codes to these segments. The researcher will then group similar codes into broader themes, continuously reviewing and refining these themes to ensure accuracy. Each theme will be clearly defined and named to accurately reflect the data. Detailed descriptions of each theme will be written, incorporating direct quotes to illustrate key points. All information will be coded and synthesized using NVivo software.

Discussion

National palliative care plans have emerged as a critical strategy for developing and integrating palliative care into health systems. ²⁰ As of 2022, approximately 31 countries had established such plans, reflecting a commitment from policymakers to ensure the universal provision of palliative care. ¹¹ However, while creating a palliative care plan is a significant achievement, it represents only the initial step; without effective implementation and measurable impact, these plans may fail to address existing equity gaps and could diminish interest in palliative care policies. ¹¹ The challenges of executing these plans are considerable, even in high-income countries, due to a lack of effective guidance.^21,22 This situation is compounded in low- and middle-income countries, which face various socioeconomic crises that hinder improvements in end-of-life care. ²³ To address these challenges, our current work aims to establish a robust methodological framework focused on stakeholder participation, particularly in rural and underserved areas, which will support the successful implementation of national palliative care plans. Participants will be invited to engage in the study, receiving information about its purpose and data collection methods; by opting to participate, they will provide implicit consent for their data to be used in the research. This consent will involve clear communication regarding the study’s objectives, data handling practices, and assurances of confidentiality while also allowing participants to withdraw at any time.

Ultimately, this approach aims to assist other countries in designing and implementing their public health plans for palliative care, with findings and methodologies disseminated through an academic paper to ensure broad accessibility and impact. In particular, our framework may be especially beneficial for low- and middle-income countries facing similar structural and socioeconomic challenges to Colombia, such as limited healthcare infrastructure, geographic barriers, and disparities in access to specialized care. For instance, according to the latest regional atlas, only a few Latin American countries have implemented a national palliative care plan. ²⁴ Furthermore, those who have adopted such plans demonstrate a more advanced level of development in public health palliative care compared to those who have not.^11,24 Lessons learned from other experiences in advocating for, designing, and implementing national palliative care plans have guided our process by providing insights into both successes and challenges. ²¹ Similarly, we hope that the Colombian experience will provide meaningful insights for other countries navigating the development and implementation of national palliative care plans. By prioritizing stakeholder engagement and adaptable implementation strategies, our findings can support context-specific policy development and promote more equitable palliative care integration in resource-constrained settings.

Conclusion

There is growing health interest in developing national palliative care plans. However, effective implementation remains challenging, particularly in low- and middle-income countries. This protocol describes the co-creation of a stakeholder-focused methodology for developing palliative care in Colombia.

Supplemental Material

sj-pdf-1-pcr-10.1177_26323524251328036 – Supplemental material for Colombia’s 5-year public health strategy for palliative care: Implementation protocol

Supplemental material, sj-pdf-1-pcr-10.1177_26323524251328036 for Colombia’s 5-year public health strategy for palliative care: Implementation protocol by Lina María Vargas-Escobar, Juan Esteban Correa-Morales, María Alejandra Umbacia, Marta Ximena León-Delgado, Erwin Hernandéz, Rene Francisco Abello Gomez, Emma Isabel Rodríguez Darabos, Carmen Rosy Ramírez and Miguel Antonio Sánchez-Cárdenas in Palliative Care and Social Practice