Abstract
Equitable access to palliative care remains an important goal for many low- and middle-income countries working to expand health care systems. This scoping review examines the development and current state of palliative care in Bolivia through the framework of the World Health Organization’s (WHO) pillars of public health strategy: health care policy, medicine availability, education, implementation, and research. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, six electronic databases were systematically searched from inception through September 2023. Studies were eligible if they specifically addressed palliative care in Bolivia. Data were abstracted and thematically synthesized according to the WHO pillars. Of 645 records identified, 507 titles and abstracts were screened, 96 underwent full-text review, and 34 studies met inclusion criteria. Most publications were descriptive or narrative in nature, with limited empirical research. Health care policy and implementation were the most frequently addressed pillars, while research was the least represented. Findings demonstrate expansion of palliative care programs since 2008 alongside gradual improvements in universal health coverage; however, barriers identified include opioid availability and accessibility, geographic distribution of care, standardized training and education, and policy development. Although palliative care in Bolivia has advanced over the past two decades, gaps remain across all WHO pillars. Ongoing and future initiatives are helping to strengthen education, policy, and research, building on recent momentum to ensure equitable and sustainable access to palliative care for all Bolivians.
Keywords
Introduction
Palliative care, an approach to care that prevents and relieves health-related suffering for those facing life-threatening illness, is recognized as an essential component of the right to health and of universal health coverage. 1 The World Health Organization (WHO) recommends that palliative care be integrated at all levels of the health care system with a person-centered approach that addresses physical, psychological, social, and spiritual suffering. 1 Despite its proven necessity and benefits, universal access to palliative care services remains limited globally, specifically for many low- and middle-income countries (LMICs). The WHO has identified four pillars of public health strategy to improve palliative care access, which include health care policy, medicine availability, education, and implementation. 2 Some experts also propose research activity as an important fifth pillar. 3
Latin America is characterized by substantial diversity in economic development, health care infrastructure, and public health priorities. 4 This leads to variable progress in palliative care delivery and integration. While over recent decades, several countries in the region have made progress in developing palliative care services, policies, and training programs, significant disparities persist.5,6 Bolivia, a lower-middle-income country with a population of approximately 11 million, faces unique challenges in advancing palliative care. These include geographic barriers with health care resources concentrated in urban areas, lack of standardized national policy frameworks to support expansion of palliative care, and challenges with prescribing and accessing critical medications. 7 Regional initiatives and nongovernmental organizations have sought to improve access, and comprehensive and systematic assessments of the country’s progress are needed.
This scoping review aims to examine the existing literature on the development and current state of palliative care in Bolivia, leveraging the WHO’s public health pillars as a framework. The findings of this review are intended to inform evidence-based recommendations for policymakers, clinicians, and researchers in developing strategies to expand access to palliative care and improve care delivery in line with broader global standards.
Methods
To guide this scoping review, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews. 8 We did not register a protocol for our review.
Eligibility criteria
We used the population, concept, and context framework to align our eligibility criteria with our research aims. 9 Studies were eligible for the review if they specifically (1) focused on a patient population that was eligible for palliative care or caring for people eligible for palliative care regardless of age; (2) described palliative care access, services, policies, or implementation strategies, including palliative approaches in sub-specialties; (3) provided information specific to Bolivia; and (4) were published in English or Spanish languages. Although medical assistance in dying (MAiD) or euthanasia is not included in the WHO definition of palliative care, we included articles addressing these topics as part of end-of-life policies or legal frameworks in the context of palliative care development, regulation, or access due to the overlapping regulatory, ethical, and service delivery implications.10,11 Studies were excluded if they described palliative care in Latin America more broadly without providing information specific to Bolivia. There was no restriction on publication type. Given the limited evidence base, inclusion criteria were intentionally left broad to maximize included sources.
Information sources and search strategy
A trained health sciences librarian (J.L.C.) developed the search strategy and searched in the following six databases from their dates of inception through September 5, 2023: APA PsycINFO (EBSCOhost), CINAHL Plus with Full Text (EBSCOhost), Global Health (EBSCOhost), Latin American & Caribbean Health Sciences Literature (LILACS), PubMed, and Scopus. All databases were searched using English language terms, and LILACS was also searched using Spanish language terms.
The search included a combination of keywords and subject headings for two concepts: the geography of Bolivia, including broader Latin America terms, and palliative care. No limits were placed on the search. Our database searches captured a variety of gray literature, including book chapters, dissertations, conference proceedings, and theses. In addition, we contacted an expert, a practicing Bolivian palliative care physician (G.A.), to provide gray literature and sources unlikely to be in official databases. The complete, reproducible search strategy for all databases is available in the supplementary files (Supplementary Data).
Study selection
All database results were exported to Endnote X9, 12 where duplicates were removed, and then all unique references were imported into Covidence systematic review software. 13 One researcher (H.R.F.) screened titles and abstracts for eligibility criteria. Two reviewers (H.R.F. and C.S.) independently reviewed at the full-text screening stage. Conflicts were resolved through discussion. As this is a scoping review, we did not assess the risk of bias of included studies.
Data charting and results synthesis
For data abstraction, we created and piloted a structured spreadsheet form that included article title, first author name, year published, journal, study design, methods, aims, conclusions, and variables relevant to the WHO public health pillars (health care policy, medicine availability, education, implementation, and research activity). A single researcher extracted data from each included study (H.R.F.). The WHO public health pillars (policy, medication availability, education, implementation, and research) were identified a priori to guide the conceptual framework of the review and applied a posteriori to categorize extracted data and structure the thematic synthesis. Of note, studies were considered to be relevant to the research activity pillar if they described insight into the research infrastructure of Bolivia, not if they were a research product (e.g., a research study that looked at medication availability but did not directly address research activity/infrastructure in Bolivia was not classified under the research pillar).
During thematic categorization, each article was reviewed for substantive content related to one or more of the WHO public health pillars. Articles were not limited to a single theme and could be classified under multiple pillars if they meaningfully addressed distinct domains in each pillar. Brief or incidental mentions of a topic were not sufficient for inclusion under that theme. This approach allowed for comprehensive yet focused mapping of literature across all pillars while ensuring that each thematic classification reflected substantive discussion and relevance.
Results
A total of 645 records were identified through database searching. After removal of duplicates, 507 articles underwent title and abstract review, and 96 underwent full text review. Thirty-two articles met inclusion criteria. Two additional articles were obtained from local field experts.14,15 A total of 34 articles were included in the review (Fig. 1; Table 1).5–7,16–46
PRISMA flow diagram for systematic review.
Summary of Studies Included in the Scoping Review and Health care Pillar Addressed
The studies were characterized by study type, with over one-third (35%, n = 12) classified as review articles (6%, n = 2 systematic review; 29%, n = 10 narrative review). Quantitative studies comprised 29% (n = 10), with subcategories of secondary analysis (6%, n = 2), cross-sectional surveys (21%, n = 7), or prospective longitudinal studies (3%, n = 1). Qualitative studies comprised 9% (n = 3) consisting of focus groups (3%, n = 1) and semi-structured interviews (6%, n = 2). Remaining study types included book chapter (3%, n = 1), editorials (12%, n = 4), and project or conference summaries (12%, n = 4) (Table 2).
Categorization of Studies Included in Scoping Review by Publication Category and Study Type
The bolded publication types are sections with unbolded publication types as subsections.
Most publications (80%) addressed Latin America or South America broadly and included data from Bolivia, while seven studies (20%) were specific to Bolivia.7,14,15,24,26,39,40 Only four studies (12%) were published in Spanish.14,15,24,46 Many of the studies also either used data from or referred to the two Latin America Atlases of Palliative Care, the first of which was published in 2012 44 and the more recent secondary edition that was published in 2020. 43
The frequency of thematic sorting of WHO health care pillars included were as follows: health policy (71%, n = 24), implementation (68%, n = 23), education (65%, n = 22), medicine availability (59%, n = 20), and research (26%, n = 9) (Table 3).
Summary of Recurrent Themes Organized by WHO Health care Pillar and the Number of Publications Which Incorporate That Theme
Health care policy
Bolivia does not have any national laws or guidelines specific to palliative care programs.6,16 Although palliative care is included in the national cancer guidelines, it is limited to certain malignancies and lacks a budget for implementation and research.38,45 Notably, palliative care is not included in the HIV/AIDS program or primary care guidelines.
44
In one study, the lack of public policies supporting palliative care was rated a highly relevant barrier to development for countries in the Andean region, including Bolivia. Of note, this was the only region in Latin America that reported a complete absence of palliative care public policies.
42
Another study found that countries with national programs did not necessarily have more palliative care services than those without national programs.
35
In a Strengths, Weakness, Opportunities, and Threats (SWOT) analysis, health care policy had the highest percent of favorable comments for Bolivia relative to the other pillars
In Bolivia, there is no formal accreditation process to certify physicians in palliative care,34,40 and it is not considered a unique medical specialty.27,33 For the providers who do practice palliative care, there is no governmental system to monitor quality or standardize the palliative care services that are delivered. 44 There are no specific federal or regional laws pertaining to advance directives 41 and no clear legal framework for end-of-life decision making. 37 Although euthanasia is considered illegal in Bolivia, 39 there are ongoing discussions regarding the ethics of MAiD in LMICs in general, and the literature suggests that many young and well-educated patients in Bolivia inquire about it. 28 Other policies noted to affect the delivery of palliative care include changes to payment models, 7 and opioid prescribing policies.22,25
The Pan American Health Organization (PAHO) is an intergovernmental agency that collaborates with ministries of health across countries.17,21,39 The division of disease prevention and noncommunicable disease programs houses the cancer control initiative, which contains a palliative care program that seeks to incorporate palliative care as a public health issue and integrate it into legislation.5,23 There is also the Asociación Latinoamericana de Cuidados Paliativos (ALCP, Latin American Association for Palliative Care), which uses education, research, and advocacy to promote palliative care in Latin America and the Caribbean. 47 The ALCP collaborated with the International Association for Hospice and Palliative care to publish the Latin American Atlas of Palliative Care, which is a core dataset for much of the literature about palliative care in the region. 31 Additionally, there are some examples of collaborative work between public and private systems. 46
The Sistema Unico de Salud de Bolivia (SUS), developed in 2019, provides universal health coverage. Prior to SUS there were other limited programs such as Seguro Universal Materno Infantil (SUMI, for mothers and children up to age 5) and Seguro Especial para Adultos (SEA, for elderly and disabled). 38 Like other countries in Latin America with universal coverage provided by the public health system, there are limited funding and resources to meet the overall demand for basic health services, including palliative care, which is compounded by challenges with central administration and management, thus limiting the overall development of palliative care. 37 Private systems exist; however, they are not accessible by most of the population, and there is little communication between public and private sectors. 46
Medicine availability
Historically, Bolivia has been identified as having the lowest rank order of opioid consumption of all countries in Latin America. 18 A study from 2013 showed that of the seven essential opioid formulations identified by the International Association for Hospice and Palliative Care, only four of them are available in Bolivia; codeine, immediate-release oral morphine, injectable morphine, and oral methadone. 18 Other survey data suggest that most of these formulations are “only occasionally” available and often unaffordable 19 Patients’ and familial financial resources are noted to significantly affect access to pain medications at end-of-life. 14 A recent study in 2021 that surveyed palliative care teams in Bolivia demonstrated that nearly all teams reported difficulty accessing opioids due to cost and availability, with specific difficulty reported with extended-release and oral solution formulations. 7 Another study specific to cancer treatment estimated that opioids were only available about half of the time. 38 In a SWOT analysis for Bolivia, opioid availability had the highest percentage of unfavorable statements, with no favorable statements noted. 32 Bolivia had seven of the eight possible restrictive domains identified as relevant for regulatory barriers to opioid access, which placed it in the second-highest group in Latin America. 19 Specific to pediatric palliative care, limited access to opioids was cited as the most significant barrier to palliative care integration. 30
Numerous administrative and judicial barriers have been identified regarding opioid availability. 38 The literature reviewed in this study stated that Bolivia is the only country in Latin America whose quantity of opioid prescribed is limited by dose instead of by days 19 with prescriptions limited to either 100 tablets or 5 ampules regardless of type, milligram, or dose. 44 If a patient can obtain a prescription from an appropriate provider, the prescription must then be validated at a ministry of health office before it is filled and then the patient must find a pharmacy that has the medication in stock. 7 Pharmacists do not accept emergency phone or fax prescriptions and are not allowed to correct technical errors. 19 Studies have identified numerous other limitations, including inadequate supply chain and inventory management, shortage of medications in the market, lack of availability in dispensing establishments, and geographic limitations.42,45 Provider knowledge and comfort with opioid rotation and access to equipment for appropriate delivery, such as subcutaneous delivery or access to elastomeric pumps, are also cited as barriers. 15
The literature suggests that social and cultural factors contribute to the significant lack of medicine availability. Studies cite prescribers fear of law enforcement, media emphasis on opioid diversion and abuse, and “opiophobia” as barriers to appropriate symptom management.5,32,38,42 In a study assessing perceptions of health professionals in the Andean region, the largest identified patient limitation to opioid accessibility was cultural and social attitudes toward pain management with patients’ fears of addiction and adverse events, although financial limitations were also identified. 42 Provider limitations cited included lack of trained professionals, inadequate education and training regarding prescriptions and pain assessment, and fear of dependence. 42 Fear of government sanctions due to prescription errors was also highly relevant. 42 Geographic, transportation, and financial barriers compound these effects and contribute to lack of access to appropriate pain management. 39
Another barrier to medicine availability discussed in the literature is the lack of pharmaceutical industry interest in developing affordable opioid medications 32 as well as the lack of communication between regulators and prescribers. 34 In the first edition of the Atlas of Palliative Care in 2012, opioid collaboration between prescribers and regulators in Bolivia was ranked at level one, which was the lowest of all Latin American countries. 44 In the second edition of the Atlas of Palliative Care in Latin America from 2020, this increased to level three, with level five being the highest possible level. 43 There have been reports in the literature of some regional workshops, 25 including a workshop for opioid regulators that took place in December 2000 in Quito, Ecuador, and included Andean countries such as Bolivia, which identified excessively restrictive laws and regulations, high cost of preparations, lack of availability, and insufficient funds to cover needs as the highest barriers. 21
The International Narcotics Control Board (INCB) is responsible for approving and setting each nation’s annual production and consumption quotas for opioids. 22 INCB estimates that Bolivia has inadequate opioid consumption for its populations, although there has been some improvement over the past two decades. 41 In general, opioid access can be estimated by opioid consumption per capita, which is statistically positively and significantly associated with palliative care services per million inhabitants. 35 From 2012 to 2020 consumption of opioid drugs increased slightly 16 as the calculated number of opioids in morphine eq/mg/capita increased from 0.4 to 1.1; however, the opioid consumption overall is lower than other countries in Latin America. 6
Education
Included literature suggests that formal training in palliative care is absent from the medical school curriculum in all 25 Bolivian medical schools16,31,34,44 and that there is very limited training around death, terminal disease, bioethics, and use of opioid analgesics more broadly.36,37,42 Additionally, the literature states that there are no accredited palliative care education, subspecialty training, or postgraduate accreditation options or formally recognized professors or faculty.7,45 Of the palliative care teams that do exist, 76% of them are associated with teaching institutions, and most physicians received their training in other Latin American countries or Spain. 7 Most of the palliative care training is focused on physicians, and there is lack of educational programs for other providers such as pharmacists, nurses, or social workers.17,27,41 Given there are limited funds for palliative care education, most specialists provide education during off-duty hours. 17 There are some informal training opportunities specifically in oncology and pain management. 39 Bolivia has six oncology training positions per year despite >14,000 new cases of cancer per year. 16 There are 12 pain specialists for a population of 11 million, and there is limited general physician training in chronic pain diagnosis and management. 27 Educational efforts have increased over the past decade, with conferences such as the ecancer “Choosing Wisely” conference being held in Santa Cruz, Bolivia, in March 2022, which highlighted updated clinical evidence in oncology to maximize patient benefit, reduce economic toxicity, and support the integration of palliative care.20,26
There are data to support the importance of palliative care training in clinical care delivery in Latin America, including in Bolivia. In one study of providers who care for children with cancer, those with palliative care training felt more comfortable addressing physical, emotional, and spiritual needs of patients and their family members and felt less overburdened by patients’ suffering. 29 Physicians with palliative care training were also less likely to identify opioid access, cost, and cultural differences as a barrier to palliative care. 30 Most notably, most physicians (96.3%, N = 842) felt greater emphasis on palliative care education is an important step to improving access to palliative care, and 94.8% (N = 829) wanted more education on how to provide palliative care for patients. 29
In Latin America more generally, medical education is generally focused on prevention, curative treatments, and life prolongment rather than symptom alleviation.31,38 There has been increased interest in students and professionals wanting to learn about palliative care, which has been identified as an area for growth. 32 From 2012 to 2020, there was an increase in the inclusion of palliative care education in Latin American Medical Schools, with a significant association between the proportion of medical schools with palliative care in the undergraduate curriculum and the number of palliative services per million inhabitants.6,35 As of 2021, there were still no professorships or professor positions in Latin America specific to palliative care, and the overall heterogeneity and lack of standardization were noted to significantly affect regional progress. 33 The education that does exist is classroom-led with few opportunities to learn in clinical environments with formal structure and feedback. 5 There are some annual interdisciplinary symposiums and training sessions related to palliative care; however, they are mostly attended by physicians and do not include nurses, social workers, or other providers involved in palliative care delivery. Although there are some online educational resources, most are in English. 17 Groups like PAHO are working to provide palliative care education through courses and seminars and produce Spanish guidelines on palliative care, expanding opportunities for improved education in the region. 23
Implementation
The presence of palliative care teams and services in Bolivia has significantly increased over the past two decades. 5 The first palliative care service was founded in 2008, and as of 2019, there were 19 teams located in the 5 most populous cities: La Paz/El Alto, Santa Cruz de la Sierra, Cochabamba, Sucre, and Oruro. 7 The second edition of the Atlas of Palliative Care published in 2020 reported 20 teams, 1 of which was pediatric, 8 inpatient, 9 outpatient, and 3 mixed. 43 Palliative care service per million inhabitants went from 0.6 in 2012 to 1.8 in 2020, with teams located in primary care increasing from 0.4 in 2021 to 1.0 in 2020. 16 Most of the teams are run by a physician and may include other interdisciplinary members such as a psychologist, nurse, social worker, and volunteers. 7 Bolivia was specifically recognized in the literature for one of the early palliative care teams being led by a specialized psychologist. 34 Most of the end-of-life care in Bolivia is delivered at home by close family members, 14 yet the lack of home-based services limits the support that can be provided. 30 In general, there are very limited inpatient hospice options, 14 though there is some growth in inpatient palliative care delivery, such as the Palliative Care Unit of the Oncology Hospital of the Caja Nacional de Salud in La Paz 24 and the Palliative Care Unit at the Instituto Oncológico del Oriente Boliviano in Santa Cruz. 15
The Bolivian Palliative Care Association was founded in 2012 and is working to improve access, develop guidelines, achieve recognition by the ministry of health, and implement training in nursing and medical school curricula. 7 The growth has also been demonstrated in the Atlas of Palliative Care in Latin America, which showed an increase in palliative care services per million inhabitants from 0.6 in 2012 to 1.8 in 2020. 43 However, Bolivia ranked in the lowest group for the index of palliative care development compared to other countries in the region in both the 2012 and 2020 Atlases. 6 Across Latin America, the number of physicians working in palliative care is positively and significantly associated with the number of palliative care services per million inhabitants. 35
Some specific barriers to implementation noted in the literature include lack of recognition of palliative care as a specialty; 33 absence of palliative care in the primary care program; 41 limited cancer registries; 38 shortage of funding and unavailability of trained teaching staff; 27 misconceptions among physicians regarding optimal timing of palliative care consultation, and physician discomfort in raising the topic of palliative care with families; 29 lack of availability of home-based services and cultural differences between physicians and families; 30 limited access to opioids; 22 limited access to palliative care specialists;31,45 location of most services in urban areas;7,45 absence of monitoring systems to guarantee quality standards; 45 and number of services not enough to meet the need. 32 Some proposed solutions include strengthening human resources 46 and the medicine supply chain; establishing palliative care as a priority of public health policy and research agenda; 42 and continued support of research and education initaitives. 26
Research
Nine publications directly provided insight into the research infrastructure/activity in Bolivia. In general, there have been a limited amount of published peer-reviewed studies on palliative care in Bolivia. One study noted that Bolivia had two published articles about palliative care in a 20-year period. 20 However, of the 19 palliative care teams assessed in one Bolivian review, 52% of teams reported contributing to scientific publications. 7 Many barriers to research advancement were noted in the literature, specifically the inability to legally participate in research trials, the need to lobby governments to authorize research studies, and the lack of consensus overall on how to monitor and report palliative care development.6,39 Given limited funds for palliative care education and research, many palliative care specialists perform these duties during their personal time. 17 Other studies cited insufficient knowledge and expertise as well as lack of interest as barriers to research development. 5
In a review of the characteristics of palliative care publications by South American authors over a 20-year period, fewer than 10% were systematic reviews, clinical trials, or prospective studies, 25% were qualitative; and only 15% had funding. 20 Most of the studies in Latin America were focused on Brazil 45 or Latin American immigrants in the United States. 41 Of existing studies, the most common theme was ethical issues, followed by provider experiences providing palliative care. The least researched topics included place of death, quality of death, and bereavement. 20 In a SWOT analysis, limited research was identified as a barrier to palliative care development, and international cooperation in research was identified as crucial to development. 32
Discussion
This scoping review synthesizes the available literature describing palliative care in Bolivia through the framework of the WHO’S public health pillars: health policy, medicine availability, education, implementation, and research. The findings demonstrate that Bolivia is in an early stage of palliative care development and has made significant progress over the past two decades, with the establishment of formal palliative care services, inclusion of palliative care in the national cancer plan, and growing professional engagement.
Regarding health care policy, the lack of formal recognition of palliative care by the Ministry of Health remains one of the largest barriers to palliative care development. 44 Although integration within cancer programs allows leveraging of existing infrastructure, it also hinders development of palliative care services for other conditions and diseases.32,48 Palliative care continues to be a low priority for policymakers and administrators. 17 Funding is often directed towards primary prevention and curative treatment. 38 Although the WHO and World Palliative Care Alliance recommend that all governments should integrate palliative care into health care programs, develop laws and guidelines that acknowledge and define palliative care, recognize palliative care as a distinct medical subspecialty, provide licensure for palliative care programs, and define national strategies for palliative care, many countries, including Bolivia, are yet to achieve these milestones in the setting of constrained financial resources, workforce shortages, and competing national health priorities. 41
With respect to medicine availability, although the published literature suggests that only four of the seven essential opioid formulations are available in Bolivia (codeine, immediate-release oral morphine, injectable morphine, and oral methadone), local experts indicate that those are the available options covered through the Single Health System model (SUS). Additional essential medications, such as injectable methadone, controlled-release oral morphine, immediate-release oxycodone, controlled-release oxycodone and injectable fentanyl, are now available to purchase outside of SUS coverage (G. Antelo, personal communication, September 8, 2025). Transdermal fentanyl, buprenorphine, and tapentadol remain unavailable (G. Antelo, personal communication, September 19, 2025). Earlier studies described limitations on quantities prescribed; however, these studies were published in 2013 (18, 19) and based on a Bolivian physician coauthor’s experiences providing care, such restrictions changed around 2018. The literature also suggests that Bolivian physicians require a specific government license to prescribe opioids, 7 however, in communication with practicing clinicians, a validated prescription pad is required, not a license (G. Antelo, personal communication, September 8, 2025). Overall, the largest barriers to medicine availability in the delivery of palliative care in Bolivia seem to be strict drug control policies, specialty prescription requirements, and lack of supply. 7 Increased collaboration with larger agencies focused on opioid access is needed to improve access to essential medications required for adequate symptom management. 38
Although the published literature does not document formal palliative care educational opportunities, based on personal communications and direct experiences of one of our coauthors who provides palliative care in Bolivia, in 2017 a postgraduate palliative care diploma became available (G. Antelo, personal communication, September 8, 2025). As palliative care education continues to grow in Bolivia, emphasis should be placed on developing capacity for formal curricula, including standardized education programs and continuing medical education training opportunities. 27 Formalized education should target knowledge and training about the use of opioid analgesics and the integration of palliative care principles into primary care. 42 Other additional important considerations noted in the literature include formal training on scientific writing, obtaining funding and protected research time, 20 building workforce capacity. 30
In personal communication with clinicians in Bolivia, including review by a physician member of our authorship team (G.A.), it is evident that the published academic literature does not fully reflect the current state of palliative care in Bolivia. For many clinicians, publication in academic journals is not a common practice. Much of the published literature is over two decades old, with recent policy changes reflecting progress occurring in the past several years. Even within the broader research published about Latin America, many of the palliative care studies were considered lower impact, with funding barriers and research designs limiting practical change. 20 This dearth of literature underscores the importance of including personal communications and gray literature in reviews such as this, as well as ensuring partnership with local clinicians and leaders providing relevant care. It also emphasizes the importance of research development and increased support for scholarly communications, especially given the reliance on clinicians using their uncompensated personal time to contribute to the academic literature. International collaborations and support for local research opportunities are one potential way to help address this imbalance.
Strengths of this review include the use of an established framework through the lens of the WHO public health pillars, which allows for comparison with other countries developing palliative care programs. Additionally, the inclusion of all type of publications, both peer-reviewed and gray literature, as well as collaboration with practicing palliative care providers in Bolivia, enhances the comprehensiveness of the study, given the limited number of formal publications available. Our review provides insight into the limitations of relying on published literature as the most reliable benchmark of knowledge in settings without robust support for research and scholarly activities, which continues to be a concern in LMICs.49,50 New guidelines are needed for ways to integrate on-the-ground experiences and context into rigorous review protocols to balance the contributions of both forms of knowledge and experience.51,52
There are several limitations to this review. Notably, of the included studies in this scoping review, less than one quarter of the studies that included Bolivia were specific to Bolivia. This may overestimate broad trends in Latin America rather than the specific situation in Bolivia. Other limitations include the study types—with many of the included studies being narrative reviews and few empirical studies. Of the existing empirical studies, many rely on the same database: The Atlas of Palliative Care. Although this study included a query of six databases in English and Spanish, there were very few articles in Spanish or published by Bolivian authors, demonstrating different cultural customs around publishing and the need for further research support in this area. Finally, this review was not registered as a protocol.
Conclusion
Bolivia has made meaningful progress in palliative care development over the past two decades with significant growth in implementation, integration of palliative care into the national cancer plan, and expanded access to essential opioid medications. By leveraging the WHO public health pillars, we provide a comprehensive review of critical areas of development and implementation. The absence of national policies, legal frameworks, accreditation systems, and formal recognition of palliative care as a medical specialty continue to limit policy development and equitable service delivery.6,16,27,43 Furthermore, overly restrictive opioid policies and cultural perceptions surrounding opioid use continue to constrain medicine availability and effective symptom management.19,42 Research remains the most underdeveloped pillar, highlighting a key area for future growth for palliative care advancement nationally. 20 Importantly, the published academic literature does not fully reflect the current state of palliative care in Bolivia, and inclusion of on-the-ground perspectives from clinicians and community leaders is needed to capture recent progress and persistent challenges. New meetings and collaborations between palliative care leaders in Bolivia underscore exciting developments in this space. 26
Building on the progress already underway, the findings highlight encouraging momentum and multiple opportunities for continued growth. Priorities include strengthening undergraduate and postgraduate education, ensuring reliable access to essential medications, and building research capacity. Sustained collaboration among policymakers, clinicians, educators, and international partners will be essential to transform emerging initiatives into a comprehensive, sustainable palliative care system capable of serving all Bolivians.
Authors’ Contributions
H.F.: Conceptualization, funding acquisition, investigation, formal analysis, visualization, writing—original draft preparation; C.S.: Conceptualization, investigation, formal analysis, methodology, writing—reviewing and editing; G.A.: Resources, supervision, validation, writing—reviewing and editing; J.L.C.: Data curation, methodology resources, writing—original draft preparation (methods), reviewing and editing; A.T.: Conceptualization, supervision, writing—reviewing and editing.
Footnotes
Acknowledgments
Thank you to Dra. Gloria Rodriguez, the Director of the Instituto Oncologico del Oriente Boliviano in Santa Cruz de la Sierra, Bolivia, for additional insight into the palliative care landscape of Bolivia.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number F30HD116454 (CS). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.