Pain Relief and Palliative Care at the End of Life: A Worldwide Gap

Worldwide, only about 14% of people who need palliative care receive it, by the estimates of both the World Health Organization (2020) and the Global Atlas of Palliative Care (2026), and cancer is the largest single disease group among the adults who need it^[1][2]. Whether someone near the end of life with cancer has their pain eased, and where they die, depends heavily on the country and the health system they live in.

Palliative care relieves pain and other symptoms of serious illness and, as WHO describes it, uses a team approach to support both the person and the people caring for them, including in bereavement^[1]. For many families it is what makes the last weeks bearable: someone who can control pain at night, a nurse who visits at home, a hospice bed when one is needed. This study sets out, at population level, how many people need that care, how unevenly it is provided, how unequally the most basic pain medicine is shared between countries, and what is known about where people with cancer die. It does not judge any individual or family's choices; the gaps it describes are gaps in services.

Around 74 million people a year need the kind of relief palliative care gives, and the number is rising

The Global Atlas of Palliative Care (Worldwide Hospice Palliative Care Alliance, with WHO technical input) estimates in its 3rd edition (2026) that about 73.5 million people needed palliative care in 2023: 27.6 million in their last year of life and 45.9 million before it. Cancer (excluding leukaemia) is the largest single disease group among adults in need, at 27.9%, though over 70% of adult need is for other conditions; 72.9% of the 63.0 million adults in need, and 96.2% of the 10.6 million children, live in low- and middle-income countries^[2]. WHO's fact sheet, last updated in 2020, still gives the Atlas 2nd edition's earlier estimate of 56.8 million people a year^[1]; the Atlas's method was considerably expanded between editions, so the rise from one total to the other is not a simple trend^[2].

The Lancet Commission on Global Access to Palliative Care and Pain Relief (2018) measured the same need another way, as "serious health-related suffering": in broad terms, the physical and psychosocial symptoms associated with life-threatening and life-limiting conditions^[3]; the Atlas's 2023 estimates use the same measure^[2]. The Commission's 2025 update estimated that this measure of need grew by 74% between 1990 and 2021 to almost 73.5 million people, with 80% of them in low- and middle-income countries, and that 63% were people who did not die that year^[4]. A further analysis put the figure at 73.6 million in 2023, 76.2% in low- and middle-income countries. Cancer was the leading cause of serious health-related suffering in high-income countries (42.7%), and in low-income countries the number of people with serious health-related suffering due to cancer rose by 17.8% between 2021 and 2023^[5].

Need will keep growing as populations age. A modelling study in The Lancet Global Health (2019), using WHO mortality projections, estimated that by 2060 about 48 million people a year, 47% of all deaths, will die with serious health-related suffering, an 87% rise from 26 million in 2016. Such deaths from cancer were projected to reach 16 million, a 109% rise, and 83% of all these deaths were projected to occur in low- and middle-income countries^[6]. These are projections that assume current patterns of disease and population change, not forecasts of what must happen.

In 2017, a quarter of countries had no known palliative care service, and only 15% had it fully part of mainstream care

The most complete country-by-country picture comes from a 2020 study that graded palliative care development in 198 countries for 2017. Forty-seven countries (24%) had no known palliative care activity, and 13 (7%) were only building capacity. The largest group, 65 countries (33%), had isolated provision: services that exist in some places but are not generally available. Only 30 countries (15%) had advanced integration of palliative care into mainstream health services. The authors concluded that palliative care at the highest level of provision was available to only 14% of the world's population (a different measure from the 14% of people in need who receive care, though it points the same way)^[7].

There has been progress. Between 2006 and 2017 there were 32 fewer countries in the two lowest categories and 17 more in the two highest^[7]. But coverage in health systems still lags. In a WHO survey of 115 countries published in 2024, only 39% of participating countries covered the basics of cancer management in their health benefit packages, and only 28% additionally covered care for people who need palliative care, including general pain relief^[8]. Our study on the global cancer gap sets out how this fits the wider shortfall in diagnosis and treatment in lower-income countries.

WHO names the barriers plainly: national health policies that leave palliative care out, little or no training for health professionals, inadequate access to opioid pain relief, low awareness of what palliative care offers, cultural and social beliefs about death and dying, and misconceptions, including that palliative care is only for people with cancer or only for the last weeks of life^[1].

Four in five people in the world share 13% of the morphine used for pain

Morphine and related opioid medicines are among the main medicines used to relieve severe pain in palliative care, and the figures suggest the gap in access is not a shortage of the drug itself. WHO, citing the International Narcotics Control Board, reports that in 2018, 79% of the world's population, mainly people in low- and middle-income countries, consumed only 13% of the morphine used for the management of pain and suffering, a quantity equal to just 1% of the 388 tons of morphine manufactured worldwide. In 2014 the figure had been 80% of the world's population consuming 9.5%^[1]. A small change across four years should not be read as a firm trend.

The Lancet Commission compared the opioids actually distributed in each country with the amount needed to relieve serious health-related suffering. By the estimates its authors reported in 2025, the poorest 10% of the world's population receives on average 200 mg of morphine-equivalent opioid per person with serious health-related suffering per year, which the authors note is not even enough for seven days of a typical starting dose, while the richest 10% receives about 200,000 mg^[3]. In a benchmark group of 19 Western European countries in 2019, distributed opioids averaged more than eight times the amount needed for palliative care, ranging from 59% of need in Malta to over 2,000% in Austria; the authors caution that opioids also have other clinical uses and can be wasted or stockpiled, so a figure above 100% does not by itself show that every person's need is met^[3].

Sales data tell a similar story from another angle. A study of opioid analgesic sales in 66 countries and regions found consumption in 2019 in the lowest quarter of countries ranged from 0.01 to 5.40 morphine milligram equivalents per 1,000 people per day, "despite high income levels and cancer death rates in some of them", and that consumption was associated with the Human Development Index. Over 2015 to 2019, sales fell by 12.8% a year in North America while rising in South America, Eastern Europe and Asia^[9].

WHO lists the belief that improving opioid access will increase substance misuse among the misconceptions that keep pain relief from people who need it^[1]. The evidence here is about medical access at population level: in much of the world, the problem for people dying of cancer is too little pain relief, not too much.

Where people with cancer die varies more between countries than the illness would explain

Place of death is one of the few end-of-life measures recorded for almost everyone, on the death certificate. It is not a measure of good or bad care on its own: a hospital or hospice can be exactly the right place for one person, and home for another. But large differences between similar countries show how much the organisation of services shapes what is possible.

A study of death certificates for 1.36 million cancer deaths in 14 countries, mostly in 2008, found that between 12% (South Korea) and 57% (Mexico) of cancer deaths happened at home, and between 26% (the Netherlands and New Zealand) and 87% (South Korea) in hospital. The differences were partly explained by how many hospital beds, long-term care beds and general practitioners each country had^[10].

Most people say they would prefer to die at home, though not everyone. A systematic review of 210 studies covering just over 100,000 people in 33 countries found moderate evidence that most people prefer a home death; among the higher-quality studies, the share of patients preferring home ranged from 31% to 87%. About one in five patients in the studies that asked again (20% of 1,395) changed their preference as illness progressed, though the review notes this was not tested statistically. The authors concluded that this supports home-based care while urging policymakers to secure hospice and palliative care elsewhere for people who think differently or change their mind^[11].

In several countries with good registration data, cancer deaths have been moving out of hospital. In the United States, among 9.6 million cancer deaths from 1999 to 2015, the share in hospital fell from 36.6% to 24.6%, home deaths rose from 38.4% to 42.6%, and deaths in hospice facilities rose from 0% to 14.0%^[12]. In England, across 2.28 million cancer deaths from 1993 to 2010, hospital remained the most common place of death (48.0% over the whole period, against 24.5% at home and 16.4% in a hospice), with home and hospice deaths rising after 2005^[13].

Scotland's national statistics give one of the most recent pictures. Of 49,474 cancer deaths in 2022 to 2024, 39.4% were in NHS hospitals, 37.0% at home and 15.4% in hospices. Between 2015 and 2024 the hospital share fell from 43.3% to 40.1% and the home share rose from 29.6% to 35.8%; the hospice share, around 20% until 2020, was 16% in 2024. Public Health Scotland notes that pandemic restrictions contributed to more deaths at home and fewer in hospital in 2020 and 2021^[14].

Within countries, the same patterns of disadvantage appear at the end of life

Inside a single health system, who dies where is not random. In England, people with blood cancers were roughly half as likely as people with bowel cancer to die at home or in a hospice (proportion ratios 0.46 to 0.52), people aged 85 and over were less likely than those aged 25 to 54 (0.66 to 0.72), and people who were single, widowed or divorced were less likely than married people. People living in less deprived areas were somewhat more likely than those in more deprived areas to die at home or in a hospice (proportion ratios 1.02 to 1.12). The authors note that they had no data on individual preferences, so these figures cannot say whether people died where they wished^[13].

In the United States, younger age and Black or Asian race and Hispanic ethnicity were associated with hospital death. In 2015, 32.8% of cancer deaths among Black people happened in hospital, against 23.1% among white people, and the gap had widened since 1999. Half (50.9%) of cancer deaths at ages 15 to 24 were in hospital, compared with 15.0% at 85 and over^[12]. Some of these differences may reflect differing needs and wishes; the studies cannot separate choice from access. Our study on deprivation and income looks at these patterns earlier in the illness, and the study on carers and families covers the people who provide much of the care at home.

What the evidence asks of us

The figures point to a small number of clear actions, most already agreed by governments.

• Make palliative care part of every health system. In 2014 the World Health Assembly adopted resolution WHA67.19, the first global resolution on palliative care^[1]. A decade on, only 28% of countries in WHO's 2024 survey covered palliative care in their health benefit packages^[8]. Including it, and funding it, is the practical test of that commitment.
• Close the pain-relief gap. With most of the world's population sharing a small fraction of medical morphine^[1], the task is to remove the policy, training and supply barriers WHO identifies while keeping sensible safeguards, so that effective pain relief reaches people dying of cancer wherever they live.
• Plan for rising need. Projections of an 87% rise in deaths with serious health-related suffering by 2060, most of them in low- and middle-income countries^[6], mean that workforce and service planning needs to start now, especially in countries that today have isolated provision or none^[7].
• Offer real choice of place. Most people prefer to die at home, but not all, and some change their minds^[11]. Services need enough community support to make home possible and enough hospice and hospital palliative care for people who need or want it.
• Count who is missed. Routine statistics on place of death from cancer, like those Scotland publishes^[14], together with data on whether people received palliative care at all, broken down by age, deprivation, ethnicity and cancer type, would let commissioners see and close the gaps the research has found^[12][13].

Language: this piece says "people with cancer" and "people living with and after cancer", and describes the illness and its treatment plainly, without combat metaphors. Clinical terms such as "stage", "incidence" and "net survival" are used in the sense the cited source defines them.

Why we're publishing this

Hospices, palliative care teams and the charities that support people at the end of life have argued for decades that a good death should not depend on where someone happens to live. The figures here support that case. They show that the need is large and growing, that the medicines and services which ease it are shared very unequally between and within countries, and that these gaps are a matter of policy and funding, not of illness. We have gathered them in one place, with sources, so that people affected by cancer, and the organisations that stand with them, can use them. This study is part of our cancer research library.

How to read this data

The global need figures are modelled estimates, built from cause-of-death data and assumptions about which conditions need palliative care; WHO's 2020 figure and the serious health-related suffering estimates use different methods, so their totals should not be compared directly. The palliative care development levels are expert ratings against indicators, not counts of people served. Opioid figures measure medicines distributed or sold, not what reached each person. Place of death comes from death certificates, which are complete in countries with good registration but say nothing about the quality of care, whether a palliative care team was involved, or whether the person died where they wished. The 14-country comparison uses 2008 data. Most detailed place-of-death research comes from high-income countries; for much of the world, where need is greatest, there are few routine data at all. Associations with age, ethnicity or deprivation describe groups and do not show cause.

Use this data

Free to cite with attribution to Better Health For Everyone. Charities, campaigners and journalists are welcome to reuse these figures and charts. For the underlying figures as a spreadsheet, get in touch.

Important: This article summarises published research for general information. It is not medical advice and cannot be used to diagnose, treat or predict anything about an individual. If you have concerns about your own or someone else's health, please speak to a qualified health professional.

Sources

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3. Knaul FM, Arreola-Ornelas H, Kwete XJ, et al. Distributed Opioids in Morphine Equivalent: A Global Measure of Availability for Palliative Care. Journal of Pain and Symptom Management, 2025;69(2):204-215. europepmc.org/article/PMC/PMC11778810
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6. Sleeman KE, de Brito M, Etkind S, et al. The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions. The Lancet Global Health, 2019;7(7):e883-e892. europepmc.org/article/MED/31129125
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8. World Health Organization. Global cancer burden growing, amidst mounting need for services (news release), 1 February 2024. WHO, 2024. who.int/news/item/01-02-2024-global-cancer-burden-growing--amidst-mounting-need-for-services
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10. Cohen J, Pivodic L, Miccinesi G, et al. International study of the place of death of people with cancer: a population-level comparison of 14 countries across 4 continents using death certificate data. British Journal of Cancer, 2015;113(9):1397-1404. europepmc.org/article/PMC/PMC4815784
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14. Public Health Scotland. Place of Death from Cancer in Scotland: 2015-2024. Public Health Scotland, 27 January 2026. publichealthscotland.scot/publications/place-of-death-from-cancer-in-scotland