2023 theme: Close the care Gap: Uniting our voices and taking action.
By Agbor N. Ebuta MD
Cancer is a major health condition which burdens the health care system globally. It is a shared burden affecting the developing countries putting a strain on their healthcare system.
In 2020, the WHO reported that annually 10millon persons succumb to the cold hands of death, as a result of being directly affected by cancer. Two third of this burden is in low- and middle-income countries.
The sub-Saharan Africa story is disturbing, especially when one considers that projections suggest that cancer incidence will spike to 85% within the next fifteen years, with a projected 1,100,000 new cases and 700,000 deaths expected annually by recent estimates, a number that is expected to continue to rise if measures are not put in place to mitigate the promoting factors.
Recent quotes suggest that for Nigeria, between 102,000 to 250,000 newly diagnosed cancer cases occur yearly, with an estimated 10,000 to 72,000 of whom die, an unacceptable number.
Sadly, in the first 33 days of 2023, it was reported that 10,000 Nigerians developed cancer, while a staggering 7,000 died from cancer.
Africa has 3% of the world cancer facilities, despite accounting for 16.72% of the world population. This fact is further embellished by a huge deficit in all aspects of health system components.
Cost of care is almost always prohibitive, a situation complicated by high poverty rates, low insurance penetration, competition for few service centers and chronically debilitating nature of most cancers. A situation with cost running into millions of naira, means that a huge number of patients who enroll into care sadly drop off due to poor financial sustainability, while the most are unable to even commence treatment.
The commonest cancers are breast and cervical cancer (in women) making up ~50.3% of all cancers. In men prostate, liver and Non-Hodgkin lymphoma cancer represent the three commonest contributors to the burden.
As much as 51% of cancer patients die as a direct result of cancer in Nigeria, a much higher ratio than is obtainable in developed countries.
The reason is multifactorial. Most cancer patients in Nigeria, follow a convoluted path to diagnosis, delayed by factors like poor access, rampant ignorance, missed diagnosis, faith-related interferences, poor insurance up take and an out-of-pocket health expenditure at population level of ~70%. All these conspire to produce a situation in which as much as 80% of cancer patients commence treatment at the late phase.
The failure of stake-holders to put in place a screening programme; the failure of effort to produce reliable data, which is a key input in any serious or realistic National cancer plan means that, all plans can only be hinged on projections or at best intelligent guesses. The prevention, diagnosis and treatment of cancer requires a multi-disciplinary team. The inability to train, attract, recruit , retain and motivate a comprehensive team remains a daunting task. This is further complicated by the stiff global competition for skill health work force that is currently playing out.
For example, diagnosis is critical and must be timely to detect, estimate severity and determine best treatment strategy for cancers. This typically will involve, screening, pathological evaluation, molecular or immunological diagnostics deployments to arrive at precise diagnosis.
Treatment involves the timely combination of multi-modal methods, which include surgery, radiation, chemotherapy, nuclear medicine, immunotherapy and- of course, palliative methods, when all else fails. These options of care are best ideally delivered, via multidisciplinary team-based patient centered vehicle.
Sadly, few centers have these in place, and even when they do in low- and middle-income countries, equipment break-down, prohibitive cost of care vis a vis a high poverty rate and low insurance penetration, and an absent or near absent insurance cover for cancer, within the context of weak health system ensure poor outcomes.
While treatment may not always provide cure, it can prolong life and improve quality of life lived, sadly this is hardly an option for most.
Investment in health though improving, remains grossly inadequate. In the USA, estimated $200 billion is spent on cancer care yearly. This easily translates to 150 trillion Naira which represents about 7 times the National budget of the Federal Republic of Nigeria. This clearly shows we are yet to scratch the surface.
Health system approach to address these challenges is a super-necessity if we are to make progress sustainably.
We have to look at financing health more robustly and sustainably. We need to reinforce the health work-force supply, push for a functional health information system, ensure access to the required medicine/consumables and provide the institutional leadership and health system governance required to deliver a sustained, effective, flexible and adjustable solution to mitigate this scourge.
Leadership and governance, will require that we provide a policy driven health ecosystem, that provides realistic guidelines that address all aspects of cancer care, promoting the standardisation and institutionalisation of reforms when they happen. The preparation of beautiful plans, which we consistently fail to implement, is becoming a tradition, this must stop. Any new plans must have inbuilt fool-proof mechanisms to see them through, should this require legislation to ensure full implication, so be it. However, lessons from why future plans failed to meet the desired outcomes must be elucidated to ensure success going forward.
Key stake-holders have to promote health financing models that ensure a deliberate improvement in health system funding. This will be in line with ‘Abuja health declaration of 2001’, which had many African Heads of Government promising to commit 15% of their gross national budgets to directly finance health. This in-turn will ensure that more funds are available for the health sector. The promotion of universal health coverage, and an immediate operationalisation of the NHIA act of 2022, will bring us closer to health for all mandatorily, as signed into law.
The development of deliberate policy environment that stimulates sustainable access to health inputs like chemotherapy, immunotherapy, radiotherapy inputs, in order to ensure a cost friendly and un-interrupted flow of treatment require using logistically and economically sustainable models. Disruptive innovation is urgently required here.
Globally, the heightened demand driven flux in human resource for health work space appears to have impacted adversely of supply of key players in health service delivery. In Nigeria especially, the harsh reality need not be recast, the truth about our dire situation is out there. Thus stake-holders have to close the gap to address these challenges in the short, medium to long -term. A failure literally means many more will die.
Apart from retaining the in-country healthcare worker, efforts to recruit, train, motivate and empower for service, must be painstakingly attended to ensure that this disturbing trend is mitigated.
The International Atomic Energy Association recommends 4 to 8 machines per million, that will mean Nigeria needs about 880 to 1, 760 machines for an estimated population of 220miliion. Thirty African countries do-not have a single radiotherapy machine. Although Nigeria can boast of 13 of such Machines (i.e a ratio1 machine/ 15.34 million) nine of which are owned partly or wholly by Government. Most are affected by dearth of trained personnel, poor staffing at centers, sub-optimally trained, frequent machine break-downs and all other challenges facing the health sector. Human resources for RTH are radiation oncologist, medical physicist and therapy radiographer. The sorry supply state of this human resources restates the challenges bedeviling the health care system in low and medium income countries, LMIC.
If we must move deliberately to close the care gap, all hands must be on deck to ensure a comprehensive reaction to this burden. Is there light at the end of the tunnel? May be, may be not, but let us all remember, we are all stakeholders and should endeavor to give our best when and where-ever possible.
▪︎ Dr. Ebuta is the Vice President, Medical Initiative for Africa.