Cancer – Doing the Maths!

Cancer – Doing the Maths!

Cancer is one of the world’s leading causes of death and long-term illness, accounting for 8.8 million reported deaths in 2015 alone. The large group of diseases that make up this generic category ranks second only to ischaemic heart disease and stroke in the list of the world’s biggest killers from all causes over the last few decades. Globally, approximately 1 in 6 deaths is caused by cancer of various types. The socioeconomic impact of the disease is significant and escalating, and the annual economic cost to individuals and communities all over the world is estimated in excess of US$ 1 trillion. The accuracy of these figures is somewhat undermined by a pattern of institutional under-reporting in some parts of the developing world. World Health Organization (WHO) estimates suggest that only 1 in 5 low and middle-income countries have the necessary data to drive a well-articulated global or national cancer care policy. Considerable uncertainty exists regarding the true prevalence of cancer in many sub-Saharan African countries, leading to a gross underestimation of the scale and impact of the problem and the inability to channel resources effectively on behalf of communities and population groups.

70% of cancer deaths occur in low and middle-income countries

As this insidiously devastating picture unfolds across the globe, we observe regional variations in the landscape of disease distribution mediated expectedly by environmental and behavioural factors such as diet, obesity, smoking and alcohol. Socioeconomic indices that apply disproportionately in low and middle-income countries tend, on the other hand, to skew outcomes and statistics negatively in the direction of increased mortality in these areas.

Health follows a social gradient. The level of poverty and socioeconomic deprivation encountered in these countries, and historic failures in approaches to funding and administration of healthcare delivery services link inextricably with problems of delayed clinical presentation, inadequate access to diagnostic and treatment services, and infrastructural under-development and poor treatment outcomes across the region.

Indeed, for many cancers presenting in sub-Saharan African communities, the almost inevitable consequence of these problems is a near-approximation of the risks of developing and dying from the disease. Presently, 7 out of 10 cancer deaths occur in low and middle-income countries and the number of new cancer cases is projected to rise by approximately 70 per cent over the next two decades.

In Nigeria, cancer is reportedly responsible for 72,000 deaths each year and an estimated 102,000 new cases annually. Breast and cervical cancers as the two most common types of cancer in females, together responsible for approximately 55 per cent of cancer deaths occurring each year.

In keeping with patterns across sub-Saharan Africa, where infectious diseases are collectively responsible for a third of known cancer cases, hepatitis B, HIV/AIDS and human papillomavirus (HPV) remain a significant driving force in the aetiology of conditions such as liver cancer, Kaposi sarcoma and cervical cancer.

The country does not currently have a national immunization scheme for HPV. Screening and early detection services for cervical, breast and colorectal cancer are not routinely available in the public sector. There are no warning labels on tobacco products, chemotherapy and radiotherapy services are not generally available within the public health system.

Vast improvements have been made in the number of cancer registries, now 284 in total distributed across the country. 198 of these are however hospital-based, further highlighting an institution-centred approach to healthcare across the region. There are ongoing problems with information systems, consistency of data management, training and development of registry staff and a relative absence of population-based primary research in Oncology.

The National Cancer Control Plan (NCCP, 2018 – 2022) proposes to address prevention and treatment pitfalls in the management of cancer through 7 priority areas of action at an estimated budget of US$ 309 million (average US$ 61.8 million annually). This budget takes into consideration an acknowledged funding gap of 25 percent, to be supplied by “donors and development partners” over the next 5 years.

The total health allocation in the 2018 national budget is just under US$ 1 billion, representing a per capita health expenditure of just over US$ 5 per citizen (Nigerians are reported to spend roughly the same amount on medical tourism each year). Of this sum, US$ 750 million is ringfenced for recurrent expenditure on operations, salaries, goods and services, grants and existing subsidies, leaving an outstanding pot of just over US$ 200 million for capital expenditure, which it must be said has declined marginally in percentage terms in comparison to the 2017 budget. There is little doubt that the NCCP details comprehensive plans to address prevention and treatment strategies over the course of the stipulated 5-year period. What may well be missing, however, is a commitment to short-term goals (and budgetary allocations) designed to satisfy the requirements of performance indicators, clearly stated within the document for each of the 7 identified improvement domains.

It may be correct on the other hand, to advance the argument that the detail of such focused planning would not necessarily be contained within the body of a high-level strategic document such as we now have in the NCCP. There is indeed a clear stipulation within the plan for each of the 36 states of the country to develop an annual operational plan that feeds directly into the framework of the national cancer control initiative.

The inevitable consequence of these problems is a near- approximation of the risks of developing and dying from the disease

However, it is important to recognise with the very best of intentions, that the region of sub-Saharan Africa (and sovereign nations comprised therein) does have considerable form in similar circumstances, in being long on rhetoric but short on detail!
The WHO is emphatic in recognising that regardless of resource constraints faced by a country, a well-conceived, well-managed and collectively-funded NCCP helps reduce the prevailing cancer burden and improve services on behalf of patients and families.

Achievement of this 5-year strategic plan will depend largely on organisational ability, political will and availability of required financing and specialised resources. Consistent application of information technology will be hugely important in enabling crucial efficiencies in communication, data management, confidentiality and reporting. Keeping a tight leash on planning will go a long way to ensure success in these areas and guarantee the attainment of the 7 priority action domains.

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