Cancer ecosystem assessment in West Africa: health systems gaps to prevent and control cancers in three countries: Ghana, Nigeria and Senegal

Introduction Sub-Saharan Africa is experiencing a rapid epidemiological transition with the increasing incidence of Non-Communicable Diseases (NCD). Among these, cancer is one of the main causes of death in adults. This is a public health problem whose burden is unknown due to lack of statistical data. In addition, the already overburdened health systems are experiencing enormous constraints to address the problem with the double challenge of communicable and NCDs. Methods The purpose of this evaluation was to assess the capacity and needs of health systems to prevent and control cancer. A cross-sectional study, using both quantitative and qualitative methods, was conducted between April 2017 and February 2018 in target countries, through in-depth interviews with key actors, direct observations and documents review. The WHO framework for health system strengthening with the 6 pillars was used for the gaps analysis. Results Little priority is given to the fight against cancer because of low political commitment. Programs´ resources are very limited and there is a poor coordination of the actions. Human resources are insufficient, and most of them are concentrated in the capital city. This limits access to care with a late consultation of patients. Diagnosis and treatment services are expensive and generally paid by households. Finally, the unavailability of reliable data at national level hinders the decision-based evidence. Conclusion There is an urgent need to create strong partnerships at national and regional levels to (i) Advocate for a strong political commitment; (ii) Strengthen the coordination of actions and create more synergy among stakeholders; (iii) Improve the quality and quantity of human resources; (iv) Extend universal health coverage to cancer and improve program funding; and (v) Set up cancer registries at national level.


Introduction
In most countries in sub-Saharan Africa, the burden of noncommunicable diseases (NCDs) is increasing rapidly whilst infectious diseases continue to pose major challenges [1], giving a double burden of disease to the sub-region. Cancers are among the major NCDs with high morbidity and mortality rates in Africa. According to the most recent Global Burden of Disease (GBD), NCDs constituted the greatest portion of deaths in 2017, at 73.4% -this represents a 22.7% increase from just ten years earlier in 2007 [2]. The global cancer statistics of 2018 had estimated that there will be 18.1 million new cancer cases and 9.6 million cancer deaths this year. According to the report, in both sexes, lung cancer is the most commonly diagnosed cancer (11.6% of the total cases) and the leading cause of cancer deaths (18.4%), followed by female breast cancer (11.6%), prostate cancer (7.1%) and colorectal cancer (6.1%) [3,4]. It is commonly suggested that the rise in incidence and deaths of noncommunicable diseases is linked to poor socioeconomic status of individuals especially in low-and middle-income countries of Africa [5,6]. Late presentation, poor diagnosis, and lack of access to treatment are major contributory factors to poor prognosis in most developing countries [5,7]. In 2017, it was reported that pathology services were available in only 26% of low-income countries [5].
In a broad scope, developing countries, in particular African ones, are not ready to face the upcoming pandemic, with consideration to the rapidly increasing incidence of the NCDs, the weakness of the health system, and the very slow trends of the financial resource allocation [8]. Despite this threat, the burden of cancer is unknown in most of the African countries mainly because of a lack of data or under-reporting of cases. In addition, the national and subnational health systems in these countries face challenges such as inadequate diagnostic facilities, limited access to care, inadequate technical capacity and infrastructure, and all of these contribute to a weak response to the cancer burden. There is a dearth of reliable institutional data on cancers, so countries rely mostly on modelled data such as the GLOBOCAN (Global burden of cancer) report.
Consequently, countries do not have the vital data needed to make informed decisions and policies [5]. This dearth of reliable and representative oncology data in Sub-Saharan Africa resulted in the World Health Organization (WHO) midwifing the GLOBOCAN project [9], which aims to provide on a regular basis, updated statistics on the incidence and prevalence of major types of cancer in 184 countries of the world, through combined sources including research and national statistics. To adequately plan prevention, diagnosis and management of cancers both at the community and health facility levels requires data. Amref Health Africa conducted a rapid needs assessment in Nigeria, Ghana and Senegal to better understand the current gaps in order to inform where to focus their attention towards the disease prevention and treatment. This paper assesses the needs and capacity of the three countries´ health systems to prevent and control cancers.  [10]. In Ghana and Senegal health systems organization is structured around three levels: national, regional and district. Ghana has 10 administrative regions with each having a regional hospital and 216 districts, while Senegal has 14 administrative regions (with 14 regional hospitals) and 76 health districts. On the other hand, Nigeria is a federal government system with 36 states and one Federal Capital Territory (Abuja), all of which combine the 774 local government areas (LGAs). In each country healthcare is delivered through various health facilities at primary, secondary and tertiary level. Institutions offering healthcare in Ghana includes 407 hospitals, 328 maternity homes, 1,858 clinics/ health centres and 4185 Community-based Health Planning and Services (CHPS) [11]. Senegal has hospitals 39 hospitals, 100 health centers, 1,458 health posts and 2,130 health huts [12].

Methods
And Nigeria counts 59 teaching hospitals and federal medical centers, 3,303 general hospitals and 20,278 primary health centers (PHCs) and health posts [13].

Study design: this was a cross sectional study conducted between
May 2017 and February 2018 in target countries using both quantitative and qualitative approaches.
Sample size and Selection of facilities: relevant institutions were selected at the various levels (national, regional and district) of the health delivery system, according to their role in cancer control. In Ghana the two public comprehensive cancer centers at the two Page number not for citation purposes 3 teaching hospitals (Korle-Bu Teaching Hospital KBTH, and Komfo Anokye Teaching Hospital KATH) and a private cancer center-Sweden Ghana Medical Cancer Centre (SGMC), with radiotherapy facilities were selected. Four (4) regional hospitals out of the 10 were selected and 4 district hospitals in each of the selected regions as well. At least one of the 4 district hospitals selected in the region was a private facility -overall, 23 health facilities were selected. In Senegal the assessment was conducted in all hospitals having a cancer unit or activity. These include 4 referral/teaching hospitals (Le Dantec, Grand Yoff, Fann and Principal) in Dakar and one regional hospital (Thies).
In Nigeria, 6 geo-political regions, spanning two states per region (11 states), except Borno State (due to the insurgency) were assessed.
The most established specialist referral hospital rendering specialist oncology care, in each geopolitical zone, was purposely selected. In each country key stakeholders in the NCDs´ Control Program in the respective Ministry of Health, and stakeholders in civil society organizations (CSOs) involved in cancer prevention and control were also interviewed.
Data Collection: a standardized questionnaire designed using the WHO framework for health system (Capacity assessment questionnaire for the prevention and control of cancers) [14], was developed and used to assess the key thematic areas. The questionnaire was divided into different sections for easy response filling, and in a chronological order. The questionnaire was developed in a user-friendly manner such that it could be self-administered and interviewer-administered. The assessment protocol was languagetranslated to French before adoption in Senegal. The Heads of the selected facilities or units and cancer specialists (medical oncologist, radiation oncologist, oncology nurses, pharmacist, nutritionist, psychologist, social workers) were interviewed. The various experts helped in completing the relevant sections of the tools, based on the thematic areas. Research assistants were trained in the use, interpretation and recording of the field tool. Activities included collection, transcription and summarizing qualitative data gathered through Key Informant´s Interview (KII), health facility assessment, record reviews, and observations. Completed questionnaires and check-lists were reviewed for quality, completeness, consistency and coherence, in order to ensure good quality data was generated, entered and analyzed. Desk review of literatures and documents was done in all countries.

Data analysis
The quantitative and transcribed qualitative data were subsequently analyzed. Data analysis, triangulation, encoding transcription and interpretation for all countries were conducted. In Nigeria, each question was coded, entered and analysed using the Statistical Package for Social Sciences (SPSS) version 20.0 software while Atlas to version 7 was used for the qualitative analysis. The data in Ghana was entered into EPI info version 7 and was analysed using Stata version 13.0. Whereas in Senegal, qualitative data analysis was undertaken manually using responses reduction approach and quantitative data was managed using the Excel.
Ethical considerations: approval was obtained from the respective countries. Informed consent was obtained from each respondent after explaining to them the purpose of the study and their liberty to choose to participate in the survey, or not. Confidentiality was maintained as anonymity of respondents was ensured. Unfortunately, these documents are not fully implemented yet, due to lack of funds. Besides, there is no national cancer steering committee to guide, coordinate and monitor the various interventions in Senegal.

Results
There are no evidence-based national guidelines /protocols/standards for the management of cancer through a primary care approach.  (Table 2) as the main reason why treatment is interrupted. Other reasons were because patients could no longer afford treatment, the unavailability of chemotherapy and side effects of the drugs. In Nigeria and Ghana, a referral mechanism existed for referring cancer patients and their family. In the private cancer centre in Ghana, they followed up on their patients using phone calls, even though they did not have a direct system to provide community support. Senegal lacks guidelines on referral of cancer patients in the respective health system structure. Furthermore, the country lacks an organized system for monitoring, prevention, screening, diagnosis and treatment of cancer. Furthermore, patients missed their radiotherapy sessions since the only radiotherapy machine in the country had broken down for almost a year. Fortunately, significant progresses are ongoing, with the recent acquisition of two new radiotherapy machines, Drug storage seems to be a challenge given that some of them need to be stored in cool places. Though this is done by the supplies and are only availed on request, it may turn to be a challenge since the patients have to wait for the commodities to be ordered, hence increasing the waiting time of the patients.

Health management information system (HMIS) and cancer registries
The National HMIS in Nigeria captures data from PHCs and secondary health facilities only. There is also an attempt to capture data from the tertiary centers, though this in most cases is incomplete.
The study also realized that there are no cancer-related reports being Health care financing: the Abuja Declaration [15], that at least 15% of Nigeria´s Gross domestic product (GDP) be allocated to health is yet to be implemented. In any case, there have been mixed signals on the amount to be allocated over the years with 2007 recording the highest allocation of 4.47%. The prevention and control of cancer is expensive and requires every partner and stakeholder´s effort when it comes to its financing. The financial catastrophe and impoverishment associated with cancer treatment and care is well documented in this study. This finding is consistent to a prior study which reported that though Nigeria is country that is rich with natural resources; federal hospitals have insufficient health care budgets to improve their radiotherapy delivery capacities [16]. inhabitants. According to experts, Senegal´s major human resources for health (HRH) challenges include suboptimal coordination between public and private HRH actors and unemployment of health workers [18]. According to WHO, a well-performing health workforce is one which works in ways that are responsive, fair and efficient to achieve the best outcomes possible, given available resources and circumstances. According to our study, there is need for more health workers while those available need to be well distributed. Indeed, Ghana suffers from a chronic shortage of health workers as well as inequalities in both the distribution and skills mix of workers, and this severely restricts access to service and hampers achievement of national health objectives. The country has just over 11 doctors, nurses and midwives per 10,000 population, less than half the number (23 per 10,000) deemed necessary by the WHO for achievement health Goals. Rural areas, in comparison with urban areas, are particularly poorly served as regards access to health care; in 2009, for example, there was one doctor for every 5,103 people in Greater Accra, compared with one doctor for every 50,751 people in Northern Region [19]. In addition, there is a need to train more oncologists in order to reduce the acute shortage of health workforce in the country.
Cancer care and treatment requires support from other cadres. With only a few of the workers having undergone oncology training, much needs to be done to increase this number, given the ratio of doctor to patient. Motivation is key in keeping the workforce happy and making their work productive. Most of the oncologists rated their satisfaction as moderate. This may be due to overworking, lack of equipment, poor working environment, among other reasons that may be beyond this study. The level of knowledge among the oncologists was also rated as moderate. This could be as a result of inadequate periodic training and lack of opportunities to further their knowledge.
Medical products, technologies: there is a limited chain of supply for cancer drugs, and this is worrisome. The study also found that only the tertiary hospitals had all the drugs needed, unlike the other levels of health care. Drug storage seemed to be a challenge given that some of them need to be stored in cool places. Though this is done by the supplies and are only availed on request, it may turn out to be a challenge, since the patients have to wait for the commodities to be ordered, hence increasing the waiting time of the patients. However, in a document by Brunner and others, Senegal is said to be having a well-structured and well-regulated systems for importing, manufacturing, storing, and distributing pharmaceuticals and medical commodities. The lead agency for regulation is the Direction de la Pharmacie et Medicament (DPM) which governs both the public and private sector supply chains, issues authorizations to import or manufacture pharmaceuticals products, and oversee drug assurance [18]. One of the biggest challenges to cancer diagnosis and treatment is the lack of facilities and equipment for treatment and diagnosis of cancer. Though availability and affordability scored average in the quantitative analysis, a lot needs to be done if the expression of the health workers in the qualitative analysis is anything to go by. Majority of the centers lacked radiotherapy machines and nuclear medicine services. This shows a picture of a poor functioning health system, thus comprising on the quality, safety and efficacy of cancer treatment. This is similar to a study in Nigeria in which it was found that management of patients with breast cancer is a major challenge to physicians with factors like lack of advanced technology (diagnosis and monitoring), poor access to cancer medication were cited [20]. In another study carried in Central Nigeria, the researchers noted that their institution did not have facilities for chemo-radiation and did not have a trained medical or gynecologic-oncologist in cervical cancer treatment. Due to this limitation, cervical cancer patients received either symptomatic care (including correction of anemia, treatment of infections, and pain control) or referral to Ahmadu Bello University Teaching Hospital (ABUTH), Zaria for chemoradiation [21].
Service delivery: our findings show a lack of effective service delivery to the thousands of cancer patients across these three countries. Lack of proper and legally binding partnerships with other NGOs both at the grassroots and at the national levels hinder quality personal and non-personal cancer prevention and treatment interventions to the populace. Lack of well-trained personnel and inadequate infrastructure in the public hospitals is a barrier to quality service delivery. This has led to poor adherence to medication due to high cost of treatment in the private health centers leading to high morbidity and mortality. This is similar to a report in Ghana where significant disparities of service between north and south and between rich and poor, factors such as cultural and religious beliefs, poor physical infrastructure and limited resources were cited as barriers to quality health for all people living in Ghana [19]. Service delivery should be of high quality, and be offered when and where it is needed, with minimal wastage of resources. This is not presently the case, according to our findings, as a lack of radiotherapy machines and consultation rooms makes patients travel long distances to seek treatment, while others are forced to wait for longer hours to see a health worker or to be attended to. According to Diop et al. the high concentration of care offered in urban areas in Senegal and the high cost of provided services are to blame for the lack of access to care [22]. Information and research: the fact that cancer registries are not fully functional in the three countries and they capture only data from some secondary and tertiary health facilities only is a huge gap. As a result, much cancer cases go unreported. The cancer information system in these three countries is largely paper-based. This leads to bulk in documentation, and time wasting in collection, collation, analysis and reporting. This also leads to numerous errors that can be controlled by computerizing the system. Our results are similar to a study by Zelle et al. in 2014 where it was reported that the national cancer registry in Ghana is not fully functional and local data on breast cancer stage distribution were derived from Korle Bu Teaching Hospital, Accra and Komfo Anokye Teaching Hospital, Kumasi [23].
Since this is based on presenting patients rather than on all patients, this may not reflect reality and may have biased our estimates.
Secondly, information on the epidemiology of breast cancer was not locally derived but based on the Globocan data and observations in other countries. A computerized system will lead to timely collection, Page number not for citation purposes 8 analysis, dissemination and use of reliable and appropriate information on cancer. It will also lead to better coordination of cancer related information from different states.

Conclusion
The epidemiology and types of cancer seen during this assessment is similar to those in other parts of the world, with increasing disease and death burden [24,25]. The coordination of cancer control is yet to be fully implemented in these three countries since their respective Ministry of Health developed a policy action plan, thus making the fight against cancer haphazard and that which lacks organization. The lack of an operational multi-sectoral entity in dealing with the NCDs is also a barrier to dealing with the cancer in these countries. There is an acute shortage of health personnel for cancer care, with a very high patient to cancer specialist ratio, and little or no specialists in the rural communities [26]. Majority of the health personnel available have no formal oncology training. Brain drain and increased sickness absenteeism [27], according to the literature, have deleterious effects resulting from the shortage of healthcare workers, and could possibly lower the quality of care offered to patients on cancer care. There is a lack of well-coordinated supply chain for drugs in addition to inadequate infrastructure across the states. A lot of cancer data is yet to be captured across the countries since NHMIS only captures information from PHCs and secondary health facilities on communicable diseases. The information system is largely paperbased making the activity cumbersome and prone to errors. There is a lack of effective service delivery to the thousands of cancer patients across the countries. Poor coordination with other partners, lack of well-trained personnel and inadequate infrastructure in the public hospitals are barriers to quality service delivery. In summary, little awareness, late presentation with limited access to cancer screening, diagnosis and treatment is a hallmark of cancer in these countries assessed.
Recommendations: considering all of the aforementioned, the following recommendations should be considered: high level advocacy to increase political will and commitment towards cancer prevention and control; strong partnerships and well-coordinated activities are key to combating cancers whose incidence and prevalence are on the rise. This also calls for community participation including the local leaders as has been documented as a vital strategy; creating awareness on the usefulness of early screening, and to bridge the gap in cancer care among patients; development and effective implementation of a national protocol for cancer prevention and screening is also equally advised. National protocols can be used as a monitor for choosing the method of screening for each individual, and these should be patient-centered, facilitating decision-making of cancer-screening services. Considerable effort should be put to ensure that national guidelines offer strategies based on the risk susceptibility of individuals [28]. This will aid delivery of holistic care for patients, bearing in mind the peculiarities associated with the different severities in the different stages of cancer; establishment of a sustainable and supportive financial platform for cancer treatment.
Adequate finance is needed to promote value-based healthcare [29], subsidization of drug costs, and also for limiting the occurrences of stock-outs in pharmacies of the tertiary facilities. The role of innovative healthcare financing in global public health delivery is as apt for NCDs and cancer as it is for infectious and neglected tropical diseases (NTDs). In this regard countries should take the opportunity of universal healthcare coverage to include cancer prevention and treatment into the premium; special provision of funds is also needed to limit the global shortage of human resources in specialist care [30].
This should include prompt remunerations, attractive packages and sponsored cancer care trainings; ensuring availability of equipped diagnostic and cancer care centers across countries, in order to facilitate easy access to care. Access to care will help to reduce loss to follow-up, compliance and adherence issues; Strengthening the institutional cancer registries and integrating them into the NHMIS.
What is known about this topic  Cancer is increasing rapidly in African countries and it represents one of the main causes of illness and death among adults;  Cancer burden is unknown in most of the African countries mainly because of a lack of data or poor reporting of cases.
As a result countries rely on estimated data. Health systems face several challenges but they are not well documented and/or assessed;  Efforts are ongoing to tackle the disease but they are not well designed and tailored to the needs because countries do not have the vital data needed to make informed decisions and policies.
What this study adds  The magnitude of the challenges faced by health systems to prevent and control cancer and the capacities that exist in countries;