Capacity building in sub-Saharan Africa: models of care
Authors: Patrick J Loehrer, Barry Rosen, Elkanah Omenge Orang'o, Julie R Gralow
Journal: The Lancet Global Health (2018)

The incidence of cancer is expected to increase by 70% in the next two decades, with the greatest proportion of cases coming from low-income and middle-income countries (LMICs). Additionally, mortality will be disproportionately higher in LMICs, where infrastructure, access to care, and workforce capacity is ill prepared for this crisis in cancer. Perhaps the best example of this dichotomy is in sub-Saharan Africa, where the population, after weathering an HIV/AIDS epidemic, is now facing the problems of non-communicable chronic diseases such as cancer, heart disease, and diabetes.1Ferlay J Soerjomataram I Dikshit R et al.Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012.Int J Cancer. 2015; 136: E359-E386Crossref PubMed Scopus (21366) Google Scholar Learning from the lessons of public–private partnerships that were built during the response to HIV, opportunities to address capacity building for clinical care, research, and education also exist for addressing the issue of cancer.2Graff S Africa's neglected epidemic.J Natl Cancer Inst. 2017; 109: djx169Crossref Scopus (2) Google Scholar The Academic Model Providing Access to Healthcare (AMPATH) is one such example of a collaborative and sustainable partnership whose model is to lead with care. The AMPATH consortium consists of more than a dozen North American institutions, including the University of Toronto and Indiana University, who are partners with Moi University School of Medicine and Moi Teaching and Referral Hospital in Eldoret, Kenya.3Strother RM Asirwa F Busakhala NB et al.The evolution of comprehensive cancer care in Western Kenya.J Cancer Policy. 2013; 1: e25-e30Summary Full Text Full Text PDF Scopus (17) Google Scholar Efforts to build capacity for cancer treatment began more than 12 years ago, with initial efforts for drug supplies, treatment guidelines, and formal training in gynaecological oncology, nursing, and medical oncology. These efforts have led to the creation of a cancer and chronic care facility that accommodates more than 10 000 patients and screens more than 12 000 women for cervical cancer each year.4Randall TC Chuang L Orang'o EO et al.Strengthening care and research for women's cancers in sub-Saharan Africa.Gynecol Oncol Rep. 2017; 21: 109-113Crossref PubMed Scopus (4) Google Scholar, 5Omenge Orang'o E Wachira J Asirwa FC et al.Factors associated with uptake of visual inspection with acetic acid (via) for cervical cancer screening in western Kenya.PLoS One. 2016; 11: e0157217PubMed Google Scholar This building also has bunkers for four radiation units that are expected to be delivered in early 2018. Training for physicists will be co-led by faculty from the University of Toronto. AMPATH-Oncology, under the leadership of Barry Rosen of the University of Toronto, has established Kenya's first approved curriculum in gynaecology-oncology, which has three graduates and four students in training. Fredrick Chite Asirwa and other full-time faculty of Indiana University are accelerating the clinical and education missions in medical oncology. At present, ten staff members for cancer care (four in medicine, three in gynaecology, two in radiation, one in paediatrics) and a palliative care team serve 20 million patients within the catchment area of western Kenya. For the first time, the Moi Teaching and Referral Hospital has established a department of oncology, led by Naftali Busakhala, who reports to the hospital director. With assistance from foundations and pharmaceutical companies (including Pfizer, Eli Lilly, and Celgene), all patients with cancer who need chemotherapy for effective outcomes receive drugs, irrespective of their ability to pay. A revolving pharmacy was developed for oncology to assure adequate supplies of drugs. The Fred Hutchinson Cancer Research Center (Fred Hutch) partnership with the Uganda Cancer Institute (UCI), formed in 2004 with an initial focus on infection-associated malignancies, has expanded the capacity to treat cancer in Uganda several fold. A central mission of the UCI–Fred Hutch partnership is to provide training activities to build human capacity for cancer care and research. With the support of training grants from the National Institutes of Health, the Fred Hutch has helped train more than 300 Ugandans involved in cancer research and care, including 11 physician-scientists who have visited Seattle, WA, to pursue graduate coursework, research projects, and intensive clinical training. Ongoing training activities include tumour boards and a monthly clinical case conference, supported by faculty in Seattle and Uganda. The UCI–Fred Hutch partnership led to the first comprehensive cancer centre jointly built by US and African cancer institutions in sub-Saharan Africa; the UCI–Fred Hutch Cancer Centre opened in 2015. The facility is funded in part by the US Agency for International Development's Office of American Schools and Hospitals Abroad. With funding from the African Development Bank, Uganda is establishing the East Africa Oncology Institute, a centre of excellence in oncology sciences.6African Development Bank GroupEast Africa centers of excellence Uganda.https://www.afdb.org/en/projects-and-operations/project-portfolio/p-z1-ib0-024/Google Scholar The institute will provide leadership in postgraduate education, clinical training, research, and clinical services in oncology. The centre of excellence aims to address shortages of skilled oncology professionals in east Africa. The UCI has identified several specialty areas as priorities for fellowship training, including paediatric oncology, adult haematology-oncology, gynaecological oncology, and oncology nursing. Plans include developing capacity for future training in pathology, radiology, radiation oncology, palliative care, and surgery. The implementation of the East Africa Adult Hematology and Oncology Fellowship programme will be jointly coordinated by the Ugandan Ministry of Health, Mulago National Referral Hospital, Makerere University College of Health Sciences, UCI, Fred Hutch, and the University of Washington. The steering committee has embarked on the development of a curriculum and core competencies for training in adult haematology and oncology, and the first fellowship class will begin training in 2018. A key lesson common to these relationships is the importance of addressing issues that are relevant to the LMICs, not just those deemed important by partners in high-income countries.7Olayemi E Asare EV Benneh-Akwasi Kuma AA Guidelines in lower-middle income countries.Br J Haematol. 2017; 177: 846-854Crossref PubMed Scopus (21) Google Scholar An example is from a meeting of various stakeholders and key cancer leaders from Kenya, the Kenyan Ministry of Health, and the National Cancer Institute to establish priorities for strategic growth.8Morgan C Cira M Karagu A et al.The Kenya cancer research and control stakeholder program: evaluating a bilateral partnership to strengthen national cancer efforts.J Cancer Policy. 2017; (published online March 25.)http://dx.doi.org/10.1016/j.jcpo.2017.03.012Summary Full Text Full Text PDF Scopus (5) Google Scholar From one of these retreats, the Kenyan stakeholders identified priorities for growth that span from capacity building in clinical research, strengthening pathology and cancer registries, improving cancer awareness and education, and developing the health system with a national health policy (figure). Expansion of coverage for cancer care has now been taken up by the Kenyan Government, which now places cancer as one of the four critical issues to be addressed in the next 5 years, with legislation in the parliament for the coverage of cancer health services through the National Hospital Insurance Fund. We declare no competing interests.