SUSTAINING ACCESS TO HIGH QUALITY RADIOTHERAPY CARE: A LMIC PERSPECTIVE

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1 SUSTAINING ACCESS TO HIGH QUALITY RADIOTHERAPY CARE: A LMIC PERSPECTIVE Dr Kennedy Lishimpi BSc MB ChB M.Med FC Rad Onc (SA) Director Cancer Control Ministry of Health Zambia ICARO2 21/06/17

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3 Introduction Population 15.5M Below 24 years 66% Median Age 16.7Yrs Growth Rate 2.94% Rural Population 59% Life Expectancy 52.5Yrs Literacy 63.4% Mission Statement: To provide equitable access to cost effective, quality health services as close to the family as possible Vision: People A Nation of Healthy and Productive Overall Goal: To improve the health status of people in Zambia in order to contribute to socio-economic development Key Principles: Primary Health Care (PHC) approach; Equity of access; Affordability; Cost-effectiveness; Accountability; Partnerships; Decentralisation and Leadership

4 Republic of Zambia Access to Radiotherapy Care

5 The Radiotherapy Dream The vision to establish a radiotherapy center in Zambia started in Due to the increasing numbers of cancer cases seen, Zambia needed to establish its own specialist hospital To reduce costs and Increase access to treatment to more people. Due to lack of budgetary allocation the project was delayed for many years.

6 The Dream cont. 1995, there was a firm plan by GRZ to establish cancer centre at UTH in collaboration with IAEA GRZ to construct building, and IAEA to provide equipment and training of staff GRZ was to contributed K100m ($25000) for the project Project did not take off

7 Dream cont April 2001, GRZ Submitted Project Proposal to OFID June 2001, Project Appraissal Mission followed by approval By OFID in August September 2002 Loan Became Effective Contracts for construction and equipment signed in 2003.

8 Cancer Diseases Hospital During Before 2006 GRZ had been sending cancer patients abroad. At $ per patient Due to limited budget allocations for treatment abroad, only 350 cases out of 5,000 were sent between 1995 and 2004 Construction started 2003 Construction Phase

9 ZAMBIA CANCER CONTROL PROGRESS 1982 ZNCR set up 2006CANREG introduced 2012 Population Based Registry for Lusaka Province 2006 Cancer Diseases Hospital Completed and officially opened on 19 th July ST QUATRO MISSION 2010 IMPACT MISSION 2016 CDH Phase II complete 2017 Construction of two radiotherapy satellite centers 2006 cervical cancer screening set up 2012 HPV vaccination introduced 2013 cervical cancer screening available in all provinces 2018 national HPV vaccine scale up 2016 National Cancer Control Strategy signed

10 Proportion of deaths by cause in SSA, 2010 Tuberculosis 3% 6% 4% 12% HIV/AIDS Malaria 25% 13% Other communicable diseases Maternal,perinatal and nutritional causes Noncommunicable diseases 15% 23% Road traffic injuries Other injuries Health Observatory Data Repository:

11 Proportion of mortality by cause in Zambia in 2014

12 Overall Cancer Problem in Zambia The overall age-standardized cancer incidence rate for both sexes in Zambia in 2012 was per 100,000 (10,593 cases) for all cancers The age-standardized mortality rate to be per 100,000 (7,521 deaths) This means that the majority (71%) of new cancer cases in Zambia die from the disease.

13 Challenges of Accessing Quality Radiotherapy Care in LMIC Inadequate primary and secondary prevention national programmes ( Late Presentations ) Underfinanced or poorly resourced cancer care activities (from Community to TC) Inadequate trained Human Resource Poor Infrastructure Lack of appropriate equipment and its maintenance

14 RADIOTHERAPY SERVICES IN ZAMBIA YEAR ACTIVITY & OUTPUT Million USD set aside OFID/IAEA/GRZ for the development of the first radiotherapy centre in Zambia Phase I Million USD set aside OFID/GRZ for construction of CDH Phase II Million USD has been set aside BADEA/OFID/GRZ for the development of the first two satellite centers in Zambia Phase III YEARLY Parliament appropriates money for running costs and cancer medicines and supplies on yearly basis

15 CDH Phase I & II: 252 in-patient department 8 bed Nuclear Medicine unit Theatre Block Out-patient department Chemotherapy unit with 80 beds Radiotherapy area Mould room and workshop Pharmacy unit Diagnostic wings X-Rays, MRI, CT MMG, US & various Lab equipment Administration block CDH Today

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17 CDH Phase II Chemo & Ward

18 Cobalt 60 & Linear Accelerator

19 Treatment Planning & Second Cobalt 60 Unit

20 2 High Dose Rate Brachytherapy Units

21 Simulator & CT Scanner

22 Mammogram & MRI

23 PROGRESS SINCE QUATRO MISSION 1. EQUIPMENT 2009 QUATRO FINDINGS PROGRESS 2017 COMMENT 1 linear accelerator STILL 1 PLANNED TO BUY ONE AND REPLACE 2006 ONE LATER 1 Cobalt 60 2 DONE UNDER CDH PHASE 2 1 Orthovoltage (Not working) 1 DECOMMISSIONED 1 High Dose Rate brachytherapy unit 2 DONE UNDER CDH PHASE 2 Treatment Planning System (Not in use) STILL NOT IN USE THERAPLAN CANNOT BE FIXED OUTDATED 1 Conventional Simulator 1 OUT OF USE PROCURED A CT SIM TO BE READY BY SEPTEMBER 2017 Mould Room and workshop. STILL SAME

24 PROGRESS SINCE QUATRO MISSION 1. EQUIPMENT 2009 QUATRO FINDINGS PROGRESS 2017 COMMENT Mammography 1 1 Working Ultrasound 2 2 Working Laboratory equipment Functional X Ray Unit 0 1 Digital Fluoroscopy unit CT Scanner 1Planned 1 Functional MRI Scanner 1Planned 1 Functional Nuclear Medicine Treatment Units Planned Available Full complement

25 PROGRESS SINCE QUATRO MISSION 1. HUMAN RESOURCE 2009 QUATRO FINDINGS PROGRESS 2017 COMMENT Total Staff 131 (86 Clinical) 410/752 (281 Clinical Staff) NEWLY APPROVED ESTABLISHMENT ROs Training in RSA and 16 will start training at CDH M.Med Clin Onc SO, GO, PO Employed and all going to TMH for 12 months training NMP 0 2 In training in RSA MPs Complete 2 doing clinical training 1 just joined RTTs Lab Techs 4 11 Pharmacy 6 24 Nurses

26 ZNCR CONSOLIDATED REPORT Total cases = 17,795 Female = 11,451 Male = 6,344

27 Top Ten Cancers in Males Top Ten-Male Kapsoi Sarcoma % Prostate % Esophagus % Eye % Non Hodgkin Lym % Liver % Bladder % Stomach % other skin % Penis % Penis other skin Stomach Bladder Liver Non Hodgkin Lymphoma Eye Esophagus Prostate Kapsoi Sarcoma Tiop Ten-Male

28 Top Ten Female Cancers TOP TEN-FEMALE Cervix % Breast % Kaposi sarcoma % Eye % Non Hodkin Lymp % Ovary % Bladder % Esophagus % Stomach % Other vskin % Liver % Liver Other vskin Stomach Esophagus Bladder Ovary Non Hodkin Lymphoma Eye Kaposi sarcoma Breast Cervix Top Ten-Female

29 Provincial Distribution Cases Per Province Central 1568 Copperbelt 1875 Eastern 2228 Luapula 710 Lusaka 6821 Muchinga 511 North Western 613 Northern 808 Southern 1542 Werstern 872 Unknown 247 Total Total Cases Per Province Central Copperbelt Eastern Luapula Lusaka Muchinga North Western Northern Southern Werstern Unknown

30 Childhood Cancer Registration in Zambia, 2013 Cancer Type Total Liver Bone Kaposi sarcoma Kidney Retinoblastoma Brain/Nervous system Hodgkin Lymphoma Burkitt lymphoma Non hodgkin lymphoma Leukeamia Skin Eye Other Total

31 CDH Statistics for 2015 Years # of pts cancer trends in the last four years have maintained a stable balance. This could be attributed to inadequate sensitizations to the community through various medias Total 13827

32 Top 10 cancers for Both Males & Females The mean age is 47 The ratio between Male 687 to Female 1349 = 1:

33 Republic of Zambia Sustaining Radiotherapy Services in Zambia

34 National Cancer Control Strategic Plan Developed, signed by Minister of Health August 2016and Launched February 4 th 2017 Director Cancer Control Unit Appointed with the Coordination Unit Cost plan for five years

35 Improving Access to Radiotherapy in Zambia

36 IAEA TECHNICAL COOPERATION ZAM 6010 Establishing the First Radiotherapy Centre in Zambia ZAM 6012 Improving the Quality of Cancer Treatment ZAM 6016 Strengthening the Delivery of Radiotherapy Services ZAM 6019 Expanding the Capacity for Radiation Oncology through Sustainable Local Human Resource Development to Benefit National Cancer Control ZAM 6020 Consolidating the Delivery of Cancer Treatment Services

37 HRH Development Established RTT TEVETA accredited Diploma, First students started June 2012 CDH Training College M.Med Clinical & Radiation Oncology BSc Therapy Radiography BSc Oncology Nursing MSc Medical Physics

38 VUCC: An instrument for access to Cancer Control Education & Training at home IN-SERVICE PRE-SERVICE PREVENTION 1. Community Health Workers (Cancer Skills Package) EARLY DETECTION DIAGNOSIS & TREATMENT PALLIATIVE CARE 2. Screening Workers (Cervical Cancer: VIA) 3. Pathology Technicians 4. Surgeons (Surgical Oncology Modules) 9. Palliative Care practitioners (Short Courses) 5. Radiation Therapy Technicians 6. Clinical Oncologists 7. Oncology Nurses 8. Pathologists SURVEILLANCE 10. Data Collectors*

39 Thank You!