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

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: A Nation of Healthy and Productive People

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

Republic of Zambia

Access to Radiotherapy

Care

PresenterPresentation NotesAt Bellagio, we were invited by Dr. Emmanuel Makasa…We are at the beginning of a very long process…As we said many times in the Commission report, every country is different, and context specificity to recommendations is criticalThese slides represent simply an initial application of the LCoGS report methodologies to one specific country, here Zambia, to begin the conversation on how to strengthen surgical servicesZambia is a lower-middle-income country by WB income group

The Radiotherapy Dream

• The vision to establish a radiotherapy center in Zambia started in 1982.

• 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.

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

Dream cont’

• April 2001, GRZ Submitted Project Proposal to OFID

• June 2001, Project Appraissal Mission followed by approval By OFID in August 2001.

• September 2002 Loan Became Effective • Contracts for construction and equipment

signed in 2003.

Cancer Diseases Hospital During Construction Phase

• Before 2006 GRZ had been sending cancer patients abroad.

• At $10 000 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

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 19th July 2007 • 2009 1ST 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 2017 – 2021 signed

Proportion of deaths by cause in SSA, 2010

4%

12%

13%

23%15%

25%

3%

6%

Tuberculosis

HIV/AIDS

Malaria

Other communicable diseasesMaternal,perinatal and nutritional causesNoncommunicable diseasesRoad traffic injuries

Other injuries

Health Observatory Data Repository: http:/apps.who.int/ghodata

Proportion of mortality by cause in

Zambia in 2014

Overall Cancer Problem in Zambia

• The overall age-standardized cancer incidence rate for both sexes in Zambia in 2012 was 136.2 per 100,000 (10,593 cases) for all cancers

• The age-standardized mortality rate to be 104.9 per 100,000 (7,521 deaths)

• This means that the majority (71%) of new cancer cases in Zambia die from the disease.

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

RADIOTHERAPY SERVICES IN ZAMBIA

YEAR ACTIVITY & OUTPUT

2001 7 Million USD set aside OFID/IAEA/GRZ for the development of the first radiotherapy centre in Zambia – Phase I

2012 8 Million USD set aside OFID/GRZ for construction of CDH Phase II

2016 25 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

CDH Today • 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 Phase II Chemo & Ward

Cobalt 60 & Linear Accelerator

Treatment Planning & Second Cobalt 60 Unit

2 High Dose Rate Brachytherapy Units

Simulator & CT Scanner

Mammogram & MRI

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

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

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

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 5 + 6 7 + 10 3 Training in RSA and 16 will

start training at CDH M.Med Clin Onc

SO, GO, PO 0 4 + 3 3 Employed and all going to TMH for 12 months training

NMP 0 2 In training in RSA MPs 3 5 + 1 3 Complete 2 doing clinical

training 1 just joined RTTs 13 35 Lab Techs 4 11 Pharmacy 6 24 Nurses 31 162

2009 QUATRO FINDINGS

PROGRESS 2017

COMMENT

Total Staff 131 (86 Clinical)

410/752 (281 Clinical Staff)

NEWLY APPROVED ESTABLISHMENT

ROs 5 + 6

7 + 10

3 Training in RSA and 16 will start training at CDH

M.Med Clin Onc

SO, GO, PO 0

4 + 3

3 Employed and all going to TMH for 12 months training

NMP 0

2

In training in RSA

MPs 3

5 + 1

3 Complete 2 doing clinical training 1 just joined

RTTs 13

35

Lab Techs 4

11

Pharmacy 6

24

Nurses 31

162

ZNCR CONSOLIDATED REPORT 2008 - 2014

• Total cases = 17,795 • Female = 11,451 • Male = 6,344

Top Ten Cancers in Males 2008 – 2014

0 200 400 600 800 1000 1200 1400 1600

Kapsoi Sarcoma

Prostate

Esophagus

Eye

Non Hodgkin Lymphoma

Liver

Bladder

Stomach

other skin

Penis

Tiop Ten-Male Top Ten-MaleKapsoi Sarcoma 1513 23.85%Prostate 1387 21.86%Esophagus 331 5.22%Eye 324 5.11%Non Hodgkin Lym 274 4.32%Liver 239 3.77%Bladder 233 3.67%Stomach 196 3.09%other skin 156 2.46%Penis 148 2.33%

Top Ten Female Cancers 2008 – 2014

6009

1119

972

369

244

206

196

185

171

171

157

0 1000 2000 3000 4000 5000 6000 7000

Cervix

Breast

Kaposi sarcoma

Eye

Non Hodkin Lymphoma

Ovary

Bladder

Esophagus

Stomach

Other vSkin

Liver

Top Ten-Female TOP TEN-FEMALECervix 6009 52.48%Breast 1119 9.77%Kaposi sarcoma 972 8.49%Eye 369 3.22%Non Hodkin Lymp 244 2.13%Ovary 206 1.80%Bladder 196 1.71%Esophagus 185 1.62%Stomach 171 1.49%Other vSkin 171 1.49%Liver 157 1.37%

Provincial Distribution Cases Per ProvinceCentral 1568Copperbelt 1875Eastern 2228Luapula 710Lusaka 6821Muchinga 511North Western 613Northern 808Southern 1542Werstern 872Unknown 247Total 17795

1568

1875

2228

710

6821

511

613

808

1542

872 247

Total Cases Per Province

Central Copperbelt Eastern Luapula

Lusaka Muchinga North Western Northern

Southern Werstern Unknown

Childhood Cancer Registration in Zambia, 2013

Cancer Type 0-4 5-9 10-14 Total Liver 0 0 3 3 Bone 1 4 5 10 Kaposi sarcoma 7 8 6 21 Kidney 15 11 1 27 Retinoblastoma 25 6 0 31 Brain/Nervous system 3 4 1 8 Hodgkin Lymphoma 3 3 3 9 Burkitt lymphoma 1 3 0 4 Non hodgkin lymphoma 1 1 0 2 Leukeamia 1 6 5 12 Skin 1 0 1 2 Eye 1 3 4 8 Other 3 3 4 10 Total 62 52 33 147

CDH Statistics for 2015Years # of

pts

2006 35

2007 719

2008 1204

2009 1285

2010 1282

2011 1302

2012 1828

2013 2049

2014 2065

20152058

Total 13827

0

500

1000

1500

2000

2500

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

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

CDH Statistics for 2015

Years # of pts

200635

2007719

20081204

20091285

20101282

20111302

20121828

20132049

20142065

20152058

Total13827

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

Series 120062007200820092010201120122013201420153571912041285128213021828204920652058

Top 10 cancers for Both Males & Females - 2013

0

5

10

15

20

25

30

35

05

10152025The mean age is 47

The ratio between Male 687 to Female 1349 = 1:2

Republic of Zambia

Sustaining Radiotherapy

Services in Zambia

PresenterPresentation NotesAt Bellagio, we were invited by Dr. Emmanuel Makasa…We are at the beginning of a very long process…As we said many times in the Commission report, every country is different, and context specificity to recommendations is criticalThese slides represent simply an initial application of the LCoGS report methodologies to one specific country, here Zambia, to begin the conversation on how to strengthen surgical servicesZambia is a lower-middle-income country by WB income group

National Cancer Control Strategic Plan 2016 - 2021

• Developed, signed by Minister of Health August 2016and Launched February 4th 2017

• Director Cancer Control Unit Appointed with the Coordination Unit

• Cost plan for five years

Improving Access to Radiotherapy in Zambia

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

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

IN-SERVICE PRE-SERVICE

PREVENTION 1. Community Health Workers (Cancer Skills Package)

EARLY DETECTION 2. Screening Workers (Cervical Cancer: VIA)

DIAGNOSIS & TREATMENT

3. Pathology Technicians 4. Surgeons (Surgical Oncology Modules)

5. Radiation Therapy Technicians 6. Clinical Oncologists 7. Oncology Nurses 8. Pathologists

PALLIATIVE CARE 9. Palliative Care practitioners (Short Courses)

SURVEILLANCE 10. Data Collectors*

VUCC: An instrument for access to Cancer Control Education & Training at home

Thank You!

Slide Number 1Slide Number 2IntroductionSlide Number 4The Radiotherapy DreamThe Dream cont.Dream cont’Cancer Diseases Hospital During Construction PhaseZAMBIA CANCER CONTROL PROGRESSProportion of deaths by cause in SSA, 2010�Proportion of mortality by cause in Zambia in 2014�Overall Cancer Problem in ZambiaChallenges of Accessing Quality Radiotherapy Care in LMICRADIOTHERAPY SERVICES IN ZAMBIACDH TodaySlide Number 16CDH Phase II Chemo & WardCobalt 60 & Linear AcceleratorTreatment Planning & Second Cobalt 60 Unit2 High Dose Rate Brachytherapy UnitsSimulator & CT ScannerMammogram & MRI PROGRESS SINCE QUATRO MISSION�1.EQUIPMENTPROGRESS SINCE QUATRO MISSION�1.EQUIPMENTPROGRESS SINCE QUATRO MISSION�1.HUMAN RESOURCEZNCR CONSOLIDATED REPORT �2008 - 2014Top Ten Cancers in Males �2008 – 2014 Top Ten Female Cancers �2008 – 2014 Provincial DistributionChildhood Cancer Registration in Zambia, 2013Slide Number 31Top 10 cancers for Both Males & Females - 2013 Slide Number 33National Cancer Control Strategic Plan 2016 - 2021Improving Access to Radiotherapy in ZambiaIAEA TECHNICAL COOPERATIONHRH DevelopmentSlide Number 38Slide Number 39