September is the month for childhood cancer awareness, a time to shine the light on a disease which is often not part of the global health discourse. There are approximately 300,000 new cases of childhood cancers diagnosed each year globally. Despite relatively high cure rates for some cancers when detected early, survival rates remain poor in low- and middle-income countries (LMICs), where nearly 90% of children with cancer reside. While improvement in treatment modalities are necessary, how do we also ensure the child reaches a treatment centre in the first place? Upon reaching the centre, how do we ensure the child (and family) are cared for without depleting them economically or emotionally?
In Ghana, there are only two childhood cancer treating centres where approximately 330 patients are seen annually (less than the expected 1200 patients based on a population of 29 million). One major barrier is late presentation, where only 30% of patients who report to the tertiary facility in Accra for example, receive treatment on account of the advanced stages in which they present. Late presentation in Ghana occurs as a result of a myriad of system and individual-related barriers. A patient has to travel several kilometers across regions to seek specialized health care, with a resultant financial toll as well as disruption of the family unit. An example in addressing the barrier of late referrals has been through NGOs like World Child Cancer which provide the resources for training of various cadres of health care providers across the country.
On the other side of Africa, in Eldoret (a town in Kenya), a 16-bed ward in a public tertiary hospital caters to 200 children with cancer annually (although extrapolation of incidence rates expects 1000-1200 children to be diagnosed annually). It is the only public hospital capable of providing comprehensive cancer care in Western Kenya. The under-diagnosis of childhood cancers in this setting is due to an interplay of several factors similar to Ghana. An example in addressing some of these barriers has been through clinicians partnering with Hope for Cancer Kids, an NGO that pays hospital insurance fees for a period of one year for all newly diagnosed children with cancer. In addition, to improve awareness of childhood cancers at primary care levels, the clinicians hold two weekly virtual clinics and case discussions with clinicians from primary care facilities within the hospital’s catchment areas.
Similar barriers to care are also found in India and other LMICs which often see abandonment of treatment and ultimately low survival rates. Moreover, most LMICs do not have expanded Universal Health Coverage where childhood cancers can be included. It is clear that access to childhood cancer care is a global problem especially for settings with poor health systems. A diagonal approach to health systems strengthening, “aiming for disease-specific results through improved health systems” is the need of the hour. Factors such as infrastructure, financial coverage, availability of medicines and a trained health workforce are examples of essential components in optimal service delivery. However, access to the health system is also often influenced by social determinants which require wider multi-sectoral interventions. Improving childhood cancer care should thus focus beyond treatment regimens and patient-provider relationships. It must be perceived through a global health lens to ensure equitable outcomes for all children.
Crucial to adopting such a lens are declarations by major global health institutions, such as the 2018 WHO Global Initiative for Childhood Cancer (including the recently signed collaboration with UNICEF to promote and monitor the global action on childhood cancer care). As seen in the past couple of years, a global dialogue on this issue through various expert working groups such as the International Society of Paediatric Oncology and the Lancet Oncology Commission for childhood cancers has also been critical for progress. Additionally, stakeholders at the local level such as NGOs, parent-support groups and health care professional networks continue to complement these efforts. Together, the ongoing bottom-up activities begin to fill the gap when top-down governance approaches to prioritising childhood cancers are weak or non-existent. Governments must invest in health systems strengthening and include childhood cancer care in national cancer control plans. If not, progress to saving more lives of children with cancer may be painfully slow.
As we leave September, it is our hope that childhood cancer care will continue to be a part of the global health discourse, where barriers are addressed not just by stakeholders involved in the daily care for children with cancer but by the larger community of global health professionals, advocacy groups and policymakers.
Dr. Neha Faruqui is a global health researcher at the University of Sydney, Australia.
Dr. Lily Gloria Tagoe is a paediatric oncology fellow at the Korle-bu Teaching Hospital, Accra, Ghana.
Dr. Gilbert Olbara is a pediatric oncology fellow at Moi University School of Medicine, Eldoret, Kenya.
Conflict of Interest