Strengthening systems in low resource settings

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Published: 10 Oct 2017
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Prof Richard Sullivan - Kings College London, London, UK

Prof Sullivan speaks with ecancer at the RSM meeting on cancer control to discuss how healthcare systems in developing economies are overcoming barriers to accessing cancer therapies and supportive care.

Considering a global range of healthcare systems, as well as the internal variation in care provision alongside international differences, Prof Sullivan draws attention to the difference in care available between urbanised and isolated regions, where basic care and well-maintained patient databases are still a challenge.

He also considers the pressures on healthcare systems resulting from displaced populations and the refugee crisis, which can move management of chronic diseases to emergency care settings.

Cancer care is really fundamentally sensitive to improvements in overall health system strengthening. Cancer really stresses all that we know about health systems in terms of their weaknesses, their strengths and the opportunities and in order to deliver really good high quality cancer outcomes you need to have built into your healthcare system all the foundational aspects – medicine, pathology, surgery. So overall health system strengthening is absolutely crucial to delivering high quality cancer outcomes.

How do these systemic barriers affect low and middle income countries?

In low and middle income countries we’re seeing very different health transitions from what we experienced in high income countries. They’re aging far more rapidly; there are some very complex transitions occurring so they’re not experiencing just cancer and other non-communicable diseases, they’re also having to deal with parallel increases in communicable diseases as well. This makes it very complex for health system strengthening in these countries. Really the message is that we need to develop a new paradigm for cancer control within health system strengthening in many of the low income and emerging economies. That’s going to require a lot more research, a lot more political engagement with individual countries and a lot more understanding of the different trajectories that these health systems are going through.

What of emerging economies such as India?

Emerging upper middle income emerging economies like India have seen extraordinary transition, very rapid growth in their development, in their income in terms of GDP, but also really substantial challenges, not just in the burden of cancer as these populations start to rapidly age but also in the changing socio-demographics, so rapid urbanisation of populations but also a huge difference in access to treatments depending on where you live in India. Access to high quality cancer treatment down in the south, for instance in states like Kerala, is, of course, far better than in geographically isolated areas like Kashmir and Jammu or in relatively poor states like Uttar Pradesh for example. So India is an exemplar of all the different cancer systems in the entire world in one country which makes it extraordinarily challenging but also interesting in terms of developing new treatments, new pathways and also new models of care for national cancer control planning.

There is also the issue of the refugee movement in the Middle East and North Africa.

We’re also seeing in many countries very different transitions based on major problems in terms of resilience and conflict. For instance, the Middle East and North Africa we’re seeing countries that had completely demographically transitioned to non-communicable disease burdens suddenly going backwards because of conflict. Syria, Libya, for example, and these are having huge knock-on effects on other countries as refugees migrate across searching for cancer services and other health services. So, for example, Libyan refugees moving into the Tunisian system; we’re also seeing huge numbers of Syrian refugees as well moving into the systems in Turkey, in Lebanon and Jordan. So whilst we can perhaps develop new models of care and pathways within controlled environments such as the refugee camps, the reality is many refugees, and in fact in some countries most refugees, are what we call sans-papiers, they live outside these normal refugee camps within the domestic populations. This is a huge burden on those host countries and it’s also a critical issue for delivering cancer services, not just to the host country’s vulnerable populations but also to the refugees. We really have to understand these migration pathways and develop new economic models to support the development of cancer services in these host countries and the protection of the refugees as well. The meetings we’re having today, for instance, at the Royal Society of Medicine that’s being hosted looking at global health and low and middle income countries and cancer control are absolutely crucial to bring together all the different sorts of expertise and political players, from those individuals interested in public policy and health services research all the way through to developing novel technical solutions, for instance, in models of care of surgery, pathology. We’re hearing a lot about this today here at the Royal Society of Medicine meeting.