Cancer is emerging as a major threat to the health of populations in low- and middle-income countries (LMICs) such as South Africa. According to global cancer incidence data, 13% of global deaths are cancer-related and 72% of these were in LMICs.

The current global rise in cancer is likely to particularly affect countries like ours where contributing factors such as poor diet and lifestyle, smoking, environmental factors and late diagnosis are prevalent. Cancer is currently already responsible for 9.1% of all deaths in South Africa.

Cancer care requires a coordinated system including cancer prevention, community awareness of cancer symptoms, screening and early diagnosis at primary health level, adequate access to surgery and oncology treatments and then systems for rehabilitation, community reintegration and palliative care.

South Africa’s healthcare system, struggling with the inherited challenges of fragmentation and uneven development between urban and rural areas and between provinces, as well as competing for health priorities such as HIV, has not coped with this cancer burden.

This crisis in cancer care hit the headlines in 2017/2018 when issues in KwaZulu-Natal became national and international news. As a result, oncology services came under the spotlight and some very startling data was revealed. The general state of oncology services was not only poor but also varied dramatically between different centres and different provinces, with disturbing inequities in access to cancer care demonstrated both between public and private health systems and within the public sector.

In 2017, the National Cancer Strategic Framework (NCSF) for South Africa (2017-2022) was released as an overarching cancer policy document for the National Department of Health (NDoH). This provided a detailed assessment of need, and outlined a strategy for dealing with the “oncoming train” of increasing numbers of cancer patients in South Africa.

Since 2017 the NDoH has partnered with various organisations in an attempt to better quantify the problem, and in some provinces allocated additional resources to cancer care for equipment and staffing. There has also been development of various cancer guidelines including Breast and Cervical Cancer Control Policies and Palliative Care Management Guidelines.

Despite these positive efforts, it is clear that, halfway through the period outlined by the NCSF, improvements in cancer care are happening very slowly. A national strategic framework can only have an impact if there is a collective awareness and commitment to it coupled with resource support for implementation by national and provincial departments of health.

The implementation itself can only occur by inspiring and upskilling health teams involved in cancer care in the entire pathway of care, from the primary care nurse to surgical and oncology units at academic centres and palliative care specialists.

However, none of this is possible with a workforce that is already at breaking point. The public service cares for about 85% of the health needs of the population but only retains approximately 15% of the oncology specialists in the country. A similar situation exists in radiology and pathology, and significant inequities in surgery and nursing also exist.

Three possible solutions

1. Building a national consultative and implementation process for cancer care:

Involvement of senior cancer-care clinicians to advise and provide relevant information to the NDoH and the minister of health is crucial. The Ministerial Advisory Committee on the Prevention and Control of Cancer (MACC) was established in 2013. This was an important step in recognising the need to lead on cancer care in South Africa, but representation and objectives as well as the accountability framework for this committee have not yet been clearly established.

There is an urgent need for a national process which has representation from all stakeholders in cancer care including nurses, nuclear physicians, oncologists, surgeons, radiologists, pathologists, allied healthcare workers, palliative care workers and patient advocacy groups, to champion the implementation of the National Cancer Strategic Framework and to advise on ongoing policy development in the cancer arena. Such a national process should have clear lines of representation and accountability so that cancer plans penetrate all parts of the country and all users of the health system including more vulnerable poor and rural communities.

2. Supporting and retaining the cancer-care workforce:

Innovative ways of retaining staff in the public sector in all areas of cancer care are crucial. Our clinics and hospitals continue to suffer the effects of the brain drain to the private sector and out of the country. In addition, frozen and unfilled posts place an intolerable burden on those committed clinicians who remain in the system.

While public-private partnerships may have a role to play at some level, temporarily contracting in specialist services is expensive and unsustainable and often worsens inequality. Rather, a comprehensive human resource plan for cancer should include active recruitment into the public sector, fixing and upgrading equipment to help with staff retention and a commitment to training the next generation of cancer specialists.

3. Improving efficiency and effectiveness through innovation:

While greater resource allocation is necessary to improve cancer services, we are also cognisant that there is a limit to these resources and a need to utilise current resources more effectively. South Africa needs to look at context-specific strategies to maximise the impact of our resources such as, for example, task shifting, using telemedicine for remote follow-up of cancer patients and making sure our local cancer policies are appropriate to our particular needs and health systems processes.

In conclusion, the increasing cancer burden in South Africa and on the continent represents a significant threat to the health of the nation and the capacity of the health system’s delivery of care. Successfully meeting this challenge is only possible if there is political will to bridge the gap between our cancer policy documents and the reality faced by thousands of cancer patients in the health system. Empowering and partnering with health workers, patients, communities and advocacy groups is, we believe, the first step on the necessary path of transforming policy into practice. MC

*Professor Jeannette Parkes is head of radiation oncology at Groote Schuur and Professor Lydia Cairncross is a doctor in the Department of Surgery at Groote Schuur and the University of Cape Town.

This article was produced for Spotlight – health journalism in the public interest.