I recently watched the launch of the Breast Cancer awareness campaign with the theme, “Itse MABELE a gago”, which was live streamed on NAHPA Facebook page, with the presentation given by the patron of Cancer Association of Botswana, Dr Gloria Somolekae. In her keynote address, Dr Somolekae touched on key pertinent issues which we need to reflect on. Firstly, how much progress are we making as a nation in fighting the NCDs?, What is the data telling us and most importantly what is that we are doing as a nation to address some of the key challenges in fighting these diseases such as shortage of oncologists as well as strategy in terms of raining and securing the right human resources.
It is basis of the awareness campaign that compelled me to write this piece to share more insights using the lens of health policy analysis and the need to look into issues of policy transfer and integrated and adoption of UHC and horizontal approach in the response.
The NCDs are the leading cause of mortality in sub-Saharan Africa and account for 38% of deaths in Botswana. Globally, Breast cancer is the cause of approximately 25 percent of all cancers in women and in Botswana, the incidence of Breast cancer is increasing at alarming rate. It represents the most common cancer among women followed by cervical cancer, it accounts to 9.4% of all cancers in Botswana and 16% of all female cancers in the country as was reported by the Patron of the Cancer Association of Botswana. It is the leading cause of cancer related death of women in most low – and middle-income countries, outstripping cervical in all but poorest nations and populations.
Studies elsewhere have shown that survival rates are much lower for poorer women within and across countries, less than 50 percent in low -income countries compared to more than 75 percent in high-income countries compared to more than 75 percent in high-income nations. Responding to the challenge of breast cancer in low-and middle-income countries is thus both a health and an equity imperative.
Breast cancer is a disease amenable to both primary, population wide interventions and secondary intervention through early detection. Appropriate diagnosis is complex and key to effective treatment, which tends to be lengthy, often spanning years to drug regimes. Survivors require medical attention and other types of interventions to enable them to fully participate in their communities including for example, reducing stigma in the work setting. Palliation and pain control are important for patients who will die of constituents an ideal tracer disease to map an effective health system response along the care continuum, providing informative lessons for other noncommunicable diseases and chronic illness.
Studies have also indicated that in the case of breast cancer, the cancer divide disparities in cancer morbidity and mortality between the rich and poor as a result of differentials in access to health care and socioeconomic factors is evident at each stage of the disease continuum. Poor women face to exposure to risk factors and lack of awareness about healthy lifestyles, inadequate access to information and screening interventions to promote timely detection, poor diagnostics that lead to costly and ineffective treatment, lack of access to appropriate treatments with the disease and limited survivorship care which is worsened by stigma and discrimination that is magnified by gender inequity. Appalling levels of limited access to pain control and palliative care compounds needless suffering through the course of the disease and at the end of life.
In the case of Botswana the response to NCDs has been dire, for instance, Scholars have reported that before 2016, the only national policy instruments related to NCDs in Botswana were the Alcohol Policy, Tobacco Policy, Nutrition Strategy, Essential Health Services Package and Botswana Public Health Act, and these did not comprehensively address the response to the Non-Communicable Diseases. During this period, a national policy or strategy on non-communicable diseases was lacking. Furthermore, there were no national clinical guidelines for NCDs, and this was accompanied by poor management of adults with chronic respiratory disease and cancer, cardiovascular, diabetes and hypertension and haphazard referral system.
Despite the high economic and human burden, the policy response and its interrogation in sub-Saharan Africa and Botswana is limited. It must be noted that following the UN Political Declaration on Non-Communicable Diseases at the 2011 United Nations General Assembly High Level Meeting, (UNGASS), non-communicable diseases (NCDs) have come to receive greater recognition and attention globally and in sub-Saharan Africa. Previously this was not the case as too much attention was placed on responding to communicable diseases more particularly to HIV/AIDS and little attention given to NCDs.
The UN political declaration, 2011 on NCDs thus created a momentum and a policy window that called for concerted global action and for governments to respond to the pandemic. The UN agenda 2030 for Sustainable Development Goals (SDGs) also played a significant role by firmly establishing NCDs as an urgent global health priority, which were conspicuously absent in the Millennium Development Goals (MDGs) by including them in SDGs target 3.4.
The increasing burden of cancer especially in low‐ and middle‐income countries (LMICs) and the adoption of UHC as a goal in 2015 has created an opening for progress on cancer. The updated WHO “Best Buys” for noncommunicable diseases now include treatment of stages I and II colorectal, cervical, and breast cancers as “Good Buys”. Building a health system that integrates breast cancer care in a developing health system is a significant undertaking. Previous studies from the BHGI have discussed some of the health system components needed to sustain breast cancer programs within a resource‐stratified framework.
The 70th World Health Assembly included a resolution on cancer prevention and control and in response, the WHO and the International Agency for Research on Cancer are developing a cancer costing and prioritization tool that will cover 7 adult cancers, including breast cancer and select pediatric cancers. The goal is to develop a tiered framework similar in approach to the Breast Health Global Initiative (BHGI) Resource‐Stratified Guidelines, where different approaches are adopted according to the affordability in each country.
The emphasis on health systems and universal health coverage (UHC) in the United Nations’ Sustainable Development Goals provides an impetus to improve cancer care and survival worldwide, with Botswana not being an exception. The longstanding earlier focus of global health on communicable disease, “quick wins,” and vertical programs left cancer which requires many components of health systems to work together lower on the priority list. Reports are indicating that the previous World Health Organization (WHO) “Best Buys” for tackling noncommunicable diseases paid scant attention to cancer treatment, focusing primarily on prevention (hepatitis B vaccination and attention to diet, exercise, and use of alcohol and tobacco). The only cancer‐related treatment included was for precancerous cervical lesions by contrast, treatment options for cardiovascular disease were included as indicated in the WHO report.
UHC promises access to effective and cost‐effective lifesaving cancer treatment without catastrophic financial consequences, at least for some cancers initially, and with increasing population and disease coverage over time. All these developments are important for making progress on breast cancer, which accounts for more disability‐adjusted life‐years lost by women globally than any other cancer.
What is Universal Health Coverage?
Universal Health Coverage is an explicit goal of health systems strengthening and a corner stone of health reform. The WHO defines Universal health coverage as ensuring that all people receive the promotive, preventive, curative, rehabilitative and palliative health services they need of sufficient quality to be effective, while the use of these services does not expose their financial hardships.
Achieving Universal Health Coverage has become especially challenging in the face of epidemiological transition that has brought an increasing burden of Non-Communicable Diseases. UHC is achieved through progress along three stages:
1: Legislation and affiliation to ensure coverage of all people.
2: Cost effective health services in line with economic growth.
3: Financial protection that contributes to achieving highest level of health outcomes and quality health care.
4: These can also be achieved through integration of health care.
It is important to note that while Health Systems in Sub-Saharan Africa have been designed to provide episodic care for acute condition, however, the burden of disease has shifted from having to deal with the disease double burden as is the case in Botswana. Despite the major impact of Breast Cancer and Non-Communicable Diseases on the population, the evidence presented in Botswana demonstrates a lack of attention to the policy process for responding to NCDs and their risk factors in general, including the lack of policy alignment, actor coordination.
Although the National Strategic Framework on NCDs was launched in 2019, much still need to be done that require health system to function in an integrated manner from prevention to palliation. Currently Botswana is faced with great challenges in responding to NCDs and Breast cancer due to late screening and diagnosis. There is also an urgent need to decongest GPH and have equipment and facilities around also health centers country wide. Absence of which may led to patients dying prematurely with late detections and some even dying in pain.
Thabo Lucas Seleke is a Researcher & Scholar, Global Health Policy
