National Cancer Strategic Framework for South Africa 2017-2022

Objectives

The National Cancer Strategic Framework 2017–2022 seeks equitable and comprehensive cancer prevention and control for all people in South Africa, reducing cancer-related deaths, disability, financial strain, suffering and distress while protecting the dignity and rights of people with cancer, their families and communities.[1][2][3]It adopts a patient-centred, human rights-based and evidence-based approach across the life course, with particular attention to populations facing poverty, lack of insurance, rural residence, racial inequity and other barriers to care.[1][4][3]

• Reduce preventable cancers by addressing tobacco use, harmful alcohol consumption, poor diet, physical inactivity, obesity, excessive sun exposure, occupational hazards and infection-related risks.[5][6]
• Deliver an integrated continuum spanning surveillance, awareness, vaccination, prevention, screening, early detection, diagnosis, treatment, rehabilitation, psychosocial support, survivorship and palliative care.[7][8][3]
• Prioritise lung, colorectal, cervical, prostate and breast cancers in adults, alongside cancers affecting children, adolescents and young adults, while allowing provinces to address additional locally relevant cancers.[6][7]
• Improve timely and equitable access to cancer education, diagnostics, treatment and support irrespective of location, educational attainment or financial means.[9]
• Strengthen governance and leadership, services, human resources, technology and infrastructure, vaccines and medicines, surveillance and research, and sustainable financing as the framework’s six overarching goals.[10]
• Contribute to Sustainable Development Goal 3, including target 3.4, and the World Health Organization objective to reduce non-communicable disease mortality, including cancer, by 25% by 2025.[2][4]

Implementation

Implementation is designed for national, provincial and district application through a person-centred health-system model that builds on existing service platforms, World Health Organization health-system building blocks, related legislation and cancer policies.[7][3][10]The National Department of Health has priority activities for 2017 to 2023, while provincial departments are expected to develop context-specific implementation plans and packages of care that support equitable access from prevention to treatment.[11][12]

• Organise care through linked pathways from households and communities to primary care, district hospitals, diagnostic centres and secondary, tertiary or quaternary treatment facilities, with referral back to community-level services where appropriate.[13][14][3]
• Provide prevention through community and facility platforms; deliver screening and early detection through primary health care, community health centres and hospitals; and concentrate complex diagnosis and treatment in appropriately equipped specialist facilities.[13][15]
• Establish flexible up-referral and down-referral arrangements, including direct referral from primary care to tertiary services for detected malignancies and prompt referral of people at risk to designated diagnostic centres.[15][14]
• Develop inter-provincial agreements as an immediate measure to improve geographic access, while establishing more equitably located cancer-care centres over the longer term.[13][16]
• Deliver definitive treatment through multidisciplinary teams including oncology, haematology, radiation oncology, specialised surgery, diagnostic, nursing, psychosocial and rehabilitation professionals, using protocols aligned with national and international guidance.[17][15][18]
• Build workforce capacity through pre-service and in-service cancer training for generalist and specialist health workers, and increase trained public-sector personnel.[10][19]
• Engage national, provincial and district health authorities, civil society, communities, academia, researchers, non-profit organisations, private providers, pharmaceutical organisations, traditional healers, schools and community-level workers.[8][13][10]
• Use the Ministerial Advisory Committee on the Prevention and Control of Cancer to strengthen liaison among non-profit, academic, research and private-sector organisations.[7]
• Apply public-private partnerships only through transparent and fair agreements where these increase public-sector capacity, and develop criteria to govern such partnerships.[16][10]
• Implement immediate measures to reduce treatment backlogs, augment designated treatment centres, and phase investment according to facility needs and treatment-centre tiers.[11]
• Strengthen surveillance through compulsory notification and the National Cancer Registry, maintain pathology-based registration, and establish four representative population-based registry sentinel sites to support national incidence modelling.[8][16]
• Monitor implementation through a monitoring and evaluation plan, information systems and proposed indicators covering policies, screening, early diagnosis, diagnostic and treatment delays, laboratory turnaround, loss to follow-up, staffing, equipment availability and downtime, medicine and vaccine availability, facility reporting and registry function.[10][19]
• Undertake facility audits to establish service-delivery baselines and identify corrective interventions, particularly in underserved provinces and paediatric oncology centres.[17][20]
• Develop a National Cancer Survivor Care Plan to coordinate treatment histories, surveillance, follow-up responsibilities and health priorities, and maintain monitoring and evaluation systems for palliative care.[21][12]
• Complete detailed costing of optimal cancer services, increase funding incrementally through phased implementation, protect priority inputs such as medicines, laboratories, blood, equipment, maintenance, infrastructure and vaccines, and assess equipment contracts or leasing arrangements.[11][22]

Monitoring & Evaluation

The framework combines implementation monitoring, cancer surveillance, service-performance measurement and policy accountability, led principally by the National and Provincial Departments of Health. It envisages an implementation plan with targets, a monitoring and evaluation plan, and proposed indicators to track progress across the cancer continuum.[7][3][19]

• Strengthen surveillance through compulsory notification of confirmed cancer diagnoses and the National Cancer Registry, established under regulation 380 of the National Health Act of 2003.[7]Notification regulations introduced in 2011 were associated with a marked increase in reported patients.[8]
• Maintain the pathology-based registry for national incidence data while addressing under-estimation of cancers diagnosed clinically or radiologically and delays arising from labour-intensive coding.[4][16]
• Establish four representative population-based registry sentinel sites, each serving 1.5 to 3.5 million residents, to model national incidence for international reporting.[16]
• Use the National Pathology Based Registry, the South African Children's Cancer Study Group Tumour Registry and population-based cancer registries, alongside epidemiological and routine operational datasets, to identify data gaps and inform planning and resource allocation.[19]
• Release cancer-mortality data routinely to assess cancer’s effect on life expectancy and prioritise cancers for intervention and research.[23]Mortality data require cautious interpretation because death-certification data may be inaccurate and include deaths among prevalent as well as incident cases.[24]
• Monitor implementation through indicators on approved policies and strategies, screening and early-stage diagnosis, screening-to-diagnosis and diagnosis-to-treatment intervals, laboratory turnaround times, loss to follow-up, workforce training and vacancies, equipment downtime and repairs, availability of equipment, vaccines and medicines, facility reporting, laboratory testing and functioning registries.[10]
• Use facility audits to establish a baseline for cancer-service delivery and identify corrective interventions.[17]Monitor treatment waiting times, including radiation-treatment delays, because waits exceeding 12 weeks may harm outcomes.[20]
• Apply cancer surveillance before new programmes begin to establish the scale of need, then use it to monitor longer-term implementation outcomes, trends, successes and shortfalls.[16]
• Document adverse events associated with cancer medicines as part of pharmacovigilance, and manage potential interactions between cancer chemotherapy, antiretroviral medicines and tuberculosis medicines.[18]
• Establish and maintain monitoring and evaluation systems for palliative care, and use a National Cancer Survivor Care Plan to coordinate surveillance schedules, health priorities and follow-up responsibilities.[21][12]

Accountability is linked to government responsibility for effective, cost-efficient service delivery, implementation responsibilities assigned to the National Department of Health, and provincial implementation guidance.[1][11]The Ministerial Advisory Committee on the Prevention and Control of Cancer is intended to strengthen liaison among non-profit organisations, research and academic institutions and private health companies.[7]Detailed reporting frequencies, evaluation methodologies and formal accountability procedures are not specified in the supplied extracts.[7][11]

Costing & Financing

The framework identifies sustainable financing as one of its six overarching goals and recognises that cancer services are underfunded, with inequitable access, inconsistent implementation and poorer outcomes in underserviced areas.[10][11]It calls for detailed costing and phased investment to support universal, sustainable cancer prevention and control.[11]

• Complete detailed costing of optimal cancer prevention and control services, while verifying treatment-centre analyses, validating caseload assumptions and revising expenditure estimates where health-system data are limited.[11]
• Increase funding incrementally through phased implementation of the cancer plan and strengthen treatment facilities alongside prevention, screening, diagnosis, treatment and support services.[11]
• Develop sustainable funding and service-delivery models, and monitor whether these models have been established to implement the framework.[10]
• Define transparent and responsible public-private partnerships, including criteria for cancer-care partnerships, where these can expand public-sector capacity in the interests of patients.[10][11]
• Establish transversal contracts or equivalent leasing arrangements for oncology equipment based on cost analysis.[11]
• Phase investment in treatment centres according to need: Tier 1 requires minimal capital investment; Tier 2 requires significant investment in human resources, equipment and maintenance; and Tier 3 requires decisions on radiotherapy establishment, leasing or public-private partnerships.[11]
• Protect essential provincial health-service priorities during constrained economic conditions, including medicines, laboratory services, blood supplies, equipment and maintenance, infrastructure maintenance, vaccines and antiretrovirals.[22]
• Specify staffing, equipment, medicines, consumables, transport and laboratory requirements within provincial packages of care tailored to local needs.[12]
• Reduce financial barriers for patients and survivors, including high out-of-pocket costs that may delay medical care or screening.[21]Cancer treatment costs may also make standard-of-care interventions unaffordable for partially insured and uninsured people.[4]
• Use Standard Treatment Guidelines and Essential Medicines Lists to support clinically evidence-based, cost-effective, affordable and equitable access to cancer medicines while containing public-health costs.[18]

Financial constraints include inadequate government financing, high-priced originator medicines, patent protection, delays in generic registration, tender irregularities, deregistration of older medicines and supply-chain inefficiencies.[18]The supplied extracts do not provide a total budget, currency-denominated allocation, quantified funding gap, unit cost, financing target or economic assumption.[10][11]