Cost-effectiveness of childhood cancer treatment in Egypt: Lessons to promote high-value care in a resource-limited setting based on real-world evidence

Background
Childhood cancer in low-and middle-income countries is a global health priority, however, the perception that treatment is unaffordable has potentially led to scarce investment in resources, contributing to inferior survival. In this study, we analysed real-world data about the cost-effectiveness of treating 8886 children with cancer at a large resource-limited paediatric oncology setting in Egypt, between 2013 and 2017, stratified by cancer type, stage/risk, and disease status.

Methods
Childhood cancer costs (USD 2019) were calculated from a health-system perspective, and 5-year overall survival was used to represent clinical effectiveness. We estimated cost-effectiveness as the cost per disability-adjusted life-year (cost/DALY) averted, adjusted for utility decrement for late-effect morbidity and mortality.

Findings
For all cancers combined, cost/DALY averted was $1384 (0.5 × GDP/capita), which is very cost-effective according to WHO–CHOICE thresholds. Ratio of cost/DALY averted to GDP/capita varied by cancer type/sub-type and disease severity (range: 0.1–1.6), where it was lowest for Hodgkin lymphoma, and retinoblastoma, and highest for high-risk acute leukaemia, and high-risk neuroblastoma. Treatment was cost-effective (ratio <3 × GDP/capita) for all cancer types/subtypes and risk/stage groups, except for relapsed/refractory acute leukaemia, and relapsed/progressive patients with brain tumours, hepatoblastoma, Ewing sarcoma, and neuroblastoma. Treatment cost-effectiveness was affected by the high costs and inferior survival of advanced-stage/high-risk and relapsed/progressive cancers.

Interpretation
Childhood cancer treatment is cost-effective in a resource-limited setting in Egypt, except for some relapsed/progressive cancer groups. We present evidence-based recommendations and lessons to promote high-value in care delivery, with implications on practice and policy.

Funding
Egypt Cancer Network; NIHR School for Primary Care Research; ALSAC.

Healthcare Services for the Physically Challenged Persons in Africa: Challenges and Way Forward

This chapter is based on persons with physical disabilities in Africa, their challenges, and how it affects their health-seeking behaviors. We noticed that physical challenge has a substantial long-term adverse effect on one’s ability to carry out normal day-to-day activities. Both the causes and the consequences of physical disability vary throughout the world, especially in Africa. Environmental, technical, and attitudinal barriers and consequent social exclusion reduce the opportunities for physically challenged persons to contribute productively to the household and the community and further increase the risk of falling into poverty and poor healthcare services. The inability of the physically challenged persons to perceive the lack of points of interest of government has intensified to make significant recommendations and possible solutions. This is appalling because the rate to which a community provides and funds restoration is a way of grading how much interest it has, and importance it connects to the quality of life of its citizens. We advocate and recommend swift actions and disability inclusiveness to accommodate persons with physical disabilities in Africa for them to have a good perception of life.

Postoperative outcomes associated with surgical care for women in Africa: an international risk-adjusted analysis of prospective observational cohorts

Background
Improving women’s health is a critical component of the sustainable development goals. Although obstetric outcomes in Africa have received significant focus, non-obstetric surgical outcomes for women in Africa remain under-examined.

Methods
We did a secondary analysis of the African Surgical Outcomes Study (ASOS) and International Surgical Outcomes Study (ISOS), two 7-day prospective observational cohort studies of outcomes after adult inpatient surgery. This sub-study focuses specifically on the analysis of the female, elective, non-obstetric, non-gynaecological surgical data collected during these two large multicentre studies. The African data from both cohorts are compared with international (non-African) outcomes in a risk-adjusted logistic regression analysis using a generalised linear mixed-effects model. The primary outcome was severe postoperative complications including in-hospital mortality in Africa compared with non-African outcomes.

Results
A total of 1698 African participants and 18 449 international participants met the inclusion criteria. The African cohort were younger than the international cohort with a lower preoperative risk profile. Severe complications occurred in 48 (2.9%) of 1671, and 431 (2.3%) of 18 449 patients in the African and international cohorts, respectively, with in-hospital mortality after severe complications of 23/48 (47.9%) in Africa and 78/431 (18.1%) internationally. Women in Africa had an adjusted odds ratio of 2.06 (95% confidence interval, 1.17–3.62; P=0.012) of developing a severe postoperative complication after elective non-obstetric, non-gynaecological surgery, compared with the international cohort.

Conclusions
Women in Africa have double the risk adjusted odds of severe postoperative complications (including in-hospital mortality) after elective non-obstetric, non-gynaecological surgery compared with the international incidence.

State of African neurosurgical education: a protocol for an analysis of publicly available curricula

Background
Africa bears >15% of the global burden of neurosurgical disease. Yet to date, Africa still has the lowest neurosurgical workforce density globally, and efforts to fill this gap by 2030 need to be multiplied. Although the past decade has seen an increase in neurosurgery residency programs in the continent, it is unclear how these residency programs are similar or viable. This study aims to highlight the current status of neurosurgical training in Africa as well as the differences within departments, countries or African regions.

Methods
A literature search using keywords related to ‘neurosurgery’, ‘training’, and ‘Africa’ and relevant names of African countries will be performed on PubMed and Google Scholar. If unavailable online, the authors will contact local neurosurgeons at identified training programmes for their curricula. The residency curricula collected will be analysed against a standardized and validated medical education curriculum viability tool.

Results
The primary aim will be the description of African neurosurgical curricula. In addition, the authors will perform a comparative analysis of the identified African neurosurgical curricula using a standardized and validated medical education curriculum viability tool.

Discussion
This study will be the first to evaluate the current landscape of neurosurgery training in Africa and will highlight pertinent themes that may be used to guide further research. The findings will inform health system strengthening efforts by local training programme directors, governments, policymakers and stakeholders.Background
Africa bears >15% of the global burden of neurosurgical disease. Yet to date, Africa still has the lowest neurosurgical workforce density globally, and efforts to fill this gap by 2030 need to be multiplied. Although the past decade has seen an increase in neurosurgery residency programs in the continent, it is unclear how these residency programs are similar or viable. This study aims to highlight the current status of neurosurgical training in Africa as well as the differences within departments, countries or African regions.

Methods
A literature search using keywords related to ‘neurosurgery’, ‘training’, and ‘Africa’ and relevant names of African countries will be performed on PubMed and Google Scholar. If unavailable online, the authors will contact local neurosurgeons at identified training programmes for their curricula. The residency curricula collected will be analysed against a standardized and validated medical education curriculum viability tool.

Results
The primary aim will be the description of African neurosurgical curricula. In addition, the authors will perform a comparative analysis of the identified African neurosurgical curricula using a standardized and validated medical education curriculum viability tool.

Discussion
This study will be the first to evaluate the current landscape of neurosurgery training in Africa and will highlight pertinent themes that may be used to guide further research. The findings will inform health system strengthening efforts by local training programme directors, governments, policymakers and stakeholders.

Telesurgery’s potential role in improving surgical access in Africa

An estimated five billion people worldwide lack access to surgical care, while LMICs including African nations require an additional 143 million life-saving surgical procedures each year.African hospitals are under-resourced and understaffed, causing global attention to be focused on improving surgical access in the continent. The African continent saw its first telesurgery application when the United States Army Special Operations Forces in Somalia used augmented reality to stabilize lifethreatening injuries.Various studies have been conducted since the first telesurgery implementation in 2001 to further optimize its application.In context of a relative shortage of healthcare resources and personnel telesurgery can considerably improve quality and access to surgical services in Africa.telesurgery can provide remote African regions with access to knowledge and tools that were previously unavailable, driving innovative research and professional growth of surgeons in the region.At the same time, telesurgery allows less trained surgeons in remote areas with lower social determinants of health, such as access, to achieve better health outcomes. However, lack of stable internet access, expensive equipment costs combined with low expenditure on healthcare limits expansive utilization of telesurgery in Africa. Regional and international policies aimed at overcoming these obstacles can improve access, optimize surgical care and thereby reduce disease burden associated with surgical conditions in Africa.

Design and Rationale of the National Tunisian Registry of Percutaneous Coronary Intervention: Protocol for a Prospective Multicenter Observational Study

Background:
Coronary artery diseases remain the leading cause of death in the world. The management of this condition has improved remarkably in the recent years owing to the development of new technical tools and multicentric registries.

Objective:
The aim of this study is to investigate the in-hospital and 1-year clinical outcomes of patients treated with percutaneous coronary intervention (PCI) in Tunisia.

Methods:
We will conduct a prospective multicentric observational study with patients older than 18 years who underwent PCI between January 31, 2020 and June 30, 2020. The primary end point is the occurrence of a major adverse cardiovascular event, defined as cardiovascular death, myocardial infarction, cerebrovascular accident, or target vessel revascularization with either repeat PCI or coronary artery bypass grafting (CABG). The secondary end points are procedural success rate, stent thrombosis, and the rate of redo PCI/CABG for in-stent restenosis.

Results:
In this study, the demographic profile and the general risk profile of Tunisian patients who underwent PCI and their end points will be analyzed. The complexity level of the procedures and the left main occlusion, bifurcation occlusion, and chronic total occlusion PCI will be analyzed, and immediate as well as long-term results will be determined. The National Tunisian Registry of PCI (NATURE-PCI) will be the first national multicentric registry of angioplasty in Africa. For this study, the institutional ethical committee approval was obtained (0223/2020). This trial consists of 97 cardiologists and 2498 patients who have undergone PCI with a 1-year follow-up period. Twenty-eight catheterization laboratories from both public (15 laboratories) and private (13 laboratories) sectors will enroll patients after receiving informed consent. Of the 2498 patients, 1897 (75.9%) are managed in the public sector and 601 (24.1%) are managed in the private sector. The COVID-19 pandemic started in Tunisia in March 2020; 719 patients (31.9%) were included before the COVID-19 pandemic and 1779 (60.1%) during the pandemic. The inclusion of patients has been finished, and we expect to publish the results by the end of 2022.

Conclusions:
This study would add data and provide a valuable opportunity for real-world clinical epidemiology and practice in the field of interventional cardiology in Tunisia with insights into the uptake of PCI in this limited-income region.

Trial Registration:
Clinicaltrials.gov NCT04219761; https://clinicaltrials.gov/ct2/show/NCT04219761

International Registered Report Identifier (IRRID):
RR1-10.2196/24595

Improvements in Child Cancer Diagnostics and Treatment in Africa

In Africa, more than 50% of cases of childhood cancer go undiagnosed. Africa accounts for 146,000 of the projected 397,000 new cases globally per year (including both diagnosed and undiagnosed cases) (Ward et al, 2019a). Of the diagnosed cases, only 11.6% of children in Africa survive (Ward et al, 2019b). Based on the above modeling exercise, we estimate that only about one-third of those who are diagnosed actually receive treatment; no hard data are available. Increasing access to treatment will increase survival, although to reach survival rates comparable to high income countries, investments will also be needed to decrease treatment abandonment and improve quality of treatment (Ward et al, 2019b).We recommend investing to expand treatment of five key cancers that are both treatable and affordable. These five cancers together account
for 40% of the burden of childhood cancer in Africa. Studies of cost per child treated in subSaharan Africa for three of the conditions (Burkitt lymphoma, nephroblastoma and earlystage retinoblastoma) were $1248, $1976 and $2202 USD respectively in various low- and lower-middle income countries in Africa. More conservatively, costs of a comprehensive cancer centre in one African country which achieved a projected 5-year survival rate of 35% for a cohort of children with multiple cancer types, were around $10,000 per child in 2018 USD, or around 6.5 times per capita GNI (see text below for all study references).
Benefit:cost ratios were estimated as 9.1 to 19.3 for the three diseases for which studies were available, and a more conservative 5.2:1 for a comprehensive centre which treats not only the priority diseases, but also provides treatment for other less-treatable conditions and palliative care to children for whom cure is not possible. Ratios would be a little lower (4.6:1) but still very attractive if indirect costs to families were included in treatment costs, and higher if non-profit organizations took the lead in small investments to reduce treatment abandonment rates, as has been done successfully in a number of low- and middleincome country (LMIC) contexts.
Expanding care from the estimated one-third of those diagnosed to all those currently diagnosed would cost $407m using the comprehensive cancer centre model. This amount would double, if 90% coverage of were attained (i.e. if 80% of all undiagnosed children could be diagnosed and linked to treatment). The value of the benefits would however be an estimated 5.2 times the costs, or $2116m. There are other potential unquantifiable benefits, such as helping to show that cancer is indeed curable and helping reduce the stigma associated with cancer in Africa, potentially leading adults with cancer to seek care earlier and improve their survival. In addition, improving capabilities to treat childhood cancers has the potential to strengthen health systems more broadly, by developing radiologic and pathologic services, medicines procurement and supply management, surgical facilities, health human resource training and retention, and supportive care capacities.

Burn Admissions Across Low- and Middle-income Countries: A Repeated Cross-sectional Survey

Burn injuries have decreased markedly in high-income countries while the incidence of burns remains high in Low- and Middle-Income Countries (LMICs) where more than 90% of burns are thought to occur. However, the cause of burns in LMIC is poorly documented. The aim was to document the causes of severe burns and the changes over time. A cross-sectional survey was completed for 2014 and 2019 in eight burn centers across Africa, Asia, and Latin America: Cairo, Nairobi, Ibadan, Johannesburg, Dhaka, Kathmandu, Sao Paulo, and Guadalajara. The information summarised included demographics of burn patients, location, cause, and outcomes of burns. In total, 15,344 patients were admitted across all centers, 37% of burns were women and 36% of burns were children. Burns occurred mostly in household settings (43–79%). In Dhaka and Kathmandu, occupational burns were also common (32 and 43%, respectively). Hot liquid and flame burns were most common while electric burns were also common in Dhaka and Sao Paulo. The type of flame burns varies by center and year, in Dhaka, 77% resulted from solid fuel in 2014 while 74% of burns resulted from Liquefied Petroleum Gas in 2019. In Nairobi, a large proportion (32%) of burns were intentional self-harm or assault. The average length of stay in hospitals decreased from 2014 to 2019. The percentage of deaths ranged from 5% to 24%. Our data provide important information on the causes of severe burns which can provide guidance in how to approach the development of burn injury prevention programs in LMIC.

Nonphysician Sedation Providers in Africa: What Counts and What Is Being Counted?

“Not everything that can be counted counts, and not everything that counts can be counted.” – WB Cameron, Informal Sociology: A Casual Introduction to Sociological Thinking, 1963.

Does your anesthesia providers’ level of training impact your outcomes? This question has been widely evaluated and debated in the perioperative literature. With increasing demand for surgical and procedural services facilitated by anesthesia care globally, an answer will continue to be sought. Van der Merwe et al1 in their article “Postoperative outcomes associated with procedural sedation conducted by physician and non-physician anesthesia providers: findings from the prospective, observational African Surgical Outcomes Study (ASOS)” published in this month’s Anesthesia & Analgesia, have added to this discussion, with a secondary analysis of data from the African Surgical Outcomes Study (ASOS). Although their study provides some interesting insights into the outcomes of procedural sedation across the continent, our opinion is that the question remains largely unanswered.

To date, most of the literature evaluating the association between anesthesia care provider type and outcomes has focused on anesthesia care in highly developed health care systems. Questions have focused on task-shifting, where the responsibility for tasks is shifted from a more highly trained health care provider to health workers with shorter training and fewer qualifications, and task-sharing, where both levels of providers perform the task and may even work closely together. Examples include family doctors in Canada providing unsupervised anesthesia care in community hospitals after adding an additional year of training in anesthesia to their family medicine residency program; certified registered nurse anesthetists (CRNAs), practicing independently in many US states; and French anesthesiologists supervising nurse anesthetists with a 1:2 ratio. Ultimately, the hope is that by shifting/sharing tasks, access to care will improve with less-resource input and with similar (or in the case of task-sharing) even safer outcomes.2

Countries with a gross national income per capita of <$12,696 US dollars (USDs) are often (problematically) lumped together as low- and middle-income countries (LMICs)3 regardless of the profound diversity in this categorization, which contains around 85% of the world’s population.4 There is a critical shortage in human resources for health (HRH) globally, particularly in anesthesia. However, HRH are one of the most complex parts of health systems, with huge international variation in terms of numbers of health care workers, their training, their point of entry into training, their scope of practice, interprofessionalism, resilience, burnout, and retention of health care workers within the system.5–7 Developing a deep understanding of how to most effectively and efficiently provide safe anesthesia care is an urgent priority in improving global surgical outcomes; however, nuances in context make generalizations problematic.

Ven der Merwe et al1 aimed to evaluate this question by comparing patient outcomes when procedural sedation was delivered by nonphysician versus physician anesthesia providers. The primary data source, the ASOS, is a landmark study, where investigators collected a large amount of data (11,422 patients) over a relatively short amount of time, with good coverage of a broad geographic area.8 Its largely descriptive statistical analysis has been highly informative of perioperative outcomes in Africa, which appear to be much worse than previously published global data. In contrast, the Van der Merwe et al1 study is a small subset of the primary data (336 patients, ~3% of the full cohort), with a more complex comparative statistical analysis, with the authors concluding that receipt of sedation from a nonphysician provider was significantly associated with increased odds of severe complications. While these results must be interpreted with great caution (as we will outline below), the findings raise important questions about perioperative health care systems in Africa.

How Climate Change May Threaten Progress in Neonatal Health in the African Region

Climate change is likely to have wide-ranging impacts on maternal and neonatal health in Africa. Populations in low-resource settings already experience adverse impacts from weather extremes, a high burden of disease from environmental exposures, and limited access to high-quality clinical care. Climate change is already increasing local temperatures. Neonates are at high risk of heat stress and dehydration due to their unique metabolism, physiology, growth, and developmental characteristics. Infants in low-income settings may have little protection against extreme heat due to housing design and limited access to affordable space cooling. Climate change may increase risks to neonatal health from weather disasters, decreasing food security, and facilitating infectious disease transmission. Effective interventions to reduce risks from the heat include health education on heat risks for mothers, caregivers, and clinicians; nature-based solutions to reduce urban heat islands; space cooling in health facilities; and equitable improvements in housing quality and food systems. Reductions in greenhouse gas emissions are essential to reduce the long-term impacts of climate change that will further undermine global health strategies to reduce neonatal mortality.