Kenya Society for Hematology and Oncology recently gathered over 450 professionals involved in cancer care from Kenya, East Africa and the world for the first virtual Kenya International Cancer Conference and challenged them to develop strategies to incorporate value-based care into their practice.
Why does this matter? Because value is perhaps the most critical conversation in cancer care. Value is not something doctors alone can generate or drug makers or even patients—it is something we all need to come together to achieve; we all have a part to play.
The National Academy of Medicine in the United States has developed a widely accepted approach that describes high-value health care as safe, timely, effective, efficient, equitable and patient-centred. Value is a product of the quality of care divided by the cost of treatment. As such, one would be able to improve the value of care by either increasing the quality of services or decreasing the cost of care.
What is the current scenario in Kenya? We have made good progress. We have a national cancer policy, National Cancer Control Programme and the National Cancer Institute of Kenya that have led in the development of screening and treatment guidelines for cancer patients.
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The National Hospital Insurance Fund now covers partial costs of treatment including surgery, chemotherapy and radiotherapy, enabling more patients to complete their treatment. While this is promising, more effort is required as majority of patients (about 70 per cent) are still diagnosed with advanced versions of cancer and do not complete their treatment.
There are many factors behind this, including the fact that despite some relief from NHIF, patients still largely pay out of pocket for cancer care. This is further compounded by dysfunctional health systems and poor referral pathways. Despite engaging with the health systems, patients may be falsely reassured, misdiagnosed or have delays in their diagnosis due to missing reagents, equipment that delay their diagnoses.
In addition, we must acknowledge our own health-seeking behaviour.
The prevalent attitude to health reviews and check-ups is ‘why go looking for trouble? This is compounded by the myths and stigma that exist in our communities around cancers and the use of alternative therapies. Frequently, our populations are unaware of the basic signs and symptoms of cancer so will not seek help.
For instance, women may not seek help for a breast lump because it is painless, not being aware that the most frequent presentation of a breast cancer is a “painless” breast lump. Or they may be too scared to seek medical attention if they do find a lump, not knowing that nine out of 10 lumps are not cancerous.
Sometimes, our cultural norms act as barriers as elderly women may not want to disclose that they have new onset vaginal bleeding, which may point to gyneacological cancers because it may be taboo to discuss these.
While clinical outcomes are important, there is a growing consciousness among physicians that the experience of the patient is central and key to any treatment strategies.
Sir William Hutchinson, a physician in the 1900s, admonished against making the ‘cure worse than the disease’. With patient-centred outcomes there is a concerted effort to view any treatment through the lens of the patient, ensuring that their voice resonates throughout the care experience.
There is an added drive to address the financial well-being of patients as this is critical to ensure that not only do they complete their treatments, but they are also in the correct frame of mind to focus on their care. Patient education and empowerment is key to this.
Unless the patient actually understands what cancer means, how it will affect their lives and why adherence to treatment is important, it will be difficult to get patients to partner with clinicians in their treatment goals.
The onus is on clinicians, policymakers and caregivers to create an enabling environment for patients to receive cancer care. We need to communicate effectively to patients so that shared decision-making between patients and clinicians can occur in cancer treatment.
The movement towards value is not an endpoint in itself, but a continuous iterative process that the oncology community must strive towards. However, we need to take serious steps to consolidate the basics of care. Policymakers need to critically review the percentage of our GDP dedicated to health as this has direct implication on the population’s ability to access care.
Dr Mutebi is a breast surgical oncologist and assistant professor Surgery, Aga Khan University