Prof. Messaoud Zitouni, head of the Algerian National Cancer Plan, highlights the Plan’s main advancements since 2015 as well as the gaps to still address.
Three years after the launch of the Cancer Plan, what is the current status on achievements?
Initially laid out as a five-year plan, two now remain and we can take a step back an consider the achievements. Overall, we see that they have been positive. Strategically, we can say that the Cancer Plan in itself was a great achievement for Algeria, as it was the first of its sort.
What makes it original is that it was in part ordered by the president of the Republic himself, and subsequently adopted by the ministries in 2015. The President himself decided there would be a piloting and follow-up committee for the Cancer Plan, and that it was to be inter-sectorial. I was charged with coordinating the committee and spent the first two years putting in place all the needed procedures.
To me, it made an important difference that the country’s highest authorities felt responsible for the Cancer Plan, and the strategic success came from that incentive, as well as from the fact that for the first time since the independence, we witnessed such great mobilisation of healthcare professionals. I think this is beneficial for all involved, society and patients, but also the professionals, who, for the first time, see that their work is actually finding fulfilment.
The Cancer Plan was established following a crisis in 2009-2010, the so-called crisis of radiotherapy, when we realised that the number of cancer centres and the number of radiotherapy equipment had remained unchanged for almost 20 years. Algeria had only four centres and less than 10 radiotherapy units. In 2018, we have 20 centres, six private centres and a total of 38 treatment units. This huge leap forward is the direct result of political will and the mobilisation of professionals on the field. While improvement is still necessary, the waiting times have already diminished drastically.
To what extent has the Plan managed to redefine treatment pathways for cancer?
Another dimension along which we see important improvement is in new pathways for cancer patients. Previously, it was being treated in an archaic and anachronic manner; cancer was viewed as an acute or transmittable disease in the pathway, and hence diagnostic and treatment were both very far from corresponding to a speciality standard of care.
What developed countries have established for a while now is that cancer has to be treated as an interdisciplinary area, because it touches so many different fields in medicine. While Algeria has only recently made this a topic, this pluri-disciplinary approach now lays at the heart of our strategy. Interdisciplinarity—as implemented in France for instance—is the only way to change the pathway of care and overcome the bureaucratic machine of administration in Algeria.
Of course, while the results of this change will not be visible immediately, our improvements in radiotherapy will bear fruit much more rapidly. On a different note, we also expect positive changes from the interdisciplinary dimension on some behaviour patterns of overexpressed grandeur in many doctors. By having to communicate more with others, they gain new perspectives, and it is known that shared knowledge multiplies.
And what about efforts to introduce onco-pharmaco-economics?
After those two first achievements, we also made significant advancement in onco-pharmaco-economy. Before the Cancer Plan was born, no one ever talked of this. The practitioners were in charge of deciding upon drugs to approve, to import, they would be at the direct end of reception and then administrate the treatment. Today, a large part of the decision-making and supply chain process is given to the pharmaco-oncologist. The concept, born in the US in 1976 shifts responsibility and the oncologist can concentrate on the prescription and result measurement.
We also have established four pilot units focusing on the reconstruction of cytotoxin. Their results will be measured in two years. The fourth alley we are pursuing is to put the physician at the centre of cancer coordination. The main struggle for patients in their treatment process is often the pathway, which is like a maze to them. They do not know where to turn to or where to expect information from.
In many other countries, this is now taking in charge, through coordinating nurses, and the results are patients feeling better and ultimately, better outcomes. In Algeria, we decided for various reasons to put the responsibility in the hands of physicians rather than nurses. We remain very focused on bringing better structure to all wilayas (the 48 regions of Algeria), and are confident that better coordination will help us advance greatly in terms of outcomes.
Our fifth priority touches upon price control, or rather, the management of expenses. There is a global trend to rationalisation of means in healthcare systems that are more and more cash-strapped and prices for drugs that hit astronomically high prices with no technical or scientific justification. While we remain aware that we are talking about the value of life, it is the responsibility of the government to balance societal interests with scientific innovation. We view NICE as well as the French Haute Autorité de Santé as examples to follow in this, with NICE really being a pioneer, inventing the health technology agencies. Drugs are no longer just about the science behind them, they are trading goods.
What role do you see for foreign multinational drug developers in helping to further the objectives of the national cancer plan?
In Algeria, we view cancer as an important field, but the advancements are fast and so disruptive, that we have no other choice than following behind the developed countries. I like to draw the comparison between Muslims going for pilgrimage to Mecca, and oncologists going to ASCO and returning with the latest scientific knowledge about innovation, a knowledge that needs however to be contextualised and adapted for each country following its own realities.
When it comes to our relationship with industry, I also think we can benefit from partnerships with the private sector as they rely on extensive knowledge. AstraZeneca for instance has been long involved in breast cancer. However, I feel that, until now, we have been pursuing a communication strategy that is too fragmented. Algeria has to take a more global stance, uniting as one voice in discussions with pharmaceutical companies.
In general, I think much should change in how we work with industry. For instance, I am against companies taking over the expenses of professors and doctors travelling to congresses abroad. A French study showed that after company visits to local practitioners, their products would go through sales peaks. I would not go so far as to talk of collusion, nonetheless, I believe some marketing campaigns can influence a doctor’s neutrality to an important degree.
The best response Algeria can muster is to be found in training. Medicine studies have to adopt an ethical lecture, as it is the case in France today. It is essential this happened early in the career, because companies are not content to visit only exercising practitioners anymore, they come to the study room. Our country has been overwhelmed after liberalisation, as training and studies, once entirely in the public domain, have been infiltrated by medical representatives. I see the danger of over-prescription looming.
As with everything, the solution lays in striking the right balance: all voices should be united at the table when it comes to discussions around training of our future care takers, just as all should be united when deciding on best treatment options: scientific, administrative, social, ethical… What matters it that the end result can be considered as neutral.
On a final note, we also aim to enrich and diversify our collaboration with external partners. For instance, in the frame of the research and development, some of the big firms are already participating in the implementation of programs in line with the cancer plan, such as AstraZeneca for breast cancer screening.
Where do you identify infrastructure shortages for cancer care today?
Much of cancer care is not limited to specialised centres, and Algeria is in a good place when we consider infrastructure from a merely quantitative perspective. Five years ago, a study was conducted here, concluding that the per bed occupation ratio in Algeria was of 52 percent. This is rather low and due to regional differences as well as to insufficiently trained carers. This number means that 40 percent of beds are not utilised correctly. Hence, those calling for more beds might reconsider their standpoint. The remedy for Algeria’s cancer patients categorically does not just lie in further hospital construction.
The previous ministry perhaps placed too much attention just on hardware. The plan to construct seven new CHUs was hyped up in a way that was misguided. It was presented almost as a silver bullet and then, no less than 6 months later, it was frozen indefinitely. I personally feel this plan was too ambitious anyway. Two additional CHUs would doubtlessly be helpful for our healthcare system, but seven would likely be very difficult to assimilate and manage efficiently so quickly. Moreover, just calling for additional hardware is too simplistic and risks misdiagnosing the underlying root problems that we need to fix.
Many of the cancer treatments, such as chemotherapy, can be adequately administered within our existing structure. Radiotherapy is the exception and that is the area, which we have been trying to catch up and actually have been succeeding. We have another 20 specialist centres to come on-stream over the next decade. We already have five in the population-sparse southern desert hinterland of the country which means that that citizens living down their actually have superior coverage per capita that in the coastal cities. So the real bottleneck is not a lack of equipment or material resource, but rather incapability to smartly and rationally organise it. By transforming behaviours and mind-sets, the cancer plan seeks to address this deficiency.
