With cancer being the second leading cause of death globally, it is necessary to include cancer care into the global health agenda. An initiative known as City Cancer Challenge (C/Can) aims to do this through work with stakeholders at a local level and dialogue on cancer care between cities and partners across the world. Its CEO talked to HealthManagement.org about the challenges cities face on their path to better care and what results they can achieve with global support.
Please give us some background information about C/Can.
C/Can was launched in 2017 at the World Economic Forum annual meeting in Davos by the Union of International Cancer Control (UICC), which is an organisation representing over 1,100 members from more than 170 countries. Obviously, there were clear commitments and resolutions to support advances in cancer including the 2017 World Health Organization Cancer Resolution, commitments embedded within the Sustainable Development Goals, and the resolutions of the World Health Assembly on palliative care and access to essential medicines. However, it was very difficult for those to be translated to local action. There was still a lack of guidance and limited platforms, no interaction on the ground, and patients were not seeing the benefits of those global commitments. UICC decided to take action and form a group of people, including myself, to create a programme called City Cancer Challenge. This was the first time that anyone had tried to build a bottom-up, community-led approach whereby not the organisation itself, but the cities were the lead, the main driver. It was very much a new approach, a new way of thinking and quite an ambitious step into a very different space for UICC at the time.
In 2019, given the early successes that we’d seen in engaging people and cities, City Cancer Challenge became a standalone foundation, and our mission is to support cities as they work to improve quality equitable cancer care. It means to support cities through a journey that takes them from assessing what is available in their city in terms of treatment and care to identifying the gaps, as well as the opportunities to strengthen care and the priority areas that we could help them build upon. We like to talk about strengthening existing action. Cities have clear ways of working, they have unique healthcare ecosystems that frame the way they deliver cancer care, so it is really about understanding that whole ecosystem across the health system and supporting them to adopt a holistic approach that takes into account the unique and changing needs of their populations.
Fundamentally, it’s this bottom-up, community-led approach that distinguishes us from other organisations in the way we work.
A new call for the City of Tomorrow initiative was launched in October. Considering the pandemic context, why now? What are your expectations from this call?
The City of Tomorrow is an aspirational campaign to bring this way of working to cities around the world. We want to share the most impactful and inspiring learnings from our cities. We want to create a movement of cities that are able to support and learn from each other and to take best practice and help each other move cancer care forward in this holistic way.
You might think that now is indeed a difficult time, but in fact it’s building on the momentum that cities have created through the pandemic as frontrunners in health. They have been on the frontline, and they’ve shined especially this year. The city level is where things are implemented, where the action happens, and where the connection to local stakeholders is really possible.
We’ve seen this before coronavirus, emerging increasingly in other areas, e.g. in climate action, but I think there’s been a reluctance to really elevate the role of cities in health. That’s changed considerably in 2020. We saw a few weeks ago the first meeting of cities under the UN umbrella. We’ve seen cities take very clear steps towards resilience through this pandemic. I believe that cities will emerge even stronger than they are today, that’s what history tells us: strength inevitably comes through a crisis. So we are hopeful that this campaign will actually consolidate and leverage much of the work that cities have led this year and take it into a new sphere.
From your experience, what are the most common challenges a city might face when attempting to elevate its level of cancer care?
There are indeed some common threads. We work with cities on more than 70 projects. One of the most prominent is around guidelines and protocols. It doesn’t sound very exciting, but the foundation of quality cancer care comes from understanding the protocols and guidelines that can inform that care. These are processes and ways of working that really have been proven, time and time again, to support quality care and quality outcomes for patients and their families. For example, we talk about multidisciplinary team care and not everyone knows what that is. Essentially, it’s about bringing different health professionals, different specialities together around the care of a person, very much putting the person at the centre of that discussion and understanding what the best course of treatment for that individual is. It takes different perspectives, it brings in pathologists, a surgeon, a treating oncologist as well as allied health professionals, such as speech therapists or physiotherapists. It’s a more holistic way of working, and we know that it leads to better outcomes, there is evidence to support that. This is an area where we’re partnering with organisations like the American Society of Clinical Oncology (ASCO) to really work across cities, to provide guidelines and protocols about multidisciplinary care and support the adoption of that way of working at the city level.
On this way, what are the major obstacles for C/Can?
It’s about investing time and resources into bringing stakeholders together. What we see time and time again in cities is that people are busy. They have incredibly heavy workloads, they are engaged 120% in delivering care, and particularly in an environment like we have today where cancer health professionals are also managing emergency situations and the pandemic. It’s really about getting people in a room, facilitating a discussion and the exchange. That’s a challenge because you need to bring people together, build trust between stakeholders and create an open and transparent space for dialogue. Because ultimately, as I said in the beginning, change comes from the community and from the local stakeholders. For that to happen, you need to take the time to bring people together and to get them talking. Once again, it sounds very simplistic, but very often dialogue, conversation, consultation is really the start of any change that we see.
How do you facilitate international interaction and collaboration between the participants under the
When we talk about city level, it is important to understand that ‘city’ doesn’t mean not facilitating regional, national and then global dialogue. In any city ecosystem you want to bring in the regional government, the national cancer institute or the national cancer registry. You also need alignment with national cancer control plans.
Furthermore, you want to make sure that these lessons that we learn, this type of work is also elevated and made visible to the global community, and that’s where the city-to-city exchange is essential. We need to get cities talking to each other, and then cities, of course, are talking to other stakeholders, to other forums, so it’s really about expanding the dialogue. It’s ensuring that at every stage this consultation is inclusive, that it’s not isolated – and that’s where C/Can comes in. The advantage and the benefits we have as a global organisation is connecting the dots, joining the conversations. Over 60 partners are supporting C/Can right now, and they are part of our ecosystem. If we’re having a dialogue, such as we’ve just had on to leapfrog solutions in cities, then we have the capacity to bring together the global stakeholders and partners and connect them with local stakeholders. Once again, it’s about bringing the people together and elevating the conversation.
During the pandemic any kind of conversation is a challenge. How do you manage?
Well, like everybody else. We were able, very fortunately, to switch online quickly in as early as March remembering that we’re a global and predominantly virtual team, this is embedded in the way we work. We have a city manager, a person who’s working on the ground, in every city, but of course during this time they’re also often working virtually. Sometimes, when we might’ve had an in-person meeting with 25 people in the room, we’ve run five smaller virtual meetings to ensure that the dialogue is rich and the information is shared.
I really believe that we’re going to come out of this in 2021 much more connected to our stakeholders because 90% of the time we’ve got very close contact across video, we’ve all been reminded that we’re only a click away from each other.
Is the lack of digital skills in people on the ground sometimes a problem?
Of course, and one of the lessons that we are really trying to share with the global community is that digital is transforming, that virtual is a facilitator and an enabler in many aspects. Connectivity is essential, and there needs to be investment in meaningful connectivity. In many countries that we work in, there are challenges involved in simply being part of virtual meetings.
Digital literacy is also what we’d like to really promote and see more consideration of. If you’re expecting health professionals and patients to shift so quickly the way they work, you need to be ready to invest in the whole package. Countries have, on the most part, been very quick to change their policy environment. We’ve seen changes that perhaps have lagged, but sometimes local leaders have pushed through to ensure that telemedicine, for example, is available and that there are ways of embedding this into the national health system. However, that also needs investment in health professional training, in digital literacy for patients and communities, and particularly for vulnerable populations including women. It’s really important to ensure that people are equipped with the skills, the infrastructure, and the actual technologies themselves, so that they can engage and not be isolated through this process even further.
The majority of the cities participating in C/Can is in the global south. Are you expecting C/Can to expand its scope soon?
That’s part of the global call for cities. Our global call is exactly that, a global call. We want cities from all over the world to join this movement. We have worked predominantly in middle-income countries to date, and a part of C/Can is about engaging communities and cities who might be completely different from each other. It’s also very important to understand the diversity in health systems, from cities that have, currently, very limited access to national health insurance to cities with full population universal health coverage that face other challenges like fragmentation of care or coordination of the patient journey. It’s not so much as to focus overall on this country or this region, but to understand the very clear challenges that cities around the world face, such as guidelines and protocols, insurance and coverage, or access and financial protection. There is also the maturity of the health system or the place of the investment and elevation of cancer on the political agenda, and that can be very different.
Could you give some examples of the participating cities’ best practices?
I’d like to give a couple of very different examples. One of them relates to regulation and the ability to embed cancer care into national policy. In Asuncion, in Paraguay, there had been a push for some time, before C/Can existed, to elevate cancer into the political agenda through a national cancer law. It had not been successful. As we started to work in Paraguay, the group of local stakeholders had come together as a City Executive Committee. Their work was successful, the cancer law was passed through the Senate, and for the first time Paraguay has a national cancer law. That has really snowballed, and the discussion about cancer law and what it means to have cancer embedded into national legislation is really starting to become much more prominent in the global health dialogue.
When you’re looking at the plethora of changes that have happened across the health system in the last three years, you really need to think about how cities connect and change together. For example, it was considered a major priority to look at the quality of pathology in Cali in Colombia, and particularly access to diagnostic support at a specific type of laboratory that a public hospital didn’t have available. The local stakeholders, with support from one of our partners, the American Society of Clinical Pathology (ASCP), worked with Cali to look at quality assurance, protocols, processes and guidelines; to support training programmes for pathology technicians from a more holistic health workforce perspective. That, in turn, led the city to the development of a new pathology laboratory that is really supporting more accurate and timely diagnosis of cancer patients. Through the needs assessment we’d also seen that there was complete absence of training for oncology nurses. This resulted in a conversation about building a curriculum locally for oncology nursing training, which is being done and has already started – it’s really about building the capacity of the local workforce.
Once again going back to this need for protocols and guidelines – in Yangon in Myanmar, we’ve just seen guidelines for pain management and for quality assurance for radiotherapy adopted by the national government and the national ministry of health. This is the first time that such guidelines exist. They will really change and transform the way care is delivered in Yangon. We’re expecting those guidelines to be adopted nationally, which is going to change the care for many millions of people.
What will be the pandemic-caused long-term consequences for cancer care? What steps should be taken to ensure cancer care receives due attention?
Cancer patients have been challenged considerably through this period. Globally there’s been a significant reduction in cancer surgeries. We know from our own cities there are huge reductions in consultations, e.g. mammography appointments. There are other immediate issues around consultations. We talked about this switch to telehealth without facilitated training and infrastructure, which has really challenged many of our cities. There’s also been reallocation of resources. Through the first phase of the pandemic we saw that in many cases the oncology workforce was being reallocated to managing COVID-19. Now that we’re in the second wave, we expect that will happen again. Policymakers are obviously focussed very much on pandemic response and are being diverted from other areas, so there will be an enormous impact over time for cancer patients.
On the other hand, what we’ve also seen is the recognition of issues that have never really gone away, for example the lack of investment in the health workforce, which we knew about. If you pick up any global health publication on workforce pre-2020, it would’ve talked about the stresses and strains that are put on any health system if there’s not resilience built into the system, and one of the aspects of resilience is investing in a skilled health workforce. That was always there. I’m hopeful once again that we’re going to see a recognition of this coming through 2021 and an investment in health workforce and the people that serve the health system.
We need to think about the things that have really stretched the capacity and the resilience of the system through this period, and seek to address those quite proactively. Health workforce is obviously one of them, investment in infrastructure is another, and particularly we’ve talked about going into a new era of digital health and expansion of services that are around digital technologies. We need to be much more prepared than we have been. We’ve started this conversation with cities being stronger tomorrow than they are today, and I think this is the most important message to give.
How does C/Can see itself in 2021?
We’re very excited about 2021. We have seven out of nine cities who have reached the stage of implementing projects and moving through to delivering on the targets, priorities and objectives that they’d set in the last couple of years. Of course, there is a challenge in making sure that cities, the local stakeholders have the support they need.
Speaking of any specific challenges, it is to push, as hard as we can, on a message that nothing can happen in isolation. Commitment is needed to multisectoral action in health platforms and sectors working at different levels of government, embracing inclusivity in terms of multilateralism but also across partner profiles, which includes the public and private sectors. Otherwise we won’t be able to support what people really want to do on the ground. It’s just imperative. One of my greatest frustrations is to still go to a meeting where someone poses the question, ‘Should we be partnering in this?’ I really want that question to go away and be replaced with ‘How can we accelerate partnerships in the right way? How can we work more effectively with more partners? How can we ensure that technology companies are at the table with people talking about health system change? How can we ensure that the financial community is engaged in conversations with health professionals around financing for cancer and SDGs? How do we build this ecosystem of partners and platforms that are interconnected and reflect truly the ethos of the SDGs, which is cooperation and collaboration?’ That’s where we started the conversation long before 2015, it’s embedded in those commitments. I don’t think we’ve seen full embracing or engagement in that ethos, and the major challenge for C/Can and for all work like this is to foster this different way of working.
Is there anything else you would like to add?
In every conversation we highlight the people. The people are the centre of this conversation, not C/Can itself, not the global health community. It really has to be about the patients. It’s so important to just take a moment and think why you’re doing this. I’ve certainly had personal experiences with cancer and good and bad experiences of the health system that supported that person. But if we keep that front of mind, if we continue to talk about the person at the centre, then many of our challenges will be made easier. I really believe that there is sometimes a disconnect between what the real challenges are, faced by a person navigating what is a really complex system, and understanding that even changes that make that journey easier, improve that person’s life. We have to continue to talk and to think about it in that way to really embrace what we’re trying to do.
Conflict of Interest