27 Introduction The purpose of this policy brief is to share considerations for an NCA in South Africa, as well as guide decision makers, along with other stakeholders on requirements for goal setting, funding and accountability mechanisms. These outcomes are crucial to ensuring equitable access to comprehensive population-based cancer care for all in South Africa, particularly as the country is facing a growing cancer burden. Drawing lessons from a desktop review of six NCAs, we contrast South Africa's current cancer legislative and policy frameworks to derive key elements that could be incorporated into new legislation for South Africa. Scope of cancer care As South Africa recovers from the COVID-19 pandemic, and manages other competing health crises, the state must rethink how it prioritises public health resources for cancer. This is even more critical with the recent passage of the National Health Insurance (NHI) Bill [B11-2019] in Parliament. While NHI intends to improve access to health care services, it only describes a nancing mechanism at present. There is no mention of the minimum benets to be covered, nor is there a denition of quality standards for health care services. In particular, and despite high treatment costs, there is no clarity on standards, processes and outcomes measures for cancer management under the NHI. The NHI is particularly challenging given that the health needs of South Africans far exceed the current capacity of the health sector. This places immense pressure on an already severely constrained public health system, which serves 84% of the population. In terms of human resources as well, 80% of health care professionals work in the private sector. Of the country's 200 specialist radiation oncologists, only 20% are employed in public facilities. Therefore, the issue is not simply the lack of resources, but also the inequitable and inefcient distribution of those resources. Cancer requires interventions at all levels of care (primary, secondary, tertiary and quaternary) and across the entire continuum of care, including education, prevention, screening, diagnosis, treatment, support, rehabilitation, survivorship, and palliative care through to the end of life. Contemporary evidence-based cancer care further necessitates costly machinery, technology, medicines and personnel to diagnose, treat and otherwise intervene in the disease process. While these activities are expensive, there are proven priority interventions identied by the World Health Organisation based on cost-effectiveness and other considerations aimed at driving down costs, especially with a shift to prevention and early detection programmes. Why should cancer prevention and control be singled out for special consideration? • Factors, including the prevalence, progression and complexity of cancer prevention and treatment may alone justify privileging cancer for special consideration. In addition, the burden on patients, their families and caregivers to nance treatment as well as the emotional impact and stigma often result in patients delaying, discontinuing or forgoing treatment altogether. Furthermore, the current inequities between public vs private cancer care exacerbate these challenges and support the demand for a dedicated funding stream. • Given the complexity of integrated cancer care, a dedicated focus on cancer will contribute to health systems strengthening, which would then benet the prevention, early detection, diagnosis, treatment monitoring and palliative care of other diseases and conditions. • Policies, as opposed to legislation, are often dictated by the political agenda of the government in power, and subject to reprioritisation. Legislation, such as an NCA, would guarantee that cancer remains a priority even with a change in government. • Regulations are useful but are not always appropriate for cancer which demands a multisectoral and whole of government approach, extending beyond the Department of Health. An NCA, or a considered approach to bolstering existing legislation, would provide coordination over the current fragmentation characteristic of cancer prevention and control. UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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