Each year, more than 300,000 children around the world are diagnosed with cancer. Most of these children live in low- and middle-income countries (LMIC) where treatment is either unavailable or unaffordable. As a result, only a fraction – approximately a third of children with cancer in LMICs survive, compared with more than 80% in high-income countries (HIC). This inequity is a threat to the attainment of universal health coverage and the realization of political commitments in the 2030 United Nations (UN) Agenda for Sustainable Development.
Inclusion of childhood cancer as a public health priority is feasible, effective and sustainable. It offers an important opportunity to catalyze progress in cancer control and to demonstrate success in the noncommunicable diseases agenda. Member states have expressed commitment to childhood cancer and have given World Health Organization (WHO) a clear mandate to prioritize childhood cancer programs.
In September 2018, WHO launched the Global Initiative for Childhood Cancer with the goal of reaching at least a 60% survival rate for children with cancer by 2030, while reducing suffering. This initiative brings together stakeholders from around the world and across sectors toward a shared goal of scaling up capacity to save lives and reduce suffering for children with cancer. If successfully implemented, approximately one million additional children with cancer can be saved in the next decade.
Too many children have their lives cut short by cancer, and survival rates in poor countries are scandalously lower than those in wealthy countries…We hope our partnership with St. Jude will be a step towards redressing that injustice.
Tedros Adhanom Ghebreyesus, PhD, Director-General of WHO
A Coordinated Approach
We will increase capacity of countries to provide quality services for children with cancer and increase prioritization of childhood cancer at the global and national levels. This will take concerted efforts at the global, regional and national levels with distinct expected outputs and activities.
Goal, objectives, outputs and activities and approach for the global initiative
The initial focus for the initiative is on six cancers selected as tracers for monitoring progress across the health system.
Six common cancers for initial focus within the global initiative
The initiative serves all children with cancer around the world – not only those in particular regions or with select cancers. There are still unacceptable inequities affecting children in high-income countries, with many children who still suffer from long-term toxicities of therapies, and families affected by significant and persistent financial harm from cancer treatment. Accordingly, improvements in care are needed for every child with cancer, and now is the time for concerted action to accelerate and translate scientific advances for all.
Defining the Initiative at the Global Level
The WHO Global Initiative is guided by CURE All, a strategic and practical approach to implementing the initiative through core pillars of action:
- Centers of excellence and care networks that are fit-for-purpose, with a sufficient and competent workforce to increase capacity to deliver services;
- Universal health coverage for essential quality services;
- Regimens and roadmaps for diagnosis and treatment that are context-appropriate and facilitate delivery of quality services through evidence-based use of essential technologies and medicines;
- Evaluation and monitoring, with robust information systems and research to ensure effective implementation, quality assurance and ongoing improvement in outcomes.
These pillars are underpinned by cross-cutting foundational enablers:
Advocacy,
Leveraged financing, and
Linked governance.
These pillars together support comprehensive policies, access and coverage of services, and quality health systems for sustainable care.
The CURE All technical package is supplemented by global products, regional and country insights and actions to support implementation at the country level, aligning with existing WHO guidance on cancer, health systems and universal coverage.
To support these pillars, the initiative includes additional global products being developed and/or expanded by WHO. These include:
Tool to support priority setting, budgeting and health system planning
Building on the WHO OneHealth Tool that is used by governments in national health planning, a specific module on cancer is being developed to help national decision-makers understand the impact, cost and feasibility of more than 200 different cancer interventions and identify an optimal scale-up scenario given current capacity, fiscal space and identified targets. This tool will also allow for a country-specific investment case.
Tool to facilitate national dialogue in health workforce planning
Utilizing the framework WHO Human Resources for Health 2030, a customizable tool has been developed to assist stakeholders in understanding the unmet need in cancer workforce, and to identify strategies to address workforce shortages using a labor market approach.
WHO management guidelines or guidance for six index childhood cancers and supportive care
Connecting WHO guidance materials including for priority medical devices and the WHO Model List of Essential In Vitro Diagnostics, the WHO Model List of Essential Medicines, as well as cross-cutting resources for supportive care, new resources will be developed to guide management across various care settings.
Access to cancer medicines program
A program to address global and national barriers to accessing cancer therapies will be developed, linked to tools and options for strategic and policy interventions. Dimensions of this program will span the pharmaceutical value chain, including post-market surveillance for quality, pooled procurement, a forecasting tool and a database on manufacturers, suppliers and price.
Defined global research priorities
Aligning with the approach used by WHO Global Observatory on Health Research and Development, a global framework for research priorities will be established. Other areas of global priorities with WHO technical guidance and resources, such as patient safety and antimicrobial resistance, will also be potential cross-cutting research areas.
Dataset for cancer registries and monitoring of programs
Extending from defined indicators monitored and/or reported at the national, regional and global levels, a core set of measures will be identified for continued monitoring and quality assurance.
Definition and Selection of Focus Countries
At least one focus country from each of the six WHO regions has been identified in 2019.
After the launch in 2018, a process was established for the selection of focus countries. At least one country per WHO Region was selected in 2019. As the critical starting point, WHO consulted with governments and reviewed country cooperation strategies to identify those with existing strong political commitments to support childhood cancer.
Two additional parameters were used in country selection: i) anticipated to demonstrate early measurable progress, and ii) suitable to illustrate actions increasing capacity for provision of quality services, and/or prioritization of children with cancer, while providing feedback to refine assessment and implementation tools.
Global Workshops
Five countries initiated specific implementation steps and hosted WHO national workshops in 2019: Myanmar (WHO South-East Asia Region), Peru (WHO Region of the Americas), the Philippines (WHO Western Pacific Region), Uzbekistan (WHO European Region), and Ghana (WHO African Region). A sixth country has initiated specific implementation steps and hosted WHO national workshop in 2020, Zambia (WHO African Region). Additional focus countries are being identified for implementation efforts in 2020.
Below is an overview of these national workshops led and supported by WHO, together with government ministries and St. Jude as WHO Collaborating Centre for Childhood Cancer, with multiple St. Jude Global regional and transversal teams contributing on site and remotely:
- Yangon and Nay pyi taw, Myanmar, May 2019: engaged more than 115 national, regional and international stakeholders from more than 46 organizations. This resulted in a clear situational analysis of the current status and essential actions to achieve Myanmar’s priority action goals in childhood cancer by 2021, as well as defined collaborative opportunities to align with broader regional and global objectives through the WHO Global Initiative for Childhood Cancer.
- Lima, Peru, June 2019: engaged more than 76 national, regional and international stakeholders from 52 organizations. This resulted in the establishment of 10 national core commitments to advance childhood cancer care spanning the CURE All framework, and over 60 individual pledges for actions between now and 2021 to accelerate progress for children and adolescents with cancer and that can advance the core commitments.
- Manila, Philippines, September 2019: engaged more than 85 national, regional and international stakeholders from 62 organizations. This resulted in the establishment of a proposed national CURE All progress monitor to guide implementation, monitoring and evaluation of activities in alignment with national, regional and global priorities, alongside more than 56 pledges for actions between now and 2021 to accelerate progress aligned with the CURE All progress monitor for children and adolescents with cancer.
- Tashkent, Uzbekistan, October 2019: engaged more than 80 national, regional and international stakeholders from more than 33 organizations. This resulted in the first locally prioritized set of ten CURE All strategic projects and considerations for how these may be implemented in the national context, in addition to individual pledges to support these from local, regional and international stakeholders.
- Lusaka, Zambia, February 2020: engaged more than 69 national, regional and international stakeholders from more than 35 organizations. Participants discussed the current state of childhood cancer access and treatment in Zambia, and began defining opportunities for improvement at the national level. Participants also identified which of the core projects in the CURE ALL technical package best aligned with the highlighted areas for improvement.
In addition, through efforts led by World Child Cancer with the WHO and the local Ministry, a two-day national stakeholder workshop was held in Ghana in November 2019, resulting in plans supported by local, regional and international partners to form a national childhood cancer steering committee as well as a national professional society for pediatric hematology/oncology.
Overall, more than 200 experts from more than 90 organizations have contributed invaluable time and expertise to the planning, implementation and follow-up from these workshops in support of WHO, government ministries and local stakeholders, alongside International Agency for Research on Cancer (IARC), International Atomic Energy Agency (IAEA) and United Nations agencies including UNICEF and United Nations Development Programme (UNDP). In particular, the International Society of Paediatric Onccology (SIOP), Childhood Cancer International (CCI) and International Psycho-Oncology Society (IPOS) are among the international organizations in official relations with WHO that have consistently partnered alongside St. Jude in supporting this global initiative on behalf of children with cancer everywhere.
National and regional dialogues to support childhood cancer in line with CURE All in 2020 include a regional consultation in the Caribbean, and national workshops in additional focus countries, including in Zambia (WHO African Region) and Morocco (WHO Eastern Mediterranean Region), among others.
Connecting Global, Regional and Country Actions
WHO Regional and Country Offices, as well as government authorities, all serve distinct and critical functions in the effective implementation of this Initiative. These entities are linked to a robust implementation network including academic partners, civil society and other non-state actors. At the regional level, select outputs will include developing and sustaining an appropriate governance structure to define and accomplish shared objectives and outputs; supporting dialogue among neighboring countries regarding regional centres for training, clinical or logistics needs; coordinating country-level action; and aligning country-specific strategies with regional priorities.
Strategic approach by level of action
Global initiative
- Develop technical package (CURE All)
- Support multi-sectoral dialogue to strengthen workforce and increase access to cancer medicines and technologies
- Provide platforms for priority-setting, research and exchange of best practices
- Coordinate global reporting on progress indicators
Regional action
- Provide regional governance structure to define and accomplish shared objectives and outputs
- Support dialogue among neighboring countries regarding regional centres for training, clinical or logistics needs
- Coordinate country-level action within region
- Align country-specific strategies with regional priorities
Country acceleration
- Define needs for in-country implementation (country support plan) of technical package
- Convene stakeholders across sectors toward shared objectives
- Apply and coordinate four-step process to scale-up capacity: assess; plan, cost & finance; implement; and monitor & modify
- Generate case studies and best practices, with feedback for regional/global processes
Outputs at the country level will be focused on country implementation, framed by multi-sectoral action and progress in the technical package pillars. Case studies and best practices will then motivate and accelerate regional and global action. Pertaining to country action, this will proceed in a four-phase process.
Phases to successful implementation of CURE All
Tailored for each country’s context, areas of support corresponding to this four-phase process are outlined below:
Assessment Tools
The first critical step is assessing the current situation of childhood cancer services, using a specialized tool for this initiative linked to the technical package. Assessments will be conducted at institutional and national levels using a standardized WHO tool, coupled with site visits as appropriate (involving WHO as well as childhood cancer experts), to support the government in identifying high-impact opportunities across the health system.
The situational analysis outputs will include broad stakeholder mapping of existing activities by local, regional and international partners; a rapid assessment of cancer control considering national- and facility-level data inputs; and a preliminary country profile summarizing the national childhood cancer landscape. WHO will provide and coordinate support through Headquarters, Regional and Country Offices, alongside implementation partners as appropriate, to help Ministries and government partners to implement all steps of the situational analysis.
Prioritization and Policy Dialogues
The next step is a strategic national workshop or consultation, attended by key leaders and implementing partners, to formulate a prioritized action and operational plan. Country-identified priorities will then be matched to implementing partners to build on or expand to new areas of collaboration for capacity building, service delivery, and financing. Sample outputs will include stakeholder feedback on initial situational analysis outputs; country-specific costing and prioritization analyses; workforce planning analyses; policy dialogues to support integration and alignment of childhood cancer within national planning; and defined action plans for implementation.
Program Implementation Support
Effective implementation of childhood cancer programs requires the engagement and participation of focal points within the government, facilities, partnering organizations and civil society, particularly patient and parent support groups and communities.
As appropriate, regional and local governance structures will be established to support the ongoing alliance between community-based support activities with government policies, and ensure programme success toward the shared goal of improving outcomes. Each Regional and Country Office will also help define priority needs to support focus country implementation actions, including potential additional personnel or activity funds. WHO guidance for the management and supportive care for the six index childhood cancers is anticipated, linked to technical support for access to cancer medicines and technologies as well as for workforce scale-up.
Monitoring and Improvement Support
Extending from the global framework and technical package as well as the core global set of defined indicators, countries will be supported to monitor and respond to identified programme needs focusing on quality improvement, and local data and research gaps.
Toolkit to support implementation of CURE All across the phases of country action
Participation in the Global Initiative and implementation of the CURE All technical package will yield tangible benefits for participating countries. Countries will receive intensive support for implementation of country-identified priorities matched to contributions from broad multi-sectoral partners. Specific strategic projects span the phases of country action as well as CURE All elements. Systematic analysis and documentation of the findings in the focus countries will form the basis for revision of the technical package and identify scalable solutions. WHO will support focus countries to assess programme effectiveness and equity.
Sample strategic projects to be developed in focus countries, across country phases of action and CURE All elements
Resources allocated by St. Jude Children’s Research Hospital (WHO Collaborating Centre for Childhood Cancer) as well as other sources, are being disbursed to WHO Regional and Country Offices via Headquarters and Regional Offices to meet needs for staff support, as well as for priority activities and programmes within regions and focus countries as needed.
Focus countries will have first access to WHO-developed tools for childhood cancer and receive priority support for activities related to the Global Initiative. In addition to the anticipated benefits for children with cancer as well as their families and care providers, focus countries will have the opportunity to help define national models and practical approaches to address needs in childhood cancer care, help shape regional and global dialogues, and earn global visibility for their efforts and success.
Engaging All
The robust model of partnerships underpinning this Initiative has already proven useful in childhood cancer, as the majority of countries already have strong implementing partners who range from academic centres, non-governmental organizations, professional societies, and/or patient and parent support and advocacy groups. This Initiative is expected to catalyze and mobilize stakeholders and resources, resulting in new networking relationships and technical cooperation activities to support in-country work. Additional resources from international partners is anticipated as the Initiative grows, helping to extend benefits beyond focus countries and across all regions. Engagement of all stakeholders and sharing of collective lessons learned as the CURE All framework is applied will be invaluable to extend benefits to more children with cancer and accelerate the achievement of the national, regional and global targets of this initiative.