title: Establishing and Delivering Quality Radiation Therapy in Resource-Constrained Settings: The Story of Botswana.
abstract: There is a global cancer crisis, and it is disproportionately affecting resource-constrained settings, especially in low- and middle-income countries (LMICs). Radiotherapy is a critical and cost-effective component of a comprehensive cancer control plan that offers the potential for cure, control, and palliation of disease in greater than 50% of patients with cancer. Globally, LMICs do not have adequate access to quality radiation therapy and this gap is particularly pronounced in sub-Saharan Africa. Although there are numerous challenges in implementing a radiation therapy program in a low-resource setting, providing more equitable global access to radiotherapy is a responsibility and investment worth prioritizing. We outline a systems approach and a series of key questions to direct strategy toward establishing quality radiation services in LMICs, and highlight the story of private-public investment in Botswana from the late 1990s to the present. After assessing the need and defining the value of radiation, we explore core investments required, barriers that need to be overcome, and assets that can be leveraged to establish a radiation program. Considerations addressed include infrastructure; machine choice; quality assurance and patient safety; acquisition, development, and retention of human capital; governmental engagement; public-private partnerships; international collaborations; and the need to critically evaluate the program to foster further growth and sustainability.
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe. jefstathiou@partners.org.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Efstathiou
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Magda
authors.initials: M
authors.lastname: Heunis
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Talkmore
authors.initials: T
authors.lastname: Karumekayi
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Remigio
authors.initials: R
authors.lastname: Makufa
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Memory
authors.initials: M
authors.lastname: Bvochora-Nsingo
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: David P
authors.initials: DP
authors.lastname: Gierga
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Gita
authors.initials: G
authors.lastname: Suneja
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Surbhi
authors.initials: S
authors.lastname: Grover
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Joseph
authors.initials: J
authors.lastname: Kasese
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Mompati
authors.initials: M
authors.lastname: Mmalane
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Howard
authors.initials: H
authors.lastname: Moffat
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Alexander
authors.initials: A
authors.lastname: von Paleske
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Joseph
authors.initials: J
authors.lastname: Makhema
authors.affiliation: Jason A. Efstathiou, David P. Gierga, Massachusetts General Hospital, Harvard Medical School; Scott Dryden-Peterson, Brigham and Women's Hospital, Boston, MA; Magda Heunis, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa; Talkmore Karumekayi, Remigio Makufa, and Memory Bvochora-Nsingo, Gaborone Private Hospital; Joseph Kasese, Bokamoso Private Hospital; Mompati Mmalane, Joseph Makhema, and Scott Dryden-Peterson, Botswana Harvard AIDS Institute; Howard Moffat, Botswana Ministry of Health, Gaborone, Botswana; Gita Suneja, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT; Surbhi Grover, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Alexander von Paleske, Mpilo-Hospital, University of Zimbabwe, Bulawayo, Zimbabwe.
authors.forename: Scott
authors.initials: S
authors.lastname: Dryden-Peterson
mesh_terms: D001902:Botswana; D003695:Delivery of Health Care / Q000379:methods*; D003906:Developing Countries; D006801:Humans; D009369:Neoplasms / Q000532:radiotherapy*