title: Pursuing equity in cancer care: implementation, challenges and preliminary findings of a public cancer referral center in rural Rwanda.
abstract: BACKGROUND
  Cancer services are inaccessible in many low-income countries, and few published examples describe oncology programs within the public sector. In 2011, the Rwanda Ministry of Health (RMOH) established Butaro Cancer Center of Excellence (BCCOE) to expand cancer services nationally. In hopes of informing cancer care delivery in similar settings, we describe program-level experience implementing BCCOE, patient characteristics, and challenges encountered.
  
  
  METHODS
  Butaro Cancer Center of Excellence was founded on diverse partnerships that emphasize capacity building. Services available include pathology-based diagnosis, basic imaging, chemotherapy, surgery, referral for radiotherapy, palliative care and socioeconomic access supports. Retrospective review of electronic medical records (EMR) of patients enrolled between July 1, 2012 and June 30, 2014 was conducted, supplemented by manual review of paper charts and programmatic records.
  
  
  RESULTS
  In the program's first 2 years, 2326 patients presented for cancer-related care. Of these, 70.5% were female, 4.3% children, and 74.3% on public health insurance. In the first year, 66.3% (n = 1144) were diagnosed with cancer. Leading adult diagnoses were breast, cervical, and skin cancer. Among children, nephroblastoma, acute lymphoblastic leukemia, and Hodgkin lymphoma were predominant. As of June 30, 2013, 95 cancer patients had died. Challenges encountered include documentation gaps and staff shortages.
  
  
  CONCLUSIONS
  Butaro Cancer Center of Excellence demonstrates that complex cancer care can be delivered in the most resource-constrained settings, accessible to vulnerable patients. Key attributes that have made BCCOE possible are: meaningful North-south partnerships, innovative task- and infrastructure-shifting, RMOH leadership, and an equity-driven agenda. Going forward, we will apply our experiences and lessons learned to further strengthen BCCOE, and employ the developed EMR system as a valuable platform to assess long-term clinical outcomes and improve care.
authors.affiliation: Botswana Ministry of Health, Gaborone, Botswana. ntapela@gmail.com.|Dana-Farber/Brigham & Women's Cancer Center, Boston, USA. ntapela@gmail.com.|Harvard Medical School, Boston, USA. ntapela@gmail.com.|Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA. ntapela@gmail.com.
authors.forename: Neo M
authors.initials: NM
authors.lastname: Tapela
authors.affiliation: Rwanda Ministry of Health, Kigali, Rwanda.
authors.forename: Tharcisse
authors.initials: T
authors.lastname: Mpunga
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.|Dana-Farber/Brigham & Women's Cancer Center, Boston, USA.|Harvard Medical School, Boston, USA.
authors.forename: Bethany
authors.initials: B
authors.lastname: Hedt-Gauthier
authors.affiliation: University of Vermont College of Medicine, Burlington, USA.
authors.forename: Molly
authors.initials: M
authors.lastname: Moore
authors.affiliation: Rwanda Ministry of Health, Kigali, Rwanda.
authors.forename: Egide
authors.initials: E
authors.lastname: Mpanumusingo
authors.affiliation: Harvard Medical School, Boston, USA.
authors.forename: Mary Jue
authors.initials: MJ
authors.lastname: Xu
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.
authors.forename: Ignace
authors.initials: I
authors.lastname: Nzayisenga
authors.affiliation: Rwanda Ministry of Health, Kigali, Rwanda.
authors.forename: Vedaste
authors.initials: V
authors.lastname: Hategekimana
authors.affiliation: Rwanda Ministry of Health, Kigali, Rwanda.
authors.forename: Denis Gilbert
authors.initials: DG
authors.lastname: Umuhizi
authors.affiliation: Harvard Medical School, Boston, USA.
authors.forename: Lydia E
authors.initials: LE
authors.lastname: Pace
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.
authors.forename: Jean Bosco
authors.initials: JB
authors.lastname: Bigirimana
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.
authors.forename: JingJing
authors.initials: J
authors.lastname: Wang
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, USA.
authors.forename: Caitlin
authors.initials: C
authors.lastname: Driscoll
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.
authors.forename: Frank R
authors.initials: FR
authors.lastname: Uwizeye
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.|Dana-Farber/Brigham & Women's Cancer Center, Boston, USA.|Harvard Medical School, Boston, USA.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Drobac
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.
authors.forename: Gedeon
authors.initials: G
authors.lastname: Ngoga
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.
authors.forename: Cyprien
authors.initials: C
authors.lastname: Shyirambere
authors.affiliation: Rwanda Ministry of Health, Kigali, Rwanda.
authors.forename: Clemence
authors.initials: C
authors.lastname: Muhayimana
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.|Dana-Farber/Brigham & Women's Cancer Center, Boston, USA.|Harvard Medical School, Boston, USA.|Boston Children's Hospital, Boston, USA.
authors.forename: Leslie
authors.initials: L
authors.lastname: Lehmann
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.|Dana-Farber/Brigham & Women's Cancer Center, Boston, USA.|Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA.
authors.forename: Lawrence N
authors.initials: LN
authors.lastname: Shulman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003695:Delivery of Health Care; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000453:epidemiology* / Q000473:pathology / Q000628:therapy; D010342:Patient Acceptance of Health Care; D012424:Rural Population; D012432:Rwanda; D012959:Socioeconomic Factors
keywords: Cancer; Capacity building; Implementation; Resource-limited setting; Rwanda; Task-shifting; Twinning