Global Oncology Directly-Observed Care (DOC)

A novel, patient-centered program to accompany cancer patients and caregivers from diagnosis through treatment to improve care and outcomes

Belize is currently establishing the first public sector cancer treatment program.  In 2013, 41% of its population lived below the poverty line. In Belize, non-communicable diseases are the leading cause of DALYs and cancer is the leading cause of death.

Patients living in poverty face unique challenges in accessing and benefiting from oncology care around the world.  Because of Belize’s significant poverty there will be major challenges to providing care:

·    Patient level: Unclear expectations about cancer care, financial and insurance barriers to access, logistical barriers, including transportation, childcare, nutrition, etc., and barriers in communicating with their providers

·    Provider level: High volume of patients per medical provider, lack of specialized oncology nursing expertise

·    System level: Crucial reliance on multiple partners for the success of the oncology program (pathology, lab, radiology, surgery, etc.), lack of radiation oncology capacity in the country, budgetary constraints in procuring chemotherapy medications.

As cancer care is time-sensitive, if the above barriers lead to delays in care, patients are likely to suffer or die as a result.

We propose a novel delivery model for cancer care in Belize: Directly Observed Care (DOC). This model draws from other immensely successful health interventions including Directly Observed Therapy Short Course for tuberculosis and patient navigation programs pioneered by Dr. Harold Freeman in Harlem which drastically improved oncologic outcomes for patients living in poverty.

This comprehensive patient navigation intervention is based on five core principles:

1.     Accompaniment of cancer patients throughout their care journey

2.     Proactive removal of barriers to ensure that every patient receives high-quality, timely cancer care

3.     Availability of expert consultation network of specialist oncologists

4.     Patient education and empowerment

5.     Rigorous measurement and evaluation leading to continuous improvement

This project will change Belize, and the world by proving that with accompaniment and intensive engagement, cancer patients can overcome challenges in LMICs. The DOC program has the potential to revolutionize cancer care in resource-limited settings, where poverty, logistical challenges, and lack of familiarity with cancer care can severely hinder patients’ ability to access and attain quality care.

We believe DOC can be adapted to and replicated in multiple countries that have high rates of poverty, centralized oncology care in big cities, and want to improve outcomes among their most impoverished patients.  We also believe that the principles of DOC are broadly applicable to any chronic and complex disease and that our pilot in Belize can inform the design of future programs in oncology and other non-communicable diseases.

We are creating a patient navigation program for a resource-limited setting with no integrated cancer care currently available. The foundations are: 

1) dedicated personnel (“DOC officers”) with patient navigation training, who will guide patients through cancer care and remove barriers patients face; 

2) an online, mobile-friendly patient tracking platform that allows real-time dashboard viewing of the patient progress  across the care continuum. 

This will enable providers to proactively intervene when patients miss care milestones or are at risk for doing so. Pieces of this solution have been implemented, but never been combined to deliver cancer care in a resource-limited setting.

Technology is at the core of our solution: we propose the creation of an online, cloud-based, mobile-enabled, patient-tracking platform that allows doctors, patient navigators, and nurses to track the progress of individual patients along their care continuum to reduce delays in diagnosis and treatment. This will allow real-time understanding of the progress of both individual patients and specific patient cohorts (i.e. all patients with a specific type of cancer). The platform will create accountability among care providers and provide an accurate picture of the rate-limiting steps of the delivery of high-quality cancer care in a resource-limited setting.

Over the next 12 months, we aim to hire and train 2 patient navigators who will assume the responsibility of tracking patient progress along their care continuum. We expect to enroll approximately 100 cancer patients into our program. We also aim to select and implement the online patient tracking platform and collect the first batch of data that will allow us to understand patient barriers in cancer treatment. Lastly, we aim to establish collaboration with cancer programs in other countries in the Central American and Caribbean region to share lessons learned and technology solutions.

If successful in Belize, DOC will be scalable to other resource-limited settings. The pilot in Belize will allow us to better understand the types of barriers patients face in accessing cancer care and the types of interventions that can successfully address these barriers. Using lessons learned, we hope to scale the Belize pilot to other countries in the region and across the globe. The establishment of a robust, secure, cloud-based platform for patient tracking and real-time data analytics will be easily scalable across national borders, as long as top-level privacy and security measures are put in place from the beginning.

GO DOC will be fully integrated with the nascent public sector cancer detection and treatment program in Belize starting with the very first patient getting cancer treatment. All patients who present for care at the cancer center will offered the option to participate in the GO DOC program. This will allow our program to capture all aspects of a patient’s health care, which are already documented in Belize’s national electronic medical record system. Given the substantial unmet demand for cancer care in Belize, we expect that enrollment of patients into DOC will be rapid.

The patients interviewed during the needs assessment (N=35) are largely impoverished, live relatively far from the city (many over 4 hours away by public transportation), and have little to no familiarity with cancer treatment. They face logistical, financial, cultural, and emotional barriers to accessing care which is complex and physically and mentally taxing. As we design the program, we will include patient perspectives. We will craft a participatory process through which patients can provide feedback and propose new services, ideas, or interventions that could ease their suffering or improve the logistical and financial burden that cancer treatment imposes.

We expect to enroll 100 patients over the next 12 months. Each patient will be paired with a patient navigator,who will be primarily responsible for assisting with patients’ cancer care journey and accountable for the successful completion of treatment. These will largely be impoverished patients, with a variety of malignant diagnoses and treatment plans. We aim to provide patients with timely, evidence-based cancer care that is fully integrated within the public healthcare system. We expect the effects of the program to be seen within the first 6 months, as patients begin to progress through their treatment plans.

Dr. Franklin Huang is a Harvard-trained medical oncologist who has assisted with the development of cancer treatment programs in several resource-limited countries across the world. Dr. Ramon Yacab is the only medical oncologist working full-time in the country of Belize, and the head of the nation’s only public cancer care program. Dr. Yannis Valtis has extensive experience in programmatic implementation in resource-limited settings, as well as in negotiating large-scale donations of healthcare software for use in poor settings.

GO will partially fund the pilot project with unrestricted funding. We anticipate that the government of Belize will support general operations of the oncology treatment program, as it is responsible for the health of its population. The Ministry of Health and the Social Security Board have expressed interest in providing funding as well. The local tertiary care hospital (KHMH) has committed to funding the salary of the medical oncologist, four full-time oncology nurses (two in year one and an additional two in year two), equipping the chemotherapy treatment room, and purchasing chemotherapy medications for the first 25 patients. The Ministry of Health is planning to fund the purchase of chemotherapy medications after that and is currently in the process of establishing a procurement plan.  GO will engage other organizations for specific investments into the program. For example, as pathology strengthening will be a crucial activity to improve cancer diagnosis, we hope to collaborate with organizations with expertise and funding around strengthening of pathology laboratories.

Solve brings together a unique and highly influential community of judges, applicants, and leaders in global health who will engage to improve our solution and achieve maximum impact. The “Frontlines of Health” challenge chairs/leadership group bring an unparalleled breadth and depth of expertise in programmatic implementation and transformative impact. We hope to utilize the Solve community to iterate on our solutions, receive mentorship, and create partnerships that will benefit cancer patients in Belize and the rest of the world. The Solve Prize would allow us to jump-start development of the online platform and deliver DOC in Belize more rapidly.

The selection and deployment of an appropriate software platform to track patients is one of the key challenges we will face in starting the DOC program. Developing a platform de novo will likely be too expensive and time consuming. Thus, we hope to receive guidance from the Solve community on how to approach companies with existing solutions and negotiate a reasonable pricing model. The other key challenge will be developing an appropriate training program for the DOC officers in Belize. We hope to utilize Solve expertise in workforce development in diverse settings to create a robust and effective training program.