Bridging the pediatric cancer budgeting gap in national cancer control plans

Photo of Nickhill Bhakta and Nancy Bolous

(L to R) Senior author Nickhill Bhakta, MD, MPH, and first and corresponding author Nancy Bolous, MD, MA, MSc, St. Jude Department of Global Pediatric Medicine

Budgeting is a blessing and bane for family finances. Whether accounting for childcare or saving for a trip, items that make it into budget planning are prioritized while excluded items must wait until the next budget cycle for funding. Nations also budget their expenses, including budgeting for cancer care. While many countries have joined initiatives to improve cancer survival rates, few specifically budget for pediatric cancer care, leaving a dearth of funding for this urgent medical need.

The reason is not one of malice but rather a byproduct of limited data collection and lack of expertise to conduct such analysis. To rapidly improve cancer care, countries develop national cancer control plans every five to six years and create budget proposals. The complexity of collecting the necessary information on the cost-effectiveness of pediatric cancer care and the length of time to do so are prohibitive compared to adult data. Such projects can take several months up to years to complete, while a cancer control plan needs to be drafted in weeks or months, leading to the exclusion of pediatrics in favor of adult cancer care.

To address the need for a rapid budgeting method, St. Jude researchers created the Childhood Cancers Budgeting Rapidly to incorporate the Disadvantaged Groups for Equity (CC-BRIDGE) tool. The CC-BRIDGE tool, published recently in Cancer, can rapidly estimate the cost of pediatric cancer care in low- and middle-income countries.

“Countries cannot spend large sums of money on every single disease; they must prioritize,” said first and corresponding author Nancy Bolous, MD, MA, MSc, St. Jude Department of Global Pediatric Medicine. “The CC-BRIDGE tool gives an evidence-based estimate of how much money can be invested and what the return for the country over the next five years will be, with minimal time and labor to perform the analysis.”

“It’s exciting that we finally have a tool that fills a critical need and addresses the inclusion of children in the financial planning process associated with cancer control policies,” said senior author Nickhill Bhakta, MD, MPH, St. Jude Department of Global Pediatric Medicine. “Many governments are drafting new policies in response to the World Health Organization–St. Jude Global Initiative for Childhood Cancer. Yet they need help defining these policies to create budgets and ensure their cancer programs are sustainable. The CC-BRIDGE tool is designed to help governments all around the world with that process.”

Partnering for rapid cancer control planning

“The purpose of the CC-BRIDGE tool is to give a holistic, high-level cost-effectiveness estimate in a methodologically sound yet quick manner,” Bolous explained. “It also doesn’t require highly technical skills or extensive effort from the partner to use the tool.”

Planning for long-term improvements in cancer care is often challenging, especially for clinicians in low- and middle-income countries. The physicians charged with such projections often lack policy writing and governmental budgeting experience. Several partners from such countries came to St. Jude, which is the first and only World Health Organization Collaborating Centre for Childhood Cancer, for guidance in drafting both the cancer control plan and the proposed budget to submit to their local government quickly. 

“Our partners often tell us, ‘We needed it yesterday and don’t have a year or more to do a comprehensive cost-effectiveness analysis,’” Bhakta said. “So, we thought, ‘Can we at least do something that’s rapid and gets them into the right ballpark?’”

The CC-BRIDGE tool was born of that need. Bhakta created the first comprehensive country-level cost-effectiveness models more than a decade ago. The St. Jude team used that previous data and experience to create the CC-BRIDGE tool. They identified the biggest and most consistent contributors to cost: personnel, inpatient/outpatient utilization and pharmacy needs. They quickly assembled this information for each of their three partners, working directly with local teams. 

“This tool aims to generate quick numbers,” Bolous explained. “It took a few weeks. The partner had to complete an Excel spreadsheet that took a week to 10 days. Then I did all the calculations and followed up with some calls to walk them through the data, validate some assumptions and tailor several input parameters to their context.”

The local partners then offered amendments and adjustments based on their circumstances, providing a bespoke estimate for each country. The partnership was the critical factor, often drastically changing estimates as the local group accounted for their unique circumstances. Once they finalized the estimates, partners had enough time to integrate them into their cancer control plans, capitalizing on a historically missed opportunity. 

Getting ahead of the national cancer control planning cycle 

“It’s the first time that something like this has been available, so that when countries now say, ‘Tomorrow we’re starting our cancer control plan,’ there doesn’t have to be that panic that children will be missed when allocating funds,” Bhakta said. “There’s now an available tool that teams can use rapidly to ensure there’s pre-determined funding from the government incorporated into their plans.” 

These plans are only drafted twice a decade, so missing the planning window can be a significant blow to pediatric cancer care funding. 

“These are every five- or six-year processes that go through an entire governmental effort,” Bhakta explained. “I am optimistic that we won’t miss any more cycles with the CC-BRIDGE. I hope that by making our tool broadly available, we’ll be able to enhance every new cancer control plan, regardless of how quickly the plan needs to come together.”

Importantly, even though the CC-BRIDGE tool is being used for national planning, it gives an estimate, not an exact value. A more comprehensive approach would find different numbers. Historically, when challenged to provide budgeting for childhood cancer care, countries have ignored explicitly addressing pediatric disease and chosen not to do a comprehensive cost-effectiveness analysis. The result was worse than receiving a low budget: dedicated funding was completely absent from national cancer control plans.

“It’s a placeholder to have something instead of neglecting to include childhood cancer in these plans completely,” Bolous said. “This should not be the only measure to develop these numbers. It is meant to be the first step to lay the ground for a more detailed analysis.”

Empowering physicians to plan for pediatric cancer care

A partial explanation for the past lack of dedicated national funding for pediatric cancer care was the absence of physician’s experience with policy writing and economic analysis. The St. Jude team hopes to empower clinicians to advocate for childhood cancer care support when their country begins the cancer control planning cycle. 

“Clinicians focus almost exclusively on treatment and how to get the patient to survive, which is extremely important,” Bolous said. “But sometimes they undervalue cost and budgeting policy. Clinicians can help prove to policymakers that pediatric cancer care is an area that is worth investing money in, helping more children survive.”

The CC-BRIDGE tool promises to provide that evidence for physicians in low- and middle-income countries, enabling them to budget and bring national resources to help children with cancer.

“This is an essential tool to empower governments, advocates, patients and physicians to ensure that this neglected group — children with cancer — are not ignored,” Bhakta concluded. “Using the CC-BRIDGE tool, children can now easily be incorporated into the planning process and become part of the dialogue with governments and multiple stakeholders during national cancer control policy planning and budgeting processes.”

About the author

Scientific Writer

Alex Generous, PhD, is a Scientific Writer in the Strategic Communications, Education and Outreach Department at St. Jude.

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