Health facility preparedness for early detection of symptomatic cancer in Southern Africa: A multi-centre cross-sectional study

Early detection and diagnosis of cancer in African contexts is challenging. Health services should identify people with symptoms suggestive of cancer, refer timeously, and implement diagnostic processes efficiently. This requires the resources and infrastructure to provide these services. This study, the first in Southern Africa, reports on the availability of these services across referral pathways in four provinces of two Southern African countries, South Africa and Zimbabwe. As part of the African Awareness of Cancer and Early Diagnosis (AWACAN-ED) programme, we conducted a quantitative cross-sectional study, from February to September 2023 at primary care (PC), secondary and tertiary (ST) level public sector health facilities. PC's role is to identify and refer patients, while the definitive diagnosis mostly occurs at ST level. Data were collected on the availability of staff, infrastructure, diagnostic services, referral pathways and community engagement, and analysed descriptively. A total of thirty-four (N = 34) facilities were included. Twenty-two (n = 22) were PC facilities, serving a population of 1,068,177, with a nurse-to-1000-person ratio of 0.46, and doctor-to-1000-person ratio of 0.04. Twelve (n = 12) ST facilities were included, serving a population of 18,750,387, with a nurse-to-1000-person ratio of 0.42, and doctor-to-1000-person ratio of to 0.06. PC and ST facilities differed in availability of adequate communication infrastructure (40% vs 42%); patient transport systems (50% vs 100%); cervical smears/visual inspection (77% vs 100%) and colorectal clinical assessment (9% vs 58%). Mammography was not available at any Zimbabwean facilities. There was low availability of clinical protocols in primary care for cervical (30%) and breast (9%) cancer, and none for colorectal cancer. Community engagement activities focused on breast and cervical cancer. This study identifies areas for improving early cancer diagnosis and provides a baseline for quality improvement interventions in facility infrastructure and referral pathways.