Oncology Nursing in Africa¹

Figure 1. Numbers of health workers in Morocco and Niger.

The importance of oncology nursing in developing countries depends to a large degree on the priority given to cancer control. Although oncology nurses are often thought of as practicing exclusively in cancer centers, professional nurses with specialized knowledge of cancer and able to practice in a variety of settings, in general hospitals and in the community, should be an important element in the cancer control strategy. General nurses must be able to provide simple information and advice to patients and families about cancer and its treatment, provide nursing care for cancer patients, and work closely with other team members, especially the medical staff.

Unfortunately, African health systems suffer from both a lack of human resources and organizational weaknesses, the latter, to a degree, resulting from the former. Sub-Saharan and North Africa for example are facing a huge shortage of qualified nurses and midwives (Figure 1). The limited numbers of medical staff that can be trained is compounded by the exodus of nurses (and doctors) to more developed countries. This affects the entire health systems of such countries, but is felt even more in disciplines that require highly trained specialists, such as chronic diseases in general and cancer in particular.

South Africa 933 Nigeria 466 West Indies 352 Zimbabwe 311 Ghana 272 Pakistan 205 Zambia 162 Mauritius 102	Kenya 99 Botswana 91 Nepal 73 Swaziland 69 Malawi 52 Sri Lanka 47 Lesotho 43 Sierra Leone 24
Total: 3301
Initial Registrants: 33,257; Overseas (non-EU): 11,477; India: 3,690; Philippines: 2,521; Nigeria: 466
Table 1. Nurses who joined the UK register from countries from which recruitment is banned. Figures from the 2005 Annual Report of the Nursing and Midwifery Council of the UK. In 2004/5, approximately one third of nurses who joined the register were from outside the European Union, and over three thousand were from countries from which recruitment is banned.

Unsatisfactory working conditions, nurses rotating between specialty and general units and unsuitable or non-existent medical oncology infrastructures, as in Niger, are the most important factors severely limiting the provision of necessary treatment. Until these problems are solved, there will continue to be serious repercussions on the quality and availability of oncology care.

Casablanca, Morocco, Nov. 2006: a Moroccan nurse next to the 1st International Onco-nursing training course poster.

It must be noted that in most of sub-Saharan Africa, poor working conditions, low pay and status for nurses, and the paucity of specialist nursing training lead to a frequent lack of knowledge and professionalism. There is no oncology training in nursing schools. In many cases, the only possibility for training is provided by doctors working in the hospitals and they are not necessarily familiar with up-to-date oncology nursing care. These doctors are often responsible for teaching the entire multidisciplinary team. The lack of physicians (for example, there are 0.02 physicians per 1000 people in Niger according to WHO 2004) also handicaps training and the maintenance of standards in caring for patients. Once qualified, nurses, who are also in short supply (although there are 10 nurses for every physician), receive no further training. They are routinely excluded from seminars and workshops where new knowledge about cancer care and treatment is transmitted.

In North Africa, the situation is a little better. In Morocco, for example, there are five public cancer centers and more physicians per 1000 people, based on WHO data from 2004 for the country (0.51 per 1000 people). There are, however, only slightly more nurses than doctors (0.71 per 1000). No specific oncology training for nurses was offered, however, until 2006 when cooperation between local and European associations for nursing education in the field of cancer was initiated.

AMCC's Training Program in Cancer Nursining

Nursing oncology training courses organized by the French branch of INCTR (AMCC) were held in Morocco in 2006 and Niger in 2005 and 2006. These objectives were to offer nurses and midwives both general oncology training, linking theory to practice (e.g. in chemotherapy) and specific cancer care training (e.g. cancer prevention, risk factors and palliative care). The courses in Morocco were supported with funds provided by the Moroccan non-governmental cancer organization "Lalla Salma", and those in Niger by the UICC, the French League against Cancer and "Tous unis contre le cancer".

AMCC, supported financially by the NCI (USA), UICC Technology Transfer fellowships (ICRET reverse fellowship) and the French League against Cancer, has in the past, held specialist training for nurses and oncology physicians in over nine African countries, consisting of courses and workshops lasting three to five days. As the demand for nursing training continues to grow, AMCC is now working, in conjunction with cancer units and nursing schools, on curriculum development for oncology nursing training. This is important because of the differences among the various countries in the general levels of nursing, in health systems structure, in resources devoted to cancer control and in the priorities of policy makers. Once specific guidelines for curricula are developed, they will provide a uniform reference source for education in cancer nursing, and will help to promote higher and more uniform standards of care.

Conclusion

Nurses have an important role to play in cancer control. Specialist training of cancer nurses will not only benefit patients, but help to elevate the status of nurses, such that the temptation to emigrate is reduced and more young women will wish to take up nursing as a career. More attention should be paid to the role of nurses in the several areas of cancer control, and training course appropriate both to these roles and to the existing health care system should be developed. In regions or countries where cancer units exist, training hospitals should develop nursing curricula adapted to the needs of the national health services, and providing a variety of types of training based on the nursing role anticipated – e.g., oncology nurse versus general hospital nurse with special knowledge of cancer, or community nurse, more involved in the provision of advice on prevention and palliative care. Ideally, a small number of institutions in a country – those already providing cancer services – should take responsibility for nursing education.

AMCC will continue to work with nurses and doctors in developing countries, particularly in Africa, to provide necessary training and education for nurses, and to advocate for nurses in the broader context of national cancer control.

Sabine Perrier-Bonnet, AMCC<sup>2

1</sup> The present article is based on observations made by the author during training missions carried out in Morocco and Niger
² Project manager, Alliance Mondiale Contre le Cancer,
INCTR French branch,
Montpellier, France