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									     GAMBIA
    CANCER
   INSTITUTE




 A Preliminary Feasibility Study
            for the
Development of a Cancer Center
       in Gambia, Africa
            [DRAFT]


          March 2009
                              TABLE OF CONTENTS


I.   EXECUTIVE SUMMARY                                4

II. ONCOLOGY                                          7

       2.1    Definition
       2.2    Occurrence
       2.3    Diagnostics
       2.4    Treatments

III. INTRODUCTION                                     11

       3.1    Project Objectives
       3.2    Project Rationale
       3.3    Project Feasibility


IV. REGIONAL OVERVIEW                                 14

       4.1    General Area Description
       4.2    Regional Socio-Economic overview
       4.3    Healthcare & Hospital Industry Sector
       4.4    Regional Oncology Data


V. PROJECT OVERVIEW                                   21

       5.1    Project Description
       5.2    Mission and Vision
       5.3    Directors & Founders
       5.4    Human Resource Requirements
       5.5    Advisors and Consultants
       5.6    Site Possibilities
       5.7    Infrastructure & Space Requirements
       5.8    Market Area Identification
       5.9    Service Area Identification
       5.10   Model




                                           2
VI.     FINANCIAL PLAN                       29

        6.1   Capital Requirements
        6.2   Operating Budget
        6.3   Long Term Projections
        6.4   Funding Sources
        6.5   Control/Monitoring Plans


VII.    PROJECT IMPLEMENTATION SCHEDULE      31

VIII.   LEGAL CONSIDERATIONS                 31

IX.     RISK FACTORS                         31

X.      CONCLUSION                           32




                                         3
I.   EXECUTIVE SUMMARY

     Definition - Oncology is a branch of medicine that deals with cancer, the group
     of diseases characterized by uncontrolled growth and spread of abnormal cells.

     Occurrence - Globally, there were an estimated 12.4 million new incident cases
     of cancer in 2008 and 7.6 million deaths from cancer Cancer is projected to
     become the leading cause of death worldwide in the year 2010.

     Diagnostics - Cancer diagnosis requires clinical assessment through the use of a
     variety of modalities such as medical history, biopsies, endoscopy, imaging etc.

     Treatments - There are several different kinds of cancer treatments depending
     on the patient’s general state of health and the type, stage & extent of the cancer.
     These include surgery, chemotherapy, radiation therapy, biotherapy and hormone
     therapy.

     Project Objectives – The project mainly aims to establish a non-profit center
     and hospital in Gambia that would be a center of excellence in the region for
     providing high quality, sustainable, comprehensive multimodal cancer care.

     Project Rationale - Gambia is in need of a health institution dedicated to the
     prevention, diagnosis and management of cancer due to the absence of a
     significant cancer control program in a region where the cancer burden is
     growing and taking a backseat to other health programs.

     Project Feasibility - There are a number of factors that make the project viable
     including the relative economic & political stability in the country, its geography
     & land area, and the availability of a medical learning institution.

     General Area Description – Gambia, a presidential republic, is the smallest
     country in Africa with a population of 1.7 million.

     Regional Socio-Economic Overview - Gambia is among the poorest countries
     in the world, ranking 155th out of 177 countries a United Nation’s index ranking.
     However, it aims to be a dynamic middle-income country by 2020 as mapped out
     in its ambitious socio-economic strategy called Vision 2020.

     Healthcare & Hospital Industry Sector - The healthcare system in Gambia is
     built around 3 levels which are Primary, Secondary and Tertiary. There are 3
     referral hospitals, 8 main health centers, 16 smaller centers, 200 plus mobile clinic
     unit teams, a Medical Research Council, private clinics and a few health focused
     NGOs.




                                        4
Regional Oncology Data - According to the International Union Against
Cancer there is an impending cancer crisis in Africa with the continent
accounting for over a million new cancer cases a year. Life-saving radiotherapy is
available in only 21 of Africa's 53 countries, or to less than 20% of the
population. This falls far short of being able to respond to even a portion of
current demands.

Existing Facilities - Health care facilities are relatively sparse in Gambia
although new health clinics are being developed in the country. The Republic
currently has no facility focused on cancer care. There are three main referral
hospitals that provide tertiary care -- the Bansang Hospital, Royal Victoria
Teaching Hospital and a new facility in Ferafenni.

Description of Project - The Gambia Cancer Institute would be a 300-bed non-
profit cancer center focused on cancer through treatment, prevention and early
detection, education and training, and community programs for cancer patients
and persons at risk for developing cancer in the region.

Mission and Vision - Gambia Cancer Institute’s mission is to provide high
quality, sustainable comprehensive curative cancer care services to patients in
need in Gambia and in the region. Its vision is to become a model institution of
excellent integrative cancer care in the African region.

Management Team - The hospital’s management team would consist of a
professional team from clinical and administrative backgrounds. The hospital
would also have a Board of Directors.

Human Resource Requirements - A lean & minimal medical staff would
include: doctors of various oncology specialties, nurses, ward attendants,
pharmacists, medical physicists, therapy radiographers, laboratory technicians
and administrative and ancillary services staff

Advisors and Consultants – The Compliance Doctor, LLC, and its associated
consultants would be commissioned to assist in the development of a complete
feasibility study for this project.

Site Possibilities - Specific site possibilities for the hospital would be finalized
prior to the initial development phase. These sites may be located in two well
populated urban areas in Gambia – Banjul & Farafenni.

Infrastructure & Space Requirements – Space allocation information is
outlined in the report including clinical & administrative space.

Market Area Identification - The non-profit cancer hospital would serve
patients from the 5 divisions of Gambia plus the city capital as well as the West
Africa region.




                                   5
Service Area Identification - Gambia Cancer Institute would be developed as a
center of excellence in multi-modal cancer care incorporating Surgical Oncology,
Medical Oncology, Radiotherapy, Diagnostic Services among others.

Model - Identifying model cancer hospitals / institutions in low to middle
resource countries in the African region would be helpful in project
development. Some of these centers include the African Cancer Center in
Nigeria, the National Cancer Diseases Hospital in Zambia, the Ocean Road
Cancer Institute (ORCI) in Tanzania and a planned Cancer Hospital in Ethiopia.

Capital Requirements - The capital cost of the project is estimated to be about
$19 million dollars with a tentative breakup detailed in the feasibility study.

Operating Budget - Prior to final project planning, the operating budget would
be outlined as monthly and annual operating budgets for the center including
payroll, supplies, lease payments, travel, physician compensation, revenues (if
any), funding, and ongoing operational cash flow requirements.

Long-term Projections – Projected funding and income projections, if any,
represented in a table with 5 year projections.

Funding Sources - The project is largely dependent on developing funding
sources for the overall capital budget. These may include grants, individual &
corporate donations, fundraising events and volunteers & in-kind contributions

Control/ Monitoring Plan – The project would utilize strategic and operational
controls that would monitor the use of funds for financial optimization.

Project Implementation Schedule - A detailed project implementation
schedule would be prepared for each phase of the project for the next five years.

Legal Issues - The primary legal consideration would be the legal corporate
structure of Gambia Cancer Institute, in compliance with the republic’s medical
regulation pertaining to non-profit organizations and hospitals. The structure
could be a non-profit Corporation.

Risk Factors – Risk factors for the project include the nature of a start-up,
capital inadequacy, competition in funds and an economic downturn that may
limit resources.

Conclusion - Overall, the Gambia Cancer Institute project appears to be viable
primarily due to a true need for cancer care in the country coupled with its
relative economic & political stability, the growing awareness on the region’s
cancer burden and the healthcare set up of the nation.




                                  6
II.         ONCOLOGY

      2.1     Definition

              Oncology is a branch of medicine that deals with cancer including the study
              of its development, diagnosis, treatment, and prevention.

              Cancer is a group of diseases characterized by uncontrolled growth and
              spread of abnormal cells. Cancer can arise in any organ or tissue in the body
              except fingernails, hair, and teeth. If the spread is not controlled, it can result
              in death.

              Cancers are classified in two ways: by the type of tissue in which the cancer
              originates (histological type) and by primary site, or the location in the body
              where the cancer first developed.

              There are several sub-specialties within oncology that have to do with the
              basis of the type of treatment provided such as Radiation Oncology, Surgical
              Oncology, Pediatric Oncology, Medical Oncology , Gynecologic Oncology
              and Interventional Oncology.


      2.2     Occurrence

              The global cancer crisis is growing as the burden shifts from high-resource to
              low-resource regions. According to the latest World Cancer Report from The
              International Agency for Research on Cancer (IARC):

                 Cancer is projected to become the leading cause of death worldwide in
                  the year 2010,
                 The burden of cancer doubled globally between 1975 and 2000. It is
                  estimated that it will double again by 2020 and nearly triple by 2030. This
                  translates to far greater numbers of people living with – and dying from –
                  the disease.
                 Globally, there were an estimated 12.4 million new incident cases of cancer
                  in 2008 (6.7 million in men and 5.8 in women) and 7.6 million deaths
                  from cancer (4.3 in men and 3.3 in women).
                 Over half of the incident cases occurred in residents of four WHO
                  regions with a large proportion of countries of low- and middle-
                  income—including the African region.
                 Globally, lung cancer was the commonest incident cancer and cause of
                  cancer-related mortality in men; in women, the most common incident
                  cancer and cause of cancer-related death was breast cancer.


                                              7
         The projected numbers for the year 2030 are 20-26 million new
          diagnoses and 13-17 million deaths.
         The growing cancer burden includes global increases of incidence of
          about one percent each year, with larger increases in China, Russia, and
          India.
         Reasons for the increased rates include adoption of Western habits in less
          developed countries, such as tobacco use and higher-fat diets, and
          demographic changes, including a projected population increase of 38
          percent in less developed countries between 2008 and 2030.
         In addition to increases in cancer incidence and death rates, the report
          identifies challenges in cancer care, especially in Africa, where pain
          management and palliative care are very limited because any use of
          narcotics is prohibited by law in several countries.


2.3   Diagnostics

      Cancer diagnosis requires clinical assessment through the use of a variety of
      modalities:
       Medical History is widely considered as the most important diagnostic
         tool it involves the character of the complaints and any specific
         symptoms (fatigue, weight loss, unexplained anemia, fever of unknown
         origin, paraneoplastic phenomena and other signs)
       Biopsy, either incisional or excisional; is a preferred method to confirm
         the diagnosis of cancer and may also pinpoint the primary and secondary
         cancer site. Biopsies can provide information about histological type,
         classification, grade, potential aggressiveness and other information that
         may help determine the best treatment
       Endoscopy, either upper or lower gastrointestinal, bronchoscopy, or
         nasendoscopy;
       X-rays, CT scanning, MRI scanning, ultrasound and other radiological
         techniques
       Scintigraphy, Single Photon Emission Computed Tomography, Positron
         emission tomography and other methods of nuclear medicine;
       Blood tests, including Tumor markers, which can increase the suspicion
         of certain types of tumors or even be pathognomonic of a particular
         disease.

          Some of these diagnostic tools (especially imaging by CT scanning) are
          often used to determine operability, i.e. whether it is surgically feasible to
          remove a tumor in its entirety.




                                      8
2.4   Treatment

      There are several different kinds of cancer treatments and the most
      appropriate cancer treatment program may consist of a combination of these
      modalities depending on the patient’s general state of health and the type,
      stage & extent of the cancer.

         Surgery
          Cancer surgery is a local treatment to physically remove tumors from the
          affected area and possibly also removing adjacent tissue. Cancer surgery
          also plays an important role in diagnosing cancer, learning how far it has
          spread and predicting the likelihood of a recurrence and the need

         Chemotherapy
          Chemotherapy is a systemic cancer treatment that uses chemical
          agents/drugs to kill cancer cells. Many different kinds of drugs are used,
          either alone or in combination, to treat different cancers. The specific
          drug or combination used is chosen to best combat the type and extent
          of cancer present. It can be administered through a vein, injected into a
          body cavity or taken orally in the form of a pill.

         Radiation Therapy
          Radiation therapy, or radiotherapy, is a local treatment that uses high-
          energy rays – in the form of a special kind of x-ray, gamma rays or
          electrons – to damage cancer cells so that they cannot multiply.
          Radiation therapy may be externally or internally delivered. External
          radiation delivers high-energy rays directly to the tumor site from a
          machine outside the body. Internal radiation, or brachytherapy, involves
          the implantation of a small amount of radioactive material in or near the
          cancer.

         Biotherapy/Immunotherapy
          Biotherapy or Immunotherapy is one of the newest and most advanced
          types of therapies available to treat cancer. It uses drugs or biological
          response modifiers aimed at the patient's immune system to help fight
          cancer throughout the body. While chemotherapy is focused on cancer
          cells, biotherapy is directed on stimulating the patient’s immune system
          to produce more white blood cells.

         Hormone Therapy
          Hormone manipulation is a well established therapeutic intervention for
          cancer particularly in the treatment of breast and prostate cancer.
          Hormone therapy, similar to chemotherapy, is a systemic treatment in
          that it may affect cancer cells throughout the body


                                    9
Other cancer treatments include:

   Blood and Bone Marrow Transplants
   Supportive Care
   Nutritional Therapy
   Stem Cell Transplantation
   Photodynamic Therapy




                             10
III.         INTRODUCTION

       3.1     Project Objectives

               Health programs in West Africa have largely been focused on managing
               communicable diseases. There has been less significant activity towards the
               control and treatment of cancer

               Due to population growth, lifestyle changes, growing urbanization and
               environmental degradation etc., cancer is emerging as a major health concern
               in the region.

               The project aims to:

                  Establish a non-profit hospital that would be a center of excellence in the
                   region for providing high quality, sustainable, comprehensive multimodal
                   cancer care.
                  Reduce the rate of complications and death from cancer in the urban and
                   rural communities of Gambia
                  Provide modern & compassionate palliative care services, pain
                   management and cancer support programs
                  Raise cancer awareness and to expand the population’s knowledge
                   base on preventive oncology, early detection and cancer treatment
                  Provide a venue to conduct fundamental & applied cancer research
                   programs
                  Initiate & develop a cancer data registry system ultimately supplying
                   cancer data to concerned agencies within or outside the country (e.g.
                   UN Agencies) to further the cause of education, prevention, control
                   and better management of cancer.
                  Coordinate with local health centers/organizations and create
                   nationwide cancer control programs (e.g. Mobile Cancer Diagnostic
                   Clinics) to promote cancer prevention and early detection
                  Provide basic education and training in cancer care to health care
                   professionals in the country




                                             11
3.2   Project Rationale

      Gambia is in need of a health institution dedicated to the prevention,
      diagnosis and management of cancer.
           There is a growing cancer burden in the region but being a low
             income resource country like others in West Africa, Gambia is forced
             to put it in the backseat to address other public health issues such as
             the spread of communicable diseases, infant mortality and maternal
             health.
           There is an absence of a significant cancer control program in
             Gambia and in the West Africa region as a whole specifically in the
             fields of prevention, detection / treatment and research.
           Cancer represents a heavy economic burden to patients and their
             families. With 69 percent of the population living below the poverty
             line, its prevention, diagnosis, and management are not priorities in
             household healthcare spending
            There is a lack of basic ―needs assessment‖ in cancer care as well as
             local, effective and sustainable research & cancer data which are key
             to obtaining financial support from donors and the international
             community

3.3   Project Feasibility

      There are a number of factors that present opportunities and make the non-
      profit cancer hospital a viable project to undertake.

         Relative economic & political stability in the region
              o Gambia is one of the few west African countries to have
                  extended periods of political stability since gaining independence
                  from Britain in 1965
              o In a 2008 report, the IMF hailed the country’s economic stability
                  citing its good fiscal performance and a strong GDP growth at
                  over 6% a year
              o The same report notes high growth in construction, tourism and
                  telecommunications sectors facilitated by a steady inflow of
                  foreign direct investment and remittances.
              o It came third in a recent World Bank assessment of financial
                  probity/honesty in all Africa
         Continental Africa's smallest nation, Gambia’s geography & land area
          would contribute to a feasible implementation of the project’s cancer
          control program
              o Coordination with local health centers for cancer registry data,
                  patient referrals and cancer prevention & diagnostic programs are




                                   12
             realistic. According to World Bank data, the average distance to a
             basic health facility for a rural population is 7.5 kilometers.
   A cancer ―needs assessment‖ and other such related research essential to
    obtaining funding would also be practicable in a smaller country such as
    Gambia.
   There is a medical learning institution in the country which was
    established in the capital, Banjul, more than a decade ago as part of the
    University of The Gambia. Medical students complete clinical rotations
    at the biggest tertiary hospital Royal Victoria Teaching Hospital (RVTH)
    as well as the major health centers throughout the country. This may be
    crucial in easing the shortage of medical professionals in the region and
    in the long term goal of the project to become a venue for education and
    training in basic & advanced cancer care especially for local health care
    professionals.




                              13
IV.     REGIONAL OVERVIEW

  4.1     General Area Description

          Officially known as the Republic of The Gambia, The Gambia is a country in
          Western Africa. Commonly known as Gambia, it is the smallest country in
          the continent.

             It is almost an enclave of Senegal, with all of the 740 km border zones in
              the north, east and south touching Senegal. It has an 80 km coastline on
              the Atlantic Ocean in the West.
             Its borders roughly mirror the path of the Gambia River, the nation's
              namesake, which flows through the country's center and empties into the
              Atlantic Ocean.
             On 18 February 1965, Gambia was granted independence from the
              United Kingdom and joined The Commonwealth.
             The country is less than 48 km wide at its widest point and has a total
              area of 11,300 km² with approximately 1,300 km² of that covered by
              water. The total area of the Gambia is slightly less than twice the size of
              the American state of Delaware.
             The nation’s population was estimated at 1.7 million (July 2008) with a
              current growth rate of 2.72%
             Gambia is a presidential republic, The President of The Gambia,
              currently President Yahya A.J. Jammeh, is both head of state and head of
              government, and of a multi-party system. Executive power is exercised
              by the government. Legislative power is vested in both the government
              and parliament.


 4.2      Regional Socio-Economic Overview

          Gambia aims to be a dynamic middle-income country by 2020 as mapped
          out in its ambitious socio-economic strategy called Vision 2020.

          The Republic at present has a number of challenges which ought to be
          addressed in order to achieve the national development objectives. At the
          same time, the country has inherent strength and potential which need to be
          properly harnessed for national socio-economic advancement.

                 Gambia is among the poorest countries of the world, ranking 155th
                  out of 177 countries in the 2007/2008 United Nation’s Development
                  Programme Human Development Index rankings (HDI).




                                        14
            Economic development is very reliant on continued multilateral and
             bilateral aid and on prudent economic management by the
             government as espoused by the International Monetary Fund's fiscal
             help and advice.
            Its liberal, market-based economy is characterized by traditional
             subsistence agriculture, a historic reliance on groundnuts (peanuts)
             for export earnings, a re-export trade built up around its ocean port,
             low import duties, minimal administrative procedures, a fluctuating
             exchange rate with no exchange controls, and a significant tourism
             industry (The Gambia's natural beauty and proximity to Europe has
             made it one of the larger markets for tourism in West Africa.)
            The manufacturing sector is undeveloped even by West African
             standards, providing only 5 percent of GDP and displaying little
             dynamism.
            Apart from having a narrow industrial base, it is also a low food-
             producing nation. Thus, it imports most products for consumption
             including rice, sugar, flour and milk
            Unemployment and underemployment rates remain extremely high
             although exact figures are not available
            GDP per capita is $1,200 (2008 est.)
            GDP – real growth rate is 4.5% (2008 est.)


4.3   Healthcare & Hospital Industry Sector

      The healthcare system in Gambia is built around 3 levels which are Primary,
      Secondary and Tertiary. There are to date:
       3 referral hospitals which are operated by the government
       8 main health centers
       16 smaller centers
       200 plus mobile clinic unit teams
       A Medical Research Council funded by the UK Government
       A number of privately run clinics
       A few health focused NGOs




                                   15
Primary Health Care            Secondary Health Care            Tertiary Health Care

      Focused on villages            Provided by the large           3rd level health
       with a population of            and small health                 services are delivered
       over 400                        centers                          by 3 main referral
      Village Health                 There are around 7               hospitals, the Medical
       Worker and                      main government-                 Research Council
       Traditional Midwife             run/private health               (MRC)
       are initially trained           centers, 12 smaller             Several private clinics
       then deliver primary            centers and 19                   and NGO operated
       health care to their            pharmacies                       clinics.
       assigned village               Responsibilities                The main referral
      Responsibilities                include in-patient               hospital is at the
       include out-patient             treatment, out-                  Royal Victoria
       care, community                 patient treatment and            Teaching Hospital in
       health education,               referrals to hospital            the capital on
       ensuring medication             for at risk patients             Independence Drive.
       stock, home visits             Each center has its             The other 3 are
      Provide referrals to            resident nurses,                 located at Bansang,
       local health center             doctors and ancillary            Farafenni and Bwiam
       for at risk patients            staff



          According to a World Bank report titled ―Health and Poverty in Gambia‖ the
          lack of health manpower is a major challenge for the country:

             With one physician per 5,000 people and one nurse per 1,300 people,
              Gambia fares less well than countries in other regions of the world with
              comparable income (one physician per 2,000 people).

             Its situation is nonetheless enviable compared to sub-Saharan Africa with an
              average of one physician per 10,000 people.

             With no training facilities within the Gambia until recently, 91 percent of all
              the physicians working in the Gambia are expatriates supported by donors
              and the government. The sustainability of the approach is a concern.

             The recent development of a Gambian medical college is likely to increase
              the number of qualified Gambian physicians. Yet time will be needed to get a



                                             16
      steady flow of physicians trained, and the government will have to rely on
      transient solutions in the short term.

     The training of medical staff is only a first step. As foreign-trained Gambian
      medical doctors often do not return to work in the Gambia, the success of
      the program is likely to be jeopardized if the working and earning
      environment is not attractive enough to retain native doc
								
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