this general template and guide will enable you to look at any prospective new health care business and assess it for the purpose of trying to formulate a presentation that can be used to obtain funding via backers, loans, contributions, and grants. This template has been given to assist you in essentially placing your information in the place of the info that is currently on the document. a good resource to assist in the development.
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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