As of 2012, cancer became responsible for 72,000 deaths in Nigeria with an estimated 102,000 new cases occurring yearly [1]. The mortality-to-incidence ratio of cancer in Nigeria is high compared to other nations, and cancer in Africa is “characterized by late presentation, low access to treatment, and poor treatment outcomes” [1]. Particularly concerning are reports that as more people begin to survive the burden of infectious diseases, chronic non-infectious diseases, such as cancer, are becoming more prevalent [2]. The dramatic shift in cancer incidence rate is likely due to several factors, but overall it is in line with the new reality of a population that is living longer [3].

For policymakers, challenges exist in financing improvements to the health sector to meet the challenges of this population. The National Health Act, passed in 2014, was intended to provide 1% of the consolidated revenue fund, the funding arm of the federal government, towards revamping the health sector—a possible 60.6 billion Naira ($147 million) per year, but as of 2018 it is yet to have been implemented [4, 5]. The implication of this unrealized revenue is that as resources fall short of expectations, scarcity will dictate that certain goals become neglected [4].

 Financial barriers to access care and poor health literacy contribute to poor health outcomes in cancer care [2]. Therefore, it can be challenging to engage the public in meaningful discourse about how to implement behavioral approaches to improving health [8]. Such engagement is essentially useful as interventions directed at modifying behaviors and perceptions related to cancer could offer a substantialtool to improve outcomes [9]. Population-level public health strategies can often translate to an effect on individual and organizational behavior, and may be effective in targeting behavior to prevent and control cancer [9]. Although the aim is coordinated at a population level, it is important to appreciate the individual response to population-level strategies [9].

The Federal Ministry of Health in Nigeria has published several national plans to address cancer care, most outlining goals for 2018 to 2022 [1]. With an increased interest in directing national efforts to reduce cancer mortality and prevalence, it would be beneficial to explore how stakeholders could implement policy to reduce cancer burden. Some considerations to improve approaches based on the goals of the national plan follow:

• "Coordinating effective cancer awareness and advocate for cancer amongst the populace.”

According to the national plan, there are existing structures that mainly address HIV prevention that arepropelled by non-governmental organizations and international funding [1]. Similar structures can be craftedor existing ones utilized and expanded for cancer prevention. A national cancer initiative beyond the scope of the current National Cancer Control Programme would be well suited to guide such measures and would ensure that funds for research and programs are not weighted against competing for health interest such as is possible under the current architecture [2]. A distinct and useful benefit could be seen with the development of specific teams under the cancer initiative that solely serve the interest of reducing cancer morbidity and mortality through integrative efforts at the population level. These teams could address the needs of decision-makers and scientists alike, and examples include such projects as tobacco policy study groups initiated by the Canadian Cancer Society's Centre for Behavioural Research and Program Evaluation (CBRPE) [10].

• “To conduct and support integrated programs that provide high-quality cancer data for dissemination, research, and planning.”

Efforts to increase coordination of data collection and use in registries and promotion of organizations and teams involved with collecting data would assist all stakeholders in curtailing the burden of cancer. The cancer registries of Nigeria all have CanReg5 software developed by the International Agency for Research on Cancer for data management, but some parties report that they are still not comfortable using the software [1]. This software is particularly set up to collect registry data but may lack standardization of downstream data sources for related study work such as those in behavioral sciences. The CBRPE offers some examples of how Canada standardized their indicators and data systems to generate practice-based evidence [10]. These standards were originally for tobacco prevention; however, their utility could be expanded to Nigeria’s specific needs.

• “To ensure effective coordination and adequate resources for cancer control and care.”
  

The national plan suggests that the current structure of the National Cancer Control Programme is impaired in achieving the overall goal of improving cancer care through inadequate coordination, funding, poor capacity, and competing priorities [1]. Assessing the examples of some other countries that have already developed and successfully implemented such programs may assist in guiding what aims should strive for. The Precision Medicine Initiative of the Cures Act offers one such example, particularly, the million-plus participant cohort study “All of Us.” The Cures Act enables continued funding of this initiative over a decade. The initiative promotes the convergence of genomic and electronic health record data and a range of social and behavioral data obtained from surveys, home and wearable sensor technologies to form a comprehensive resource for research. The application of behavioral and social research findings is promoted alongside their collection in order to foster the sustained engagement of participants as research partners [11].

These examples provide some rationale for the promotion of an organized approach to improving cancer health outcomes in Nigeria. Overall, the recommendations are aimed at creating an environment that effectively captures and guides the national efforts to reduce cancer burden. Many of the stated goals invoke a sense of need for previously employed strategies from countries that have had their share of successes and failures alike. These lessons offer invaluable opportunity for stakeholders to apply their resources in a guided manner. One important caveat to improving health by behavioral approaches is that successful implementation depends on an engaged population. As such, health literacy is a critical component in such an envisioned, well-informed society and should not be forgotten when considering how to help Nigerians in all health-relatedissues. 

REFERENCES

[1] Nigeria Cancer Control Plan 2018-2022, in: F.M.o. Health (Ed.) Abuja, 2018.

[2] K. Eguzo, B. Camazine, Beyond limitations: practical strategies for improving cancer care in Nigeria, Asian Pacific journal of cancer prevention : APJCP 14(5) (2013) 3363-8.

[3] E. Jedy-Agba, M.P. Curado, O. Ogunbiyi, E. Oga, T. Fabowale, F. Igbinoba, G. Osubor, T. Otu, H. Kumai, A. Koechlin, P. Osinubi, P. Dakum, W. Blattner, C.A. Adebamowo, Cancer incidence in Nigeria: a report from population-based cancer registries, Cancer epidemiology 36(5) (2012) e271-e278.

[4] O. Onigbinde, Nigeria: Health Budget Analysis - Policy Brief First Quarter 2018, 2018. http://yourbudgit.com/wp-content/uploads/2018/04/Nigeria-Health-Budget-Analysis.pdf. (Accessed 01/16/2019 2019).

[5] O. Enabulele, J.E. Enabulele, Nigeria's National Health Act: An assessment of health professionals' knowledge and perception, Nigerian medical journal : journal of the Nigeria Medical Association 57(5) (2016) 260-265.

[6] The World Poverty Clock. https://worldpoverty.io/. (Accessed 02/04/2019 2019).

[7] O. Lawal, F.J. Murphy, P. Hogg, N. Irurhe, J. Nightingale, Mammography screening in Nigeria-A critical comparison to other countries, Radiography 21(4) (2015) 348-351.

[8] O.E. Nwafor-Orizu, Health Literacy for Rapid Development in Nigeria. https://www.academia.edu/16645776/Health_Literacy_for_Rapid_Development_in_Nigeria. (Accessed 02/05/2019 2019).

[9] W.M.P. Klein, M. Bloch, B.W. Hesse, P.G. McDonald, L. Nebeling, M.E. O’Connell, W.T. Riley, S.H. Taplin, G. Tesauro, Behavioral Research in Cancer Prevention and Control: A Look to the Future, American Journal of Preventive Medicine 46(3) (2014) 303-311.

[10] R. Cameron, B.L. Riley, H.S. Campbell, S. Manske, K. Lamers-Bellio, The Imperative of Strategic Alignment Across Organizations: The Experience of the Canadian Cancer Society's Centre for Behavioural Research and Program Evaluation, Canadian Journal of Public Health 100(1) (2009) I27-I30.

[11] W.T. Riley, K.D. Blizinsky, Implications of the 21st Century Cures Act for the Behavioral and Social Sciences at the National Institutes of Health, 44(3) (2017) 356-359.

Motolani Ogunsanya, DPh, PhD, is an Assistant Professor in Clinical and Administrative Sciences in the Department of Pharmacy at the University of Oklahoma Health Sciences Center. She joined the department after receiving doctoral training in Pharmaceutical Sciences (with a focus on Health Economics and Outcomes Research) at The University of Texas in Austin.) Dr. Ogunsanya’s research focuses on health economics and outcomes research using mixed methodologies. Her research interests primarily involve understanding health behaviors among underserved, minority groups and the use of patient-reported outcomes to capture disease burden in patients with rare diseases, cancer, and other disease conditions. Additional research interests include psychometrics (instrument development and validation) and examining quality of life through theoretical frameworks and large-scale retrospective database analyses. Her current research is focused on developing a mHealth platform for Black prostate cancer survivors.