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Radiotherapy services in countries in transition: gross national income per capita as a significant factor
Radiotherapy and Oncology 63 (2002) 147–150 www.elsevier.com/locate/radonline
Radiotherapy services in countries in transition: gross national income per capita as a significant factor Victor Levin*, Hideo Tatsuzaki Section of Applied Radiation Biology and Radiotherapy, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency (IAEA), Wagramer Strasse 5, P.O. Box 200, A-1400 Vienna, Austria Received 7 September 2001; accepted 18 January 2002
Abstract Background and purpose: The acquisition of radiotherapy by countries in transition (CITs) is an evolutionary process from having no resources whatsoever, to meeting the standards adopted by well-developed countries. The influence of the economic ability of a country to acquire and sustain this technology has intuitively been accepted as a major factor but has not before been subjected to analysis for a large group of countries. This information has been analysed to provide guidance to countries commencing and expanding radiotherapy services. Material and methods: The number of linear accelerators and 60Co megavoltage teletherapy machines in 72 CITs, those with gross national income per capita (GNI/cap) , $12 000 per annum (pa) and a sample of 12 countries with GNI/cap . $12 000 pa were expressed as machines per million population (MEV/mil) and used as an index of the ability of the country to provide a service. This figure was related to GNI/cap. The average populations of 24 further countries without radiotherapy were compared with 21 countries with radiotherapy facilities having the same range of GNI/cap. Results: The relationship log10 MEV=mil ¼ 22:90 1 0.85 log10 GNI/cap was identified between the machines and income. Also verified was that small low income countries were less likely to have the technology than those with large populations. Conclusions: The increase in the number of teletherapy machines is closely linked to the GNI/cap of a country. Our sample of well developed countries failed to demonstrate a levelling off of equipment acquisition with income. In the lower income group, smaller countries were less likely to have radiotherapy services than those with large populations. q 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Radiotherapy; National health planning; Equipment/supplies; Health care facilities; Economics
1. Introduction Teletherapy machines are an essential component of any radiotherapy service which in turn is a significant modality for proper cancer management on a national level. In welldeveloped countries, standards for teletherapy machines such as those of the Inter-Society Council for Radiation Oncology of the USA [3] may be applied which recommend the number of patients treated on a single megavoltage teletherapy machine per year. Underlying these figures are norms accepted for working days per year, work hours, staff allocated to each machine, a ratio of radical to palliative treatment courses administered, etc. To relate these numbers of patients to populations, three significant national figures need to be applied: the percentage of cancer patients referred for radiotherapy, ranging from 15% in Japan to 49% in the United States [2] and unknown in most developing countries; the population age pyramid; and the
national age-specific incidence rate of cancer. Irrespective of the factors which need to be applied, the number of teletherapy machines per million population is an essential marker for the ability to deliver a service. The influence of the economic ability of a country to acquire and sustain this technology has intuitively been accepted as a major factor but not before been subjected to analysis for a large group of countries. This information has been analysed to provide guidance to countries commencing and expanding radiotherapy services. Countries which have no radiation oncology services are thought to be characterized by low levels of technology and widespread poverty. However, there were no reports documenting this over a broad range of countries nor identifying factors which underlie this deficiency. Countries in transition (CITs) for the purposes of this study include countries with radiation therapy and an arbitrary upper level of income.
* Corresponding author. 0167-8140/02/$ - see front matter q 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0167-814 0(02)00010-5
148
V. Levin, H. Tatsuzaki / Radiotherapy and Oncology 63 (2002) 147–150
2. Materials and methods
3. Results
The International Atomic Energy Agency (IAEA) is an autonomous intergovernmental organization within the United Nations system and conducts activities in the area of human health, focusing on the common concerns of member states that can be most effectively addressed by nuclear technology. Programs of the IAEA support radiation therapy by means of publications, meetings and technical co-operation projects. The IAEA has, over the past 5 years, run more than 140 national or regional technical co-operation projects in the field of radiation oncology over the developing world, providing the authors with a rich source of data through these projects. The data of the number of megavoltage teletherapy machines in each country were gathered through these activities and were also derived from the Directory of Radiotherapy Centres (DIRAC), the IAEA-WHO database. These are the best available data as of the time of writing. The population data for 1999 were taken from the United Nations (UN) statistics [5] and the gross national income per capita (GNI/cap) for 1999 was taken from the World Bank record [6]. Twenty-four countries without teletherapy machines and populations greater than 1 million were identified. The populations of these were compared with 21 countries with teletherapy machines in similar range of GNI/cap. Student’s t-test was used for comparison. The countries referred to in this paper predominantly include member states of the IAEA where the data on radiotherapy facilities are known with confidence at the time of writing. Eighty-four countries with teletherapy machines were divided into five groups according to economic status and the geographical locations. Those countries with GNI/cap more than US$12 000 were considered as high-income countries independent from the geographical regions. The 12 high-income countries selected to represent countries with well-developed radiotherapy facilities included Australia, Austria, Canada, Denmark, France, Italy, Japan, New Zealand, Norway, Singapore, Sweden and the United States. Countries in transition include countries with radiation therapy and with an arbitrary upper level of GNI/cap of US$12 000 per annum.. The number of CITs in each geographical region used for the analysis was Africa 21, Asia 12, Latin America 21 and East Europe 18. The 18 Eastern European countries included the Commonwealth of Independent States (CIS) and middle-eastern European and former Yugoslavian countries. Russia was not included. These data were examined to determine if a relationship between GNI/cap and the number of megavoltage machines per million population (MEV/mil) was present. Multivariate analysis of variance (ANOVA) was used for statistical comparisons of the geographical regions in countries with radiotherapy.
3.1. Countries with no radiotherapy The absence of a functional radiotherapy unit is difficult to confirm. Some countries are included in Table 1, which after diligent enquiry, failed to yield any information on viable radiotherapy facilities. Some of the more developed countries found to be without radiotherapy services such as Andorra, the Holy See, Liechtenstein and Seychelles have extremely small populations. The 24 countries identified without radiation therapy and with greater than 1 million population are predominantly in Africa. The maximum GNI/cap identified was US$670 (Cote d’Ivoire). These countries had an average GNI/cap and population weighted GNI/cap of US$298 and US$302, respectively, and an average population of 7.63 million inhabitants. It was noted that 21 of our 84 countries with radiotherapy had a GNI/cap under this figure of US$670. These 21 countries have an average GNI/cap and population weighted GNI/cap of US$383 and US$424, respectively. Their mean population of 91.07 million inhabitants per country is statistically significantly higher than in the 24 countries without therapy by Student’s t-test (P , 0:01). The relationship between economy and population both for countries with and without teletherapy machines is shown in Fig. 1. 3.2. Countries with radiotherapy The GNI/cap and the number of MEV/mil was plotted on a log–log scale (Fig. 2). This revealed a statistically significant linear relationship (P , 0:01) between the log10 GNI/ cap and log10 MEV/mil. The relationship was determined as log10MEV=mil ¼ 22:90 1 0:85 log10 GNI=cap
ð1Þ
The correlation coefficient was 0.87. There was evidence in the Africa region of a difference in MEV/mil versus GNI/cap from the composite of the other groups. Africa demonstrated a lower MEV/mil analysed by multifactor ANOVA with GNI/cap as a covariate (P , 0:05). Eastern Europe, in contrast, demonstrated a higher MEV/mil analysed by multifactor ANOVA with GNI/cap as a covariate (P , 0:01). No difference was found between the composite and Latin America, Central America and South-East Asia. The group of 12 high-income countries representing welldeveloped facilities did not demonstrate any significant difference (P ¼ 0:39) from the overall trend. 4. Discussion It is intuitively accepted that health services as measured by various indices, would improve with increased prosperity as measured by GNI/cap. Radiotherapy, even with a century of practice, is still considered in developing countries to be
V. Levin, H. Tatsuzaki / Radiotherapy and Oncology 63 (2002) 147–150
149
Table 1 Availability of radiotherapy facilities Countries without radiotherapy
Countries with radiotherapy in similar range of GNI/cap
Country
Population (million)
GNI/cap (US$)
Country
Population (million)
GNI/cap (US$)
Burundi Sierra Leone Guinea Bissau Malawi Niger Eritrea Chad Mozambique Burkina Faso Mali Rwanda Cambodia Angola Central Africa Rep. Lao PDR Togo Gambia Zambia Benin Mauritania Haiti Guinea Lesotho Cote d’Ivoire
6.48 4.72 1.19 10.64 10.4 3.72 7.46 17.3 11.62 10.96 7.24 11.94 12.48 3.55 5.3 4.51 1.27 10.41 6.19 2.6 7.8 7.36 2.11 14.53
120 130 160 180 190 200 210 220 240 240 250 260 270 290 290 310 330 330 380 390 460 490 550 670
Ethiopia Madagascar Nigeria Tanzania Uganda Sudan Kenya Bangladesh Vietnam Mongolia Ghana Moldova Nicaragua India Pakistan Armenia Senegal Zimbabwe Indonesia Cameroon Georgia
61.67 15.5 108.95 32.79 21.62 28.88 29.55 126.95 78.71 2.62 19.68 4.38 4.94 986.61 134.51 3.8 9.28 13.08 209.26 14.69 5.01
100 197 260 260 320 330 360 370 370 390 400 410 410 440 470 490 500 530 600 600 620
high technology medicine. Because of the high technology and high capital costs, it is predominantly practised in tertiary hospitals under governmental budgetary constraints or in the private sector. The number of patients treated per machine can exceed a few hundred, accepting that the capacity of a single teletherapy machine if used predominantly for palliative treatment is about 800 per annum. Thus, a number of smaller wealthy countries find it economically
Fig. 1. Population vs. gross national income per capita (GNI/cap) in log– linear scale. Closed squares represent countries with no radiotherapy equipment. Open circles represent countries with radiotherapy and GNI/cap less than US$670.
advantageous to obtain services in adjoining countries. For the same reasons of high technology and high capital costs (both of acquiring the equipment and the technology), a significant number of countries with low GNI/cap, mostly under 500 dollars, have yet to acquire radiotherapy. Equation (1) indicates the average number of teletherapy
Fig. 2. Gross national income per capita vs. megavoltage machines per million population on a log–log scale. The countries are divided initially by incomes over US$12 000 (High income), then by geographical regions: Africa, Latin America (LA), Eastern Europe (EEurope), and Asia. Solid line is a linear regression line and broken lines show 80% prediction limits. Vertical dotted line indicates the criteria of high-income countries, GNI/cap of US$12 000.
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V. Levin, H. Tatsuzaki / Radiotherapy and Oncology 63 (2002) 147–150
machines per million population in a country with given GNI/cap. This number of teletherapy machines does not mean the acceptable level nor the target level; this is rather a reasonably achievable level considering the economic circumstances. Poor health status is considered to be one dimension of ‘poverty’ [7]. This study clearly confirms the correlation between economic status and the acquisition of radiation therapy facilities. The results showed some regional differences from the composite results. The high MEV/mil for GNI/cap in Eastern European countries may be attributable to disparate factors: their higher public expenditure on health than other regions [8]; their population pyramid which has a lower birth rate than the other developing regions with a higher percentage of the population at risk of cancer and the declining GNI/cap with the existing teletherapy machines remaining in operation. In Africa, the number of MEV/mil appeared to be lower than the level sustainable by the economy according to our composite model. Factors such as other priorities than health, other diseases than cancer or recent introduction of radiotherapy may play a part. The results did not show a flattening of MeV/mil value for high income countries as may be expected when the equipment reaches a level when all demands for services can be met. Some high-income countries have more machines than the standard recommended by professional societies. This suggests that incentives exist to purchase machines even though the machines would not be used to capacity. Alternatively, the usage of some advanced treatment techniques (e.g. total body irradiation or stereotactic radiotherapy) requires more machine time per patient treated. The quality of machines and their condition are important factors. However, the condition of any unit is dynamic and data difficult to obtain. The type of teletherapy machines may have some effect on the treatment capacity. Simplistic systems exist for accounting for the type of a megavoltage unit; for example a 60Co unit may be equated to 0.5 of a linear accelerator [1]. This system was rejected for this
group of countries as no evidence exists of enhanced utility of linear accelerators over 60Co units in the context of the treatments routinely administered in CITs. A sufficient number of well-qualified personnel is also essential for full utilization of radiation therapy equipment. This may well be a more limiting factor in patient treatment than machine availability in some regions [4]. Staffing, however, is beyond the scope of this article. 5. Conclusions The increase in number of teletherapy machines is closely linked to the GNI/cap of a country. The equipment in Africa is below the levels expected by linear regression while in Eastern Europe the levels are exceeded. Our sample of well-developed countries failed to demonstrate a flattening of the acquisition of equipment with income. In the lower income group, smaller countries were less likely to have radiotherapy services than those with large populations. References [1] Department of Health (of United Kingdom). A survey radiotherapy services in England, 1999. Available at http://www.doh.gov.uk/ cancer/pdfs/radiotherapy.pdf [2] Huh SJ. J Jpn Soc Ther Radiol Oncol 1998;10:151–152. [3] Inter-Society Council for Radiation Oncology. Radiation oncology in integrated cancer management, report of Inter-Society Council for Radiation Oncology. Merrifield, VA: ACR Publications, 1991. [4] Tatsuzaki H, Levin V. Quantitative status of resources for radiation therapy in Asia and Pacific region. Radiother Oncol 2001;60:81–89. [5] United Nations. UN Monthly Bull Statist 2001;55:1–6. [6] World Bank. Size of the economy. World development indicators, Washington, DC: World Bank, 2001. pp. 12–15. [7] World Bank. The nature and evolution of poverty. World development report, 2000/2001: attacking poverty, New York: Oxford University Press, 2001. pp. 15–30. [8] World Bank. Selected world development indicators. World development report, 2000/2001: attacking poverty, New York: Oxford University Press, 2001. pp. 286–287.
Radiotherapy services in countries in transition: gross national income per capita as a significant factor Victor Levin*, Hideo Tatsuzaki Section of Applied Radiation Biology and Radiotherapy, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency (IAEA), Wagramer Strasse 5, P.O. Box 200, A-1400 Vienna, Austria Received 7 September 2001; accepted 18 January 2002
Abstract Background and purpose: The acquisition of radiotherapy by countries in transition (CITs) is an evolutionary process from having no resources whatsoever, to meeting the standards adopted by well-developed countries. The influence of the economic ability of a country to acquire and sustain this technology has intuitively been accepted as a major factor but has not before been subjected to analysis for a large group of countries. This information has been analysed to provide guidance to countries commencing and expanding radiotherapy services. Material and methods: The number of linear accelerators and 60Co megavoltage teletherapy machines in 72 CITs, those with gross national income per capita (GNI/cap) , $12 000 per annum (pa) and a sample of 12 countries with GNI/cap . $12 000 pa were expressed as machines per million population (MEV/mil) and used as an index of the ability of the country to provide a service. This figure was related to GNI/cap. The average populations of 24 further countries without radiotherapy were compared with 21 countries with radiotherapy facilities having the same range of GNI/cap. Results: The relationship log10 MEV=mil ¼ 22:90 1 0.85 log10 GNI/cap was identified between the machines and income. Also verified was that small low income countries were less likely to have the technology than those with large populations. Conclusions: The increase in the number of teletherapy machines is closely linked to the GNI/cap of a country. Our sample of well developed countries failed to demonstrate a levelling off of equipment acquisition with income. In the lower income group, smaller countries were less likely to have radiotherapy services than those with large populations. q 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Radiotherapy; National health planning; Equipment/supplies; Health care facilities; Economics
1. Introduction Teletherapy machines are an essential component of any radiotherapy service which in turn is a significant modality for proper cancer management on a national level. In welldeveloped countries, standards for teletherapy machines such as those of the Inter-Society Council for Radiation Oncology of the USA [3] may be applied which recommend the number of patients treated on a single megavoltage teletherapy machine per year. Underlying these figures are norms accepted for working days per year, work hours, staff allocated to each machine, a ratio of radical to palliative treatment courses administered, etc. To relate these numbers of patients to populations, three significant national figures need to be applied: the percentage of cancer patients referred for radiotherapy, ranging from 15% in Japan to 49% in the United States [2] and unknown in most developing countries; the population age pyramid; and the
national age-specific incidence rate of cancer. Irrespective of the factors which need to be applied, the number of teletherapy machines per million population is an essential marker for the ability to deliver a service. The influence of the economic ability of a country to acquire and sustain this technology has intuitively been accepted as a major factor but not before been subjected to analysis for a large group of countries. This information has been analysed to provide guidance to countries commencing and expanding radiotherapy services. Countries which have no radiation oncology services are thought to be characterized by low levels of technology and widespread poverty. However, there were no reports documenting this over a broad range of countries nor identifying factors which underlie this deficiency. Countries in transition (CITs) for the purposes of this study include countries with radiation therapy and an arbitrary upper level of income.
* Corresponding author. 0167-8140/02/$ - see front matter q 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0167-814 0(02)00010-5
148
V. Levin, H. Tatsuzaki / Radiotherapy and Oncology 63 (2002) 147–150
2. Materials and methods
3. Results
The International Atomic Energy Agency (IAEA) is an autonomous intergovernmental organization within the United Nations system and conducts activities in the area of human health, focusing on the common concerns of member states that can be most effectively addressed by nuclear technology. Programs of the IAEA support radiation therapy by means of publications, meetings and technical co-operation projects. The IAEA has, over the past 5 years, run more than 140 national or regional technical co-operation projects in the field of radiation oncology over the developing world, providing the authors with a rich source of data through these projects. The data of the number of megavoltage teletherapy machines in each country were gathered through these activities and were also derived from the Directory of Radiotherapy Centres (DIRAC), the IAEA-WHO database. These are the best available data as of the time of writing. The population data for 1999 were taken from the United Nations (UN) statistics [5] and the gross national income per capita (GNI/cap) for 1999 was taken from the World Bank record [6]. Twenty-four countries without teletherapy machines and populations greater than 1 million were identified. The populations of these were compared with 21 countries with teletherapy machines in similar range of GNI/cap. Student’s t-test was used for comparison. The countries referred to in this paper predominantly include member states of the IAEA where the data on radiotherapy facilities are known with confidence at the time of writing. Eighty-four countries with teletherapy machines were divided into five groups according to economic status and the geographical locations. Those countries with GNI/cap more than US$12 000 were considered as high-income countries independent from the geographical regions. The 12 high-income countries selected to represent countries with well-developed radiotherapy facilities included Australia, Austria, Canada, Denmark, France, Italy, Japan, New Zealand, Norway, Singapore, Sweden and the United States. Countries in transition include countries with radiation therapy and with an arbitrary upper level of GNI/cap of US$12 000 per annum.. The number of CITs in each geographical region used for the analysis was Africa 21, Asia 12, Latin America 21 and East Europe 18. The 18 Eastern European countries included the Commonwealth of Independent States (CIS) and middle-eastern European and former Yugoslavian countries. Russia was not included. These data were examined to determine if a relationship between GNI/cap and the number of megavoltage machines per million population (MEV/mil) was present. Multivariate analysis of variance (ANOVA) was used for statistical comparisons of the geographical regions in countries with radiotherapy.
3.1. Countries with no radiotherapy The absence of a functional radiotherapy unit is difficult to confirm. Some countries are included in Table 1, which after diligent enquiry, failed to yield any information on viable radiotherapy facilities. Some of the more developed countries found to be without radiotherapy services such as Andorra, the Holy See, Liechtenstein and Seychelles have extremely small populations. The 24 countries identified without radiation therapy and with greater than 1 million population are predominantly in Africa. The maximum GNI/cap identified was US$670 (Cote d’Ivoire). These countries had an average GNI/cap and population weighted GNI/cap of US$298 and US$302, respectively, and an average population of 7.63 million inhabitants. It was noted that 21 of our 84 countries with radiotherapy had a GNI/cap under this figure of US$670. These 21 countries have an average GNI/cap and population weighted GNI/cap of US$383 and US$424, respectively. Their mean population of 91.07 million inhabitants per country is statistically significantly higher than in the 24 countries without therapy by Student’s t-test (P , 0:01). The relationship between economy and population both for countries with and without teletherapy machines is shown in Fig. 1. 3.2. Countries with radiotherapy The GNI/cap and the number of MEV/mil was plotted on a log–log scale (Fig. 2). This revealed a statistically significant linear relationship (P , 0:01) between the log10 GNI/ cap and log10 MEV/mil. The relationship was determined as log10MEV=mil ¼ 22:90 1 0:85 log10 GNI=cap
ð1Þ
The correlation coefficient was 0.87. There was evidence in the Africa region of a difference in MEV/mil versus GNI/cap from the composite of the other groups. Africa demonstrated a lower MEV/mil analysed by multifactor ANOVA with GNI/cap as a covariate (P , 0:05). Eastern Europe, in contrast, demonstrated a higher MEV/mil analysed by multifactor ANOVA with GNI/cap as a covariate (P , 0:01). No difference was found between the composite and Latin America, Central America and South-East Asia. The group of 12 high-income countries representing welldeveloped facilities did not demonstrate any significant difference (P ¼ 0:39) from the overall trend. 4. Discussion It is intuitively accepted that health services as measured by various indices, would improve with increased prosperity as measured by GNI/cap. Radiotherapy, even with a century of practice, is still considered in developing countries to be
V. Levin, H. Tatsuzaki / Radiotherapy and Oncology 63 (2002) 147–150
149
Table 1 Availability of radiotherapy facilities Countries without radiotherapy
Countries with radiotherapy in similar range of GNI/cap
Country
Population (million)
GNI/cap (US$)
Country
Population (million)
GNI/cap (US$)
Burundi Sierra Leone Guinea Bissau Malawi Niger Eritrea Chad Mozambique Burkina Faso Mali Rwanda Cambodia Angola Central Africa Rep. Lao PDR Togo Gambia Zambia Benin Mauritania Haiti Guinea Lesotho Cote d’Ivoire
6.48 4.72 1.19 10.64 10.4 3.72 7.46 17.3 11.62 10.96 7.24 11.94 12.48 3.55 5.3 4.51 1.27 10.41 6.19 2.6 7.8 7.36 2.11 14.53
120 130 160 180 190 200 210 220 240 240 250 260 270 290 290 310 330 330 380 390 460 490 550 670
Ethiopia Madagascar Nigeria Tanzania Uganda Sudan Kenya Bangladesh Vietnam Mongolia Ghana Moldova Nicaragua India Pakistan Armenia Senegal Zimbabwe Indonesia Cameroon Georgia
61.67 15.5 108.95 32.79 21.62 28.88 29.55 126.95 78.71 2.62 19.68 4.38 4.94 986.61 134.51 3.8 9.28 13.08 209.26 14.69 5.01
100 197 260 260 320 330 360 370 370 390 400 410 410 440 470 490 500 530 600 600 620
high technology medicine. Because of the high technology and high capital costs, it is predominantly practised in tertiary hospitals under governmental budgetary constraints or in the private sector. The number of patients treated per machine can exceed a few hundred, accepting that the capacity of a single teletherapy machine if used predominantly for palliative treatment is about 800 per annum. Thus, a number of smaller wealthy countries find it economically
Fig. 1. Population vs. gross national income per capita (GNI/cap) in log– linear scale. Closed squares represent countries with no radiotherapy equipment. Open circles represent countries with radiotherapy and GNI/cap less than US$670.
advantageous to obtain services in adjoining countries. For the same reasons of high technology and high capital costs (both of acquiring the equipment and the technology), a significant number of countries with low GNI/cap, mostly under 500 dollars, have yet to acquire radiotherapy. Equation (1) indicates the average number of teletherapy
Fig. 2. Gross national income per capita vs. megavoltage machines per million population on a log–log scale. The countries are divided initially by incomes over US$12 000 (High income), then by geographical regions: Africa, Latin America (LA), Eastern Europe (EEurope), and Asia. Solid line is a linear regression line and broken lines show 80% prediction limits. Vertical dotted line indicates the criteria of high-income countries, GNI/cap of US$12 000.
150
V. Levin, H. Tatsuzaki / Radiotherapy and Oncology 63 (2002) 147–150
machines per million population in a country with given GNI/cap. This number of teletherapy machines does not mean the acceptable level nor the target level; this is rather a reasonably achievable level considering the economic circumstances. Poor health status is considered to be one dimension of ‘poverty’ [7]. This study clearly confirms the correlation between economic status and the acquisition of radiation therapy facilities. The results showed some regional differences from the composite results. The high MEV/mil for GNI/cap in Eastern European countries may be attributable to disparate factors: their higher public expenditure on health than other regions [8]; their population pyramid which has a lower birth rate than the other developing regions with a higher percentage of the population at risk of cancer and the declining GNI/cap with the existing teletherapy machines remaining in operation. In Africa, the number of MEV/mil appeared to be lower than the level sustainable by the economy according to our composite model. Factors such as other priorities than health, other diseases than cancer or recent introduction of radiotherapy may play a part. The results did not show a flattening of MeV/mil value for high income countries as may be expected when the equipment reaches a level when all demands for services can be met. Some high-income countries have more machines than the standard recommended by professional societies. This suggests that incentives exist to purchase machines even though the machines would not be used to capacity. Alternatively, the usage of some advanced treatment techniques (e.g. total body irradiation or stereotactic radiotherapy) requires more machine time per patient treated. The quality of machines and their condition are important factors. However, the condition of any unit is dynamic and data difficult to obtain. The type of teletherapy machines may have some effect on the treatment capacity. Simplistic systems exist for accounting for the type of a megavoltage unit; for example a 60Co unit may be equated to 0.5 of a linear accelerator [1]. This system was rejected for this
group of countries as no evidence exists of enhanced utility of linear accelerators over 60Co units in the context of the treatments routinely administered in CITs. A sufficient number of well-qualified personnel is also essential for full utilization of radiation therapy equipment. This may well be a more limiting factor in patient treatment than machine availability in some regions [4]. Staffing, however, is beyond the scope of this article. 5. Conclusions The increase in number of teletherapy machines is closely linked to the GNI/cap of a country. The equipment in Africa is below the levels expected by linear regression while in Eastern Europe the levels are exceeded. Our sample of well-developed countries failed to demonstrate a flattening of the acquisition of equipment with income. In the lower income group, smaller countries were less likely to have radiotherapy services than those with large populations. References [1] Department of Health (of United Kingdom). A survey radiotherapy services in England, 1999. Available at http://www.doh.gov.uk/ cancer/pdfs/radiotherapy.pdf [2] Huh SJ. J Jpn Soc Ther Radiol Oncol 1998;10:151–152. [3] Inter-Society Council for Radiation Oncology. Radiation oncology in integrated cancer management, report of Inter-Society Council for Radiation Oncology. Merrifield, VA: ACR Publications, 1991. [4] Tatsuzaki H, Levin V. Quantitative status of resources for radiation therapy in Asia and Pacific region. Radiother Oncol 2001;60:81–89. [5] United Nations. UN Monthly Bull Statist 2001;55:1–6. [6] World Bank. Size of the economy. World development indicators, Washington, DC: World Bank, 2001. pp. 12–15. [7] World Bank. The nature and evolution of poverty. World development report, 2000/2001: attacking poverty, New York: Oxford University Press, 2001. pp. 15–30. [8] World Bank. Selected world development indicators. World development report, 2000/2001: attacking poverty, New York: Oxford University Press, 2001. pp. 286–287.