Examining the scarcity of oncology healthcare providers in cancer management: A case study of the Eastern Cape Province, South Africa

1.1 Scarcity of oncology resources and human capital

The scarcity of oncology specialists poses a critical challenge in addressing the global burden of cancer, disproportionately impacting urban and rural communities across high-income and low-income countries (LICs) [1,2,3]. The distribution of the oncology workforce reveals significant disparities, particularly in the oncologist-to-population ratio across various regions.

A global study indicated that the lower bound for an optimal cancer surgical workforce in lower-middle-income countries, such as the Philippines, should be at least 166,000 professionals [4]. In stark contrast, LICs experience significantly lower ratios, with some regions reporting as few as 1 oncologist per 500,000 to 1 million individuals. This disparity results in acute shortages, particularly in rural areas [5,6]. For example, Zimbabwe has an oncologist-to-population ratio of 1 oncologist per 1.057 million people, while the United States has a ratio of approximately 1 oncologist per 26,418 individuals [7].

The situation is even more alarming in certain African nations, such as South Sudan, Lesotho, Benin, Gambia, and Sierra Leone, which lack trained oncologists altogether [8]. In LICs, the median ratio of clinical oncologists is alarmingly low, with only 0.006 oncologists per 100,000 population and 0.01 oncologists per 100 cancer patients [9]. This severe shortage underscores the urgent need for targeted interventions to strengthen the oncology workforce and improve access to cancer care in under-resourced regions. Furthermore, these disparities are exacerbated by socio-economic challenges, including inadequate healthcare funding, poverty, and a lack of oncology training programmes [10].

The shortage of oncologists has widespread consequences for cancer care, particularly in regions where specialists are sparse. Patients in such areas often experience delays in receiving diagnoses and beginning treatment, which can lead to late-stage cancer diagnoses and significantly poorer outcomes [11]. This situation is worsened by extended appointment waiting times, further prolonging the time between symptom onset and therapeutic intervention [2,5]. Delays in treatment initiation reduce the effectiveness of therapies, negatively impacting patient survival rates [12].

In addition to delayed care, oncology resource scarcity limits patients’ access to comprehensive treatment modalities. Cancer care often requires a multidisciplinary approach involving medical oncologists, radiation oncologists, surgical oncologists, and allied healthcare professionals [10]. However, in areas with insufficient specialists, patients may lack access to critical therapies such as chemotherapy, radiation, and immunotherapy [12]. Consequently, patients often travel significant distances to reach specialised cancer centres, placing financial and logistical burdens on them and their families [11,13].

This scarcity of oncology specialists also contributes to stark disparities in cancer care. Patients in rural and underserved regions face more significant challenges in accessing oncological services due to geographic isolation, inadequate healthcare infrastructure, and financial constraints [14]. Moreover, marginalised communities, often affected by socio-economic disparities such as low income, limited education, and lack of health insurance, experience further obstacles in obtaining timely and appropriate cancer care [2,13]. These inequities perpetuate health disparities and worsen cancer-related outcomes, highlighting the urgent need for equitable distribution of oncology resources and improved access to cancer care services across all populations [2,6].

Overall, the unequal distribution of oncology specialists, particularly in low-income and rural regions, underscores the need for targeted strategies to enhance access to cancer care. By addressing the systemic barriers that limit the availability of oncology services, healthcare systems can work towards mitigating the global burden of cancer and improving patient outcomes [3,15].

1.2 Rationale

The scarcity of oncology specialists is a critical issue that demands attention due to its profound impact on global patient outcomes and healthcare systems.

• Public health impact: Insufficient oncology resources have a direct impact on the quality of patient care, resulting in delayed diagnosis, extended waiting periods for treatment, and restricted availability of specialist therapies [2,5]. This, in turn, contributes to poorer health outcomes and increased mortality rates among cancer patients.

• Socio-economic implications: Regions facing oncology resource scarcity often exhibit socio-economic challenges, such as poverty, unemployment, and limited access to healthcare services [2]. These disparities further exacerbate the effects of oncology resource scarcity, disproportionately affecting underserved populations and marginalised communities [14].

• Healthcare system sustainability: The shortage of oncology specialists’ strains healthcare systems, leading to inefficiencies, increased healthcare costs, and compromised quality of care ([2], Maphumulo and Bhengu [16]).

1.3 Problem statement

The scarcity of oncology specialists presents a pressing challenge in addressing the burden of cancer diseases globally and in local communities, leading to delayed diagnosis, prolonged waiting times for appointments, and limited access to specialised treatments and therapies [17]. The Eastern Cape province of South Africa exhibits a notable dearth of resources, characterised mainly by socio-economic challenges and insufficient healthcare facilities (Morris-Paxton et al. [18,19]). These factors further exacerbate inequalities in cancer treatment and negatively impact patient outcomes. The combination of socio-economic challenges and limited healthcare infrastructure intensifies disparities in cancer care, ultimately hindering the effectiveness of treatment for patients [20].

1.4 Aim

This review study aims to raise awareness of the pressing challenge posed by the scarcity of oncology specialists in addressing the burden of cancer diseases, mainly in the Eastern Cape province of South Africa.

1.5 Research methods

This review employed a concurrent mixed-method research design, combining an empirical literature review with a case study approach (Creswell [21]; Fetters et al. [22]). Yin [23] described case study research as an in-depth investigation of a phenomenon within its real-world context, mainly when the distinction between the phenomenon and its setting is unclear. The case study in this research focused on oncology resource scarcity in the Eastern Cape province of South Africa, using existing data to evaluate its effects on patient care [18,24,25].

The data sources included peer-reviewed literature on oncology resource allocation, cancer-related mortality rates, and national healthcare reports. Cancer incidence and death rates were analysed to identify the challenges associated with timely diagnosis and treatment. The literature review provided a broader analysis of oncology care trends, while the case study examined specific regional dynamics in the Eastern Cape. Qualitative and quantitative data analysis techniques were applied (Creswell, 2009; Fetters et al. 2013). Qualitative thematic analysis uncovered recurring themes, such as barriers to healthcare access, resource limitations, and policy gaps. The quantitative analysis supported the case study findings, mainly cancer incidence and mortality rates. The eligibility criteria for the literature review focused on peer-reviewed studies, government reports, and epidemiological data published between 2000 and 2023 that addressed oncology resource allocation and healthcare access in South Africa.

While the study employed a mixed-method approach, further details on integrating the case study with the broader literature review are required. The Eastern Cape’s selection as the case study site was justified by its high unemployment, widespread poverty, and significant socio-economic challenges, which worsened healthcare access issues. Additionally, the region experienced a substantial shortage of oncology practitioners, making it an important case for investigating the effects of oncology resource scarcity on patient care (Yin, 2018). The study drew from public and private sector reports, including data from Statistics South Africa, the Health District Information System, and the Council for Medical Schemes [26,27,28,29]. Data on oncology service providers were cross-referenced with Medpages and annual statutory returns submitted to the Council for Medical Schemes [30]. This triangulation of diverse data sources provided a comprehensive overview of oncology resource distribution across different healthcare settings. The combination of these datasets strengthened the study’s validity and reliability, enabling the identification of critical gaps in oncology service provision in the Eastern Cape province.

1.6 Clarification of concepts

The concepts shown in Table 1 have been considered and used in the analysis better to understand the setting and the study’s context.

1. Ethical considerations: Ensuring equitable access to oncology care is an ethical concern, as all individuals have the right to timely and quality healthcare services, regardless of their geographic location or socio-economic status. Addressing the scarcity of oncology specialists aligns with ethical principles of justice and benevolence, promoting fairness and maximising the well-being of all individuals affected by cancer.

2.1 Eastern Cape case study – South Africa

The Eastern Cape province, located on the southeastern coast of South Africa, is characterised by its diverse landscapes, rich cultural heritage, and economic challenges. It covers an area of approximately 168,966 square kilometres. As counted in Census 2022, the Eastern Cape’s total population increased by 10.2% from 6.5 million more than a decade ago in Census 2011 to 7.2 million in the latest population and housing census [27]. The province’s economy is primarily agrarian, with agriculture, livestock farming, and forestry playing significant roles in employment generation and the gross domestic product (GDP). According to StatsSA [31], the province contributes 7.6% to the national GDP. The Eastern Cape faces numerous challenges, including high unemployment and widespread poverty, particularly in rural areas [32]. The province has the second highest prevalence of adult poverty, with a rate of 67.3%, and has the highest unemployment rate at 37.4% [33]. These socio-economic challenges significantly hinder access to essential health services in the region. Furthermore, the provinces face considerable obstacles in accessing screening services due to their distant locations, exacerbating the difficulties in obtaining critical healthcare interventions such as cancer screening and diagnosis for other life-threatening conditions.

2.2 Cancer incidence

Recent data reported by Ramaliba et al. [34] indicate a notable increase in new cancer cases, rising from 1193 in 2013 to 1666 in 2017, representing a 40% increase. This surge underscores a growing demand for cancer-related services and resources. The surveillance data further highlight regional disparities, with the southern part of the surveillance area consisting of five rural and one urban magisterial area. In contrast, the northern part comprises only three predominantly rural magisterial areas. Among females, the age group of 50–69 years accounts for approximately a quarter of cancer incidence, while 165 new cases were reported among males. The top three most prevalent cancers in males are prostate (C61), oesophagus (C15), and trachea, bronchus, and lung (C33–34). Conversely, among females, the leading cancers are cervix uteri (C53), breast (C50), and oesophagus (C15).

2.3 Morality cancer

This section presents data on the number of cancer-related deaths in the Eastern Cape province compared to the national figures. According to the table provided, the median number of cancer-related deaths in the province was 5,212 [28]. The data reveal that the number of deaths has consistently remained in this range, except for between 2011 and 2023, during which it dipped below 5,000. Over the 11-year review period, the Eastern Cape accounted for approximately 12.5% of the countrywide cancer-related deaths, with 2017 and 2018 representing 13% of the total (Table 2).

Figure 1 presents information extracted from Statistics South Africa regarding the top 10 cancers contributing to mortality in the province in 2018 [28]. According to the data, bronchus and lung cancer emerge as the predominant cause, representing approximately 14% of cancer-related deaths. Following closely is oesophagus cancer, which accounted for approximately 12% of mortality cases. Oesophagus cancer was highest compared to the other eight provinces, with 386 in Gauteng, 459 in KwaZulu Natal, and 355 in the Western Cape.

Figure 1

Cancers contributing to mortality in Eastern Cape, 2018 – Select the top 10. Source: Adapted from StatsSA [28].

2.4 Facilities

Facilities with oncology departments in the Eastern Cape vary widely across urban and rural areas, as depicted in Table 3. While cities like Port Elizabeth, East London, and Mthatha boast modern infrastructure, including airports, ports, and major highways, rural communities often lack essential services such as electricity, clean water, and adequate healthcare facilities. Access to oncology services is also prevalent in these urban areas, as illustrated by the data in the private sector sourced from Medpages [30], which depict that most of the oncology departments/units are located in Gqebera (Gqeberha, was known as Port Elizabeth, Nelson Mandela Bay), according to Table 3. The radiation oncology department appears also to be based in Gqeberha.

2.5 Access and availability of oncology services

The scarcity of oncology medical service providers presents a pressing concern that directly impacts patient care and outcomes. Like many others in South Africa, the region grapples with significant disparities in access to specialised healthcare services, particularly in oncology. The shortage of oncologists and cancer treatment facilities has profound implications for our community’s well-being. The limited number of oncologists and treatment centres translates into long waiting times for appointments, delays in diagnosis, and restricted access to vital treatments and therapies. The issue becomes further exacerbated by the fact that most oncology services in South Africa are centralised within the private sector, which only serves a fraction of the population, estimated to be less than 15%. This concentration of services creates a significant disparity in access to cancer care between those who can afford private healthcare and the majority who rely on public services. South Africa has little over 200 clinical or radiation oncologists, with 80% in the commercial sector and 20% in the public health sector, according to van Eeden et al. [35]. This resource gap makes radiation harder for many patients. The nationwide deployment of radiation units complicates matters. Nearly 77% (64 units) of the nation’s 83 teletherapy units are in three of its nine provinces.

Patients in rural and underserved areas are most vulnerable, where geographic barriers compound the difficulties of accessing quality oncology care. Figure 2 depicts the count of claiming Independent Practice Specialist Radiation Oncologists in the medical schemes. The graph illustrates a pronounced concentration of oncologists in the Nelson Mandela Bay/Gqeberha and Buffalo City areas. Conversely, no practising oncologists were in the Chris Hani District Municipality and Joe Gqabi District in 2022. In addition, there were no more than three independent practice specialist radiation oncologists in these areas, which mirrors the situation in the OR Tambo and Sarah Baartman districts, which are mainly rural.

Figure 2

Count of Independent Practice Specialist Radiation Oncologists claiming from medical schemes for 2018–2022 by Eastern Cape district. Source: Generated from the CMS (2024) unpublished report.

2.6 Select screening services: Cervical screening coverage

This section discusses cervical screening coverage, defined as the proportion of eligible individuals who undergo screening within a specified timeframe. For individuals aged 25–49 years, screening should occur within 3.5 years, while for those aged 50–64 years, it should occur within 5.5 years [36]. Cervical cancer screening coverage serves as a critical monitoring indicator for the World Health Organization’s (WHO) cervical cancer elimination plan. Figure 3 illustrates an increase in coverage ratios at both provincial and national levels, with the province showing slightly higher coverage compared to the national average, reaching 50% relative to 46.8% nationally in 2019, which is both below and below the target of 70% set by the WHO [26,37,38]. The data presented demonstrate a significant decline in screening rates due to the influence of the COVID-19 pandemic in 2020. The substantial decrease in screening rates from 2020 to 2022 may potentially have an adverse impact on the number of related deaths.

Figure 3

Cervical cancer screening coverage (%) (2020 NIDS): Eastern Cape Province and National: Source Ntshangase and Sebitloane [26].

2.7 Key interventions and learnings from other countries

Due to the scarcity of these services in the province, immediate intervention is needed to partner with the private sector, as a more significant majority of oncology service providers operate in the private sector. Addressing the scarcity of oncology resources and human capital requires a multifaceted approach encompassing various interventions and drawing lessons from successful strategies implemented in other countries (Table 4).