Review Article
Vol. 6, Issue 1, 2026 · P1-12
Bridging the Gap: Cancer Care Models in Low- and Middle-Income Countries
Bidushi Pokhrel, MBBS,Prakash Neupane, MD
Submission received: 2026-02-10 / Accepted: 2026-02-10 / Published: 2026-03-18
Abstract
Focused, actionable strategies are needed to improve cancer care delivery and outcomes, particularly in low- and middle-income countries (LMICs). This article examines two effective and context-specific care models: the long-standing collaboration between Fred Hutchinson Cancer Center (FHCC) and the Uganda Cancer Institute (UCI), and the Binaytara Foundation's (BTF) grassroots initiatives in Nepal.
The FHCC and UCI partnership serves as a model of research-oriented cancer care, contributing significantly to workforce training, policy development, and treatment infrastructure in Uganda. It has achieved notable progress in managing Kaposi's sarcoma, Burkitt lymphoma, and numerous other malignancies predominant in that region and in initiating locally relevant immunotherapy programs. Conversely, the BTF's efforts in Nepal reflect a community-based, bottom-up strategy. Since 2018, the foundation has developed a comprehensive cancer center in southern Nepal, offering services including chemotherapy, radiation, and surgery. Its focus on medical education, collaborative networks, and public engagement has led to improved access to service and tailored early detection efforts.
The above two initiatives illustrate the pivotal role of local leadership, strategic partnerships, and culturally informed solutions in advancing cancer care in LMICs. Both strategies provide scalable and replicable methods by combining clinical practice, teaching, and research. Collectively, they show that robust, inclusive systems that support global collaboration, empower communities, and invest in local talent can deliver equitable cancer care.
Introduction
Over the past few decades, there has been significant progress in the diagnosis and treatment of cancer. However, it remains an enormous public health challenge around the globe with a continually rising incidence.1 More so, the Low and Middle Income Countries (LMICs) shoulder a disproportionately higher mortality burden.1 This is attributed to systemic barriers such as delayed diagnosis, insufficient medical infrastructure, scarcity of trained personnel, and limited diagnostic capabilities and access to treatment.2,3 According to the AACR Cancer Progress Report (2020),2 survival rates in high-income countries (HICs) have improved significantly over the past decades, whereas Sub-Saharan Africa still experiences high mortality from preventable or treatable cancers, often twice as high as in the HICs.4,5
This review synthesizes insights from two impactful care models: a two-decade collaboration between Fred Hutchinson Cancer Center (FHCC) and the Uganda Cancer Institute (UCI), and Binaytara Foundation's (BTF) grassroots efforts in Nepal. Both initiatives offer valuable lessons in innovation, local capacity-building, and equitable care delivery.
Barriers to Effective Cancer Care in LMICs
Addressing effective cancer care in LMICs requires a nuanced understanding of the multifaceted barriers that hinder access to timely treatment. The following sections elaborate on these barriers.
1) Delays in diagnosis and treatment Initiation
A review published in 2025, including 29 studies on women from LMICs, found that patients experienced significant delay in diagnosis from symptom onset averaging 7.4 months and 4.9 months from diagnosis to treatment initiation in these participants, owing to barriers such as financial challenges (~65%), geographical difficulties (35%), health system limitations (55%) and low health literacy (52%).3 Major obstacles included poor awareness of symptoms and risk factors, difficulty navigating care pathways, cancer-related stigma, unreliable transportation, and frequent misdiagnoses.2 Most diagnostic technologies and cancer treatments remain unaffordable in these settings. While the economic burden per cancer patient in high-income countries (HICs) such as the United States, the United Kingdom, and Japan ranges between US$183 and US$460 annually, it is dramatically lower, only US$0.54 to US$7.92 in regions like South America, India, and China. Overall, high-income countries invest five to ten times more per capita in cancer control than LMICs.6 Therefore, strengthening cancer awareness, affordability, and health-system capacity is essential to shorten diagnostic timelines and improve treatment access in LMICs.
2) Logistical Barriers to Accessing Oncologic Care
Access to treatment is often hindered by logistical challenges, including shortages of diagnostic and treatment facilities, limited domestic manufacturing of cancer therapies, weak regulatory systems, and inadequate infrastructure for integrated oncology services.7,8 A study from seven African nations highlights severe gaps in medical imaging, pathology, surgical oncology, chemotherapy, and radiotherapy availability.8 In several LMICs, such as Ethiopia and Malawi, radiation machines are absent or restricted to capital-city hospitals.9 A World Health Organization (WHO) survey found that only 22% of African countries had anti-cancer medicines available, compared with 43% in South-East Asia and 57% in the Americas- far below the 91% availability reported in Europe.10 In the Madhesh region of Nepal, patients previously had to travel up to 10 hours to receive basic cancer care, reflecting a lack of local treatment facilities.11
3) Shortages of Healthcare Personnel
Critical shortages of health professionals remain a dire challenge in LMICs. For instance, it has been reported that only 5% of the optimal number of radiation oncologists are available per capita, emphasizing the urgent need for capacity building in these regions. Reports indicate there are an estimated two radiation oncologists for every 45 million people in Uganda, and 34 African nations lack any cancer specialists altogether.12 Moreover, the migration of healthcare workers constitutes a critical dimension of the workforce crisis in these regions. HICs significantly attract healthcare professionals from LMICs, leading to a detrimental "brain drain" effect, where the very individuals trained to address local cancer care needs are drawn to more lucrative positions abroad.13 The resultant healthcare inequities are stark, with recent findings suggesting that approximately 70% of cancer deaths occur in LMICs, yet these regions possess less than 5% of global healthcare resources.14
4) Absence of Screening Programs
Effective cancer prevention and early detection through screening programs are critically underrepresented in LMICs. Only about 5% of women in sub-Saharan Africa and India undergo cervical cancer screening in their lifetimes.15, 16 For every one million people of LMICs, there are fewer than five mammography units and fewer than 10 radiologists in Africa, thus making breast cancer screening extremely inaccessible in these parts.17 Colorectal cancer screenings are very limited in LMICs due to a lack of infrastructure and resources, a lack of knowledge of the disease, their relevance to public health, and low adherence to guidelines by clinicians.17
5) Social Determinants of Health and Underrepresentation in Cancer Research
Cancer disparities among ethnic and racial minority groups belonging to the LMICs arise from a combination of social determinants of health (SDOH) and genetic or epigenetic differences linked to ancestral backgrounds. Nonetheless, the majority of cancer research models, including commonly used cell lines, have been developed from individuals of the US or European heritage. This lack of genetic and racial diversity in research limits the applicability of findings for other populations, particularly those that bear a higher cancer burden.18 Certain cancers have significantly higher incidence rates in Africa, particularly sub-Saharan Africa, compared to the United States and Europe. Kaposi’s sarcoma (KS) occurs about 10 times more frequently in Africa, and cervical cancer rates are roughly 5 times higher, both largely due to infectious causes. Sub-Saharan Africa, especially Malawi, has the highest global rate of cervical cancer, driven by human papillomavirus (HPV), HIV, and smoking. Additionally, women of African descent are more often diagnosed with aggressive forms of breast cancer, such as triple-negative breast cancer. KS remains endemic in sub-Saharan Africa, caused by the KS-associated herpesvirus.19 Consequently, many research outcomes may not fully address the needs of underserved or disproportionately affected groups.
6) Financial Constraints
Out-of-pocket expenses represent a major hurdle for patients seeking cancer treatment in LMICs. Studies indicate that a significant proportion of patients, between 18% and 93%, experience financial toxicity due to the high costs associated with cancer diagnosis and treatment.20, 21 In many LMICs, families often bear catastrophic health expenditures, which can deplete household savings and lead to poverty, particularly for patients requiring prolonged treatment.21 For instance, a systematic review highlighted that out-of-pocket costs can account for up to 50% of total healthcare expenditures, pushing families into debt and impacting their livelihood and overall health.22 Health expenditures for cancer care in LMICs constitute only 6.2% of global cancer expenditures, despite these regions comprising a substantial burden of cancer cases worldwide.23 Additionally, insurance coverage in the LMICs is often inadequate, posing significant financial toxicity due to high co-pays and deductibles, which can be overwhelming to people regardless of their income status.24
Addressing Cancer Burden in Resource-Limited Settings
Effective cancer control in resource-limited settings requires targeted, context-specific strategies to overcome systemic barriers and improve patient outcomes, some of which are elaborated below:
1) Priority setting in cancer screening
LMICs often lack the resources to implement comprehensive cancer screening for all major cancers. As a result, they must strategically prioritize cancer control programs with limited resources, optimizing early detection measures that target those cancers associated with the highest burden (cancer incidence, morbidity, and mortality). The WHO packages highlight low-cost, high-impact measures including tobacco reduction, hepatitis B vaccine, oral cancer visual inspection, human papillomavirus (HPV) vaccination, and cervical cancer screening.25 Cancers of colorectal, breast, and cervical origin that have been shown to benefit from early identification should be the focus of targeted screening.12
2) Health education and community awareness
Public education and awareness campaigns play a significant role in promoting behavioral changes and dispelling misconceptions about cancer screening and prevention. Implementing culturally relevant mass media campaigns across various platform such as radio, television, print, and social media has proven effective in increasing awareness and encouraging preventive behaviors.12, 23 A Nepalese study in 2018 demonstrated significant increase in awareness regarding oral carcinogens such as tobacco, quid and cigarette smoking and change of attitude towards production, sale and advertisement of these products after a three-month mass media campaign.26
3) Addressing workforce shortages
Addressing the shortage of specialists and improving accessibility in impoverished LMIC regions, it necessitates task-sharing and delegating that empowers mid-level practitioners to deliver cancer services, including screening, diagnosis, treatment, and palliative care. Notable examples include Zambia's use of allied health workers for cervical cancer screening, which raised coverage from 4 to over 50%; Nigeria's use of community health worker home visits for education on breast self-examination and prompt referrals; Mozambique's associate clinicians performing cancer staging, administering chemotherapy and managing common side effects following specialized training; and Uganda's palliative care nurses improving pain management through the use of oral morphine.27,28,29,30
4) Strengthening local research capacity
The role of research is indispensable in cancer control in LMICs, primarily because it addresses the etiology of cancers unique to those countries, ultimately leading to the development of locally appropriate strategies for cancer prevention and treatment. It will contribute to affordable, cost-effective, and evidence-based interventions that can be integrated into the existing clinical framework and public health policies. Research will create numerous opportunities for mentorship and leadership for scientists and academicians hailing from LMICs, thus enabling the formulation of new directions for cancer research, establishing agendas to address cancer prevention, enabling early detection, and providing cost-effective treatment options.31 This can avoid significant healthcare costs associated with cancer care, economic burden, and loss of social status.32 Even after prevention and control initiatives are implemented, research needs to be employed as an inevitable component of the evaluation of efficacy and sustainability of the interventions by generating evidence, quantifying the impact, ensuring safety, and informing regulatory decisions.
5) Collaborative partnership and policy frameworks
The formation of partnerships and networks is a crucial way of building effective cancer research programs while facilitating improvements in multidisciplinary cancer care in LMICs. An example is the establishment of mobile screening units through public-private partnerships, which have shown promise in increasing cancer diagnosis among underserved populations.12 Another unique initiative is a public-private partnership in Senegal leading to the formation of the Institute for Training and Research in Urology-Family Health Care (IFRU-SF). This institution has been crucial in facilitating collaborative clinical and research activities in the country related to male and female urogenital cancers.31,33
The Uganda Model: A Case Study in Cancer Capacity Building
The long-term collaboration between the FHCC in Seattle, Washington, and the UCI is recognized as one of the most impactful global oncology collaborations. It was founded in 2004 to address the cancer survival gap in East Africa.34 The partnership demonstrates a comprehensive model of cancer care through integration of research, education, and clinical services.
The FHCC and UCI partnership established the first comprehensive cancer facility in Uganda in 2015 with a goal of serving 43 million people. One of the important components of this collaboration is its emphasis on building local capacity through training programs. The partnership has established scholarship and fellowship opportunities to support Ugandan healthcare professionals in gaining critical skills in oncology. Since its inception, it has trained over 350 healthcare professionals, including 15 oncologists and 23 cancer-specialized nurses, reflecting a strong emphasis on human resource development.34 This investment directly addresses the shortage of specialized personnel in the region. Such initiatives ensure that research and clinical practices developed in high-income contexts can be adapted and applied effectively within Uganda's unique healthcare environment.
Due to the success of the alliance, it has currently transitioned to the Ugandan government.34 The alliance has conducted landmark studies on virus-associated cancers in Africa. Their findings clarified the role of viruses such as Epstein-Barr Virus (EBV), Human Herpesvirus 8 (HHV-8), Hepatitis B Virus (HBV), and Human Papilloma Virus (HPV) in cancer development.35 These studies have contributed significantly to understanding tumorigenesis and progression in immunocompromised patients,35 characterization of the contribution of HIV infection to the development of and survival with cancer in Sub-Saharan Africa,36 evaluation of natural history and presentation of cancer in resource-limited settings37,38 and policy guidance on building capacity for care and management of cancer in Africa.39,40,31 Currently, nine Ugandan investigators are involved in 15 active grants at the institute.34
As a result of the partnership, substantial achievements have been witnessed in cancer care delivery in the region, including notable improvements in cancer diagnostics, oncology imaging, surgical services, equipment acquisition, and medication availability.41 In 2020, the team launched an institute focused on introducing immunotherapy in LMICs, facilitating local production of tumor vaccines and other biologics. This leap helps democratize access to cutting-edge cancer therapies. Additionally, a 2018 breast cancer study is exploring the use of oral-only treatments and aims to map the molecular traits of breast cancer in Uganda. Other ongoing clinical trials focus on treatment responses for HHV-8 and KS, cancer-related infections, and HPV-related and colorectal cancers.34
The institute's work on implementing a comprehensive BL treatment program is a great example of sustainable health system strengthening. Through locally tailored protocols, the UCI was able to provide cost-efficient treatment by international standards, accounting for only US97$ per Disability Adjusted Life Years (DALY) compared to $301 internationally. The ratio of cost per DALY averted to per capita gross domestic product was 0.14, reflecting a very cost-effective intervention.42 The facilitated peer mentoring program at UCI has successfully helped develop a new generation of researchers who are taking up roles of mentors and role models, a very efficient model of career development in resource-limited settings like Uganda.43
The FHCC and UCI partnership had initially received partial funding from two United States Agency for International Development grants, totaling $1.4 million, awarded through the American Schools and Hospitals Abroad program, along with an $8.6 million contribution from Fred Hutch. Additional support was provided by the Government of Uganda, including the allocation of land, staffing and equipment assistance, and technical expertise. This strategic investment has transformed the UCI from a modest, resource-constrained institution into a modern regional cancer center with the capacity to train future oncology specialists and foster high-impact research with global relevance.44 Other partners, such as The Burkitt Lymphoma Fund for Africa has provided funding for comprehensive initiatives, including transportation subsidies, case management, diagnostic improvements, and treatment support to improve outcomes for children with Burkitt lymphoma in East Africa.45
The collaboration between FHCC and the UCI exemplifies a transformative approach to improving cancer care access in Uganda and Sub-Saharan Africa. Through comprehensive training programs, joint research efforts, the integration of care services, and the implementation of innovative screening initiatives, this partnership addresses key barriers to effective cancer management. As the landscape of cancer care continues to evolve in resource-limited settings, such partnerships will play a critical role in shaping durable solutions to confront the rising cancer burden in the region.
The Nepal Experience: A Grassroots Model of Equity and Innovation
The BTF has made a meaningful contribution to the transformation of cancer care in Nepal's Madhesh State, home to six million people but devoid of a cancer center as recently as 2018. Founded in 2007, the foundation has worked to address disparities in cancer care in Nepal through a combination of institution-building, clinical training, academic conferences, and policy advocacy.11
With the mutual partnership of the University of Illinois, Chicago (UIC), BTF, and the Civil Service Hospital in Kathmandu, Nepal's first blood and marrow transplant unit was established in 2012. This included the phase-wise rollout over the span of four years, featuring site visits, training of staff abroad, and joint educational initiatives and government-funded facility construction, including a specialized stem-cell lab. Autologous Hematopoietic Stem Cell Transplantation (HSCT) was first introduced in 2016, followed by allogenic HSCT in 2017.46 This marked a significant milestone in cancer care in Nepal and effectively demonstrated that HSCT is feasible and effective in a resource-constrained setting when supported by a strategic international partnership. Moreover, clinical outcomes achieved were comparable to the global standards at a much lower cost and with fewer resources.
Before the BTF's efforts, patients in Madhesh had to travel over ten hours for cancer treatment. Today, the region houses a cancer center offering affordable oncologic services, including chemotherapy, diagnostic imaging, surgery, pathology, and palliative care, serving over 1,800 patients since its inception in 2018. The foundation also established the first histopathology lab, performed the first oral cancer surgery in the region, and became one of the few centers in South Asia to fully implement a paperless Electronic Health Record (EHR) system. By 2027, the foundation has plans to expand its cancer center to a 200-bed state-of-the-art institution with comprehensive cancer care services in the region and serve more than 20,000 patients annually, offering services such as radiation oncology, surgical oncology, and advanced chemotherapy.11
BTF has consistently demonstrated its commitment to strengthening the human resource capacity of LMICs. Through partnerships with U.S.-based academic institutions and local medical schools, it has provided continuing medical education (CME), clinical mentoring, and hands-on training to hundreds of healthcare professionals. Annually, it hosts Global Oncology Summits in Nepal, drawing international faculty and local trainees. It organizes nurse training programs in palliative care and chemotherapy administration, and surgical oncology workshops in collaboration with local and international partners. In the US, it organizes several oncology conferences that facilitate cross-cultural collaboration, knowledge and skill exchange, and foster dialogues on cancer care equity. These programs serve as a platform for emerging researchers from LMICs to present their work and provide educational content to oncologists from over 30 countries.11
Community engagement is an integral part of the BTF approach, which is what makes it unique and innovative. Health camps, oral and cervical cancer screenings, and educational campaigns have helped increase awareness and early detection. These initiatives mitigate the financial and logistical obstacles that often prohibit rural patients from seeking care. The foundation has identified unique cancer trends, such as a high incidence of gallbladder cancer, and tailored its diagnostic protocols accordingly. Cultural competency increases patient trust by ensuring that care is provided respectfully and efficiently. By 2027, BTF plans to complete a 200-bed, state-of-the-art cancer center expected to treat over 20,000 patients annually.11
The BTF generates revenue through diverse sources. The fiscal year 2024 annual report shows that the largest portion comes from conference and program revenues, which support educational and training initiatives. This is supplemented by grants from foundations and partner organizations, individual donations, and in-kind contributions such as volunteer time, donated equipment, or services. Together, these funding streams allow BTF to sustain its global cancer care, research, and education programs while dedicating the majority of expenditures directly to program services.47
In conclusion, the BTF has developed a transformative and context-driven model of cancer care in Nepal that bridges systemic gaps and expands access in underserved regions. By combining community-centered outreach, culturally sensitive care, and early detection initiatives with local workforce development and strategic international partnerships, BTF has demonstrated that advanced treatments such as HSCT and sophisticated diagnostics can be successfully implemented in resource-limited settings. Its integrated approach, which includes capacity building, health education, and policy advocacy, ensures sustainability while empowering local healthcare systems. This equity-focused, scalable model offers a replicable blueprint for LMICs, contrasting sharply with the centralized, resource-intensive systems typical of HICs, and underscores the importance of locally adapted solutions in achieving oncologic equity.
Conclusions
The cancer care models implemented by BTF, FHCC, and UCI collaboratives provide compelling examples for advancing cancer care delivery in LMICs. Both initiatives emphasize the need for community engagement, capacity building, and integration of services, demonstrating that culturally informed solutions can significantly enhance access to care in resource-limited settings. The experiences gleaned from these collaborations underscore the importance of local leadership and strategic partnerships in developing viable and effective cancer care models. As such, they provide a roadmap for others aiming to improve cancer management in similar contexts.
Considering the evident success of these programs, several practice recommendations emerge. First, it is critical to continue fostering collaborative partnerships between local institutions and international organizations. Such partnerships can leverage unique strengths, sharing expertise and resources to build robust healthcare infrastructures. Secondly, a focus on strengthening local capacities through comprehensive training schemes for healthcare professionals is vital. This not only addresses staffing shortages but also ensures the sustainability of quality cancer care practices tailored to local needs. Third, community engagement initiatives should be prioritized, with a focus on health education and awareness efforts that empower individuals to advocate for their health, leading to earlier diagnoses and improved treatment outcomes. Finally, an integrated approach to cancer care that encompasses prevention, early detection, treatment, and palliative care within a single framework will be essential in enhancing the overall effectiveness of oncology services.
By aligning these strategies with ongoing support from governments, health organizations, and funding agencies, the lessons learned from these collaborative models can be scaled and adapted, offering hope for advancing cancer care and reducing disparities for patients in LMICs.
Conflicts of Interest Disclosures: None
Data Availability Statement: Not applicable
Funding Information: None
Ethical Statements: No ethical concerns
Acknowledgement: None
Declaration of use of Artificial Intelligence (AI) in scientific writing: During the preparation of this work, we used AI-based writing software to make grammatical corrections and improve the flow of language. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
Author Contributions: Both authors (BP and PN) prepared and reviewed the manuscript
Statement: All authors have read and approved the final manuscript.
Conflict(s) of Interest
The authors declare no conflicts of interest.
Funding Information
N/A
Ethical Statements
No ethical concerns
Informed Consent
N/A
Data Availability Statement
N/A
Acknowledgements
N/A
Declaration of AI Use in Scientific Writing
During the preparation of this work, we used AI-based writing software to make grammatical corrections and improve the flow of language. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
Author Contributions
Concept and design: BP, PN
Data acquisition: BP, PN
Data analysis and interpretation: BP, PN
Drafting of the manuscript: BP, PN
Critical revision of the manuscript: BP, PN
All authors (BP, PN) approved the final version of the manuscript and agree to be accountable for all aspects of the work, in accordance with the International Committee of Medical Journal Editors criteria.
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