Report of a Workshop on “Cancer Control in East Africa” Focused on Diagnosis and Treatment

Participants at lunch in the grounds of ORCI.

INCTR’s first thematic workshop, held jointly with the International Atomic Energy Agency’s (IAEA) Program of Action for Cancer Therapy (PACT), took place in Dar Es Salaam, Tanzania, on August 22-24, 2007. INCTR Tanzania and the Ocean Road Cancer Institute were the local hosts and the meeting was primarily supported by NCI’s Office of International Affairs and IAEA (ICEDOC and the Open Society Institute also contributed). The purpose of the workshop was to identify problems or obstacles within each of the thematic areas (all of which related to diagnosis and treatment) in East Africa in general, and Tanzania in particular, and to propose feasible solutions that might be implemented with or without the need for additional resources. Approximately a third of the attendees were outside experts associated with INCTR, IAEA or other partner organizations; the remainder were from East Africa, primarily Tanzania.

The themes of the workshop included: Access to Care, Histopathology, Supportive Care (during treatment), Transfusion Medicine and Palliative Care. Each theme was introduced in a plenary session held, on the first morning, by an East African health professional, after which there was general discussion. The afternoon of Day one was occupied by visits to departments or other hospitals relevant to the thematic area (see individual reports). Day two was entirely devoted to group discussions in each of the thematic areas. On the final day, also held in plenary, rapporteurs provided summaries of the deliberations of each group. Group reports were followed by general discussion and final conclusions. After the meeting, group reports were finalized in written form (summarized below) and collated into an overall workshop report that was presented to the Tanzanian National Cancer Control Committee. This report, along with the presentations given on Day 1, are available on INCTR’s portal (INCTR Tanzania).

The Access to Care working group focused on obstacles to early detection, including the need for education of the public and primary health care providers, and the importance of screening programs.

The Histopathology working group focused on the identification of obstacles to timely, accurate diagnosis.

The Blood Transfusion working group focused on blood transfusion services in Tanzania, including blood collection, cross-matching and delivery from the blood bank to the bedside.

The Supportive Care working group focused on the identification of problems and needs relating to the support of patients undergoing cancer therapy, with a particular emphasis on chemotherapy.

The Palliative Care working group, which has already initiated a program in Tanzania, discussed progress to date and future plans.

Reports of Working Groups

1. Socio-cultural issues: poverty and illiteracy are major obstacles. Stigmata relating to certain types of cancers (breast, genital tract, particularly) result in delay in seeking help, and diagnosed patients sometimes refuse therapy. Traditional healers are generally approached first, particularly in rural settings (90% of the population), in part because of greater accessibility than medical practitioners. Fear of the “big city,” bureaucratic formalities and the lack of provisions for care of the family left at home often prevent visits to distant hospitals.
   
   
2. Community awareness: in rural settings few will know anything about cancer or, if they have heard of it, believe it to be an invariably fatal disease. This is, in part, a reality, since diagnosis is so late that few patients - even among those who reach ORCI - survive.
   
   
3. Transportation problems: since most Tanzanians live in rural districts and lack personal transportation (even bicycles), transportation is by foot or bus. Bus routes link only major centers; the rest of the journey must be made on foot. Cost and the long arduous journeys to referral centers create significant obstacles.
   
   
4. Structural issues: a major problem created by the limited resources (human and physical) for diagnosis results in lengthy waits for the required investigations – which are often performed in different hospitals - and additional delays until reports (written rather than computer generated) are available. Tracking the test results can be either immensely time- consuming or, on occasion, impossible. Reports may lack essential information and communication among the specialities is poor. Bureaucratic issues create unnecessary delays in referring patients – there may be as many as seven layers to be traversed. Surgery is usually performed by general surgeons without reference to medical oncologists or radiotherapists who are often consulted only at the time of recurrent disease. Institutional policy regarding the availability of medicines at night or weekends may influence whether or not a patient in urgent need receives appropriate therapy. Availability of drugs – cytotoxic and otherwise – is affected by inefficient procurement procedures, such that specific drugs and supplies, whether in the country or at an individual hospital, may be unavailable for some time.
   
   
5. Limited resources: the lack of staff at all levels is a major obstacle to effective care and the documentation of routine observations, treatment and treatment outcome. There are only two radiation therapy machines in Tanzania, which needs 30-40 (based on IAEA recommendations). Chemotherapy drugs are expensive, even when purchased from India (80% of the population lives below the poverty level); patients must generally pay this cost “out-of-pocket” (only civil servants have medical insurance).
   
   The need for higher level staff to conduct some private practice to supplement salaries may create an additional diminution in services available to the poorer sectors of the community.
   
   
6. Educational issues: education is a critical element of access to care at all levels – the educational level of the patient, the knowledge of the first health worker accessed and all subsequent health providers. Health personnel may lack knowledge of the early signs of cancer or not know what to do when cancer is suspected. Patients may be subject to the wrong surgical procedures (either inadequate or unnecessarily radical).
   
   
7. Compounding of problems: The lack of knowledge and/or adequate information about patients coupled to poor communication at all levels can result in delays or inappropriate action, which may in turn lead to complications and the need for added medical care.

1. Create more information on which to base solutions:
   
   1. Conduct a survey (by patient questionnaire) of problems that limit access to care and identify measures likely to have a major impact.
      
   2. Create a list of available equipment and personnel relevant tocancer diagnosis in district hospitals and ensure that all hospitals are equipped for the tasks required of them in the context of the national cancer control plan.
      
   
   
2. Increase awareness in communities and among policy makers: the major message to convey is that when cancer is detected early there are effective treatment options. This could be accomplished via radio broadcasts, community meetings and events organized by local NGOs or social clubs.
   
   
3. Improve professional education and communication: including non-specialist health care providers at points of access to the health care system. Methods might include sensitization and educational workshops and rotation of district hospital staff through tertiary care centers. Creation of regional networks between primary care facilities and secondary and tertiary facilities is strongly recommended. The following should be seriously considered:
   1. Appointment of a district “cancer coordinator” trained in the recognition of the early signs of cancer and able to provide education to primary care staff and assist in patient referrals
      
   2. Use of health passports - small, standardized notebooks carried by the patient, available to all health professionals and containing information about when and where tests were performed. Ultimately, an electronic version might be envisaged.
      
   3. Development of professional societies at which problems and solutions are discussed, educational and planning meetings held and local or national health authorities approached collectively in the context of advising them of inventions required to overcome obstacles.
      
   4. Creation of continuing education programs for a range of health professionals that provide discipline-specific information about cancer
      
   5. Institution of regular multidisciplinary and, potentially, multi-institutional meetings regarding cancer diagnosis and treatment.
   
   
   
4. Establishment of regional screening and palliative care programs: consideration should be given to screening for selected cancers, e.g., uterine cervical and breast cancer, and establishing palliative care programs at all district hospitals and, where possible, community health centers (home-based).
   

1. Low number of trained histopathologists in Tanzania: there are currently only 14 trained histopathologists for a population of 37 million. Nine of these are based at Muhimbili Hospital. There are no histopathologists in regional hospitals where medical laboratory technicians take responsibility for dealing with specimens. Recruitment into histopathology is poor with only 8 doctors training in this discipline since 1990.
   


2. Low numbers of trained medical laboratory histotechnologists in Tanzania: there are currently 13 trained histopathology technicians in Tanzania. Recruitment is poor with only 8 trainees since 1990.
   


3. Lack of equipment, poor maintenance of equipment and lack of training with new equipment.
   


4. Difficulty in obtaining and replacing essential reagents. Delayed transport of specimens from regional and district laboratories.
   


5. Long waiting times for reports.
   


6. Lack of a standardized report format that includes all information necessary for patient management.
   

1. Low numbers of histopathologists and poor recruitment:
   
   1. Pathology might be made more attractive to students if systemic pathology were taught as an integrated subject together with the appropriate clinical subject rather than as a basic science. Students would then appreciate the importance of pathology in clinical practice.
      
   2. The need for A or B grades in student academic performance in order to train as a pathologist may unnecessarily limit applications. Motivation should be taken into consideration as well as grades.
      
   3. Histopathology provides fewer opportunities for private practice. Broader training in all pathology disciplines before specializing in histopathology would better equip pathologists to work in district and regional hospitals as well as undertaking private practice in the broad subject of clinical pathology as is the case in Uganda. Apparently, private fees for histopathology are set by administrators and do not reflect the true cost of this examination. The fees structure should be re-examined, with input from pathologists.
      
   
   
2. Low number of histopathology technicians and poor recruitment: Recruitment of histotechnologists is also believed to be restricted by the limited opportunities for private practice compared with other branches of pathology. A broader education in all branches of laboratory pathology before specializing in histopathology would help resolve this problem and better fit the current needs of East Africa.
   
   
3. Lack of equipment and poor maintenance: this problem exists throughout Africa due to the widely dispersed laboratories and lack of finance. The laboratory at Muhimbili Hospital, however, has recently been refurbished and re-equipped to a very high standard with the aid of Abbot Laboratories. If laboratories in the same African region were to standardize their equipment manufacturers might be able to provide better technical support. The Association of Pathologists of East, Central and South Africa could play a pivotal role in recommending specific equipment and suppliers.
   
   
4. Difficulty of obtaining essential reagents and standardization of laboratory tests: This problem relates in part to the fact that equipment and materials are purchased centrally by administrators who may have little knowledge of the needs and priorities. The Muhimbili Hospital Laboratory used to be designated as the Central Pathology Laboratory in recognition of its national responsibilities. The group recommended that it is re-designated as the National Institute of Pathology with its own director and a protected budget. The Institute could introduce standard procurement practices throughout government laboratories and ensure the standardization of laboratory techniques. It could also take responsibility for the quality control of pathology services throughout the country.
   
   
5. Delayed transport of specimens from district and regional hospitals: The current transport arrangements are haphazard and often unsatisfactory. This problem could also be dealt with centrally if a National Institute of Pathology were re-established.
   
   
6. Long waiting times for reports: An audit of the time between receiving the specimen and the time that the report is received by the requesting physician or surgeon should be undertaken. The causes of delay should be identified and rectified. Currently reports are hand written before being typed. The use of a dictaphone or a voice recognition system should be considered.
   
   
7. Need for standardization of reports to include all information necessary for patient management: protocols for the handling and reporting of specimens need to be produced in collaboration with the clinicians concerned. Regular meetings between clinicians, radiologists and pathologists (multi- disciplinary meetings) provide an excellent opportunity for education, quality control and audit. Multidisciplinary meetings (Tumor Boards) of this kind should be held on a regular basis, as should intradepartmental pathology meetings to review material for the Tumor Board.
   
   

   DAY 1
   Welcome and Introductory Remarks	Twalib Ngoma
   Introduction to the Workshop	Ian Magrath
   Pathology in Tanzania – Strengths and Weaknesses	E. Mgaya
   PACT Model Country Demonstration Site: Tanzania	Maria Stella Stourig
   Supportive care in Tanzania – Strengths and Weaknesses	E. Kawira
   Blood transfusion in Tanzania – Strengths and Weaknesses	P. Magesa
   Palliative care in Tanzania – Strengths and Weaknesses	D.Msemo
   Access to care in Tanzania – Strengths and Weaknesses	T.Ngoma
   Cancer Treatment in Uganda –Strengths and Weaknesses	Luwaga Ahmed Kasumba
   Pathology in Kenya – Problems and Needs	Jessie Githanga
   Medical Oncology in Kenya – Problems and Needs	Nicholas Abinya
   General discussion – Actions and Interactions
   Visit to pathology laboratory at Muhimbili Hospital	Pathology group
   Visit to medical/pediatric wards at ORCI	Supportive care group
   Visit to the blood bank at Muhimbili Hospital	Blood transfusion group
   Visit to oncology wards & pharmacy at ORCI	Palliative care group
   Visit to District Hospital	Access to care group
   DAY 2
   Working Group Discussions
   DAY 3
   Access to care working group; report and recommendations	Ian Magrath
   Pathology working group; report and recommendations	Dennis Wright
   Supportive Care working group; report and recommendations	Aziza Shad
   Blood transfusion working group; report and recommendations	Gerald Sandler
   Palliative care working group; report and recommendations	Stuart Brown
   General discussion
   Concluding Remarks	Twalib Ngoma
   The program of the workshop

   
   
8. Other matters:
   
   1. Books and Journals: the Muhambili Hospital laboratory had very few bench books and histopathology journals. It is very difficult for pathologists to deal with uncommon or difficult cases if they cannot easily consult colleagues or look up illustrations in a bench book or journal. There are various potential solutions to this problem.
      
   2. Telepathology: prior to the development of telepathology for education and consultation, images could be circulated by e-mail and telephone conferences held to fulfill these purposes.
      
   3. Immunohistochemistry: it will be important to increase the amount of immunohistochemistry if diagnostic accuracy is to be improved. The use of trephine biopsies is likely to increase in future since this technique can greatly reduce the cost and morbidity of biopsies, but this approach requires access to immunohistochemistry. There is a commitment from Abbott Laboratories to help develop immunohistochemistry at the Muhambili laboratory.
      
   4. Professional Meetings: The Association of Pathologists of East, Central and Southern Africa exists. The group recommended that it meet more regularly and act as a catalyst to improving pathology services throughout the region.
      

The pathology working group in session.

1. Cost of care: in Tanzania, children aged 5 years or younger are entitled to free medicines and care, but this does not include costs of diagnosis or investigations, transportation or food. For patients older than 5 years, the costs of diagnosis, treatment and supportive care are borne by the patient’s family except for anti-malarials, anti-tuberculosis and anti-retroviral drugs. However, with respect to the latter two, distribution points are usually separate from district hospitals or facilities such as ORCI. Frequently, hospitals rely on donations of drugs or supplies from outside sources. Donors may also provide assistance in alleviating certain costs related to lengthy hospital stays, including food and accommodation for patients and their families.
   
   
2. Nursing staff: patient–to-nurse ratios are very high, particularly during night shifts and weekends when only one nurse may be responsible for monitoring 30 to 40 patients. On day shifts the ratio is usually half this. This severely limits the ability of nurses to adequately observe and document the effects of treatment or to make standard nursing observations such as temperature and fluid intake and output – which are critical to the care of acutely ill children undergoing cancer chemotherapy. Often, family members provide the only source of information for the medical staff about vital signs and side effects related to treatment.
   
   
3. Physical environment:
   
   1. Access to Information and Drugs: There is no internal hospital telephone system within ORCI to ensure rapid contact with the on-call physician or to ensure prompt transmission of laboratory or other diagnostic test results. The staff uses mobile phones to contact one another in situations such as this. Some medicines and supplies are locked away and inaccessible during the night, such that immediate intervention for the management of post-chemotherapy related febrile neutropenia or other emergencies may not be possible.
      
   2. Lack of Isolation Rooms: There are large numbers of patients in open wards with no isolation units or beds in the hospitals represented by the group, thus increasing the risk of transmission of highly contagious infections such as chicken pox. At times, isolation is accomplished in collaboration with district hospitals or other facilities, but this is usually for specific infections such as cholera and tuberculosis.
      
   3. Intensive Care Facilities: ORCI does not have an intensive care unit. Some institutions have such units but priority is given to non-cancer patients. Private hospitals are better equipped, but patients less than seven years old cannot be managed.
      
   
   
4. Laboratory resources:
   
   1. Microbiology: the capability to perform microbiological tests, including cultures and antibiotic sensitivities on body fluids or possible localized infections, is minimal at most of the institutions. Such tests may be performed for selected cases at specialized institutions but there are often significant delays in obtaining results, and samples are often lost. Most institutions can perform gram stains and most use urine microscopy for white cells to diagnose urinary infections.
      
   2. Hematology and Clinical Chemistry: basic laboratory tests such as full/complete blood counts and serum chemistries are available, but frequently these tests can only be done during the day. Automated machines are used, but when equipment is in need of repair, these tests go unperformed. Repairs are often very expensive, and downtime for maintenance can be lengthy. Machines of this kind need to be routinely calibrated and since the reagents for this are often unavailable the accuracy of the tests is often questionable
      
   
   
5. Availability of medicines and blood products:
   
   1. Availability of Medicines: the group discussed the availability of certain medicines, including chemotherapy, anti-infectious agents and other drugs relevant to supportive care. It was felt that a sufficiently broad array of agents is available for effective supportive care although compromises have sometimes to be made when particular drugs are not available or are too costly.
      
   2. Availability of Blood Products: at one remote institution, only whole blood is available whereas other institutions generally have access to packed red blood cells, platelets and plasma. The criterion used for the administration of blood transfusions are: when the hemoglobin is less than 6.0-7.0 g/dL or when the patient is symptomatic. Platelets are given for procedures requiring a platelet count of between 30,000 and 50,000 or when there are reasons to suspect that the patient is at high risk for bleeding. Most often platelets are given for active bleeding since the availability of platelet products is severely limited.
      
   
   
6. Patient-related factors:
   
   1. Problems Arising from Distance from hospitals: patients often live great distances from the treating institutions and even relatively short distances can entail arduous journeys. Other children in the family must be cared for by relatives, particularly when the mother accompanies a child for treatment. Because of the difficulties and expenses related to making the trip to a treatment facility, patients and family members often stay for the duration of treatment – either as in-patients or as out-patients. Family resources are scarce and when a parent must bear the costs of the entire treatment and supportive care for their child with cancer it places an enormous financial strain on the family, particularly when one parent loses income while staying with a child during treatment.
      
   2. Underlying Health Problems: nearly all patients have underlying health problems such as chronic infection with malaria, infestation with intestinal parasites and poor nutritional status. They are at greater risk for complications related to treatment because of the impact these factors have on their overall health.
      
   3. Traditional Healers: families often consult “traditional healers” when illness is detected, which frequently results in late presentation with advanced disease, adding to the complications of treatment.
      

1. Guidelines for supportive care: the working group members felt that guidelines for supportive care in patients undergoing cancer treatment should be developed and should include the most effective ways in which to utilize available medicines as well as guidelines for the use of blood products.
   
   
2. Human resources and physical environment: while problems related to nursing shortages, hospital environments, and laboratory capacity could not be adequately addressed, these issues were felt to be of high priority. The use of paramedical staff for simpler nursing tasks could help to relieve pressure on nurses and the creation of isolation facilities could prevent deaths from contagious infections such as chicken pox.
   

1. Transfusion services: collection of blood and the manufacture of components.
   
   
2. Hospital services: the Muhimbili Hospital has been identified as a prototype for this.
   

1. The lack of adequate equipment and storage facilities: domestic refrigerators, which do not have optimal temperature controls, are very often used.
   
   
2. The inappropriate use of blood and blood components.
   
   
3. The difficulty of distribution of blood to remote regions: this is caused by the lack of vehicles in the zonal transfusion centers.
   
   
4. The lack of educational material: necessary for updating the faculty and the technical staff.
   

1. Vehicles and equipment: the group identified a priority need for providing vehicles to transport blood from zonal transfusion centers to hospitals, particularly “hard-to-reach” hospitals. The group also identified a priority need for appropriate blood bank refrigerators for the storage of blood.
   
   
2. Advocacy of volunteer blood donation: the group recommended further development of an advocacy program which focuses on the retention of dedicated safe blood donors as a foundation for expanding the voluntary blood program.
   
   
3. Education and training: the group recommended that continuing medical education programs should be provided for both technologists at the blood centers as well as physicians supervising the programs. Physicians using blood and blood components should be updated on the rational use of these products.
   
   
4. Quality control: the group recommended the establishment of a quality control program for all stages of blood collection, testing and processing. The zonal transfusion centers will participate in the development of a Quality Assurance Program for blood donation, processing and testing.
   
   
5. Blood transfusion committees: The directors of the zonal transfusion centers expressed their concern about the lack of communication between the blood centers and the users of blood in hospitals. The group recommended that hospitals in the region organize Transfusion Committees which meet periodically. The directors of the zonal transfusion centers should be members of the hospital Transfusion committees to facilitate communication between the transfusion service and the physicians ordering blood or blood components.
   
   
6. Hospital services:
   
   1. Hospitals should support the NBTS and phase out their blood collections as soon as possible.
      
   2. Every hospital should implement the organization of Blood Utilization Committees constituted as defined by the National Blood policy.
      
   3. Inventory management is an important requirement for the hospital-associated transfusion services. Hospitals should have an appropriate program for maintaining adequate onsite inventories of blood and blood products.
      
   4. Hospitals should continue to suport continuing education programs for physicians, nurses, technologists and any other staff members associated with the collection, testing and transfusion of blood or blood components.
      

The children's ward at the Ocean Road Cancer Institute.

1. Further training and curriculum development:
   
   1. An overview of ORCI/INCTR planning, advocacy and training/sensitization to date with a focus on training in government hospitals up to district level was provided.
      
   2. The structure of government health care facilities was reviewed; these include dispensaries (serving a 3 km radius), health centers (serving an approximate population of 200,000), district hospitals (about 140), regional hospitals (about 25) and 7 referral hospitals.
      
   3. Palliative care (PC) training will also be required in the military and correctional hospital system.
      
   4. Much has already been done with respect to compiling palliative care curricula for various health professionals at ORCI.
      
   5. There is a need to develop a core group of trainers who can help with these initiatives.
      
   
   
2. Potential collaboration:
   
   1. Potential collaborators include the National AIDS Control Program, Pastoral Activities and Services for People with AIDS, Seliane, Pathfinders and Family Health International.
      
   2. TPCA could help in coordinating (in a collaborative and efficient manner) the efforts of these multiple stakeholders/providers.
      
   3. Models in which TPCA might “sub-contract” to ORCI some of the advocacy, training, and care standards were discussed.
      
   
   
3. Opioid/Essential drug availability:
   
   1. The current situation regarding opioid availability/distribution in Tanzania was reviewed.
      
   2. With current efforts, opioid use could increase dramatically and plans to provide for this anticipated increase should be in place.
      
   3. If all zonal hospital pharmacies could be trained to compound and store opioids this would improve access to opioids throughout Tanzania.
      
   4. Physicians will need to be trained in order that they are comfortable in prescribing opioids.
      
   5. “Sensitization” is a necessary step in achieving the goal.
      
   6. Most drugs on the International Association for Hospice and Palliative Care (IAHPC) Essential Drug list exist in Tanzania but the supply is sometimes limited.
      
      
4. Funding and donors:
   
   1. The need to coordinate requests to various donors was discussed.
      
   2. Limited funding has been obtained to date to support training in hospitals; much more significant funding has been made available for home-based care programs.
      
   3. Sustainability must be built into all programs.
      
   
   
5. INCTR guidelines/handbook:
   
   1. TPCA/APCA and national organizations should review the new edition of the guidelines with a view to endorsement.
      
   2. All other available guidelines should be reviewed to ensure full coverage of topics.
      
   3. National associations may be able to help with respect to local adaptation, e.g., with respect to drug availability (although this may vary over time) as well as distribution of the guidelines.
      
   4. The guidelines will need to be translated into various languages.
      
   
   
6. Data collection/minimum data set
   
   1. An overview was provided of how various data elements might be used in advocacy, assessing the quality of care, and in stimulating improvements in performance and research.
      
   2. The African Palliative Care Association (APCA) has developed a system of PC metrics. Alpha and beta testing is completed and validation is underway. This will be presented at the next APCA conference.
      
   3. Data is being collected as part of regular care and then submitted to the national palliative care association and fed to APCA.
      

1. Further training and curriculum development:
   
   1. The National Training Program in PC already initiated at ORCI should continue its work in close collaboration with TPCA.
      
   2. The group recommended that TPCA review the curriculum already developed by ORCI, ensure key stakeholder input and approve the proposed curriculum.
      
   3. The group recommended that TPCA pursue accreditation of the PC curriculum by the appropriate government Ministries (e.g., Health, Science and Technology).
      
   
   
2. Ongoing collaboration:
   
   1. It was suggested that TPCA and ORCI explore the possibilities of TPCA “subcontracting” certain elements of the TPCA work plan (eg. advocacy, training, standards of care, other activities) to ORCI.
      
   2. It was felt that TPCA should take a leadership role in examining the work currently being done by various providers/stakeholders in Tanzania and expediting the development of standards that would be accredited by the government.
      
   3. Following the completion of the recommendations for home-based care currently in progress, it was recommended that TPCA should bring stakeholders together at ORCI to discuss coordination of efforts and identify priorities (perhaps as a satellite to the home-based care stakeholders meeting).
      
   
   
3. Opioid/Essential drug availability:
   
   1. Efforts should be made to expand the distribution of morphine from ORCI to other providers by continuing to build capacity and infrastructure (including training) for all zonal hospitals to store and distribute opioids.
      
   2. The IAHPC Essential Drug List should be reviewed and modified as necessary. A means should be found of assuring constant availability of these medications.
      
   3. It was recommended that a review of available medical supplies and equipment used in PC should be undertaken and gaps identified and filled.
      
   
   
4. Funding and Donors:
   
   1. A proposal should be developed that clearly outlines the importance of ensuring hospital-based PC training initiatives in conjunction with home-based care initiatives.
      
   2. It was recommended that TPCA organize a funders meeting.
      
   
   
5. INCTR guidelines/handbook:
   
   1. APCA and national associations should be invited to review current INCTR clinical guidelines for appropriateness in Africa with a view to endorsement.
      
   2. Pending the outcome of this review, local adaptation of the guidelines including translation (if necessary) could be undertaken and locally available drugs given appropriate emphasis.
      
   
   
6. Data collection/minimum data set
   
   1. The work already done by APCA with respect to data collection should be reviewed and its utility in resource-poor settings addressed.
      
   
   This article is based on the reports produced by each working group. Group rapporteurs are listed on the Meeting Program (Day 3).