Radiotherapy services in the Philippines: exploring geographical barriers to improve access to care

Cancer is a leading cause of death globally, with increasing incidence rates in many countries. In the Philippines, a lower-middle-income country in Southeast Asia with a population exceeding 110 million, cancer incidence is high, with most prevalent cancers including cancers of the breast, lung, colon, and liver. Radiation therapy is crucial in managing these cancers, serving various roles including definitive, adjuvant, and palliative treatments. In 2020, an estimated 153,751 new cancer cases were reported. Radiotherapy (RT) is a crucial component of cancer treatment but faces significant delivery challenges due to geographical barriers, especially in archipelagic nations like the Philippines.¹ Penchansky and Thomas initially identified five key aspects that define healthcare access, as outlined in Table 1. This table also highlights the current challenges in the Philippines and suggests potential solutions to contextualize barriers in RT access.1, 2, 3 Here, we examine access to radiotherapy services in the Philippines, focusing on availability and accessibility.

Table 1.

Current status of access to healthcare as illustrated by Penchansky and Thomas.

General Classification	Specifics	Current problems	Possible solutions
Availability of Resources	Personnel	For a population of over 110 million, only 112 Radiation Oncologists, 103 Medical Physicists, and over 200 Radiation Therapy Technologists.	Enhancing training programs for specified professionals in coordination with respective societies
	Equipment	A total of 53 radiotherapy centers are distributed mainly in the National Capital Region in 82 provinces.	Expanding the number of facilities by developing new centers or satellite locations in underserved provinces would help balance the distribution of services. Enhancing the capacity of existing centers outside the National Capital Region can also accommodate more patients. Collaborating with private hospitals and clinics to establish additional treatment locations and sharing resources can further alleviate the disparity. Government incentives for healthcare providers to set up or expand radiotherapy services in less served regions would also support a more equitable distribution of care.
	Technology	Among the 53 centers, a total of 63 Linear Accelerators, 26 brachytherapy suites, 14 SRS/SBRT capable machines.
	Prevailing wait time	Depending on the treatment facility, the waiting time for radiation therapy may vary from a few weeks to several months.	Expanding the number of treatment facilities and increasing their capacity to accommodate more patients; optimizing scheduling and resource allocation within existing facilities; implementing efficient triage systems to prioritize urgent cases; and exploring partnerships with private or satellite clinics to alleviate the burden on major centers. Additionally, improving coordination between referral sources and treatment centers can help streamline the process and reduce waiting times.
Accessibility	“Close to home” care	Filipinos coming from 47 provinces (57.3%) need to travel at least 100 km to reach the nearest facility, while only 13 provinces (15.9%) can reach the nearest facility in <10 km. Furthermore, a total of 42 provinces (51.2%) need to travel at least 3 h to reach the nearest facility, while only 23 provinces (28%) can reach an RT facility within an hour	To address long travel times for radiation therapy in the Philippines, solutions include expanding the network of facilities to underserved areas and establishing regional centers. Improving transportation infrastructure and offering subsidized travel options can ease travel burdens. Implementing telemedicine and mobile health units for preliminary consultations and follow-up care can reduce the need for frequent long-distance travel. For patients needing sea or air travel, enhancing transport services and providing financial support for travel expenses are also crucial.
	Transportation	Due to the Philippines being an archipelago, patients coming from 18 (22%) and 2 (2.4%) of the provinces need to travel (most accessible) by sea and air, respectively to reach an RT facility
Accomodation	Coordination and integration of services	Delays or prevention of multidisciplinary meetings for cancer patients can result from scheduling conflicts among specialists, geographic and travel constraints, and inadequate technology for virtual meetings. Administrative issues, such as lack of dedicated time or inefficient communication channels, also play a role. Additionally, insufficient support staff and varying team priorities can further complicate the timely organization and effectiveness of these meetings.	To address delays in multidisciplinary meetings for cancer patients, solutions include implementing streamlined scheduling tools to coordinate specialists' calendars efficiently. Enhancing access to technology and infrastructure can facilitate effective virtual meetings. Allocating dedicated time for meetings and improving communication channels can reduce administrative barriers. Increasing support staff to manage logistics and ensuring consistent priorities among team members will further enhance meeting organization and effectiveness. Additionally, exploring hybrid meeting options that comb ine in-person and virtual attendance can help overcome geographic and travel constraints.
	Satellite cancer clinics	Satellite cancer clinics are not yet available for radiation therapy centers.
	Telemedicine	Telemedicine has been tried in other centers, however, the lack of access to internet, devices capable of telemedicine, and digital literacy reduces the efficacy of this method	Enhance access to reliable internet and devices capable of supporting telemedicine. Expanding digital literacy programs can help patients and healthcare providers effectively use these technologies. Additionally, providing affordable or subsidized technology and internet access, as well as offering technical support and training, can significantly improve the efficacy of telemedicine and ensure broader participation.
Affordability	Direct Medical Costs: Funding of cancer services, insurance coverage, etc.	Out-of-pocket costs for radiation therapy vary depending on the treatment location. Patients treated in government hospitals generally incur minimal to no out-of-pocket expenses, while those in private institutions often face significant costs.	Solutions include increasing funding for cancer services through government and non-profit organizations, expanding insurance coverage to reduce out-of-pocket expenses, and providing financial subsidies for low-income patients. Implementing flexible payment plans can help manage costs over time, while promoting cost transparency ensures patients can make informed decisions and better manage their expenses.
	Indirect patient costs (Lodging and transportation)	Indirect patient costs, in addition to direct medical expenses, often lead to delayed, interrupted, or discontinued treatments due to financial constraints, consuming a significant portion of patients' wages.	To address indirect costs of treatment, consider implementing financial assistance programs, expanding insurance coverage, offering flexible payment plans, and increasing access to transportation and support services.
Acceptability	Patient and provider attitudes one another	Most Filipinos still follow the Paternalistic Model, where the physician assumes a dominant role and makes decisions based on what they believe is in the patient's best interest.	Adopting a shared decision-making approach improves patient care by integrating personal values, preferences, and lifestyle factors into treatment decisions. This method ensures that care is tailored to each patient’s individual circumstances and goals, leading to more personalized and effective outcomes.
	Patient characteristics	Patients assume a passive role, relying heavily on the physician’s expertise and guidance. They have limited involvement in decision-making, often trusting and complying with the physician’s recommendations without questioning, particularly if they have lower health literacy.
	Provider characteristics	Physicians are primary decision-makers, using their clinical judgment to guide patients and assume the best outcomes. Their directive communication focuses on providing instructions rather than engaging in dialogue. Patients, often with limited health literacy, play a passive role, relying heavily on and complying with the physician’s recommendation.

The Philippines has 53 radiotherapy centers: two university centers and 51 hospital-based centers, translating to 0.47 RT centers per 1 million Filipinos. Of these, 41 are private facilities, and 12 are government hospitals. These centers house 65 bunkers and treat approximately 200–900 radiotherapy patients per year. The ideal ratio, as defined by the IAEA, is 4–8.1 RT centers per 1 million people or 1 MV per 250,000 people, indicating a significant shortfall in the number of RT facilities.

The country has 112 radiation oncologists, 103 medical physicists, and over 200 radiotherapy technologists (RTTs), with most oncologists and medical physicists concentrated in urban areas, especially in the National Capital Region (NCR).⁴ The NCR home to only 10% of the population, holds 38% of the country’s RT facilities, highlighting a significant resource disparity and creating access barriers for patients in remote areas.⁵

Due to the Philippines being an archipelago, patients from 18 provinces (22%) need to travel by sea, and those from 2 provinces (2.4%) need to travel by air to reach an RT facility. Filipinos from 47 provinces (57.3%) must travel at least 100 km to the nearest RT facility, while only 13 provinces (15.9%) can reach the nearest facility within 10 km. Furthermore, 42 provinces (51.2%) need to travel at least 3 h, while only 23 provinces (28%) can reach an RT facility within an hour. These geographical challenges exacerbate disparities in healthcare access, making timely and effective cancer treatment difficult for many.

The actual RTU rate in the Philippines is 4.5%, significantly lower than the IAEA’s recommended 53%, reflecting systemic issues in healthcare infrastructure and accessibility. The disparity underscores the need for substantial improvements in RT services availability and distribution.^1,2

In 2020, there were 153,751 new cancer cases, necessitating 154 MV-LINAC units, yet only 61 are available in the country, revealing a gap of 93 units. This highlights the urgent need for additional RT facilities and equipment. Additionally, the country needs 307 radiation oncologists, 192 medical physicists, and 465 RTTs, compared to the current 112, 103, and 200, respectively.

The geographical distribution of RT facilities highlights significant disparities. About 38% of RT facilities are located in the NCR, which houses only 10% of the national population, indicating a mismatch between facility distribution and population needs. The actual RTU rate in the Philippines is 4.5%, significantly lower than the optimal RTU of 53% recommended by the IAEA. The existing RT facilities are inadequate to meet the population's needs. To address these challenges, several interventions are proposed:

• 1.Development of Additional RT Centers

Establishing more RT facilities in underserved regions is crucial. Evaluating national and regional needs can help distribute resources effectively. Regional assessment can identify high-demand areas, guiding the development of new facilities. Integrating RT facilities into regional hospitals can also improve accessibility and reduce patient travel burdens.6, 7, 8, 9

For 2024, the Philippines has proposed a total health budget of approximately PHP 306.1 billion, with a significant focus on health infrastructure. Specifically, PHP 28.58 billion is allocated to the Health Facilities Enhancement Program (HFEP) for constructing, upgrading, and expanding government healthcare facilities, including the purchase of hospital equipment and medical transport vehicles. This reflects the government's commitment to improving healthcare infrastructure and services nationwide.¹⁰

Additionally, using the Radiotherapy Resources and Cost Calculator v21, it is estimated that $1.12 billion (approximately PHP 63.3 billion) is needed for radiotherapy in the Philippines. Currently, only $369 million (around PHP 20.85 billion) is available, leaving a shortfall of $744 million (about PHP 42.1 billion) required to meet the necessary allocation.

• 2.Public-Private Partnerships

Partnerships between the government, private funders and international NGOs can help establish more RT facilities in underserved areas. These collaborations provide funding, technical expertise and the latest technology, ensuring facilities are well-equipped and staffed. Public-private partnerships can also share best practices enhancing the overall quality of cancer care.

• 3.Training Programs

Increasing the number of trained professionals, including radiation oncologists, medical physicists, and RTTs, is essential. With only about 20 board-certified medical physicists,⁷ international collaboration in training and experience-sharing is crucial. Partnering with international institutions can provide access to the latest radiotherapy advancements and foster knowledge exchange, enhancing the healthcare system’s capacity.

• 4.Implementation of Legislation

Fully implementing the Universal Health Coverage Act and the National Integrated Cancer Control Act is necessary to improve social security, referral systems, and access to cancer care. These legislative frameworks offer a comprehensive approach to addressing the systemic issues in healthcare accessibility and equity. Effective implementation, adequate funding, and robust monitoring and evaluation mechanisms are essential for their success.⁶

• 5.Technological Advancements

Adopting advanced RT techniques, such as stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT), can improve treatment outcomes and reduce the burden on RT facilities. These RT techniques are currently underutilized, particularly in rural regions.⁸ Expanding their availability requires investment in equipment and training. Additionally, leveraging telemedicine and remote consultation technologies can enhance RT service delivery and resource efficiency.

• 6.Sustainability Measures

Sustainable development of RT facilities is essential to ensure long-term access to cancer care. This involves investing in renewable energy sources, implementing energy-efficient technologies, and adopting eco-friendly practices to cut costs and bolster infrastructure resilience. Further, fostering research and innovation in radiotherapy can advance treatment efficacy and efficiency.

• 7.Community Engagement and Awareness

Engaging communities in developing and implementing RT services is vital for success. Community outreach programs can raise awareness about early cancer detection and RT availability, addressing cultural and social barriers to treatment. Building trust and collaboration between healthcare providers and communities can enhance the acceptance and utilization of RT services.

Conclusion

Improving RT services in the Philippines is crucial to addressing the unmet needs of cancer patients. This requires developing additional RT centers, expanding training programs, and improving referral systems. Collaboration between the government, private sector, and civil society is essential to overcome geographical challenges. Efforts should focus on implementing existing health laws to ensure access to cancer care for all Filipinos. This study underscores the need for significant investments in RT facilities, medical personnel training, and policy development to support equitable distribution of services across the country.

The data presented in this study highlight the urgent need for comprehensive strategies to enhance the availability and accessibility of RT services. Addressing these challenges will require a multi-faceted approach, involving investment in infrastructure, human resources, and technological advancements. Furthermore, fostering public-private partnerships and engaging with international organizations can provide the necessary support to achieve these goals. Ultimately, improving access to RT services will have a profound impact on the quality of cancer care in the Philippines, reducing disparities and improving outcomes for cancer patients across the nation.

This paper provides important insights into the challenges of delivering RT in the Philippines and other developing countries, emphasizing the need for increased investment and policy support. By addressing these issues, the Philippines can make significant strides towards achieving equitable access to cancer care and improving the overall health and well-being of its population.

Contributors

Jerickson Abbie S. Flores—Literature search, figures, study design, data collection, data analysis and interpretation, writing, conceptualization, investigation, methodology, validation.

Charles Cedy C. Lo—Literature search, figures, data collection, data analysis and interpretation, writing original draft, review and editing.

John Michael Tomagan—Literature search, figures, data collection, data analysis and interpretation, writing original draft, review and editing.

Jaffar C. Pineda—Literature search, figures, study design, data collection, data analysis and interpretation.

Miriam Joy Calaguas—Conceptualization, Supervision, methodology, validation.

Enrico D. Tangco—Conceptualization, supervision, methodology, validation.

Misael C. Cruz—Conceptualiztion, supervision, methodology, validation.

Edward Christopher Dee—Conceptualization, supervision, methodology, validation.

Jake John P. Galingana—Data collection.

Eleanore S. Altubar—Data Collection.

Jhonatan B. Riparip—Data Collection.

Data sharing statement

This research utilized data sourced from open-access journals available through the National Institutes of Health and from surveys conducted in the Philippines. These datasets are freely accessible through the respective journals or can be requested directly from the primary author for further details.

Declaration of interests

This project is conducted in collaboration with RCARP03—RCA Research Project on Closing the Gap in Radiotherapy Access in RCA Government Parties supported by the International Atomic Energy Agency (IAEA) and the Regional Cooperative Agreement (RCA). We are deeply grateful for their invaluable contributions and guidance, particularly in providing mentorship, training and logistical support, which were instrumental in making this project. Edward Christopher Dee: NIH/NCI—ECD is funded in part through the Cancer Center Support Grant from the National Cancer Institute (P30 CA008748).