Delays in cancer care for children in low-income and middle-income countries: development of a composite vulnerability index

Lancet Glob Health. 2023 Apr;11(4):e505-e515. doi: 10.1016/S2214-109X(23)00053-0.


Background: Early access to diagnosis and care is essential to improve rates of survival from childhood cancer, particularly in low-income and middle-income countries (LMICs). Composite indices are increasingly used to compare country performance in many health fields. We aimed to develop a composite vulnerability index of risk of mortality associated with delays in care for childhood cancer in LMICs, and to compare the vulnerability index scores across countries.

Methods: The composite vulnerability index was built in ten steps. A previous systematic review of determinants of delays in cancer care for children guided data selection. We collected exposure variables (determinants of delays in care) and outcome variables (childhood cancer-related mortality) from several large datasets. Data were analysed with regression models to identify determinants of delays in care that contribute to childhood cancer mortality. Significant indicators were aggregated into domains according to the socio-ecological model. We used geospatial tools to summarise and compare the composite vulnerability index scores across countries.

Findings: We found that life expectancy, maternal education, fertility rate, availability of pathology services, bone marrow transplantation capacity, availability of treatment services (chemotherapy, radiotherapy, or surgery), number of pharmacists per 10 000 population, country income level, and out-of-pocket health expenditure were significantly associated with cancer mortality for children in LMICs. The highest levels of vulnerability were found in sub-Saharan Africa.

Interpretation: Our composite vulnerability index can potentially serve as a valuable policy decision tool to help monitor country performance and guide interventions to reduce delays in care for children with cancer in LMICs.

Funding: None.

Translations: For the Chinese, Portuguese, Arabic, Spanish and Swahili translations of the abstract see Supplementary Materials section.

MeSH terms

  • Africa South of the Sahara
  • Child
  • Developing Countries*
  • Humans
  • Life Expectancy
  • Neoplasms* / therapy