This cross-national study used global health system data from WHO, World Bank, DIRAC, UNDP, and IARC to identify health system factors independently associated with lower mortality-to-incidence (M:I) ratios for cancers of the trachea, bronchus, and lung.
In a multivariable model, health spending, nurse/midwife density, universal health coverage index, and radiotherapy center density were each independently associated with lower lung cancer M:I ratio; physician density showed a small positive (adverse) adjusted association.
Ecological study design limits causal inference — associations reflect country-level averages, not individual patients. Key confounders such as smoking prevalence, stage at diagnosis, and histologic subtype distribution across countries are not accounted for. Data quality varies substantially across WHO and World Bank sources, especially in low- and middle-income countries.
Health system planners should prioritize investments in nursing workforce, radiotherapy infrastructure, and universal health coverage to reduce lung cancer mortality — these factors showed independent benefit beyond physician density alone.
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