services in most countries. When looking at the price of radiotherapy treatment compared with incomes in LMICs, the cost is staggering and most patients, having no health insurance, would find it impossible to pay for treatment on their own. 19 The inability to pay for treatment could create a different form of inaccessibility that prevents even those in close proximity to a cancer centre from receiving treatment. Even in LMICs that maintain government owned radiotherapy facilities with the potential to provide therapy for free or at a negligible cost to the patient, services at these facilities are commonly paid for through social security fees, which could make treatment unattainable for the poorest members of society [1.10]. For those who can afford social security, the economic cost of treatment is then shared with the government. When governments bear a portion of the cancer treatment cost, it is generally for procuring and maintaining radiotherapy equipment, maintaining facilities and paying staff. With some radiotherapy packages selling for up to US $4 million, and with building costs for a radiotherapy treatment room ranging from US $40 000 to US $1 million, many countries are deterred by the capital costs associated with initiating a national radiotherapy service [1.11]. In addition to these costs there are auxiliary costs for source replacement (for 60Co units or brachytherapy afterloaders) and QA procedures. Yet, despite these expenses, the administration of radiotherapy, when evaluated per fraction throughout the lifetime of a machine, is actually a relatively cost effective procedure. Even after factoring in all levels of costs related to the procurement, maintenance and operation of a machine, estimates place the cost per fraction for a 60Co machine at a median of US $4.87 and for linear accelerators (linacs) at a median of US $11.02, which, compared with chemotherapy costs which can reach over US $600 per treatment, are comparatively inexpensive [1.11]. With radiotherapy’s low fraction cost, it has been estimated that, when curative treatment has been received by an individual and upon his or her return to the workforce, the costs incurred by the government for providing this radiotherapy treatment will be regained in the form of that individual’s economic contribution (increasing the gross national income per capita as defined by the World Bank) over the course of a few years, with the exact number of years required depending on a country’s gross national income. The mean break-even point on a radiotherapy investment for low income, low middle and upper middle income countries is 12.1, 4.5 and 1.9 years, respectively [1.12]. When analysing results from treatment in high income countries, it is found that 60% of adult cancer patients are still alive five years after treatment, making the prospect of reaching these break-even points quite attainable [1.12]. In this respect, the cost of investing in a radiotherapy service will, in some cases, show future returns that provide a country with the potential to at least break even on its investment, making radiotherapy a cost effective solution to the growing cancer problem. However, it must also be noted that curative treatment is seldom administered in LMICs, as in the absence of public awareness and adequate cancer services, the majority of cases currently present with advanced stages, making palliative 20 radiotherapy and end of life care the only realistically possible form of treatment for most patients [1.9]. Outside the realm of costs, other challenges can arise in the establishment of a radiotherapy service, particularly in the selection and procurement of radiotherapy equipment. For LMICs, the radiotherapy manufacturer from which the government is purchasing a unit is generally located far from the purchasing country, most commonly in Europe or North America. Besides the additional transportation costs associated with shipping from distant locations, there are also issues that arise in terms of unit maintenance, particularly the length and extent of a unit’s warranty. If the warranty is inadequate, countries that are already operating with limited resources could be confronted with the need to replace a radioactive source or