Background and purpose The lack of equitable access to radiotherapy (RA) linear accelerators (LINACs) is a substantial barrier to cancer care in low‐ and middle‐income countries (LMICs). These nations are expected to bear up to 75% of cancer‐related deaths globally by 2030. State‐of‐the‐art LINACs in LMICs experience major issues in terms of robustness, with mechanical and electrical breakdowns resulting in downtimes ranging from days to months. While existing research has identified the higher failure frequency and downtimes between LMICs (Nigeria, Botswana) compared to high‐income countries (HICs, the UK), there has been a need for additional data and study particularly relating to multileaf collimators (MLCs). Materials and methods This study presents for the first time the analysis of data gathered through a dedicated survey and workshop including participants from 14 Indonesian hospitals, representing a total of 19 LINACs. We show the pathways to failure of radiotherapy LINACs and frequency of breakdowns with a focus on the MLC subsystem. Results This dataset shows that LINACs throughout Indonesia are out of operation for seven times longer than HICs, and the mean time between failures of a LINAC in Indonesia is 341.58 h or about 14 days. Furthermore, of the LINACs with an MLC fitted, % of all mechanical faults are due to the MLC, and % of cases requiring a replacement component are related to the MLC. Conclusion These results highlight the pressing need to improve robustness of RT technology for use in LMICs, highlighting the MLC as a particularly problematic component. This work motivates a reassessment of the current generation of RT LINACs and demonstrates the need for dedicated efforts toward a future where cancer treatment technology is robust for use in all environments where it is needed.

The lack of equitable access to radiotherapy linear accelerators (LINACs) is a substantial barrier to cancer care in Low and Middle-Income Countries (LMICs). Aside from the issue of cost, there are also issues of robustness of state-of-the-art LINACs in LMICs, which are subject to mechanical and electrical breakdowns, which can result in downtimes ranging from days to months. Recent research has identified disparities in failure frequency and downtimes between LMICs (Nigeria, Botswana) and a High-Income Countries (HIC, the UK), and highlighted the need for additional data and study particularly relating to Multi-Leaf Collimators (MLCs). This study analyses data from 14 Indonesian Hospitals with a total of 19 LINACs, and shows the pathways to failure of radiotherapy LINACs and frequency of breakdowns with an additional focus on the Multi-Leaf Collimator (MLC) subsystem. We found that LINACs through Indonesia are down for 7 times longer than HICs and the Mean Time Between Failures of a LINAC in Indonesia is 341.58 Hours, or about 14 days. Furthermore, of the LINACs with an MLC fitted, 59.02 +1.98 −1.61 % of mechanical faults are due to the MLC and 57.14 +0.78 −1.27 % of the time a component needs to be replaced, it is related to the MLC. These results outline the need to reassess the current generation of RT LINACs and ultimately work towards guiding future designs to be robust enough for all environments.

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