Adoption of the National Cancer Control Plan

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The cancer professional community and policymakers spent a lot of time developing a comprehensive cancer control plan and it was long overdue. Between June and September 2008 (with a later extension until the end of 2008!) there was an open public debate. Later, during 2009 additional consultations on the Plan took place. The final version is to be adopted by the Health Council by the end of 2009. This would enable enactment of certain programs and activities already in 2010.

Purpose of health policy or idea

These are the main goals of the National Cancer Control Plan:

1. To reduce age standardized incidence rates of cancer; acceptable increases are of 5% in men with respect to the rates of 2004/2005 and of 8% in women with respect to rates of 2003/2004,
2. To reduce age standardised mortality rates in men and women by 10% with respect to the rates of 2004/2005
3. To increase the 5-year relative survival in both sexes; for 10% in men and for 12% in women (between 2001-2005 and 2011-2015)
4. To increase the quality of life of patients through psychosocial and physical rehabilitation and to increase the share of those patients with advanced disease who get palliative care

These goals are expected to be achieved through several measures that are to be taken. They include activities in the field of primary prevention, secondary prevention, diagnostics and specific oncologic treatment, integral rehabilitation, palliative care, education, informatics, cost efficiency, participation of the civil society and coordination and control.

In order to advance the current situation to a higher level, it will also be necessary to clearly define criteria of cancer care for professionals and for providers (hospitals and diagnostic centres). These should include the minimum quantitative and qualitative requirements for these centres to be able to carry out cancer care. What needs to be stressed as one of the most important problems of the present situation is the lack of these criteria. Consequently, providers too often 'compete' in trying to get a number of cancer care programmes included in their annual contracts simply because this care is rather costly.

Primary prevention will focus on the promotion of healthy lifestyles, which have benefits for other chronic non-communicable diseases. On the other hand, advances are expected in addressing the use of tobacco and alcohol. In the field of secondary prevention the most important effort will be in supporting cancer screening programmes which should lead to higher percentages of early detectable cancers, especially cervical cancer, breast cancer and colon cancer. Following the criteria mentioned above, it will become a priority to define the relevant institutions for cancer care, where concentration and development of resources as well as sufficient turnover of patients are achieved to ensure cost-effective, high quality and safe cancer care. These efforts will be supplemented by the development of research and education as well as through the involvement of the civil society representing the different patient groups within the cancer field.

Main points

Main objectives

These are the main objectives of the National Cancer Control Plan (NCCP):

1. to reduce the number of new patients, increase survival and reduce the number of deaths due to cancer;
2. increase the impact of prevention, extend the preventative activities, ensure easy access to preventative services to all target population groups;
3. to ensure that quality specific and palliative care will be available to all patients;
4. to improve organization of oncological health care at all levels, increase human resources and equipment for diagnostics, treatment and rehabilitation of cancer patients;
5. to ensure and improve education of experts and to ensure good information to the broader public and its heightened awareness

The NCCP is supposed to provide the professional base for interventions at all levels that would lead towards the fulfilment of the goals mentioned above.The main advantage of the Plan is supposed to be its comprehensiveness over the previous partial activities related to the different locations of cancer in the human body.

Type of incentives

There should be the following incentives:

I. Financial

1. Investments in the selected infrastructure where achievements would assist in achieving the proposed goals and targets
2. Stimulating research in cancer and in all related fields and services

II. Non-financial

1. Better co-ordination of care across different levels
2. Cautious and precise delimitation of competencies in cancer management across the different involved institutions
3. A uniform information system for cancer and cancer care.
4. Intense involvement of the civil society

Groups affected

Cancer patients, Cancer professionals, Health Insurance Institute of Slovenia

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

The Slovenian NCCP is not an innovative document but it brings important structured knowledge to decisionmakers, who need to take decisions regarding each of the proposed elements. This includes in particular: screening programmes, policies related to new and innovative drugs for cancer and to the definition of reference and treatment centres for each or the principal cancers. In the case of cancers with a small incidence, the NCCP is pretty clear about requring centralisation of such specific cancers.

Political and economic background

Preparations of the NCCP have been intense over the period of 10 years. A change of government that took place in 2008 was an indirect stimulus for the speeding up of this important goal. The team preparing the Plan focused on:

1. structures and infrastructure to deliver the desired services and care
2. processes of care to be improved and evaluated for quality and cost-effectiveness
3. prevention of cancer
4. rehabilitation and palliative care

The economic background has not been evaluated in total. But it is estimated that the present approaches result in a fragmented service, which is rather costly and above all inefficient. Therefore, one of the most important proposals in the organization of cancer care is in the concentration of services in selected verified and strictly quality-controlled centres. Such an approach has already been used to structure and reorganise screening programmes for cervical and breast cancer (also see HPM 11/2008, "Launch of screening for breast and colon cancer").

Change based on an overall national health policy statement

Resolution of the National Health Plan 2008-2013

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

There has been a long process leading to the adoption of the present National Cancer Control Plan (NCCP). Cancer in terms of its management and financing occupies a particular place in the Slovenian healthcare system. It is a disease the management of which is fully covered by compulsory health insurance. This includes prevention, screening, diagnosis, treatment, rehabilitation and palliative care. For this reason there has been less pressure because of additional costs of treatment. On the other hand, there were problems in access to early diagnosis, certain types of treatment and also delays in the introduction of the recent screening programmes for breast and colon cancer. 

There have been divergent interests in cancer management across different types of providers. Due to the negotiation process between the Health Insurance Institute of Slovenia and representatives of different categories of providers, there was an exaggerated incentive in a race for treatments of more complex patients, among them cancer patients. This has led to deviations, such as setting up of mammography centres in small hospitals without adequate staff and eventually screening women who would normally not fulfil guideline inclusion criteria for screening. Sometimes discontinuity in patient treatment or disease management was observed. The National Institute of Oncology was faced with advanced diagnostics of false positive patients on inadequately performed screening tests.

Health policy ideas were therefore linked to:

1. Setting up of a multi-level programme that would stratify cancer management through primary, secondary and tertiary levels
2. Definition of criteria for each of the phases in the process of cancer management - quality criteria, criteria for diagnosis and treatment, eligible institutions for treatment
3. More efficient providers of cancer care with enough experience in the cancers they are managing
4. Stressing the importance of the central cancer institute as well as the need to have suited approaches according to incidence and location of cancer

The NCCP was initiated both by the policymakers in health care and by the cancer community. The latter was trying to achieve a more equitable distribution of providers of cancer care, while at the same time quality control criteria should ensure that the quality of care provided by a qualified provider would be according to national standards. All screening programmes should be centrally managed and monitored and closely linked to the national cancer registry. The Slovenian National Cancer Registry is one of the oldest institutions of its kind in Europe and even in the world as it was established back in 1950 and has been running in continuation ever since.

Initiators of idea/main actors

• Regierung: Co-initiator and supervisor of the preparation of cancer plan

• Patienten, Verbraucher

• Wissenschaft

Approach of idea

The approach of the idea is described as:
renewed: Inspired by policy actions in other countries, such as the UK, Sweden

Stakeholder positions

The idea of adopting a NCCP was generally seen as positive and as a step forward by all relevant stakeholders and it was not facing specific objections. The main problems related to its adoption and expected implementation were related to:

1. Relatively high total costs of cancer management
2. Problems related to the introduction of cancer screening programmes for breast and colon cancer were of concern because of the potential complexities and increased demand for each step in the cancer management process.
3. Cancer medications were a particular problem, partly related to a lengthy process of evaluation of new and innovative medicines for public funds, where patients need to wait for a particular drug to be screened and ranked according to the provisional national HTA criteria. These waiting times often exceed four or even six months and are beyond the usual times tolerated by EMEA.
4. Research in cancer in Slovenia is relatively centralised and focuses on a few selected institutions - University Clinical Centres in Ljubljana and Maribor, the National Institute of Oncology and the Clinic for Pulmonary Diseases and Allergy.

Actors and positions

Regierung
Ministry of Health	sehr unterstützend		stark dagegen
Health Insurance Institute of Slovenia	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Cancer patients	sehr unterstützend		stark dagegen
Wissenschaft
Cancer care professionals	sehr unterstützend		stark dagegen

Influences in policy making and legislation

The main formal output is the document, the NCCP itself. It will serve as the base for action according to its clearly defined elements. Public discussion regarding this document has produced a lot of useful feedback, which has been incorporated or taken account of in the preparation of the final version of the document.

The main controversy among providers was related to the concentration of influence and also delivery of care among a few selected providers. As much as this is clearly a rational move, it has brought some negative feedback to the document, often for the loss of influence in the treatment of patients with a serious and publicly visible disease.

Legislative outcome

pending

Actors and influence

Regierung
Ministry of Health	sehr groß		kein
Health Insurance Institute of Slovenia	sehr groß		kein
Patienten, Verbraucher
Cancer patients	sehr groß		kein
Wissenschaft
Cancer care professionals	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

 

Monitoring and evaluation

 

Results of evaluation

 

Expected outcome

 

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

This Plan will provide a sound base for:

1. Future work in all aspects and phases of cancer management
2. A revision of healthcare providers currently providing care but not meeting all the future standard and criteria for inclusion among cancer care providers
3. Particular attention to be given to the maintaining of the cancer registry and epidemiology supported by this registry and all activities related to cancer
4. Enactment of several measures that should facilitate a more equitable treatment for all cancer patients and easen their access to the care they need

References

Sources of Information

1. Državni program nadzora raka v Sloveniji (National Cancer Control Plan). Ministry of Health of Slovenia.
2. Health Services Act. Official Gazette of the Republic of Slovenia 1992.
3. Health Care and Health Insurance Act. Official Gazette of the Republic of Slovenia 1992.
4. Cancer incidence in Slovenia 2006, Ljubljana: Institute of Oncology Ljubljana, Cancer Registry of Republic of Slovenia, 2009.

Author/s and/or contributors to this survey

Tit Albreht

 

Empfohlene Zitierweise für diesen Online-Artikel:

Albreht, Tit. "Adoption of the National Cancer Control Plan". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/si/a14/3