Cancer programs evaluation - breast cancer program

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

As described in report (11)2008 several actions were undertaken to implement the National Program against Cancer Diseases, focusing particularly on cancer disease prevention. One of the widest screening actions was the mammography program for women aged 40 and older. Diagnostic tests have been provided to all women who wanted to check themselves and personally addressed invitations were sent to all individuals in the selected group. Evaluation showed implementation problems.

Neue Entwicklungen

The program following the Law on the National Program against Cancer Diseases for 2006-2015 (issued on July 1, 2005) was launched on January 1, 2006. As it was described in survey (8)2006, the purpose/outcome of the policy is to lower mortality resulting from cancer diseases through the implementation of European standards (early diagnosis indicators, treatment effectiveness and through the permanent monitoring of effectiveness). The Program obliged the MoH to create schedules for the year 2006 (and later on for the following years). For the implementation of the programs on cancer disease prevention and the National Program on cancer diseases as a whole (see also survey (11)2008) the responsible body was the Oncology Centre of Warsaw, contracted by the MoH. Among the goals included in the long-term program from July 2005 are:

• stopping the growth of cancer diseases cases;
• implementation of average European indicators in the sphere of early diagnosis; and
• creation of a permanent monitoring system for cancer prevention and the effectiveness of combating actions at the national and regional level.

Apart from the general objectives mentioned above the Program against Cancer Diseases enumerated 10 particular goals - for the described issue the most important are:

• Implementation of early population screening programs, especially concerning breast cancer, cervical, intestine cancer and selected cancer forms among children;
• Access to early cancer diagnosis methods, implementation of proper quality diagnostics and improvement of therapeutic procedures;
• Purchase of new equipment and exchange of old diagnostic and therapeutic equipment; 
• Dissemination and popularisation of complementary treatment methods;
• Development and dissemination of professional training methods, by including oncology education in the first stages of curricula for nurses, midwives and other health care professionals; and
• Popularisation of the knowledge on prevention, early diagnosis methods and cancer treatment among the Polish population.

The Council on Cancer Diseases was appointed to realize the programs (compare with report (8)2006). The Council was establised, among other purposes, to take on an advisory role with regard to financial resources needed for the realisation of the program as well as the sphere of necessary program activities. In case of the evaluation of the breast cancer screening, the provision on the Council opinion on the requirements for the competition offers takes a special place (for the purpose of the realisation of the prevention activities, public order procedures were not applicable - if included into a particular preventive program).

Screening tests turn out to be failure due to lack of professional competencies

The Oncology Centre started evaluation of the finished actions. One of the finished assessment processes was the breast cancer prevention program, especially the part concerning screening tests - mammography. Just this month the results of the evaluation process have been presented to the MoH, NHF and to the public, unsurprisingly widely commented by the media because the evaluation results showed that the diagnostic tests to a large extent were a failure.

The main purpose of the prevention programs, and also of the breast cancer prevention program that focused on screening tests, is to eliminate or to diminish risk factors for the development or progression of the disease in the future due to the early diagnosis. As the evaluation of the described program has proven, the effects were often quite the opposite. The selected technology and equipment was of high quality but the main problem was a lack of professional competencies on the side of the medical personnel.

The overall policy concerning cancer prevention may be defined as rather traditional (see the previous report National Program on Cancer. Primary Prevention) but the evaluation results from the implementation of the breast cancer screening program call for new solutions, a change of attitude to the issue of pre-authorization for health care units (professional competencies, ability to use technology). In the context of funding and goals, apart from MoH, also scientific institutes, researchers and medical professionals were involved in the implementation process. The last group, in many cases, was no prepared to realize the program. 

The policy aimed at a new systemic approach expected to save women's lives but also financial resources in the health care system in a long-term perspective. The cases of wrong performance in this particular program may cause the government (mainly MoH) problems when trying to introduce similar programs. The public visibility of the policy has to be defined as high, also due to media commenting on the evaluation results, and special programs with invited guests commenting on the issue (professionals, health care managers, NHF and researchers).

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

The original policy idea should be characterized as rather innovative, but at the hereby reported stage the preventive approach seems to become traditional. For the realization of goals, however, innovative methods and instruments are needed. Concerning the degree of controversy of this policy idea, the concept is still not questionned despite the evaluation results. The problematic spheres are the lack of competencies and ability particular providers to realize the program. On the health care system the policy will possibly have an important impact: changes in NHF contracts structure. Public visibility as far is quite high and in this matter no changes are expected: media will not lose such occassion for the public interest concentration on shocking news. The future development of the policy depends on systemic resources: not only finances but also (in case of some health care providers in the first place) human resources and professional competencies and skills. 

Purpose and process analysis

Current Process Stages

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

Initiators of idea/main actors

• Regierung: MoH established the Oncology Centre that was responsible for the coordination of the program and for evaluation of the proper implementation of the program and results of policy assessment (made also by external institutions).

• Leistungserbringer: Providers and medical professionals supported the idea - especially oncologists but in the contemporary situation their opinions on the program implementation influence attitude towards the policy development. They expect changes concerning money and NHF contracts.

• Kostenträger: Aiming at spending reductions (lower treatment costs and long-term care due to preventive screening) NHF supported the policy but now it is clear that in the sphere of brest cancer prevention some money was spent for nothing.

• Patienten, Verbraucher: Patients, after getting information from the media, may lose their trust in such prevention initiatives and this may be very difficult to change in future. As a consequence they can reject participation in similar programs as time consuming and useless.

• Bürgergesellschaft: For NGOs involved in the prevention of breast cancer the current situation brings difficulties in attempts for involving women in actions aiming at preventive diagnostics. NGOs support the above mentioned policy change - ie. that contracts only be made with highly qualified providers.

• Wissenschaft: Researchers and oncologists expect more control in the health services contracting process (adequately to evaluation results). They are aware of the negative impact that failures of preventive programs can have and would support more evidence-based decisions in this sphere.

• Medien: Media informed the public on the evaluation results and they will probably monitor the following policy development. Especially public broadcasts that were deeply egaged in the dissemination of information on the issue will play a great role.

Stakeholder positions

MoH will have to react to the current situation - as far the MoH did not issue any specific comments but there was an announcement of the necessary changes and  MoH actions concerning future solutions to avoid such mistakes. The MoH stated that the criteria for contracting health services with providers in case of such programs should be "more precise" and that the level of skills of medical professionals employed in healthcare units contracting such tests should be checked as well. Nothing however has happened yet - or at least is not visible.

Providers in general and in particular medical professionals (oncologists) supported the idea not only for systemic and "ideological" reasons but also because of the increase in finances for oncology. At the moment however quite different opinions can be heard from different sides: all the medical centres and health care units that turned out not to correspond with the professional requirements (and consequently  diagnostic tests done there were done wrongly and could not be treated as reliable) have not reacted yet. Mainly all the providers expect changes concerning new NHF contracts. NHF will probably not sign new contracts with providers that were proved to fail in diagnosis often.

Patients, as it was underlined before, may lose their confidence in the effectivity and necessity of preventive programs and this may influence the frequency of participation in future programs and actions.

It seems to be necessary for NGOs involved in the prevention of breast cancer to work harder on attempts for involving women in preventive diagnostics and they will support the idea of NHF contracts only for providers that are able to prove ability to perform such actions.

Media will not change attitude: the TV and press, including professional papers, will inform the public on the evaluation results and monitor the policy development.

Actors and positions

Regierung
MoH	sehr unterstützend		stark dagegen
Leistungserbringer
Medical doctors	sehr unterstützend		stark dagegen
Oncologists	sehr unterstützend		stark dagegen
Kostenträger
NHF	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patients	sehr unterstützend		stark dagegen
Bürgergesellschaft
NGO's	sehr unterstützend		stark dagegen
Wissenschaft
Oncology research centres	sehr unterstützend		stark dagegen
Medical universities	sehr unterstützend		stark dagegen
Medien
TV and press	sehr unterstützend		stark dagegen
current    previous

Influences in policy making and legislation

The original policy - approach to preventive programs - has not changed but evaluation showed an essential aspect of such actions: prevention is not a magical word that heals all. Wrongly implemented it may also cost and, which is even worse, negatively influence patients' attitudes towards prophylactic tests. Professional knowledge and competencies are fundamental for proper realization of such programs and simply for realization of the assumed objectives.

Legislative outcome

n/a

Actors and influence

Regierung
MoH	sehr groß		kein
Leistungserbringer
Medical doctors	sehr groß		kein
Oncologists	sehr groß		kein
Kostenträger
NHF	sehr groß		kein
Patienten, Verbraucher
Patients	sehr groß		kein
Bürgergesellschaft
NGO's	sehr groß		kein
Wissenschaft
Oncology research centres	sehr groß		kein
Medical universities	sehr groß		kein
Medien
TV and press	sehr groß		kein
current    previous

Positions and Influences at a glance

Adoption and implementation

In the implementation process were involved providers and the above described evaluation institutions. Directly affected in the first place are patients - some of them having wrong diagnosis, further developing a disease. The impact on criticized providers will also be strong - it is likely to happen that they will not get new contracts. Indirectly influenced are payers: MoH and NHF. The decision on changes and new rules has to be made soon.

Monitoring and evaluation

This report describes the evaluation results for the program on breast cancer prevention, namely the mammography tests financed from the program for women aged 40 and over. The breast cancer prevention program is part of the policy reported in (8)2006 and (11)2008.

The evaluation will probably lead to policy change with respect to requirements for providers who want to carry out screening tests, and it will hopefully make the policy decision makers more considerate for instance in the development of such actions regarding the problem of prostate cancers. Of course no one questions the cancer disease prevention idea and the policy cannot be abolished, but the instruments, rules, and mechanisms have to be revised.

Expected outcome

The evaluation proved that with regard to the objectives, the health policy may achieve success - meaning a reduction in cancer mortality - only under the condition that the financial resources are spend properly. Hopefully the evaluation results of breast cancer prevention programs will prevent such failures in other programs.

Impact of this policy

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

Obviously, the impact on quality of health care services may be described as fundamental (in a negative sense - evaluation proved very low quality in many cases). The influence on system equity then is of minor significance: of course much more patients could have access to services but often without the expected results. The same applies to impact on the cost-efficiency relation, which is unquestionably very high. 

References

Sources of Information

The law from the 1st of July 2005 on the establishment of the long-term "National Program against Cancer Diseases". Published on 26th of July 2005 in O.J. No 143, clause 1200 (Dz.U. nr 143, poz. 1200).

The MoH Schedule for Realisation of Tasks included in the National Program against Cancer Diseases for 2006.

Primary Prevention Program, Conference Materials, March 13, 2007, Warsaw.

Department of Epidemiology and Cancer Prevention Oncology Centre - Institute website, www.onkologia.org.pl/pl/p/34/. Annual report.

Reform formerly reported in

National Program on Cancer, Primary Prevention Process Stages: Umsetzung, Gesetzgebung

Program on cancer disease prevention Process Stages: Umsetzung, Strategiepapier, Gesetzgebung

Author/s and/or contributors to this survey

Anna Mokrzycka

Lecturer and researcher at the Health Policy and Management Department, Institute of Public Health, Jagiellonian University. Research on social protection system, disability, health insurance. Phd in Social Protection and Labour Law.

Empfohlene Zitierweise für diesen Online-Artikel:

Anna Mokrzycka. "Cancer programs evaluation - breast cancer program". Health Policy Monitor, October 2008. Available at http://www.hpm.org/survey/pl/a12/5