Evaluation of the cancer plan

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

Abstract

The national cancer plan was launched by President Jacques Chirac in 2002 for the period 2003-2007. It had ambitious objectives for improving quality of care, increasing cancer survival and changing attitudes towards the disease. The cancer plan has been evaluated recently by two different instances on its financial aspects and on its medical and scientific results. The results are not up to the expectations but there has been a real progress in some domains.

Recent developments

Cancer is the first cause of mortality in France: a third of male mortality and a quarter of female mortality are due to cancer. For the past 25 years, the incidence has increased while the risk of mortality decreased. French survival rates are above the European average, but incidence rates are amongst the highest. The French health system is not considered as strong in preventive actions and in coordination of care. Another structural characteristic of cancer in France is that there are wide social and geographic inequalities in incidence and survival. 

The cancer plan for 2003- 2007 (see also HPM report "The cancer plan - 2003-2007") aimed to define a general and coherent strategy against cancer, identifying different domains of public intervention (prevention, screening, treatment, social support structures, training, research). It included 70 measures against cancer, grouped in 6 chapters. The general objectives were improving quality of care (in particular coordination of care), increasing survival (the target was to reduce the mortality by 20% in 5 years, in particular by developing prevention, screening and access to innovation) and changing attitudes towards the disease. The plan privileged organizational measures, but also increased significantly the available resources for prevention and screening programs, for better medical equipment, more hospital and care teams, for innovation and research. The measures announced represented 100 million Euros in 2003, and up to 640 million Euros in 2007. The financing was supposed to come from increased tobacco taxes. Around 3900 new jobs were announced, among them 1700 nurses and technicians, 500 doctors, 400 jobs destined to patients' support and 660 other jobs. 

The 2003-2007 cancer plan launched the creation of the French National Cancer Institute through the 2004 Public Health Act, to coordinate national policies to fight against cancer. Under the supervision of the Ministries of Health and Research, this institute was given the responsibility to bring together all stakeholders involved in the fight against cancer in France. In order to encourage collaboration and knowledge transfer between research and health care, special regional and inter-regional structures were created, bringing together hospitals and research teams in specialized centers (the "cancéropôles"). 

Two separate evaluations were carried out in 2008 in order to verify the financial sustainability of the plan and its results. The evaluation carried out by the Auditing Court (Cour des comptes) aimed to estimate the real cost of the plan and review what has been realized compared to these resource specific objectives. The evaluation carried out by the High Council of Public Health aimed to assess the relevance and coherence of the plan, as well as its results in terms of health outcomes and other care specific indicators. 

The results of these evaluations will contribute to develop a new strategic plan for the coming years. An advisory report was in the same time commissioned by President Nicolas Sarkozy to Pr Grunfeld in order to prepare the next cancer plan. Entitled "For a new momentum", it was completed in February.

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Providers

• Patients, Consumers

• Scientific Community

• Private Sector or Industry

Stakeholder positions

Generally speaking, the idea of a strong health policy against cancer reached the agreement of the population and other stakeholders. Nevertheless, the creation of a new national cancer institute created tensions among institutional actors who contested the central role given to the new agency. The position of the institute in implementing the plan was severely judged in recent years, particularly by the General Audit Office.

Actors and positions

Providers
Hospitals	very supportive		strongly opposed
Physicians	very supportive		strongly opposed
Other health professionals	very supportive		strongly opposed
Patients, Consumers
Patients' associations	very supportive		strongly opposed
Scientific Community
Researchers in oncology	very supportive		strongly opposed
Private Sector or Industry
Pharmaceutical industry	very supportive		strongly opposed
Other health industry	very supportive		strongly opposed
current    previous

Influences in policy making and legislation

The public health act in 2004 confirmed the cancer plan as one of the five strategic health plans in the country and officially created the national cancer institute. A certification procedure has been implemented for hospitals (in 2008), including norms of activity to concentrate cancer treatment and increase quality of care on a basis of "learning by doing".

Actors and influence

Providers
Hospitals	very strong		none
Physicians	very strong		none
Other health professionals	very strong		none
Patients, Consumers
Patients' associations	very strong		none
Scientific Community
Researchers in oncology	very strong		none
Private Sector or Industry
Pharmaceutical industry	very strong		none
Other health industry	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

The origin of the plan was a strong presidential impulsion in July 2002. A scientific orientation commission presented a list of policy proposals in January 2003. The final plan was announced in March 2003. From 2003 to 2005, the implementation was coordinated by a special transversal mission in Health Department. It became the responsibility of the national cancer institute when it was created in 2004.

Monitoring and evaluation

Auditing Court and High Council of Public Health evaluate cancer plan

Despite the fact that in the actual plan it was announced that there should be a strict annual follow-up of the progress made by a special committee, this was not implemented during the five years of execution. After a change in the first board of directors of the national cancer institute ("InCa") in 2007 and after the evaluation of the Auditing Court, the new InCa team published a first detailed report on the implementation of the plan. 

In 2008 the Auditing Court assessed this implementation but considered that the medical and scientific evaluation was out of its domain of expertise. Therefore the Minister of Health asked the High Council of Public Health. This second evaluation was finalised in January 2009, which is more than a year after the end of the plan. Yet, the performance of the research activities, very important part of the plan, could not at all be evaluated. The new agency to evaluate research does not have time either to do this evaluation. 

Both evaluation reports deplore the difficulty of assessing the real outcomes of the plan. Of course health impact was impossible to assess, as it represents a longer process than the duration of the plan. 

Cost of cancer plan

From the financial point of view, the real expenditure was neither separately monitored by the Department of Health nor by the health insurance funds. There was no formal contract/agreement between the Ministry of Health and the National Cancer Institute defining the objectives of the institute. The Auditing Court was very concerned about the lack of information on the real cost of the plan (in reality the tax on tobacco was not increased as much as announced) and the difficulty of judging the results in the absence of precise indicators on many aspects. The Court estimated that the budget devoted to cancer has increased about 4% (around 600 million Euros in 2007) due to the plan. Only half of the targeted increase in employment dedicated to cancer was realised, and there were significant delays in acquiring diagnosis and treatment equipment (MRI, scanners and radiotherapy). 

Two thirds of targets fully or partly achieved

The results based indicators planned to follow up the progress were only partly developed, and the epidemiological data which was supposed to be renewed and developed according to the plan, did not progress enough to provide necessary information on cancer after 2005. Therefore, it was impossible to assess precisely the real impact of the plan. The Court assesed that only one third of the 70 targets were considered as achieved, another third partly completed, and the last third just started to be tackled or were abandoned. Prevention against tobacco was one domain considered as successful, with successful measures such as rise in tobacco price and introduction of a smoking ban in all public places. 

The High Council of Public Health also judged globally the results as notable, but incomplete and perfectible. Like the Court, the High Council noted the positive results of prevention against tobacco. But in the case of prevention against alcohol consumption and work related cancers there has not been much progress. The amount of work necessary to renew epidemiological data was considered as underestimated, but significant progress has been noticed and some recommendations were made to go on. Screening programmes were extended for breast and colon cancer, but participation rates are still not at the targeted levels. The care coordination for cancer patients was reinforced and special recommendations were given for the diagnosis announcement, but the certification procedure and norms of activity were introduced rather late for hospitals (in 2008) and care protocols are still not unified between hospitals. 

Despite all the problems with monitoring the results and progress made, both the Auditing Court and the High Council of public health consider that the plan played a significant role in improving the prevention and quality of cancer care, advocating actions for preventing cancer and better treatment.

Demand for new cancer plan to ensure sustainability of measures taken so far

Both of the reports recommend a new cancer plan assuring the sustainability of actions, but ask for a stricter follow up and control of results. The High Council of Public Health suggests carrying out a complementary work to identify the data needs and development of new information systems. 

Need for stronger focus on health inequalities

Furthermore, the lack of measures in the 2003-2007 plan for reducing social and territorial inequalities in cancer incidence and mortality was considered as one of the weakest points of the plan. The High Council report suggests that, even if on average results progressed in many aspects, probably the gap between different social categories was widened during the period.

Expected outcome

Development of new cancer plan for 2009-2013

The results of the evaluations were used as inputs for an advisory report for improving the next cancer plan, which will cover the period 2009-2013. There are recommendations to sustain and reinforce some of the actions already started, notably on better treatment and screening. There are also a number of new measures proposed: such as to improve the coordination between hospitals and the family doctors and more generally physicians in ambulatory sector. Furthermore, the advisory report underlines the importance of tackling health inequalities, referring to WHO recommendations as well as developing socio-epidemiological data and coordinated national and local action. Other measures proposed concern supporting the life after cancer by fighting against discrimination and promotion of a more positive attitude towards cancer patients, better information about consequences of treatment, better organisation of returning to work and access to insurance and loans. 

Although the research activities and organisation, in particular the cancer centres (cancéropôles) were not properly evaluated in the first plan, the advisory report reasserts that cancer research has to be the driving force of innovation, confirms the role of the "cancéropôles" and recommends to improve the coordination between the National Cancer Institute and the National Institute for Health and Medical Research (INSERM).

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

References

Sources of Information

Mission interministérielle pour la lutte contre le cancer. Cancer: le plan de mobilisation nationale. 2003. www.e-cancer.fr/v1/fichiers/public/3_brochure_plan_cancer.pdf  

Haut conseil de la santé publique. Evaluation du plan cancer-rapport final. 2009. www.hcsp.fr/hcspi/docspdf/avisrapports/hcspr20090131_EvaluationCancer.pdf

Cour des comptes. La mise en œuvre du plan cancer. 2008. www.ccomptes.fr/fr/CC/documents/RPT/2008-RPT_Cancer_JO.pdf  

Grunfeld, Pr j.-P. Recommandations pour le plan cancer 200-2013, pour un nouvel élan. 2009. www.e-cancer.fr/v1/fichiers/public/rapport_grunfeld_104pges_srm_mars_2009_v3.pdf

Author/s and/or contributors to this survey

Cases, Chantal

IRDES

Suggested citation for this online article

Cases, Chantal. "Evaluation of the cancer plan". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/fr/a13/1