Unapređenja Kontrole Raka U Republici Srbiji Za Period 2020-2022. Godina

Objectives

The 2020–2022 Programme for Improving Cancer Control in the Republic of Serbia seeks to reduce cancer morbidity and mortality, extend life expectancy, and preserve quality of life during and after treatment through an integrated continuum from prevention and early detection to treatment, rehabilitation, supportive oncology and palliative care.[1][2]Its overall objective is to improve prevention, early diagnosis and modern treatment while increasing the number of people cured and improving outcomes for patients and families.[3][4]

• Reduce modifiable cancer risks, including tobacco use, harmful alcohol consumption, unhealthy diet, obesity, physical inactivity, risky sexual behaviour, infections, environmental pollution and exposure to carcinogens.[3][5]
• Strengthen primary prevention through hepatitis B immunisation, human papillomavirus vaccination, tobacco and alcohol control, healthier living environments and public health promotion.[5][6]
• Expand organised population screening for breast, cervical and colorectal cancer across Serbia, replacing uneven coverage and supporting earlier detection.[7][8]
• Improve equitable access to high-quality diagnosis, surgery, systemic treatment, radiotherapy, molecular testing and innovative medicines through modernised clinical pathways and multidisciplinary care.[9][10][11]
• Develop rehabilitation, survivorship, psycho-oncology, supportive oncology and palliative care that address physical, psychological, social, spiritual and existential needs.[12][13][14]
• Strengthen cancer registration and research to provide nationally comprehensive, internationally comparable information on incidence, treatment, stage and survival.[15][16]

The Programme sets measurable 2022 ambitions, including reducing the all-cancer mortality-to-incidence ratio from 0.49 to 0.45, reducing smoking prevalence among people aged 18 and over from 37% to 30%, and increasing hepatitis B immunisation coverage from 90% to 95%.[4]It also targets screening coverage of 22% for breast cancer, 45% for cervical cancer and 25% for colorectal cancer, compared with 2018 baselines of 12%, 35% and 10% respectively.[4]

Its strategic rationale reflects a substantial cancer burden and poorer outcomes than in much of Western Europe, particularly for lung, colorectal and cervical cancer.[17]Primary prevention is characterised as the most effective cancer-control approach, with potential to influence more than 80% of malignant diseases by preventing or modifying risk-factor exposure.[5]The selected policy direction combines prevention and early detection with strengthened treatment capacity, recognising that expanded screening must be matched by diagnostic, surgical, radiotherapy and oncology capacity.[18]

Implementation

Implementation is designed as a sustainable, coordinated, comprehensive and multidisciplinary health-system approach, linking national planning with regional and local service delivery.[3][19]The Ministry of Health leads the Programme, while the Institute of Public Health of Serbia, its Cancer Screening Office, public-health institutes, healthcare providers, the Republic Health Insurance Fund, expert commissions and other government bodies have defined roles in delivery, monitoring, financing or technical coordination.[20][19][21]

• Deliver prevention through existing legislation, national strategies and working groups for cancer and chronic non-communicable disease prevention, including tobacco-control and harmful-alcohol-use measures.[5][22][23]
• Organise breast, cervical and colorectal screening through primary healthcare centres, with hospital support, target-population invitations, defined screening tests, double reading of results and referral for confirmatory investigation where needed.[24][20][25]
• Expand breast-screening infrastructure towards 100 mammography units, use mobile units for dispersed populations, and provide continuous training for radiologists, technicians, cytoscreeners, internists and surgeons.[8][20]
• Use a tiered service model in which secondary hospitals provide routine chemotherapy and selected procedures, while tertiary institutions manage complex diagnostics, targeted biological therapies, immunotherapy and other specialised care.[26][27]
• Establish or strengthen tumour-specific multidisciplinary teams, including participation by tertiary specialists where local expertise is insufficient, and integrate psycho-oncology, palliative care and social support into cancer care.[28][11][29]
• Develop workforce capacity through specialist education, recruitment and certification, with an identified ambition to increase oncology specialists and subspecialists towards 250.[30][31]
• Improve information systems through a national population-based cancer registry, active and passive case finding, standardised coding, electronic data exchange and a separate childhood cancer registry.[32][15][33]

Governance combines national oversight with regional coordination. National and secondary oncology centres operate under the Ministry responsible for health and its oncology expert commission; the Cancer Screening Office coordinates site-specific screening; and responsible Institute centres monitor and evaluate oncology services.[19][21]The Ministry of Health, Ministry of Education, Science and Technological Development, Medicines and Medical Devices Agency, research organisations and ethics bodies are expected to cooperate on cancer research and clinical research governance.[34][21]

Monitoring uses structural and process indicators, programme implementation status, expenditure and indicator values against targets.[21][35]The Institute of Public Health of Serbia is to prepare annual concise monitoring reports using information submitted by responsible institutions, while final reporting is to cover objective achievement, expenditure, impact, outcome and output indicators, deviations and corrective recommendations.[35][36]Registry indicators include completeness, validity, histological or cytological verification, mortality-only registration and mortality-to-incidence ratios.[15][33]

Financing combines public budgets, Republic Health Insurance Fund resources, donations and other lawful sources.[35][37]Public budgets finance health promotion, screening, registries and research, while the Republic Health Insurance Fund finances outpatient and hospital oncology care, rehabilitation and palliative care.[35]A Ministry of Health budget allocation of 209,800,000 Serbian dinars is identified for 2020 programme activities.[37]The Action Plan additionally identifies Republic Health Insurance Fund allocations of 163,600,000 Serbian dinars for 2020, 1,039,600,000 Serbian dinars for 2021 and 1,354,000,000 Serbian dinars for 2022, alongside estimated Post of Serbia resources of 63,500 Serbian dinars in each of 2021 and 2022.[38]

Monitoring & Evaluation

The Programme establishes a multi-level monitoring and evaluation approach spanning prevention, screening, treatment, registries, rehabilitation and palliative care. It combines outcome indicators, service-performance measures, registry data, implementation-status reporting and institutional verification, although some programme sections do not specify detailed reporting cycles or accountability procedures.[4][39][21][35]

• Monitor 2022 outcome targets for the mortality-to-incidence ratio for all cancers, women and men, alongside smoking prevalence, hepatitis B immunisation coverage, screening coverage and alternative financing for human papillomavirus vaccination.[4]
• Track organised screening through invitation, participation, coverage, positivity, diagnostic follow-up and confirmed-cancer measures. Breast-screening data for 2016 to 2018 included 35 participating primary healthcare centres, 11.6% national target-population mammography coverage, a 34.4% average response to invitations, 8.4% suspected malignancy findings and 0.42% histopathologically confirmed findings.[20]
• Measure cervical-screening invitation coverage and participation, reported at approximately 52% and 59.9% respectively through 17 health centres, and assess colorectal screening through faecal immunochemical testing, colonoscopy participation, adenoma removal and cancer detection.[25]
• Use screening coverage of more than 75% of the target population as a desirable implementation benchmark, while recognising that reductions in mortality and advanced disease are not expected in the first years of organised screening.[29][40]
• Assess treatment performance through indicators such as average time to chemotherapy and the proportion of patients beginning radiotherapy within 28 days of indication. From January to June 2018, this proportion ranged from 31.6% for breast cancer to 45.6% for lung cancer among data reported by six radiotherapy centres.[41][42]
• Monitor waiting times, diagnostic delays, treatment scheduling, workforce capacity, diagnostic availability, molecular testing, multidisciplinary working and communication between secondary and tertiary care.[43][26][10]
• Evaluate implementation and updating of clinical guidelines and pathways, including the 32 clinical pathways developed in 2017, and conduct quantitative analysis of access to treatment.[42]
• Maintain the population-based cancer registry as a continuous source of data on incidence, prevalence, mortality, stage, initial treatment and overall survival, supporting service planning, prevention evaluation, research and assessment of direct and indirect oncology-care costs.[44]
• Improve registry completeness, validity, coding consistency, linkage and timeliness, using histological or cytological verification, death-certificate-only registration and mortality-to-incidence ratios as data-quality measures.[15][33]
• Expand registration to national coverage, improve notification forms and information exchange, and establish a dedicated national childhood cancer registry covering diagnoses before age 18, including benign central nervous system tumours.[15][45][16]
• Monitor alcohol-prevention progress through the indicators included in the national alcohol-prevention programme, and use vaccination coverage, population surveys, health-behaviour surveys, burden-of-disease estimates and cancer-registry data to assess prevention patterns.[23][6][46]
• Assess survivorship and rehabilitation needs, service feasibility, available staff and recurrence risk; monitor late treatment complications through survivorship programmes; and monitor and evaluate palliative-care service quality.[12][13]
• Assign the Cancer Screening Office to coordinate site-specific screening, the Institute’s responsible centres to monitor and evaluate oncology services, and the Ministry of Health to use regular Institute reports to adjust implementation.[21]
• Report implementation annually through a concise Institute of Public Health of Serbia report, using responsible institutions’ information on activity status, expenditure and indicators against targets. Include final reporting on objectives, expenditure relative to achievement, impact, outcome and output indicators, trends, deviations and corrective recommendations.[35][36]

Costing & Financing

Financing is intended to support the full cancer-control continuum, with public budgets funding health promotion, screening, secondary prevention, cancer registries and research, and Republic Health Insurance Fund resources funding outpatient and hospital oncology care, rehabilitation and palliative care. The Programme identifies substantial investment needs but provides limited quantified costing outside specified budget allocations.[35][37][38]

• Allocate 209,800,000 Serbian dinars under the Ministry of Health section of the 2020 budget for programme activities; the supplied material does not provide a breakdown of this allocation or a quantified funding gap.[37]
• Provide Republic Health Insurance Fund financial-plan allocations of 163,600,000 Serbian dinars for 2020, 1,039,600,000 Serbian dinars for 2021 and 1,354,000,000 Serbian dinars for 2022.[38]
• Include estimated resources of 63,500 Serbian dinars from funds allocated to Post of Serbia in each of 2021 and 2022.[38]
• Mobilise resources through the healthcare system, budgets of state bodies and institutions, donations and other lawful sources.[37]
• Maintain Republic Health Insurance Fund financing for qualifying innovative medicines through the C list and for financial compensation when tertiary-centre specialists support multidisciplinary teams outside their own institutions.[43][11]
• Recognise continuing access gaps for biological medicines, immunotherapy and innovative targeted treatments, despite Ministry of Health and Health Insurance Fund efforts to expand availability.[43][47]
• Finance mandatory immunisation from the Republic of Serbia budget, while human papillomavirus vaccination remains in the recommended immunisation programme and presents a financing challenge; planned legal changes seek to allow partial vaccine financing.[6]
• Address the fact that smoking-cessation medicines are not covered by the Republic Health Insurance Fund and that cessation counselling has limited reach.[48]
• Prioritise equipment, facilities, specialist staffing, workforce education, diagnostic capacity, radiotherapy, multidisciplinary services and modern medicines, as diagnosis and treatment are characterised as the most expensive programme component.[49][26][50]
• Plan implementation over the following three years because the necessary resources cannot be secured solely by redistributing existing funds. Initial expenditure is expected for diagnostic and therapeutic equipment, innovative antineoplastic medicines, staff education and recruitment, and expanded diagnostic and oncology services.[18]
• Anticipate that expanded screening will initially increase demand for biopsies, colonoscopy, imaging, histopathology and surgery, while economic benefits are expected only after repeated screening cycles through reduced advanced-stage treatment, fewer absences from work and shorter recovery.[29][18][51]
• Recognise maintenance and procurement of equipment and therapy provision as the largest oncology-cost components, while seeking rational use of existing and new treatment modalities and improved expenditure control.[52]