Strategija Za Prevenciju, Tretman I Kontrolu Malignih Neoplazmi

Objectives

The Strategy for the Prevention, Treatment and Control of Malignant Neoplasms in the Federation of Bosnia and Herzegovina 2012–2020 provides a comprehensive framework to reduce cancer incidence and mortality, alleviate suffering, improve the quality of life of patients and families, reduce inequalities, and use health resources efficiently.[1][2]It responds to cancer’s substantial health, social and financial burden, recognising that prevention, early diagnosis and appropriate treatment can substantially improve outcomes.[3]

• Reduce the incidence of malignant neoplasms through health promotion, prevention and reduced exposure to behavioural, environmental, occupational and infectious risk factors.[4][5]
• Ensure early detection and organised screening, particularly for breast, cervical and colorectal cancer, integrated into routine primary health care.[4][6][7]
• Provide timely, evidence-based, accessible and quality-assured diagnosis, treatment, rehabilitation and follow-up tailored to patients’ needs.[8][9]
• Provide effective palliative care that controls pain and other symptoms, offers psychosocial support, and enables dignified end-of-life care in the most appropriate setting.[10][11]
• Establish comprehensive cancer registration, continuous data collection, monitoring, evaluation and research to guide effective cancer control.[4][12]

Prevention priorities include strengthening personal responsibility for health; promoting healthy diets, physical activity and healthy weight; reducing tobacco and harmful alcohol use; limiting harmful ultraviolet exposure; improving environmental and occupational health; and expanding hepatitis B and human papillomavirus immunisation.[5][13]The Strategy also promotes prevention across the life course, healthy public policies and universal access to health promotion, prevention and health services.[14]

The Strategy sets measurable long-term prevention ambitions, including a 10% reduction in regular smoking, harmful alcohol use, overweight and obesity, alongside a 10% increase in regular physical activity.[13]It seeks the highest feasible human papillomavirus vaccination coverage, safer food and water, and air pollution within safe limits.[13]

For secondary prevention, the Strategy aims to increase early-stage diagnosis to two-thirds of newly diagnosed tumours, reduce invasive colorectal and cervical cancers and late-stage breast cancer by 10%, and achieve screening coverage of 80% for breast cancer, 70% for cervical cancer and 70% for colorectal cancer in defined target age groups.[15]It also seeks a 10% reduction in overall cancer mortality and in mortality from selected cancers.[15]

For treatment, the Strategy aims to develop and implement standards for diagnosis, treatment and care for at least the ten most common cancers, increase survival, and improve physical, mental, occupational and social rehabilitation.[8][9]For palliative care, a stated outcome is adequate pain control for 90% of oncology patients, supported by improved access to opioid analgesics and community, hospice and inpatient services.[11]

Implementation

Implementation combines a whole-of-government, multisectoral and phased approach across prevention, screening, diagnosis, treatment, palliative care, registry development and research.[16][17]The Federal Ministry of Health leads, supervises and coordinates implementation, supported by an Expert Coordination Commission for Cancer Control and, where required, working groups for each strategic objective and action area.[17]

• Develop annual operational plans that assess the current situation, define objectives, organisational arrangements, staffing, resource needs, financial calculations, implementation actions, supervision, control and evaluation.[18]
• Prioritise interventions that improve use of existing resources, then pursue feasible medium-term resource expansion and subsequently implement actions dependent on additional resources.[18]
• Coordinate delivery with cantonal health ministries, public health institutes, health and social care institutions, health insurance bodies, professional associations, universities, local authorities, non-governmental organisations, donors and international partners.[18][19]
• Establish cantonal commissions to monitor implementation at cantonal level and coordinate professional and scientific institutions through phased annual plans.[18]

Prevention delivery relies on intersectoral health promotion, regulatory measures, public education, schools, workplaces, primary health care, community organisations and media engagement.[20][21][22]Tobacco-control action includes enforcing restrictions on tobacco use, advertising and sponsorship, strengthening smoke-free protection, supporting cessation, increasing taxation and implementing obligations under the Framework Convention on Tobacco Control.[23][21]

Screening programmes are to move from opportunistic and time-limited projects to organised, population-based, continuous programmes with defined standards, invitations, trained staff, equipment, referral protocols, access for marginalised groups and guaranteed diagnostic assessment and treatment for positive findings.[24][25][26][27]Screening implementation is phased according to available financial, human-resource and technical capacity.[25]

Diagnosis and treatment are to be delivered through integrated, multidisciplinary and patient-oriented services, supported by evidence-based clinical pathways, organisational standards, quality assurance, technology development, capital investment and workforce plans.[28][29]The Strategy calls for a referral oncology centre in the Federation and harmonised treatment across oncology centres.[9]Diagnosis and staging should be established within one month of serious suspicion, and specific oncology treatment should begin no later than one month after diagnosis.[9]

Palliative care is to be organised through primary care, social-health palliative institutions and dedicated hospital departments, using interdisciplinary teams, pain clinics, community care, rehabilitation, hospices and centres for specialised analgesic procedures.[30][11]The planned palliative-care strategy is intended to define its organisation, coordination, financing and access arrangements.[30]

The cancer information system is to define a core dataset, indicators, data-exchange protocols, nomenclature, data definitions, privacy safeguards, terminology, communication and security standards, and unique patient identification within the unified health information system.[12][31]A population-based registry should link population and treatment data to assess inequalities, screening effects, clinical care, treatment outcomes and survival.[32]

Monitoring uses process and outcome indicators covering prevention, screening coverage, early-stage diagnosis, cancer incidence, mortality, survival, service capacity, workforce, technology, beds, treatment standards and quality.[33][17]Monitoring results are to be compiled in annual progress reports for the Federal Ministry of Health and the Government of the Federation of Bosnia and Herzegovina, while the Ministry evaluates results with cantonal ministries and public health institutes using reports from the Expert Coordination Commission.[17][18]

Each operational plan must include a financial calculation and resource requirements.[18]Implementation and preparation are to be financed through the legal responsibilities of the Federation, cantons and municipalities, supplemented by Instrument for Pre-accession Assistance projects, European Union funds and donations; no monetary allocations or total budget are specified.[18]

Monitoring & Evaluation

The Strategy establishes comprehensive, continuous cancer data collection, monitoring and evaluation across prevention, screening, diagnosis, treatment, palliative care and research. It combines population-based cancer registration, activity and outcome indicators, annual reporting, continuous monitoring and periodic independent review to assess progress and revise implementation where necessary.[5][12][33][17]

• Establish a population-based cancer registry with agreed methodologies, protocols, standards, information flows, coordination, continuing education and a target of 95% coverage.[12][31]
• Define a core dataset and indicator set consistent with international recommendations, including nomenclature, data definitions, exchange protocols, data protection, terminology, communication and security standards, and unique patient identification within the unified health information system.[12][34][31][35]
• Implement the Cancer Health Information System and produce annual reports using the defined dataset and indicators.[36][31][35]
• Monitor cancer incidence, mortality, survival, exposure to carcinogens and risk factors, health inequalities, and the workforce, infrastructure, bed capacity, technical resources and organisation of cancer services.[32][33]
• Use cancer registry data linked with clinical, pathological and palliative-care databases to evaluate screening effects, treatment outcomes, clinical guidelines, care models and population-level survival.[32][33]
• Assess treatment outcomes through mechanisms for quality assurance and control of diagnosis and treatment, with all cancer-treatment and control institutions responsible for evaluating treatment results.[8][10]
• Monitor secondary prevention through early-stage versus advanced-stage diagnosis, screening coverage, reductions in invasive colorectal and cervical cancers, late-stage breast cancer and cancer mortality.[15][24]
• Track screening coverage targets of 80% for breast cancer among women aged 50–70, 70% for cervical cancer among women aged 21–60, and 70% for colorectal cancer among people aged 50–74.[15]
• Track service timeliness by establishing diagnosis and disease stage within one month of serious suspicion and starting specific oncology treatment no later than one month after diagnosis.[9]
• Measure palliative-care implementation through development of a strategy and standards, service-network milestones, medicine availability, clinician education and certification, improved quality of life, and adequate pain control for 90% of oncology patients.[11][19]
• Report annual progress to the Federal Ministry of Health and the Government of the Federation of Bosnia and Herzegovina. Evaluate results through the Federal Ministry of Health, working with cantonal health ministries and public health institutes, on the basis of reports from the Expert Coordination Commission for Cancer Control in the Federation of Bosnia and Herzegovina.[17][18]

Monitoring also covers implementation of risk-factor interventions, including tobacco control, nutrition, alcohol prevention, reproductive and sexual health, environmental protection and public campaigns. Relevant measures include enforcement inspections and penalties, campaign and training activity, participation, distributed materials, media engagement, programme quality and immunisation coverage.[21][37][22][38][39]

Data-quality limitations constrain interpretation: registry reporting coverage has been incomplete, incidence data have not been age-standardised, regional variation may reflect diagnostic and reporting differences, and available data have lacked specialist analysis of survival duration. Mortality trends are considered more reliable than reported incidence where institutional reporting is lower than expected.[40][41][2]

The Strategy specifies numerous indicators and reporting outputs, but does not provide a complete audit methodology, detailed indicator definitions for every objective, or a comprehensive evaluation timetable beyond short-, medium- and long-term phases.[15][11][35]

Costing & Financing

The Strategy adopts economy, affordability, sustainability and effective use of available resources as financing principles. It requires operational plans to identify staffing and resource needs and include financial calculations, but the supplied material provides no overall cancer-control budget, costed programme package, quantified funding gap or detailed economic assumptions.[42][43][18]

• Finance implementation through the legal obligations and responsibilities of the Federation, cantons and municipalities, supplemented by development projects, Instrument for Pre-accession Assistance projects, European Union funds and donations.[18]
• Develop financial plans and assess premises, staffing, equipment and financing when preparing population screening programmes.[26][27]
• Phase screening according to available financial, human-resource and technical capacity, while planning capital investment, health-technology development and workforce development for cancer diagnosis, treatment and control.[25][9][44]
• Invest in screening equipment, trained personnel, consumables, maintenance and servicing to integrate continuous screening into routine healthcare.[7]
• Increase radiotherapy capacity, renew depreciated equipment and establish depreciation funds, recognising that overloaded capacity contributes to delays and quality-assurance constraints.[45]
• Use central financing through the Federal Solidarity Fund for systemic medicines, while addressing supply interruptions and waiting lists associated with expanding costs, reduced financial capacity and market conditions for innovative targeted therapies.[45]
• Determine financing arrangements for palliative care through the planned palliative-care strategy, including resources for staff, medicines, opioid analgesics, education, community care, hospices and institutional networks.[11][30]
• Consider continuous financing for health-promotion interventions from existing budgetary funds raised through taxation of high-tariff goods.[6]
• Resource the population-based registry through dedicated professional time, continuing education, information-technology support and human and financial resources.[36][34]

The broader economic context includes constrained access to resources and services because of unemployment, poverty and social exclusion, while a dependency ratio of 47.3% is identified as a challenge for health-care financing. In 2009, gross domestic product per person was 5,487 convertible marks and the average net salary was 792.08 convertible marks.[46]

Cancer and other non-communicable diseases generate direct and indirect costs through health-care spending, reduced income, early retirement, social protection needs, absenteeism and lower productivity. Health promotion and prevention receive a relatively small share of government and health-system budgets, a constraint identified for particular attention.[16][14]

Screening is described as having favourable cost-benefit potential only when programmes are well designed, reach the whole target population and maintain quality throughout delivery.[24]