© 2001 by Oxford University Press
Journal of the National Cancer Institute, Vol. 93, No. 16, 1195-1198,
August 15, 2001
© 2001 Oxford University Press
NEWS |
Canadians Push National Cancer Strategy
Challenged by troubling trends in cancer incidence and mortality along with growing national criticism of cancer services, Canadian groups are going on the offensive.
With a new comprehensive national cancer plan, the Canadian Strategy for Cancer Control, a group of that country’s largest cancer-related organizations is preparing for what will perhaps be its biggest battle: convincing provincial and territorial government officials to adopt and implement their proposals.
"As a nation, the cancer burden is getting incrementally worse with time," said Simon Sutcliffe, M.D., president and chief executive officer of the British Columbia Cancer Agency. "There is a growing awareness that cancer control programs vary by province and the population does not have the same opportunities for cancer control."
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Cancer is the number one cause of premature death in Canada, with one of every two Canadians diagnosed with cancer expected to die of the disease. Meanwhile, one of every three Canadians is expected to develop cancer at some point during his or her lifetime. Current projections suggest that aging of the Canadian population will contribute to a 70% increase in cancer incidence over the next 10 years.
However, of Canada’s 10 provinces and three territories, two—New Brunswick and Prince Edward Island—do not have provincial cancer coordinating agencies. Ontario moved to dismantle its provincial agency, Cancer Care Ontario, and restructure the delivery of cancer services, while Quebec has only recently established a cancer coordinating council.
Strategic Priorities
In July, the steering committee for the national cancer plan decided to establish a national council that reserves at least a quarter of its membership for cancer activists/survivors. It also identified five key national "strategic priorities" for immediate implementation. These include establishing evidence-based national standards, primary prevention systems, reforms in cancer care, a human resource strategy, and identifying research priorities for investing resources (see box).
In addition, the plan defines roles and responsibilities, develops mechanisms for translational research, and outlines procedures for identifying and supporting new research areas and partnerships. But unlike many other national plans, it is not a laundry list of specific goals using target numbers, percentages, and rates.
Politically Sensitive
Don Carlow, M.D., chief executive officer of the British Columbia-based Canadian Association of Provincial Cancer Registries (CAPCA), said that worries over federal encroachment on provincial health care authority required a more sensitive approach.
"There will naturally be varying capabilities in following through because the provinces set their own priorities," Carlow said. "This document is there to coordinate and provide advice; to try to create and work on things together."
For these same reasons, said Barbara Kaminsky, chief executive officer of the British Columbia and Yukon Division of the Canadian Cancer Society, plan framers working with cancer officials from the federal public health agency, Health Canada, were likewise less apt to estimate costs and dictate budgets.
"If you came up with a directed plan for each province, there would be little likelihood they would accept it," said Kaminsky. "We believe that Health Canada should have a strong leadership role, but people there are also all too aware of the fact that if they appear to be driving this process the provinces will perhaps just in principle disagree."
Federal Linkages
Neil Berman, D. Phil., manager of Health Canada’s Strategic Partnerships Office in that agency’s Cancer Division, acknowledged that the adoption process is "complex and tough" in a system where the lines between federal and provincial authority require "a lot of jurisdictions to get on board." (See box for more information on the Canadian health system.)
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According to Berman, provincial deputy health ministers will consider the strategy during their next biannual meeting in December. Many provincial officials are in a "wait and see mode" but may be convinced that the plan can be linked cost-effectively to existing national initiatives for AIDS, heart disease, diabetes, and palliative care.
"A publicly funded system is both an advantage and also an Achilles’ heel," Berman said. He concedes that Canadian cancer patients sometimes face treatment delays necessitating trips to the United States. Although these trips may be inconvenient, in Canada, "getting cancer doesn’t mean you’re necessarily going to go bankrupt," he said.
Although the publicly funded approach ensures universal access to care, limits the costs of drugs and professional services, and provides comprehensive national health data, it has also led to difficulties in meeting the demand for services and in equitably distributing resources.
While planners consulted national plans developed in the United Kingdom (see News, April 4, p. 496) and more than 10 other countries, Berman and others pointed out that the Canadian plan had to address the unique "shared responsibilities" between the federal and provincial governments to garner national support.
"Work-in-Progress"
Nevertheless, Kaminsky, Sutcliffe and others say that while having unanimous provincial support for the national plan would be ideal, without it they will still move forward in implementing as many of their recommendations as possible.
"The idea is to move . . . toward a more comprehensive approach," said Berman, adding that the plan is essentially a "work in progress" designed to meet both new and existing geographic, political, organizational, and grassroots priorities.
For example, at the federal level, recommendations could be implemented in areas under direct federal jurisdiction, such as overseeing cancer-related health care for native groups and also speeding up the cancer drug approval process.
But in a universal health care system fraught with geographic and political balkanization, many Canadian cancer advocates wonder if the plan is strong enough to make a difference while at the same time garnering provincial support.
"I don’t have any doubt that when you put together all the cancer control knowledge and leadership we have in this country we know what needs to be done but lack the political will to do it," said Pat Kelly, founder of the Cancer Advocacy Coalition of Canada. "We have a system driven by partisan politics, economics, and outdated management approaches.
"We have community groups with no budget at all taking care of people in church basements, breast cancer patients sharing wigs, and people baking casseroles for the families of cancer patients. Next we’ll be having bake sales to buy MRI machines," she added.
In addition to establishing more specific national benchmarks, Kelly supports the appointment of a federal adviser who would report directly to Canada’s federal health minister and be responsible for coordinating the Strategy. Even more important, the federal government must take the lead in both funding and ensuring that the proposals are implemented nationally, she said.
Cultural Differences
Della Wilson, a First Nations cancer advocate and Strategy working group participant living at Gipanmaxx, a remote federal reservation in northern British Columbia, echoed Kelly.
"We need more accountability and transparency with respect to cancer resources. There is little or no cancer care delivery in remote areas. Here in the north, we have nothing," Wilson said. She also acknowledged the "critical need" for a national strategy, adding that the views of cancer activists and survivors, especially minorities, have not been adequately included in the plan.
The Cancer Society’s Kaminsky concedes that cancer survivors and activists were not initially brought into the "inner sanctum" of planning, but explained that it was due to "lack of a mechanism and not a lack of desire."
But Strategy steering committee member and New Brunswick activist Liz Whamond said it has been difficult to influence policymakers by identifying, unifying, and mobilizing grassroots activists.
"You have to have pressure to get the government to do anything, and, unfortunately, that’s not historically been part of the Canadian cancer advocacy culture," Whamond said.
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