Based on experience in a first set of cities across Africa, Asia, Eastern Europe and Latin America, this article highlights key challenges and enablers for translating policy into practice for quality, equitable cancer care.
- Programmatic strategies to address complex health challenges can be accelerated by enabling a policy environment.
- In the cancer care context, relevant policy including laws, regulations and legal frameworks are an important component in advancing innovative, sustainable solutions to improve access to quality care.
- Policy implementation can be limited by a number of barriers in the areas of resources, planning and coordination, leadership and ownership, measurement and accountability, and political economy.
- City Cancer Challenge’s experience in a first set of cities has demonstrated that fostering strong local leadership, ownership and engagement are key strategies in mitigating these barriers and ensuring translation of policy to practice.
The planning and implementation of programmatic strategies to address health challenges is often viewed in isolation, but equally important is ensuring an enabling policy environment. The [US] Centers for Disease Control and Prevention’s list of “Ten Great Public Health Achievements”—including motor vehicle safety, tobacco control, and maternal and infant health—all involved policy change (Porter 2018).
A holistic view of what is needed to drive successful health programme implementation, including policy change, political commitment, and multisectoral partnerships (Frieden 2014) is consistent with a health systems approach that considers all six health systems pillars (WHO 2007) and their interconnectedness. Similarly, tackling the global cancer burden, which totalled 19.3 million new cases and 9.96 deaths in 2020 (Ferlay et al. 2020), from a systems perspective, requires consideration of policy change that can support programmatic actions to address gaps in cancer care services and infrastructure.
Now operational in nine cities across Africa, Asia, Eastern Europe, and Latin America, the City Cancer Challenge (C/Can) Foundation supports cities to identify, design and implement local cancer care solutions that improve access to quality cancer care. C/Can’s “test, learn, adapt” approach has generated early learnings on the barriers and enablers of implementing programmatic and policy solutions for cancer care in low-and middle-income (LMI) cities. Based on experience in a first set of cities, this article highlights some of the barriers and enablers to translating policy solutions into practice for improved access to quality cancer care, with a focus on the need for local engagement, leadership, and ownership.
Policy Failure: Barriers to Implementation for Cancer Care
Health policy has been defined as an agreement on the health issues, goals, and objectives to be addressed at the international, national, or local level, the priorities among those objectives, and the main directions for achieving them (WHO Regional Office for Europe 1999). In the cancer control context, policy (in the form of laws, legal frameworks, and domestic regulations) can have a powerful influence on the exposure of individuals and communities to risk factors, such as tobacco and alcohol; equitable access to core cancer care services; collection and use of health information; and experiences of people affected by cancer (McCabe Centre 2021).
During a recent forum on the opportunities to accelerate cancer care using digital health solutions, thought leaders from across regions and sectors agreed on the need for new or updated regulations and legislative frameworks to facilitate the uptake of digital health interventions. Such policies can be enablers for innovative solutions by creating a common acceptance of digital technologies and by supporting decision-makers with guidance, particularly regarding data governance and privacy. C/Can’s Digital Health Discovery Forum, also underscored that whilst in some contexts, the COVID-19 pandemic had triggered the development of new policies such as broadened criteria for telemedicine (Brazil) or expanded insurance coverage for telehealth consultations (Australia), in other contexts, legislation is not strongly developed or implemented.
Literature documenting the challenges of developing and implementing effective healthcare policies has emphasised that “policies do not succeed or fail on their own merits; rather their progress is dependent upon the process of implementation” (Hudson 2019). Underestimation of the delivery challenges including lack of human and financial resources; insufficient evidence base; misalignment of stakeholder views and conflicting interests; and accountability challenges are often cited as key barriers to translating policy to action. Table 1 summarises five areas of consideration for policy implementation that are frequently observed as barriers/enablers.
In a recent dialogue convened by C/Can on “the Future of National Cancer Law in Latin America” legislators, academics and analysts from Argentina, Chile, Peru and Uruguay, where national cancer laws are at different stages of development, identified several of these barriers in the cancer context. In Chile for example, where a new cancer law has recently been adopted, one of the key barriers to its development and implementation has been the misconception that cancer can only be addressed at the Ministry of Health level. Engagement of all key stakeholders, and particularly local civil society has been an important success factor.
Bridging the Policy Implementation Gap for Cancer Care: Local Leadership and Ownership
Locally led development and health policies that place value on listening to local actors, understanding local systems, and supporting local leadership are being increasingly recognised as critical for achieving long-term, sustainable impact (USAID 2019). This principle has been validated by early experience in developing and implementing policies that support improved access to quality cancer care in C/Can’s cities.
Spotlight on Implementing Guidelines for Invasive Breast and Cervical Cancers
Implementing clinical guidelines for the management of invasive breast and cervical cancers is key to ensuring that patients receive the best quality care within the particular context of the city. This has been identified as a gap across many of the cities with which C/Can works and is being addressed through city-led projects to develop and implement locally appropriate guidelines. C/Can’s technical cooperation support for these projects has focused on creating multidisciplinary, multisectoral city-wide expert networks that share knowledge and expertise through hands-on workshops, expert consultations, and mentoring. A web-based initiative launched in 2020 with Project ECHO has also facilitated city-to-city discussions on this topic and sharing of best practices among 85+ cancer care professionals from nine cities. Common success factors identified for the uptake and implementation of clinical guidelines for invasive breast and cervical cancers included:
- Development of guidelines should be informed by robust local data gathered in a comprehensive situation assessment.
- Establishing a broad and inclusive guidelines development team from the outset is critical even if it delays the drafting process.
- Review and adaptation of guidelines is a multistep process that should be done using a participatory, multidisciplinary, and multi-institutional approach.
- It is important to involve not only the most relevant cancer care experts but also patient representatives and local decision makers and payers early on.
In C/Can’s first city - Cali, Colombia - guidelines for the management of invasive breast and cervical cancers have been developed through locally led project teams with support from the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS).
“The five guidelines that have been developed in Cali with the multidisciplinary work of health professionals are timely and very useful. When they are finalised, we should think about regulating them through the departmental cancer committee so that they can be implemented in a generalised manner and have the greatest impact on improving the quality of care for cancer patients” (Dr María Cristina Lesmes, Secretary of Health, Valle del Cauca).
What Next? Test, Learn, Adapt
As C/Can’s network of cities continues to expand and city projects mature, so too does the opportunity to better understand key drivers and barriers to effective implementation - and critically, how to sustain implementation over time. By committing to a rigorous cycle of monitoring and evaluation C/Can aims to systematically capture learning and best practices that can be shared and adapted among cities, and ultimately contribute to an evidence-base for locally led policy solutions for cancer care.
Conflict of Interest