Abstract
Background
Annually, over 131000 new cases of cancer have been identified in Iran, with an increasing trend that is predicted to grow by 40% by 2025. The most important contributing factors to this increase are the improvement of the health service delivery system, increased life expectancy, and the aging of the population. The aim of this study was to develop Iran's "National Cancer Control Program" (IrNCCP).
Methods
The present study is a cross-sectional study that was conducted in 2013 using the method of reviewing studies and documents and focused group discussions and a panel of experts. In this study, the available evidence related to cancer status and its care in Iran and other countries, as well as national and international upstream documents, were reviewed and analyzed. Then, by analyzing the current situation in Iran and other countries and conducting stakeholder analysis with the strategic planning approach, the IrNCCP was developed with a 12-year horizon consisting of goals, strategies, programs, and performance indicators.
Results
This program has 4 main components, including Prevention, Early Detection, Diagnosis and Treatment, and Supportive and Palliative care, as well as 7 supporting components including Governance and policy-making, Cancer Research, Developing facilities, equipment, and service delivery network, Providing and managing human resources, Providing and managing financial resources, Cancer information system management and registry, and Participation of NGOs, charities, and the private sector.
Conclusion
Iran's National Cancer Control Program has been developed comprehensively with cross-sectoral cooperation and stakeholder participation. However, like any long-term health intervention, strengthening its governance structure both in terms of implementation and achievement of expected goals and evaluation and modification during the implementation of the program is essential.
Keywords: Cancer control program, Cancer, Planning, Cancer Control, Cancer Planning
↑What is “already known” in this topic:
Due to the demographic characteristics and structure of the country's service delivery system, one of the most important non-communicable disease control programs is the National Cancer Control Program, which needs to be developed in the long term with a scientific approach and cross-sectoral cooperation and stakeholder participation.
→What this article adds:
• The IrNCCP has 4 main components, including Prevention, Early Detection, Diagnosis and Treatment, and Supportive and Palliative care, as well as 7 supporting components including Governance and policy-making, Cancer Research, Developing facilities, equipment, and service delivery network, Providing and managing human resources, Providing and managing financial resources, Cancer information system management and registry, and Participation of NGOs, charities, and the private sector.
• Strengthening the governance structure of the IrNCCP is necessary both in terms of full implementation of this program and achieving the expected goals and health outcomes, as well as in terms of evaluating the progress of this program and its improvement.
Introduction
Cancer was the first or second leading cause of premature deaths (30-69 years) in 134 out of 183 countries in 2016 (1). In 2020, over 19 million new cases of cancer were identified worldwide, and the Age Standardized Rate worldwide was 201. In the same year, Asia had the highest incidence (49.3%), highest mortality (58.3%), and the highest 5-year prevalence (40.8%) of cancer among all continents of the world ( 2). Estimates show an increasing trend in cancer burden by 2040, especially in developing countries (1).
In Iran, in 2020, over 131000 new cases of cancer were identified, which indicates an Age Standardized Rate of 152.7. While the annual reports published by the Cancer Department of the Ministry of Health in 2017 show a number of more than 135 thousand. In 2020, 79,000 deaths from cancer were estimated, reflecting Age Standardized Mortality rate of 94. The most prevalent cancers of both sexes were breast, stomach, colorectal, lung, and prostate, respectively (2). Estimates in Iran show that from 2016, the trend of cancers in Iran has been increasing and by 2025 will have a growth of more than 40%, although in some cancers, this growth will be more and in others, it will be less. This growth is expected to continue until 2040 when the number of cancers will more than double compared to 2020. It is important to note that over half of this growth (28.7%) is related to the population structure of Iran, which is different from European and American countries and similar to neighboring countries (3).
The range of services available for cancer includes primary prevention, screening, and early detection, diagnosis and treatment, and supportive and palliative care, in each of which cost-effective interventions have been identified worldwide. In many countries with access to adequate health services (mostly high-income countries); cancer mortality rates have dropped dramatically. Instead, the mortality rate is high in many countries, which mainly provide services to the cancer care spectrum. Instead, the death rate is high in many countries, which mainly provide end-of-life services from the cancer care spectrum.
The results of studies show that half of the cancers are preventable and there needs to be a plan for them (1). Cancer is at the top of the economic burden list of diseases (at least 2% of world GDP). Therefore, the share of the health budget will be severely diverted to it (4). This demonstrates the importance of national cancer control programs in countries to provide services that are effective, feasible and affordable and that can be adequately covered within a country's geographical area. Undoubtedly, the earlier diagnosis is made, and the disease is identified in the early and limited stages, the easier it is to treat and the possibility of complete control and recovery would be very high (1).
A cancer control program is a strategic program designed to meet the needs of the population in order to prevent, diagnose, and treat cancer as well as provide care for the patients. According to the guidelines of the World Health Organization, such a program is designed in a 4-step process, including a pre-planning stage and 3 planning stages (5). Also, designing this program in countries, like other health policies, will be carried out in a 5-stage cycle in which all stakeholders are present and its proper management, including the five principles of transparency, participation, accountability, comprehensiveness and capacity building, is very important (1). The results of studies in 2013 showed that in addition to the predictions about the burden of cancer and its importance, this disease in Iran also has special distinguishing features that need special attention from health policymakers. The main challenges of the Iranian health system regarding cancer management included the increase in cancer incidence in Iran, the weakness of the health system to deal with the future burden of cancer, diagnosing cancer at an advanced stage instead of early diagnosis, disproportionate allocation of funds and equipment to different departments and lack of attention to prevention and early detection and insufficient training for cancer human resources (2, 3, 6-12).
In addition to the above, setting a goal of a 25% reduction in premature deaths from non-communicable diseases by 2025 as one of the nine non-communicable disease control goals in the world (13) and many other international and national upstream commitments all led to cancer being considered as an important health problem in the country both as a part of non-communicable diseases as well as an independent disease and the development of a national cancer control program in 2013 was added to the agenda.
Methods
This research is a cross-sectional study and has been done by reviewing and analysis of upstream documents and conducting focus group discussions and expert panels.
The key informants' selection criteria for focus group discussions (FGDs) were: having educational and research experience in the field of cancer and non-communicable disease or having related academic education with more than 3 years of executive experience in the field of cancer management at national or local policy-making level (Ministry of Health headquarter, Medical Universities and Iran’sHealth Delivery Network). The data collection tool was a data extraction form that was designed and used to extract data from screened studies and upstream documents. In this form in addition to the specifications of each study or document, the main findings of the study were extracted and mentioned.
The method of data analysis was qualitative content analysis. Considering that in addition to using scientific methodology, the strategic planning process was carried out to conduct this research. The working method, which describes the actions taken, was summarized in continue:
In order to achieve the high goals of the health system and to promote comprehensive health, especially to reduce cancer mortality and burden, the Cancer Department of the Ministry of Health started developing the IrNCCP in 2013, with the participation of all stakeholders and experts and through face-to-face meetings and written opinion polls. In order to realize this program and also to systematize the decision-making and policy-making process, the National Cancer Committee was formed in March 2014, and it was decided that since the prevention and control of cancer is a multi-sectorial and long-term process and the guidelines and protocols of the World Health Organization have emphasized on it, the strategic planning approach be used to develop this program. For this purpose, the first national and international upstream documents were reviewed and analyzed. With regard to the national documents, upstream documents and laws and general policies governing the country and the health system were analyzed in order to orient the goals of the program in their direction of them. The main documents and policies analyzed for this program were as follows:
The fifth and sixth programs of political, economic, and socio-cultural development of the country (14, 15).
General health policies.
Vision Plan of 2025.
Comprehensive Scientific Health Map of the country
The regulatory law for part of the government's financial regulations.
Financial and transaction regulations of medical universities in the country.
National document for Prevention and Control of Non-Communicable Diseases (16).
Regarding the international documents and scientific orientations, upstream documents, guidelines, and international obligations were reviewed and analyzed. The most important of which were:
1.UN Sustainable Development Goals (17).
2.UHC2030 Objectives (18).
3.Global action plan for the prevention and control of NCDs 2013-2020 (13).
4.Cancer control: knowledge into action. WHO guide for effective program planning (5).
5.Cancer control framework in the Eastern Mediterranean region of the WHO (19, 16).
6.Seventieth World Health Assembly: Cancer prevention and control in the context of an integrated approach (20).
In the next step, the situation of Iran in terms of cancer burden and risk factors, as well as facilities and equipment, were analyzed with the help of specialized subcommittees, and the status of cancer service delivery as well as its distribution in the country, were identified. At the same time, a study was conducted on other countries and while examining the burden of the disease and its risk factors, the status of facilities, equipment and how to provide cancer care in them was extracted as a basis for comparing the situation in Iran with other countries. Also, the clinical guidelines for providing standard cancer care were reviewed. A stakeholder analysis was performed to find out the views of stakeholders involved in cancer planning. Stakeholders were first identified and then classified into two main groups of stakeholders outside the health system and stakeholders within the health system. Stakeholders outside the health system included organizations, institutions and individuals outside the health system, whether inside or outside the country and stakeholders within the health system, including organizations, institutions, associations, and individuals within the health system which were involved in the field of cancer management and control. The views and opinions of stakeholders about the program under development were obtained in various ways, including participating in meetings, sending correspondence, etc. One of the main methods for obtaining stakeholder opinions was to use specialized committees and subcommittees, which in some ways were the network of stakeholders of the program and withholding the meetings of these committees, the stages of program development (including setting goals, and determining strategies and programs) were completed with a 12-year horizon. In the process of developing each component of the program, first, the opinions of experts were gathered by holding a meeting with specialized subcommittees. In these meetings, the current situation and upstream requirements were first stated, and individuals as experts were consulted about challenges, priorities, goals, and strategies. In the next stage and after reaching a consensus on these programs, the opinions of experts of the Ministry of Health were obtained. Figure 1 shows the conceptual model used to develop the IrNCCP.
Figure 1.
IrNCCP conceptual framework
Finally, the Comprehensive IrNCCP was developed containing two general sections of main and supporting components, consisting of goals, strategies, programs, and performance indicators. It is worth mentioning that, after the declaration of the COVID-19 pandemic, according to the needs assessment conducted in March 2017, developing a cancer-specific guideline for COVID-19 prevention and care targeting the general population as well as the specialized groups became the agenda and after conducting the study phase and obtaining the opinion of experts, this guideline was prepared and announced.
Results
The IrNCCP has been developed in 11 components, of which 4 are main components, and 7 components support the main ones. The 4 main components include Prevention, Early Detection, Diagnosis and Treatment, and Supportive and Palliative care, and 7 supporting components include Governance and policy-making, Cancer Research, Developing facilities, equipment, and service delivery network, Providing and managing human resources, Providing and managing financial resources, Cancer information system management and registry, and Participation of NGOs, charities, and the private sector. The results of the existence of supporting components were studies that showed that most of these programs could not be implemented in full or even partially because they did not pay attention to the sections that support the main sections. The results of studies show that 81% of the member countries of the World Health Organization have plans to control cancer, but only 10% of them have been funded and implemented (1). Table 1-Table 11 demonstrate the details of this program listed separately in goals, strategies, and programs as well as performance indicators for each of the components.
Table 1. Summary of Goals, Strategies, Programs, and Performance indicators related to “Governance and policy-making” (G)1.
| Performance Indicators |
|
|||
|---|---|---|---|---|
| Goal 1 (G-G1): Management based on planning and priorities | ||||
| Strategy 1 (G-G1S1) Having a comprehensive national program |
G-G1S1P1 | Developing the “National Cancer Control Program” document | ||
| Goal 2 (G-G2): Determination of the program governance at the national level | ||||
| Strategy 1 (G-G2S1) Having a unified, appropriate and efficient organizational structure at the national level |
G-G2S1P1 | Establishing the “National Cancer Control Center” | ||
| Goal 3 (G-G3): Obtaining legal support for cancer management programs | ||||
| Strategy 1 (G-G3S1) Identifying notices and instructions inconsistent with the upstream documents in the field of cancer and correcting them at the level of the Ministry of Health |
G-G3S1P1 | Review and identify notices and instructions inconsistent with upstream documents for all the eleven components of cancer management | ||
| Strategy 2 (G-G3S2) Correcting laws incompatible with cancer control |
G-G3S2P1 | Review and identify laws that are incompatible with cancer control and correcting them | ||
| Strategy 3 (G-G3S3) Include legal measures to control cancer in upstream laws |
G-G3S3P1 | Develop and adopt new upstream laws to improve cancer control in the general population and care for patients and their families | ||
1.The letter G is the first letter of the word Governance, which is used to indicate the goals, strategies and programs of this section
In developing the IrNCCP, performance indicators to assess the achievements of each of the components of this program were extracted with the consensus of stakeholders so that the program could be monitored.
Table 2. Summary of Goals, Strategies, Programs, and Performance indicators related to “Cancer Research” (R)1.
| Performance Indicators |
|
|||
|---|---|---|---|---|
| Goal 1 (R-G1): Identify the current position and future prospects of cancer research | ||||
| Strategy 1 (R-G1S1) Evaluate the current situation, and identify deficiencies and needs and planning for cancer research |
R-G1S1P1 | Preparing a comprehensive document for the development of cancer research in Iran | ||
| R-G1S1P2 | Determining national priorities for cancer research | |||
| Goal 2 (R-G2): Facilitate and develop cancer research in all its dimensions | ||||
| Strategy 1 (R-G2S1) Policy-making to optimize research conditions in the field of cancer |
R-G2S1P1 | Determining cancer research hubs to delegate national and regional research missions | ||
| R-G2S1P2 | Effective presence or membership in international cancer-related organizations (including the International Agency for Research on Cancer, IARC) | |||
| R-G2S1P3 | Implement incentive policies in evaluating centers that propose and implement projects based on national needs in the field of cancer | |||
| R-G2S1P4 | Facilitate the licensing process and establishment of non-governmental research centers in the field of cancer | |||
| R-G2S1P5 | Incentive policies for linking two or more central databases to conduct data-driven research as well as research that is based on artificial intelligence | |||
| Strategy 2 (R-G2S2) Balanced development and distribution of cancer research infrastructure and facilities |
R-G2S2P1 | Centralized supply and distribution of consumer and capital equipment in accordance with the mission of cancer research hubs | ||
| R-G2S2P2 | Development of cancer biobanks | |||
| R-G2S2P3 | Quantitative and qualitative development of research laboratories | |||
| R-G2S2P4 | Establishment of governmental or non-governmental research service centers | |||
| Strategy 3 (R-G2S3) Improving the credibility of cancer research and their optimal distribution |
R-G2S3P1 | Increase the funding and allocate special funds to cancer research projects | ||
| R-G2S3P2 | Prioritize research grants for applied priority projects related to the National Cancer Control Program | |||
| R-G2S3P3 | Involve NGOs, charities and private sector in investing in cancer research in the form of social responsibility | |||
| Goal 3 (R-G3): Develop cancer research to meet national needs | ||||
| Strategy 1 (R-G3S1) Order and participate in conducting research required for policy-making and planning in the field of cancer |
R-G3S1P1 | Define research based on the priorities and prerequisites of the National Cancer Control Program and order them to research centers | ||
| R-G3S1P2 | Define research based on regional priorities and order them to cancer research hubs | |||
| R-G3S1P3 | Identify technological, product-oriented and new needs in the field of cancer and announce or order them to universities and research centers | |||
| R-G3S1P4 | Define and assign research based on existing databases | |||
1.The letter R is the first letter of the word Research, which is used to indicate the goals, strategies and programs of this section
Table 3. Summary of Goals, Strategies, Programs, and Performance indicators related to “Development of facilities, equipment and service delivery net-work” (I)1.
| Performance Indicators |
|
|||
|---|---|---|---|---|
| Goal 1 (I-G1): Identifying priorities for cancer equipment and infrastructure | ||||
| Strategy 1 (I-G1S1) Needs assessment for cancer equipment and infrastructure |
I-G1S1P1 | Spatial program and preparing the document for the development of the national cancer care network (cancer facilities, equipment and infrastructure) | ||
| Goal 2 (I-G2): Improving the standards of facilities, equipment and centers delivering cancer services | ||||
| Strategy 1 (I-G2S1) Standardization of the facilities, equipment and infrastructure for cancer care |
I-G2S1P1 | Preparing, announcing and implementing the regulations for the establishment and exploitation of cancer centers | ||
| Goal 3 (I-G3): Equitable access to facilities, equipment and, services | ||||
| Strategy 1 (I-G3S1) Improving existing cancer infrastructure according to the standards of “Development of National Cancer Care Network” document |
I-G3S1P1 | Development of existing cancer centers to be upgraded to the standard type of “chemotherapy outpatient center” | ||
| I-G3S1P2 | Development of existing cancer centers to be upgraded to the standard type “center for the diagnosis and treatment of cancer” (Type 2) | |||
| I-G3S1P3 | Development of existing cancer centers to be upgraded to the standard type of “comprehensive cancer center” (Type 3) | |||
| I-G3S1P4 | Development of existing cancer centers to include “outpatient supportive and palliative care center” | |||
| Strategy 2 (I-G3S2) Infrastructure development to establish new cancer centers according to the standards of “Development of National Cancer Care Network” document |
I-G3S2P1 | Development of “centers for prevention and early detection of cancer” (Type 1) | ||
| I-G3S2P2 | Development of “centers for the diagnosis and treatment of cancer” (Type 2) | |||
| I-G3S2P3 | Development of “comprehensive cancer centers” (Type 3) | |||
| Strategy 3 (I-G3S3) Equipping cancer centers according to the standards of “Development of National Cancer Care Network” document |
I-G3S3P1 | Equipping “outpatient chemotherapy centers” | ||
| I-G3S3P2 | Equipping “centers for prevention and early detection of cancer” (Type 1) | |||
| I-G3S3P3 | Equipping “centers for the diagnosis and treatment of cancer” (Type 2) (existing and new ones) | |||
| I-G3S3P4 | Equipping “comprehensive cancer centers” (Type 3) (existing and new ones) | |||
| I-G3S3P5 | Equipping “outpatient supportive and palliative care centers” | |||
| I-G3S3P6 | Development of Cancer Laboratory Network and Establishment of “cancer reference laboratory” | |||
| Strategy 4 (I-G3S4) Facilitating access to novel medications and treatments for cancer |
I-G3S4P1 | Provide access to modern, effective and cost-effective systemic treatments | ||
| I-G3S4P2 | Provide access to radiopharmaceuticals effective in the diagnosis and treatment of cancer | |||
| I-G3S4P3 | Improving access to effective therapies in supportive and palliative care, especially oral opioids | |||
| Strategy 5 (I-G3S5) Provide consumer equipment for cancer care programs |
I-G3S5P1 | Providing consumer equipment for cancer prevention and early detection programs (including cervical HPV testing and biopsy equipment and FIT set) | ||
| I-G3S5P2 | Provision of equipment for cancer diagnosis and treatment programs (including equipment required for automatic and semi-automatic closed methods of chemotherapy preparation, radiotherapy fixation, etc.) | |||
1.The letter I is the first letter of the word Infrastructure, which is used to indicate the goals, strategies and programs of this section
Table 4. Summary of Goals, Strategies, Programs, and Performance indicators related to “Providing and managing Human resources” (H)1.
| Performance Indicators |
|
|||
|---|---|---|---|---|
| Goal 1 (H-G1): Identify the priorities of supply and empowerment of human resources | ||||
| Strategy 1 (H-G1S1) Cancer human resource needs assessment |
H-G1S1P1 | Geo-spatial program and preparing a document for the development of human resources in the field of cancer | ||
| Goal 2 (H-G2): Expanding the oncology knowledge | ||||
| Strategy 1 (H-G2S1) Expanding knowledge of cancer control |
H-G2S1P1 | Designing a cancer control training course | ||
| H-G2S1P2 | Designing an information management and cancer registration training course | |||
| H-G2S1P3 | Designing a cancer research training course | |||
| Strategy 2 (H-G2S2) Expanding knowledge of cancer care |
H-G2S2P1 | Designing training courses on cancer prevention and early detection (including for service providers at the health network level and for specialized groups) | ||
| H-G2S2P2 | Designing cancer diagnosis and treatment courses (including chemotherapy, radiotherapy physics, auditing and quality assurance of radiotherapy) | |||
| H-G2S2P3 | Design of cancer supportive and palliative care training courses (including for nurses, general practitioners, psychology and nutrition graduates) | |||
| Goal 3 (H-G3): Having capable human resources in all aspects of the cancer control and care program | ||||
| Strategy 1 (H-G3S1) Human resource training |
H-G3S1P1 | Holding vocational skills training courses | ||
| Strategy 2 (H-G3S2) Identify and compensate for human resource shortages |
H-G3S2P1 | Recruiting human resources in service centers | ||
1The letter H is the first letter of the word Human resources, which is used to indicate the goals, strategies and programs of this section.
Table 5. Summary of Goals, Strategies, Programs, and Performance indicators related to “Providing and managing Financial resources” (F)1.
| Performance Indicators |
|
|||
|---|---|---|---|---|
| Goal 1 (F-G1): Having sustainable financial resources | ||||
| Strategy 1 (F-G1S1) Estimating and providing required financial resources |
F-G1S1P1 | Estimation of the required financial resources of the programs according to the “National Cancer Control Program Document” | ||
| F-G1S1P2 | Estimating the net price of new and high-demand services | |||
| Goal 2 (F-G2): Optimized resource management through the improved access to services | ||||
| Strategy 1 (F-G2S1) Balancing the tariff of essential services in the field of cancer |
F-G2S1P1 | Reforming the tariff for cancer pathology services based on net price | ||
| F-G2S1P2 | Reforming the tariff for cancer radiology servicesbased on net price | |||
| F-G2S1P3 | Reforming the tariff for cancer surgery services based on net price | |||
| F-G2S1P4 | Reforming the tariff for radiotherapy services based on net price | |||
| F-G2S1P5 | Reforming the tariff for chemotherapy services based on net price | |||
| Strategy 2 (F-G2S2) An approach based on increasing the insurance coverage of basic and high-demand services |
F-G2S2P1 | Development of a basic cancer insurance package | ||
| F-G2S2P2 | Increasing the insurance coverage of prevention and early detection services in the form of national programs and referral system | |||
| Strategy 3 (F-G2S3) An approach based on increasing the number of cost-effective services covered by insurance |
F-G2S3P1 | Payment and insurance coverage based on HPV-Pop Smear test service standard | ||
| F-G2S3P2 | Payment and insurance coverage based on service standard of radiotherapy by arch therapy (IMRT and VMAT) | |||
| F-G2S3P3 | Payment and insurance coverage based on service standard of radiotherapy by stereotactic radiosurgery (SRS and SBRT) | |||
| F-G2S3P4 | Payment and insurance coverage based on service standard of radiotherapy by particle therapy (carbon and proton) | |||
| F-G2S3P5 | Payment and insurance coverage based on the service standard of special reconstructive surgeries for cancer patients | |||
| F-G2S3P6 | Payment and insurance coverage based on the standard of prescribing cost-effective new drugs | |||
| Goal 3 (F-G3): Optimized resource management through the participation in service standardization with an insurance and tariff approach | ||||
| Strategy 1 (F-G3S1) A payment approach based on guidelines and service standardsguidelines and standards of services |
F-G3S1P1 | Payment and insurance coverage of services based on prescribing and providing services in accordance with guidelines and standards | ||
| Strategy 2 (F-G3S2) A payment approach based on service leveling |
F-G3S2P1 | Payment and insurance coverage of services based on service leveling in accordance with standards, especially in the form of referral system | ||
| Strategy 3 (F-G3S3) An approach based on service package payment |
F-G3S3P1 | Payment and insurance coverage based on the standard package of supportive and palliative care tariffs with emphasis on outpatient services and home care | ||
| F-G3S3P2 | Payment and insurance coverage based on the standard package of radiotherapy service tariffs in accordance with the type of cancer and the affected organ | |||
| F-G3S3P3 | Payment and insurance coverage based on the standard package of multidisciplinary consultations | |||
| Strategy 4 (F-G3S4) An approach based on incentive payment for standard service providers |
F-G3S4P1 | Incentive payment for service providers of national cancer early detection programs in the form of electronic registration and referral system | ||
| F-G3S4P2 | Incentive payment for pathology service providers in the form of electronic registration of structured reports | |||
| F-G3S4P3 | Incentive payment for prescribers of chemotherapy prescriptions in the form of electronic registration of protocols and prescriptions | |||
| F-G3S4P4 | Incentive payment for radiotherapy service providers in the form of electronic treatment plan registration | |||
| Strategy 5 (F-G3S5) An approach based on incentive payment for standard centers |
F-G3S5P1 | Higher payment for centers with higher standards based on accreditation | ||
| Goal 4 (F-G4): Financial protection of service recipients | ||||
| Strategy 1 (F-G4S1) Management and consolidation of supportive financial resources |
F-G4S1P1 | Development and implementation of financial support packages for cancer patients | ||
1The letter F is the first letter of the word Financial resources, which is used to indicate the goals, strategies and programs of this section.
Table 6. Summary of Goals, Strategies, Programs, and Performance indicators related to “Cancer information management system and registry” (RI)1.
| Performance Indicators |
|
|||
|---|---|---|---|---|
| Goal 1 (RI-G1): Integrated policy-making for cancer information system and registration | ||||
| Strategy 1 (RI-G1S1) Determine the governance and policy-making reference of the cancer information management and registration program |
RI-G1S1P1 | Integrated and coordinated management of cancer information and registration at the national and university levels | ||
| Goal 2 (RI-G2): Having a comprehensive and integrated information infrastructure | ||||
| Strategy 1 (RI-G2S1) Designing an integrated cancer information management system (CIMA) |
RI-G2S1P1 | Developing the system for recording basic cancer information: Population Based Cancer Registration (PBCR) | ||
| RI-G2S1P2 | Developing the system for recording essential cancer information: disease stage (T, N) based on structured pathology reports | |||
| RI-G2S1P3 | Developing the system for recording essential cancer information: Early detection of cancer | |||
| RI-G2S1P4 | Developing the system for recording essential cancer information: Clinical Based Cancer Registration (CBCR) including diagnosis, stage of the disease (T, N, M), survival, medical, pharmacological, and palliative care | |||
| RI-G2S1P5 | Developing the system for exchanging information with the main systems of the health system | |||
| RI-G2S1P6 | Developing the system for recording information regarding infrastructure, equipment, service centers, support and charity centers and human resources in all aspects of the national program | |||
| RI-G2S1P7 | Developing the system for recording comprehensive information of research centers, researches, research projects and cancer researchers | |||
| Goal 3 (RI-G3): Improving the standards of cancer information management system and registration | ||||
| Strategy 1 (RI-G3S1) Standardization of cancer information registration |
RI-G3S1P1 | Developing protocols for Population Based Cancer Registration (PBCR) | ||
| RI-G3S1P2 | Developing protocols for recording structured pathology reports | |||
| RI-G3S1P3 | Developing protocols for recording cancer early detection information | |||
| RI-G3S1P4 | Developing protocols for Clinical Based Cancer Registration (CBCR) | |||
| Strategy 2 (RI-G3S2) Standardization of cancer information exchange |
RI-G3S2P1 | Developing the document for the exchange of unstructured pathology reports with laboratory information systems (LIS) | ||
| RI-G3S2P2 | Developing the document for the exchange of structured pathology reports with laboratory information systems (LIS) | |||
| RI-G3S2P3 | Developing the document for the exchange of death and survival information with death registration system and the National Organization for Civil Registration | |||
| RI-G3S2P4 | Developing the document for Clinical Based Cancer Registration (CBCR) | |||
| Strategy 3 (RI-G3S3) Standardize the review and application of rules related to financial, insurance and clinical guidelines |
RI-G3S3P1 | Develop a document for reviewing and applying rules related to financial and insurance guidelines and support packages for cancer patients | ||
| RI-G3S3P2 | Develop a document for reviewing and applying rules related to cancer-related standards and guidelines | |||
| Strategy 4 (RI-G3S4) Standardize the exploitation of cancer information |
RI-G3S4P1 | Developing protocols for accessing and using cancer registry data | ||
| Goal 4 (RI-G4): Having reliable and comprehensive cancer information | ||||
| Strategy 1 (RI-G4S1) Actively collect information from various cancer information sources |
RI-G4S1P1 | Collection and Adjustment of Population Based Cancer Registration (PBCR) Information | ||
| RI-G4S1P2 | Collection and Adjustment of Clinical Based Cancer Registration (CBCR) Information | |||
| Strategy 2 (RI-G4S2) Direct information recording in the Cancer Information Registration System (CIMA) |
RI-G4S2P1 | Direct recording of structured pathology reports | ||
| RI-G4S2P2 | Direct recording of cancer early detection information | |||
| RI-G4S2P3 | Direct recording of Clinical Based Cancer Registration (CBCR) | |||
| Strategy 3 (RI-G4S3) Gather information through communication with other systems |
RI-G4S3P1 | Exchange and receive unstructured pathology reports from laboratory information systems (LIS) | ||
| RI-G4S3P2 | Exchange and receive structured pathology reports from laboratory information systems (LIS) | |||
| RI-G4S3P3 | Exchange and receive information on death and disease survival from death registration systems and the National Organization for Civil Registration | |||
| RI-G4S3P4 | Exchange and Receive Clinical Based Cancer Registration (CBCR) from Hospital Information Systems (HIS), Private offices, Clinics and Insurance Organizations | |||
| Goal 5 (RI-G5): Use information systems to manage cancer programs | ||||
| Strategy 1 (RI-G5S1) Manage financial support programs for cancer patients |
RI-G5S1P1 | Managing financial support for cancer patients based on the exchange of financial and insurance information from hospital information systems (HIS), private offices, clinics, insurance companies and non-governmental organizations and charities | ||
| Strategy 2 (RI-G5S2) Management of national standards and clinical guidelines |
RI-G5S2P1 | Managing national standards and clinical guidelines based on direct registration or exchange of Clinical Based Cancer Registration (CBCR) from hospital information systems (HIS), private offices, clinics and insurance companies | ||
| Goal 6 (RI-G6): Improve access to cancer information | ||||
| Strategy 1 (RI-G6S1) Facilitate communication between cancer management and service providers, patients and the public |
RI-G6S1P1 | Launching the website of the National Cancer Control Secretariat (Cancer Department) | ||
| Strategy 2 (RI-G6S2) Access to aggregate cancer information |
RI-G6S2P1 | Launching and providing access to the basic and essential aggregate cancer information dashboard | ||
| RI-G6S2P2 | Launching and providing access to the Cancer Spatial Information Dashboard, including infrastructure, equipment, service centers, support and charity centers, research centers and human resources in all aspects of the national program | |||
| Strategy 3 (RI-G6S3) Access to personal cancer information |
RI-G6S3P1 | Provide access to personal cancer information based on the submission of approved research projects with an ethical code | ||
1The letters RI are the initials of the words Registry and Information, which are used to indicate the goals, strategies and programs of this section.
Table 7. Summary of Goals, Strategies, Programs, and Performance indicators related to “Participation of NGOs, charities, and private sector” (N)1.
| Performance Indicators |
|
|||
|---|---|---|---|---|
| Goal 1 (N-G1): Increase the capacity, empowerment and avoidance of parallel work of non-governmental organizations and charities in the field of cancer | ||||
| Strategy 1 (N-G1S1) Creating synergies and defining common national goals |
N-G1S1P1 | Forming a network of non-governmental organizations and cancer charities | ||
| Goal 2 (N-G2): Increasing the participation of NGOs, private sector and charities in cancer control programs | ||||
| Strategy 1 (N-G2S1) Encouraging the contribution of NGOs, private sector and charities |
N-G2S1P1 | Determining the role and position of NGOs, private sectors and charities in cancer control programs and encouraging their contribution | ||
| Goal 3 (N-G3): Increasing the participation of NGOs, private sector and charities in cancer care programs | ||||
| Strategy 1 (N-G3S1) Encouraging the contribution of NGOs, private sector and charities |
N-G3S1P1 | Determining the role and position of NGOs, private sectors and charities in cancer care programs and encouraging their contribution | ||
1The letter N is the first letter of the word NGO, which is used to indicate the goals, strategies and programs of this section.
Table 8. Summary of Goals, Strategies, Programs, and Performance indicators related to “Cancer Prevention” (P)1.
| Performance Indicators |
|
|||
|---|---|---|---|---|
| Goal 1 (P-G1): Identifying national and regional priorities in the field of cancer prevention | ||||
| Strategy 1 (P-G1S1) Needs assessment for national and regional interventions based on cancer type and associated risk factors |
P-G1S1P1 | Develop a general policy for the development of cancer prevention in Iran at the national and provincial levels | ||
| Goal 2 (P-G2): Promoting public health in the field of cancer prevention | ||||
| Strategy 1 (P-G2S1) Self-care education and public health promotion in the field of cancer prevention based on national programs |
P-G2S1P1 | Raising public awareness at the community level based on national programs (including for people and policymakers) | ||
| P-G2S1P2 | Promoting public awareness at work environment level based on national programs | |||
| P-G2S1P3 | Promoting public awareness at school level based on national programs | |||
| Strategy 2 (P-G2S2) Self-care education and public health promotion in the field of cancer prevention based on regional priorities |
P-G2S2P1 | Promoting public awareness at society level based on regional priorities (including for people and policymakers) | ||
| P-G2S2P2 | Promoting public awareness at work environment level based on regional priorities | |||
| P-G2S2P3 | Promoting public awareness at school level based on regional priorities | |||
| Goal 3 (P-G3): Promoting individual health | ||||
| Strategy 1 (P-G3S1) Individual-centered interventions based on national programs |
P-G3S1P1 | Increasing personal Knowledge, Attitude, and Practice (KAP)at public health network level based on national programs | ||
| P-G3S1P2 | Managing common non-communicable risk factors (NCD) at public health network level based on national programs | |||
| P-G3S1P3 | Managing cancer-specific risk factors at public health network level based on national programs (with a focus on HBV، HCVandHPV) | |||
| P-G3S1P4 | Managing cancer-specific risk factors at work environment level based on national programs (including asbestos) | |||
| Strategy 2 (P-G3S2) Individual-centered interventions based on regional priorities |
P-G3S2P1 | Increasing personal Knowledge, Attitude, and Practice (KAP)at public health network level based on regional priorities | ||
| P-G3S2P2 | Managing cancer-specific risk factors at public health network level based on regional priorities (including helicobacter pylori) | |||
| P-G3S2P3 | Managing cancer-specific risk factors at work environment level based on regional priorities | |||
| Gola 4 (P-G4): Decreasing the burden of cancer risk factors | ||||
| Strategy 1 (P-G4S1) Determining the framework for promotion of inter-sectoral collaboration |
P-G4S1P1 | Preparation and implementation of a comprehensive document for promotion of inter-sectoral collaboration to decrease burden of cancer risk factors | ||
| Strategy 2 (P-G4S2) Extending the inter-sectoral collaboration to control tobacco use |
P-G4S2P1 | Implementation of Framework Convention on Tobacco Control (FCTC) | ||
| Strategy 3 (P-G4S3) Extending the inter-sectoral collaboration to improve nutrition |
P-G4S3P1 | Implementation of the Iran sixth development program about quality of food production especially the percentage of saturated fats, salt, sugar, food additives and packaging methods | ||
| Strategy 4 (P-G4S4) Extending the inter-sectoral collaboration to improve physical activity |
P-G4S4P1 | Improving physical activity in the society | ||
| Strategy 5 (P-G4S5) Extending the inter-sectoral collaboration to control occupational and environmental risk factors |
P-G4S5P1 | Management of exposures to occupational and environmental risk factors | ||
| Strategy 6 (P-G4S6) Extending the inter-sectoral collaboration to control infectious risk factors |
P-G4S6P1 | Management of exposures to infectious risk factors | ||
| Strategy 7 (P-G4S7) Extending the inter-sectoral collaboration to control risk factors based on regional priorities |
P-G4S7P1 | Control risk factors based on regional priorities | ||
1The letter P is the first letter of the word Prevention, which is used to indicate the goals, strategies and programs of this section
Table 9. Summary of Goals, Strategies, Programs, and Performance indicators related to “Cancer Early Detection” (E)1.
| Performance Indicators |
|
|||
|---|---|---|---|---|
| Goal 1 (E-G1): Identifying national and regional priorities for early detection of cancer | ||||
| Strategy 1 (E-G1S1) Needs assessment for national and regional interventions based on the type of intervenable cancers for early detection |
E-G1S1P1 | Develop a general policy for the development of early detection of cancer in Iran at the national and provincial levels | ||
| Goal 2 (E-G2): Promoting public health in the field of cancer early detection | ||||
| Strategy 1 (E-G2S1) Self-care education and public health promotion in the field of cancer early detection |
E-G2S1P1 | Raising public awareness at the community level (including for people and policymakers) on early detection of cancer | ||
| E-G2S1P2 | Raising public awareness at workplaces about early detection of cancer | |||
| E-G2S1P3 | Raising public awareness at schools about early detection of cancer | |||
| Goal 3 (E-G3): Improving the standards of cancer early detection services | ||||
| Strategy 1 (E-G3S1) Standardization of prescribing cancer early detection services |
E-G3S1P1 | Develop the clinical practice guideline for prescribing Breast cancer early detection services | ||
| E-G3S1P2 | Develop the clinical practice guideline for prescribing Cervical cancer early detection services | |||
| E-G3S1P3 | Develop the clinical practice guideline for prescribing Colorectal cancer early detection services | |||
| E-G3S1P4 | Develop the clinical practice guideline for prescribing cancer early detection services based on regional priorities | |||
| Strategy 2 (E-G3S2) Standardization of the process of cancer early detection services |
E-G3S2P1 | Develop the protocol for managing services related to Breast cancer early detection | ||
| E-G3S2P2 | Develop the protocol for managing services related to Cervical cancer early detection | |||
| E-G3S2P3 | Develop the protocol for managing services related to Colorectal cancer early detection | |||
| E-G3S2P4 | Develop the protocol for managing cancer services based on regional priorities | |||
| Strategy 3 (E-G3S3) Standardize the monitoring and evaluation process for cancer early detection services |
E-G3S3P1 | Develop audit and quality assurance protocols for cancer early detection services | ||
| E-G3S3P2 | Develop protocols for monitoring and accreditation of cancer early detection centers | |||
| Goal 4 (E-G4): Expanding cancer prevention and early detection in the country | ||||
| Strategy 1 (E-G4S1) Personal self-care education and health promotion in the field of cancer early detection |
E-G4S1P1 | Increase personal Knowledge, Attitude, and Practice (KAP) inside and outside the healthcare network in the field of cancer early detection | ||
| Strategy 2 (E-G4S2) Step-by-step development of cancer early detection programs at the healthcare network level |
E-G4S2P1 | Implementation of Breast cancer early detection program at the level of healthcare network | ||
| E-G4S2P2 | Implementation of Cervical cancer early detection program at the level of healthcare network | |||
| E-G4S2P3 | Implementation of Colorectal cancer early detection program at the level of healthcare network | |||
| Strategy 3 (E-G4S3) Development of cancer early detection programs outside the healthcare network |
E-G4S3P1 | Implementation of Breast cancer early detection program outside the health care network | ||
| E-G4S3P2 | Implementation of Cervical cancer early detection program outside the health care network | |||
| E-G4S3P3 | Implementation of Colorectal cancer early detection program outside the health care network | |||
| Strategy 4 (E-G4S4) Improving the quality of cancer early detection services in the country |
E-G4S4P1 | Implementation of the audit and quality assurance program for cancer early detection | ||
| E-G4S4P2 | Implementation of the protocols for monitoring and accreditation of cancer early detection centers | |||
1The letter E is the first letter of the word Early Detection, which is used to indicate the goals, strategies and programs of this section
Table 10. Summary of Goals, Strategies, Programs, and Performance indicators related to “Cancer Diagnosis and Treatment” (T)1.
| Performance Indicators |
|
|||
|---|---|---|---|---|
| Goal 1 (T-G1): Identify national and regional priorities in the field of cancer diagnosis and treatment | ||||
| Strategy 1 (T-G1S1) Needs assessment of national and regional interventions based on the type of cancers requiring specific interventions for diagnostic and therapeutic services |
T-G1S1P1 | Develop a general policy for the development of cancer diagnosis and treatment in Iran at the national and provincial levels | ||
| Goal 2 (T-G2): Increase public awareness and participation in the field of diagnosis and treatment of cancer | ||||
| Strategy 1 (T-G2S1) Self-care education and public health promotion in the field of cancer diagnosis and treatment |
T-G2S1P1 | Increase public awareness at the community level (including for people and policymakers) about cancer diagnosis and treatment | ||
| Goal 3 (T-G3): Improving the standards of cancer diagnosis and treatment services | ||||
| Strategy 1 (T-G3S1) Standardization of prescribing cancer diagnosis and treatment services |
T-G3S1P1 | Develop national clinical guidelines for prescribing services for the diagnosis and treatment of common cancers | ||
| T-G3S1P2 | Develop national clinical guidelines for radiotherapy services in 3D, IMRT, VMAT, Stereotactic radiotherapy, Particle therapy, Brachytherapy and Radiopharmaceuticals | |||
| T-G3S1P3 | Develop national clinical guidelines for prescribing commonly used and specific drugs | |||
| Strategy 2 (T-G3S2) Standardize the process of cancer diagnosis and treatment services |
T-G3S2P1 | Develop the protocol for managing chemotherapy services | ||
| T-G3S2P2 | Develop the protocol for managing radiotherapy services in 3D, IMRT, VMAT, Stereotactic radiotherapy, Particle therapy, Brachytherapy and Radiopharmaceuticals | |||
| T-G3S2P3 | Develop the protocol for managing cancer surgery services | |||
| T-G3S2P4 | Develop the protocol for managing pathology services related to cancer | |||
| T-G3S2P5 | Develop the protocol for managing radiology services related to cancer | |||
| T-G3S2P6 | Develop the protocol for managing nuclear medicine services related to cancer | |||
| T-G3S2P7 | Develop the protocol for managing multidisciplinary counseling services in the field of cancer | |||
| T-G3S2P8 | Develop the protocol for managing telemedicine services in the field of cancer | |||
| Strategy 3 (T-G3S3) Standardize the monitoring and evaluation process for cancer diagnosis and treatment services |
T-G3S3P1 | Develop audit and quality assurance protocols for chemotherapy services | ||
| T-G3S3P2 | Develop audit and quality assurance protocols for radiotherapy services in 3D, IMRT, VMAT, Stereotactic radiotherapy, Particle therapy, Brachytherapy and Radiopharmaceuticals | |||
| T-G3S3P3 | Develop audit and quality assurance protocols for cancer surgery services | |||
| T-G3S3P4 | Develop audit and quality assurance protocols for pathology services related to cancer | |||
| T-G3S3P5 | Develop audit and quality assurance protocols for radiology services related to cancer | |||
| T-G3S3P6 | Develop audit and quality assurance protocols for nuclear medicine services related to cancer | |||
| T-G3S3P7 | Develop the protocol for monitoring and accreditation of cancer diagnosis and treatment centers | |||
| Goal 4 (T-G4): Expanding quality cancer diagnosis and treatment services in the country | ||||
| Strategy 1 (T-G4S1) Self-care education and promotion of personal health in the field of cancer diagnosis and treatment |
T-G4S1P1 | Increase personal Knowledge, Attitude, and Practice (KAP) inside and outside the healthcare network in the field of cancer diagnosis and treatment | ||
| Strategy 2 (T-G4S2) Expanding quality cancer diagnosis and treatment programs in the country |
T-G4S2P1 | Implementation of national clinical guidelines for cancer diagnosis and treatment | ||
| T-G4S2P2 | Implementation of national clinical guidelines for prescribing commonly used and specific drugs | |||
| T-G4S2P3 | Implementation of national clinical guidelines for radiotherapy services in 3D, IMRT, VMAT, Stereotactic radiotherapy, Particle therapy, Brachytherapy and Radiopharmaceuticals | |||
| T-G4S2P4 | Implementation of the protocols for managing cancer diagnosis and treatment services | |||
| T-G4S2P5 | Implementation of the protocols for multidisciplinary counseling in the field of cancer | |||
| T-G4S2P6 | Implementation of the protocols for managing telemedicine services in the field of cancer | |||
| Strategy 3 (T-G4S3) Improving the quality of cancer diagnosis and treatment services in the country |
T-G4S3P1 | Implementation of audit and quality assurance protocols related to cancer diagnosis and treatment services | ||
| T-G4S3P1 | Implementation of monitoring and accreditation protocols for cancer diagnosis and treatment centers | |||
1.The letter T is the first letter of the word Treatment, which is used to indicate the goals, strategies and programs of this section.
Table 11. Summary of Goals, Strategies, Programs, and Performance indicators related to “Cancer Supportive and Palliative care” (SP)1.
| Performance Indicators |
|
|||
|---|---|---|---|---|
| Goal 1 (SP-G1): Identify national and regional priorities for cancer supportive and palliative care | ||||
| Strategy 1 (SP-G1S1) Needs assessment of appropriate national and regional interventions for cancer supportive and palliative care |
SP-G1S1P1 | Develop a general policy for the development of cancer supportive and palliative care in Iran at the national and provincial levels | ||
| Goal 2 (SP-G2): Increase public awareness and participation in cancer supportive and palliative care | ||||
| Strategy 2 (SP-G2S1) Self-care education and public health promotion in the field of cancer supportive and palliative care |
SP-G2S1P1 | Raising public awareness at the community level (including for people and policymakers) about cancer supportive care and palliative care | ||
| Goal 3 (SP-G3): Improving the standard of cancer supportive and palliative care | ||||
| Strategy 1 (SP-G3S1) Standardization of prescribing supportive and palliative care for cancer |
SP-G3S1P1 | Develop the clinical practice guideline for prescribing supportive and palliative care at home | ||
| SP-G3S1P2 | Develop the clinical practice guideline for prescribing outpatient supportive and palliative care | |||
| SP-G3S1P3 | Develop the clinical practice guideline for prescribing inpatient supportive and palliative care | |||
| SP-G3S1P4 | Develop the clinical practice guideline for end-of-life supportive and palliative care | |||
| Strategy 2 (SP-G3S2) Standardize the process of cancer supportive and palliative care services |
SP-G3S2P1 | Develop the protocol for managing at-home supportive and palliative care services | ||
| SP-G3S2P2 | Develop the protocol for managing outpatient supportive and palliative care services | |||
| SP-G3S2P3 | Develop the protocol for managing inpatient supportive and palliative care services | |||
| Strategy 3 (SP-G3S3) Standardize the monitoring and evaluation process for cancer supportive and palliative care |
SP-G3S3P1 | Develop the audit and quality assurance protocol for cancer supportive and palliative care services | ||
| SP-G3S3P2 | Develop the protocol for monitoring and accreditation of cancer supportive and palliative care centers | |||
| Goal 4 (SP-G4): Expanding cancer supportive and palliative care services in the country | ||||
| Strategy 1 (SP-G4S1) Self-care education and personal health promotion in the field of cancer supportive and palliative care |
SP-G4S1P1 | Increase personal Knowledge, Attitude, and Practice (KAP) inside and outside the healthcare network in the field of cancer supportive and palliative care | ||
| Strategy 2 (SP-G4S2) Development of cancer supportive and palliative care program at the level of health care network |
SP-G4S2P1 | Implementation of at-home cancer supportive and palliative care program at the level of health care network | ||
| SP-G4S2P2 | Implementation of outpatient cancer supportive and palliative care program at the level of health care network | |||
| Strategy 3 (SP-G4S3) Development of cancer supportive and palliative care programs outside the health care network |
SP-G4S3P1 | Implementation of at-home cancer supportive and palliative care program outside the health care network | ||
| SP-G4S3P2 | Implementation of outpatient cancer supportive and palliative care program outside the health care network | |||
| Strategy 4 (SP-G4S4) Improving the quality of cancer supportive and palliative care in the country |
SP-G4S4P1 | Implementation of the audit and quality assurance protocols for cancer supportive and palliative care | ||
| SP-G4S4P2 | Implementation of monitoring and accreditation protocols for cancer supportive and palliative care centers | |||
1.The letter SP is the first letters of the words Supportive and Palliative, which is used to indicate the goals, strategies and programs of this section.
Discussion
The IrNCCP was prepared with the efforts of many stakeholders, which led to the creation of opportunities in the country's health system. One of the most important opportunities was the experience of group cooperation in the form of an inter-sectoral strategic team in the country that can be used as a model for other health interventions. Another opportunity was to use evidence to prioritize and make policy. As mentioned, comprehensive studies were conducted both on national and international upstream documents and on identifying the current situation of Iran and other countries. All of these provided the basis for evidence-informed policymaking. Therefore, the model proposed for the IrNCCP is one of the most comprehensive models presented in the world and even higher than the standards of the World Health Organization.
Cancer control framework in the Eastern Mediterranean region of the WHO has introduced six key components including governance, Prevention, Early Diagnosis, Management, Palliative Care, and surveillance and research. IrNCCP has financial management, human resources, infrastructure, and non-governmental organizations components in addition to WHO emphasized parts (19 ). The study, which globally evaluated different countries' cancer control programs showed that the major of middle and upper-income countries have weaknesses in areas such as early detection (eg. breast cancer), cancer diagnosis and treatment (radiotherapy, essential drugs), cancer research and program finance especially for vulnerable groups. In this regard, the IrNCCP has clear objectives and programs (21). It should be noted that the objectives, programs and strategies of IrNCCP are very consistent with the outlines of European countries' cancer control programs (22).
Developing the IrNCCP, like other health system policies and health interventions, was accompanied by many challenges, the most important of which are:
Identify and resolve conflicts between stakeholders: Cancer is a complex disease, and controlling it requires the participation of different levels of the health system, from prevention to treatment and in different occupational groups from primary care providers to specialized caregivers. On the other hand, control of cancer risk is not in complete control of the health system, and most of these factors are affected by the social determinants of health in some way. Therefore, in order to control cancer, it is necessary for different sectors of the country to cooperate in this field, and inter-sectoral cooperation should be done to implement the health approach in all policies. Therefore, one of the most important parts of formulating a national cancer control program in Iran was identifying stakeholders inside and outside the health system and resolving conflicts between these groups in the form of a joint group to finally develop a program that is relatively approved by all stakeholders.
Weakness of information systems to extract the data required by the program: Planning for cancer required a variety of information on the current state of cancer and related services. It was necessary to collect disease burden information by types of cancer and identify risk factors in Iran. On the other hand, it was necessary to identify the available resources (financial, human, physical), facilities, and equipment, as well as services being provided for cancer, in order to accurately identify the current situation and to be able to set appropriate goals based on resource optimization for it. However, the existing databases in each of these sectors and at each level of service provision were separate and unconnected, and it was not possible to integrate them due to the inconsistency of the definition of the concepts used. During the development of this program, the required information was collected, cleared and categorized from various information sources as much as possible, and if necessary, statistical estimates and expert opinions were used to show the current situation of the country in the most realistic way possible.
Establishment and consolidation of the Cancer Control Program governance: As mentioned, participation of different levels of the health system in cancer prevention and control is essential, and it was necessary to determine an official organizational structure to direct the program. The Ministry of Health, the Deputy of health, the Deputy of therapeutic affairs, the Deputy of Research and Technology and the National Committee for Non-communicable Diseases were all structures that participated directly in this program and on the other hand, the World Health Organization recommended considering a structure separate from other non-communicable diseases for the management of cancer. Therefore, there needed to be a directing unit to coordinate matters related to these structures and unify them. Due to the separation of health and treatment deputies in the Ministry of Health, there were many challenges to managing conflict of interest in this area. After some follow-ups, the structure of the Cancer Department was finally upgraded organizationally, the National Cancer Control Secretariat was established, and directing the IrNCCP was entrusted to this unit. Nevertheless, the deputy of therapeutic affairs did not cooperate with the secretariat, which became a challenge to advance cancer control programs. This issue needs to be resolved so that the official structure under the name of the Cancer Department is responsible for leading the program as well as coordinating with other departments inside and outside the Ministry of Health.
Management changes in the steering team: Strategic planning is a long-term process that requires a consolidated steering team during planning and even implementation. Unfortunately, in Iran, the management period is very short, which makes the sustainability of programs difficult, and this is more important for health programs that require long-term planning. This problem happened in the process of developing the IrNCCP.
In designing this program, every effort was made to prepare a comprehensive program. However, due to the mentioned challenges and the fact that continuous improvement is essential in any planning process, after a few years of implementing the program, it was decided to update it, taking into account the following:
Designing an evaluation framework for the program: For each component, performance indicators, as well as the expected output of each program, were determined. However, considering guidelines (19) and internal necessities, there is a need to design a comprehensive assessment framework for the whole program and evaluate its progress, which is ongoing.
Updating the previous estimates: As mentioned, there was a lack of data in the assessments of the current situation, especially in the available resources and facilities, as well as in the cancer registration system, and this data was the basis for the program's estimates. Now, a few years after the implementation of this program and the completion of the information, it is necessary to review the current situation with more complete data and, if there are major changes, to update the estimates based on these numbers.
. Adding a component for childhood cancers: The IrNCCP is a complete program that pays attention to all types of cancer in different ages and genders. But in general, addressing this target group in cancer programs is one of the most important weaknesses of the world's cancer programs in high and middle-income countries (21). However, given that in the years following the development of this program, the World Health Organization published a new initiative (called GICC) to pay special attention to childhood cancers, revising the program and designing a specific component for childhood cancers is on the agenda.
Conclusion
The IrNCCP, which has been developed with a strategic planning approach, is very comprehensive, pays attention to all the required dimensions, and can be used as a model for planning other health interventions in Iran as well as countries in a similar situation. Considering scientific evidence for decision-making, cross-sectoral cooperation and stakeholder participation are among the highlights of this program. However, this program, like other programs, needs strengthening in its governance structure. Stabilization and strengthening of the official directing structure in all health interventions, especially interventions with long-term health consequences, lead to the full implementation of the interventions and at the same time the sustainability of resources and, consequently, achieving the expected health outcomes of the program. It is suggested that due to the long implementation period of this program, its directing structure be strengthened so that its implementation process is not disrupted. Also, since assessing the progress of the program is one of the main pillars of planning, it is suggested that evaluating the progress and achievements of short-term and long-term goals and their health consequences are carried out by the mentioned governance structure and the program get modified and improved during the implementation process taking into account the assessment results. Given that having databases for cancer control planning and extracting the achievements and results is one of the main pillars of the program, the creation, and integration of databases related to planning and monitoring the progress of designed interventions is another important aspect that is suggested to be strongly considered by the relevant official directing structure.
Conflict of Interests
The authors declare that they have no competing interests.
Acknowledgment
The National Cancer Control Program in Iran has been developed with the participation of all stakeholders and we would like to thank all the managers, faculty members, and experts from the Ministry of Health as well as universities of medical sciences and external institutions who have contributed to the preparation of this program.
Cite this article as : Motlagh A, Ehsani-Chimeh E, Yamrali M, Moshiri F, Roshandel G, Partovipour E, Salavati F, Khoshabi M, Tavakoli N, Asgari F, Raisi A, Malekzadeh R, Mahdavi Hezaveh A, Heidari K, Etemad K, Ostovar A. IRAN National Cancer Control Program (IrNCCP): Goals, Strategies, and Programs. Med J Islam Repub Iran. 2022 (24 Dec);36:169. https://doi.org/10.47176/mjiri.36.169
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