Problem: Rising burden of cancer; high cancer mortality rates; lack of a proactive, preventive approach to cancer care.
Solution highlights: In 2008, the Government of Montenegro released the National Cancer Control Plan. Responding to recommendations proposed by the Plan, the Institute of Public Health developed a comprehensive cancer screening programme for colorectal cancer. Following successful piloting, the colorectal cancer screening programme is now being expanded to cover other priority cancers; partnerships with stakeholders outside of the health sector provided access to technologies and tools for engaging the public. Text messaging was the main tool used for outreach; moving from a reactive to a proactive approach was important for reaching and engaging the target population and increasing uptake of screenings; a strong information system supported a data-driven initiative design, facilitated implementation and enabled monitoring and evaluation.
Description of practice
Rising noncommunicable disease in an ageing population contributed to a growing cancer burden in Montenegro. In 2010, cancer was the third highest cause of death, accounting for 14% of total mortality. Colon cancer was a particular concern, rising from 490 000 cases in 1990 to 715 000 cases in 2010. The reactive orientation of cancer screening services and lack of preventive services for noncommunicable disease contributed to suboptimal cancer mortality rates and hindered effective provision of proactive cancer care.
In 2008, the Government of Montenegro developed a National Cancer Control Plan outlining ways to address the growing cancer burden, including a recommendation that national screening programmes be established for colorectal, breast and cervical cancers. To realize this recommendation, the Institute of Public Health began an information-driven initiative to increase uptake of cancer screening, selecting colorectal cancer for initial piloting. After a three-year planning period, implementation began in 2013 and national coverage was achieved by 2014. As part of the initiative, all men and women aged 59 to 64 years are sent targeted outreach messages to their mobile phones, encouraging uptake of free colorectal cancer screenings. The initiative relies on general practitioners to engage patients, coordinate screenings and make necessary referrals. General practitioners received training on conducting outreach and are financially incentivized to message eligible patients. Messages are sent free-of-charge according to agreements established with a telecommunication company. Reaching the public via mobile phone has proved highly successful and 89% of the target population received outreach messages in the first year of the initiative. Patients choosing to access the screening programme receive a questionnaire-based risk assessment and a fecal occult blood test. If testing positive, patients are referred for a colonoscopy and to further care as needed. The pre-existing electronic information system facilitates smooth referral processes and also enables monitoring and evaluation of the initiative by the Institute of Public Health. Following the initial success of the colorectal cancer screening initiative, the Institute is preparing to implement a similar screening programme for cervical cancer; a programme for breast cancer is also anticipated.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
The Ministry of Health established the foundational policy framework for the initiative. Design and development was led by the Institute of Public Health, along with Ministry support and inputs from other stakeholders including the health insurance fund, health providers, the pharmaceutical industry and a telecommunication company. To engage stakeholders, the Institute of Public Health established a national team for colorectal cancer, bringing a wide range of professionals into the design process and helping stakeholders to develop a sense of ownership over the initiative. Today, the Institute of Public Health continues to oversee the initiative, evaluate progress and expand activities with support from key actors.
The initiative is aiming to reduce colorectal cancer mortality by 15% in the 59 to 64 age group during the next five years. So far, colorectal cancer screening has achieved national coverage and uptake of screenings is high; 89% of the target population have been invited to screenings and uptake averages around 68%. Approximately 22 000 fecal occult blood tests and 600 colonoscopies have been performed so far, detecting 12 carcinomas and 35 adenomas.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Djurdjica Ostojic
- Institute of Public Health