Abstract

Objective:

To compare trends in hospital discharges and mortality due to breast cancer (BC) in Mexico from 2004 to 2012 by insurance condition before and after incorporating BC comprehensive treatment into the System of Social Protection in Health (Sistema de Protrección Social en Salud, SPSS) in 2007.

Materials and methods:

Data on BC hospital discharges and mortality reported in women aged 25 years and over were obtained from the National Health Information System. Mortality rates were adjusted by age and state.

Results:

At the national level, a growing tendency in hospital discharges was observed, mainly for women without social security, while mortality rate remained constant. Mortality rates by state show that lower marginalization index corresponded to higher mortality.

Conclusions:

A differential behavior was observed among women according to insurance condition, partly due to the inclusion of BC treatment in the SPSS.

Keywords:
breast cancer; mortality rate; hospitalization; Mexico

Resumen

Objetivo:

Comparar las tendencias de egresos hospitalarios y mortalidad por cáncer de mama (CaMa) en México de 2004 a 2012, según esquema de aseguramiento, antes y después de la incorporación del tratamiento integral del CaMa al Sistema de Protección Social en Salud (SPSS) en 2007.

Material y métodos:

Los egresos hospitalarios y de mortalidad por CaMa en mujeres de 25 años o más se obtuvieron del Sistema Nacional de Información en Salud. Las tasas de mortalidad se ajustaron por edad y entidad federativa.

Resultados:

A nivel nacional, hubo una tendencia creciente de los egresos hospitalarios, principalmente para mujeres sin seguridad social, mientras que la tasa de mortalidad se mantuvo constante. Las tasas de mortalidad fueron mayores en estados con menor índice de marginación.

Conclusiones:

Se observó un comportamiento diferencial entre las mujeres según esquema de aseguramiento en salud debido, en parte, a la inclusión del tratamiento de CaMa al SPSS.

Palabras clave:
cáncer de mama; tasa de mortalidad; hospitalización; México

Worldwide, breast cancer (BC) is the most common cancer among women. In 2012, more than 1.67 million new cases were diagnosed, representing one in four cancers among women (25.2%) and 12% of all cancers.¹1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. Globocan 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [internet document]. 2012 [consulted 2014 April 12]. Available at: http://globocan.iarc.fr.
http://globocan.iarc.fr... Breast cancer is the fifth leading cause of cancer death worldwide. This disease causes approximately 522 000 deaths per year, and in the case of women, it represents the most common cause of cancer death.¹1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. Globocan 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [internet document]. 2012 [consulted 2014 April 12]. Available at: http://globocan.iarc.fr.
http://globocan.iarc.fr... In Latin America and the Caribbean, 27% of new cancer cases and 15% of cancer deaths are due to BC.¹1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. Globocan 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [internet document]. 2012 [consulted 2014 April 12]. Available at: http://globocan.iarc.fr.
http://globocan.iarc.fr... ^,22. Organización Panamericana de la Salud. Cáncer de mama en las Américas. Washington, DC: OMS, 2014.

Although Mexico is one of the 10 countries with the lowest incidence and mortality rates in the Americas,¹1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. Globocan 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [internet document]. 2012 [consulted 2014 April 12]. Available at: http://globocan.iarc.fr.
http://globocan.iarc.fr... ^,22. Organización Panamericana de la Salud. Cáncer de mama en las Américas. Washington, DC: OMS, 2014. standardized mortality rates per 100 000 women aged 25 years and older in 2009 ranged between 9.10 and 26.69 in the individual states.³3. de la Vara-Salazar E, Suárez-López L, Ángeles-Llerenas A, Torres-Mejía G, Lazcano-Ponce E. Tendencias de la mortalidad por cáncer de mama en México, 1980-2009. Salud Publica Mex 2011;53(5):385-393. A trend of increasing standardized mortality rates, which rose from 11.7 to 17.0 deaths per 100 000 women aged 25 years and over between 1980 and 2009, was observed.³3. de la Vara-Salazar E, Suárez-López L, Ángeles-Llerenas A, Torres-Mejía G, Lazcano-Ponce E. Tendencias de la mortalidad por cáncer de mama en México, 1980-2009. Salud Publica Mex 2011;53(5):385-393.

There are no figures available on the incidence of BC because Mexico does not have a histopathological cancer registry. However, less than 10% of BC cases are estimated to be detected in a timely manner.⁴4. Secretaría de Salud. Programa de acción: cáncer de mama, 2007-2012. México: Secretaría de Salud, 2007.^,55. Bright K, Barghash M, Donach M, de la Barrera M, Schneider R, Formenti S. The role of health system factors in delaying final diagnosis and treatment of breast cancer in Mexico City, Mexico. The Breast 2011;20(Suppl 2):S54-S59. and 50-80% of those cases are found in advanced stages.⁵5. Bright K, Barghash M, Donach M, de la Barrera M, Schneider R, Formenti S. The role of health system factors in delaying final diagnosis and treatment of breast cancer in Mexico City, Mexico. The Breast 2011;20(Suppl 2):S54-S59.^,66. Mohar A, Bargalló E, Ramírez M, Lara F, Beltrán-Ortega A. Recursos disponibles para el tratamiento del cáncer de mama en México. Salud Publica Mex 2009;51(Suppl 2):S263-S269. In Mexico⁵5. Bright K, Barghash M, Donach M, de la Barrera M, Schneider R, Formenti S. The role of health system factors in delaying final diagnosis and treatment of breast cancer in Mexico City, Mexico. The Breast 2011;20(Suppl 2):S54-S59.^,77. Unger-Saldaña K, Infante-Castañeda C. Breast cancer delay: a grounded model of help-seeking behaviour. Soc Sci Med 2011;72(7):1096-1104.^,88. Nigenda G, Caballero M, González-Robledo L. Barreras de acceso al diagnóstico temprano del cáncer de mama en el Distrito Federal y en Oaxaca. Salud Publica Mex 2009;51(Suppl 2):S254-S262. and other countries,⁹9. Piñeros M, Sánchez R, Perry F, García O, Ocampo R, Cendales R. Demoras en el diagnóstico y tratamiento de mujeres con cáncer de mama en Bogotá, Colombia. Salud Publica Mex 2011;53(6):478-485.

10. Hafström L, Johansson H, Ahlberg J. Diagnostic delay of breast cancer: an analysis of claims to Swedish Board of Malpractice. The Breast 2011;20(6):539-542.

11. Norsa'adah B, Rampal K, Rahmah M, Naing N, Biswal B. Diagnosis delay of breast cancer and its associated factors in Malaysian women. BMC Cancer 2011;17(11):141.^-1212. Richardson L, Royalty J, Howe W, Helsel W, Kammerer W, Benard V. Timeliness of breast cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program, 1996-2005. Am J Public Health 2010;100(9):1769-1776. low screening coverage¹³13. Torres-Mejía G, Ortega-Olvera C, Ángeles-Llerenas A, Villarobos-Hernández AL, Salmerón-Castro J, Lazcano-Ponce E, et al. Patrones de utilización de programas de prevención y diagnóstico temprano de cáncer en la mujer. Salud Publica Mex 2013;55(Suppl 2):S241-S248. and diagnostic delay cause lower survival, lower quality of life, less efficient use of resources and, above all, increased mortality.

A policy that reformed the Mexican health system was established in 2003.¹⁴14. Knaul F, Nigenda G, Lozano R, Arreola-Ornelas H, Langer A, Frenk J. Cáncer de mama en México: una prioridad apremiante. Salud Publica Mex 2009;51(Suppl 2):S335-S344. The System of Social Protection in Health (Sistema de Protección Social en Salud, SPSS) was established. SPSS provisions entered into force in 2004. The main financial component of SPSS is voluntary public insurance, known as Popular Insurance (Seguro Popular).¹⁵15. Frenk J, Gonzalez-Pier E, Gomez-Dantes O, Lezama M, Knaul F. Comprehensive reform to improve health system performance in Mexico. Lancet 2006;368(9546):1524-1534. Another component of the SPSS is the Fund for Protection against Catastrophic Expenditures (Fondo de Protrección contra Gastos Catastróficos, FPGC), which aims to support the Mexican population that lacks any health insurance scheme in the care of high-cost diseases and those that cause catastrophic expenditures.¹⁴14. Knaul F, Nigenda G, Lozano R, Arreola-Ornelas H, Langer A, Frenk J. Cáncer de mama en México: una prioridad apremiante. Salud Publica Mex 2009;51(Suppl 2):S335-S344.

15. Frenk J, Gonzalez-Pier E, Gomez-Dantes O, Lezama M, Knaul F. Comprehensive reform to improve health system performance in Mexico. Lancet 2006;368(9546):1524-1534.^-1616. Knaul F, Frenk J. Health insurance in Mexico: achieving universal coverage through structural reform. Health Affairs 2005;24(6):1467-1476. In 2007, a comprehensive BC treatment was included in the FPGC and thereby guaranteed that Mexican women with BC have access to comprehensive and free medical care in units certified by the SPSS.¹⁴14. Knaul F, Nigenda G, Lozano R, Arreola-Ornelas H, Langer A, Frenk J. Cáncer de mama en México: una prioridad apremiante. Salud Publica Mex 2009;51(Suppl 2):S335-S344.

A greater increase in the number of hospital discharges in hospitals affiliated with the SPSS than in the social security hospitals could be expected due to the decrease of financial barriers through the incorporation of BC into the FPGC; consequently, a decrease in BC mortality rates should be expected.¹⁷17. Secretaría de Salud. Programa Sectorial de Salud 2013-2018. México, DF: Diario Oficial de la Federación, 2013. In this context, the aim of this study was to examine the trends in hospital discharges and mortality by BC in Mexico from 2004 to 2012 according to insurance scheme to identify the medium-term changes that have been caused by the inclusion of the comprehensive BC treatment into the FPCE of the SPSS since 2007.

Materials and methods

Design

An ecological study was conducted to compare trends in hospital discharges and mortality from BC in Mexico from 2004 to 2012 among women aged 25 years and older, according to insurance scheme before and after the inclusion of the comprehensive BC treatment into the FPGC of the SPSS in 2007. This period was chosen because the SPSS entered into force in 2004 and based on the availability of hospital databases at the time the analysis was performed.

Information sources

Data on hospital discharge and mortality in the period 2004-2012 were disaggregated by age, federal state and insurance scheme. Databases in dynamic cube format, which are available on the website of the General Directorate of Health Information (Dirección General de Información en Salud, DGIS) of the National Health Information System, constituted the data source.¹⁸18. Base de datos en formato de cubo dinámico, 2004-2012. Sistema Nacional de Información en Salud (SINAIS), Secretaría de Salud [internet document] [consulted 2014 June 10]. Available at: http://dgis.salud.gob.mx/cubos.
http://dgis.salud.gob.mx/cubos... The International Statistical Classification of Diseases and Related Health Problems (CIE-10) code C50 was used to identify the pathology of interest. Projections of the female population disaggregated by age, federal state and insurance scheme for the years 1998-2011 and 2010-2015, conducted by the College of Mexico and the National Population Council (Consejo Nacional de Población, Conapo), were also used.¹⁸18. Base de datos en formato de cubo dinámico, 2004-2012. Sistema Nacional de Información en Salud (SINAIS), Secretaría de Salud [internet document] [consulted 2014 June 10]. Available at: http://dgis.salud.gob.mx/cubos.
http://dgis.salud.gob.mx/cubos... The marginalization index estimated by the Conapo¹⁹19. de la Vega-Estrada S, Romo-Viramontes R, González-Barrera A. Índice de marginación por entidad federativa y municipio 2010. México, DF: Consejo Nacional de Población, 2011. was included in the analysis to include the heterogeneity of socioeconomic development between federative states. The study was authorized by the ethics and research committees of the National Institute of Public Health (Instituto Nacional de Salud Pública, INSP) record number 774.

Information analysis

Information tables about women with BC aged 25 years or older were built per year, federal state and insurance scheme with data from the databases, drawing from discharge and mortality information. Discharges and deaths with unspecified age (0.006 and 0.057%, respectively) were excluded. Specific mortality rates among age groups of women aged 25 years and older were calculated at the national and federative state levels. For comparison purposes, it was standardized for age^** The age-standardized rates do not reflect the actual mortality risk in a population because the numerical value of age-adjusted mortality depends on the standard population used. within each group. Subsequently, the rates were adjusted by the direct method to eliminate the effects of any age difference between the insurance scheme, the federative states and the analyzed years.²⁰20. Gordis L. Epidemiología. 3° ed. Barcelona: Elservier Saunders, 2004. The standard population corresponded to the combined populations of women aged 25 or older per analyzed year, nationally and by federative state. The annual percentage change was used to assess trends, and statistical significance was estimated using joinpoint^**** Joinpoint Regression Program version 4.2.0.1. Statistical Methodology and Applications Branch, Surveillance Research Program. National Cancer Institute, 2015. models.

Results

Hospital discharges for breast cancer

Nationally, joinpoint analysis allowed the two increase periods for uninsured women (UW), 2003-2007 and 2007-2012, to be distinguished, with mean annual increases of 0.9% (p=0.9) and 34.2% (p<0.05), respectively.

For insured women (IW), these percentages were 3.3% (p<0.05) and 4.2% (p<0.05), respectively (figure 1). The numbers of hospital discharges by federative state are shown in table I. During 2004-2009, the Federal District, Veracruz and Jalisco were highlighted as the states that concentrated the largest numbers of hospital discharges for BC. However, the increase was remarkable since 2009 for Jalisco and 2010 for Michoacan. As a result, from 2007 to 2012, the percentages of the mean annual increase of hospital discharge numbers nationwide and among UW were 14.8% (p<0.05) and 34.2% (p<0.05), respectively. By excluding the states of Michoacan and Jalisco, this trend continued, but at lower rates: 5.4% (p<0.05) and 9.8% (p<0.05), respectively.

Breast cancer mortality

The number of breast cancer deaths at the national level also showed an upward trend during the periods 2004-2007 and 2007-2012 (figure 2a), with annual rates of 3.4% (p<0.05) and 3.9% (p<0.05). The analysis of mortality among women with and without social security showed that mortality was higher in IW; however, the annual growth rate during 2004-2007 was higher (4.2%, p=0.3) in the UW group than in the the IW group (2.4%, p<0.05). After 2007, deaths reached a higher rate in the UW group, with an annual growth rate of 7.1% (p<0.05), while the death rate was 2.9% (p<0.05) in the IW group.

The mortality rates standardized by age in 25-year-old women or older show that mortality remained constant over the 2004-2012 period nationally (figure 2b). However, when analyzed by insurance scheme, the mortality rates of the IW group were above the national rates, opposite to the situation seen with the rates in UW. For IW, joinpoint analysis allowed the observation that the annual mortality rate remained constant for the 2004-2007 period; however, an annual percentage change of -1.9% (p=0.1) was observed for the 2007-2012 period. In contrast, in UW, although the annual mortality rate was also constant from 2004 to 2007, for the second period, a percentage of annual growth of 3.3% (p<0.05) was observed. The adjusted mortality rates by federative state were higher in the IW group than in UW; this finding agrees with nationwide results (table II).

In general, the distribution of mortality rates by federative state indicates that BC remained constant until prior to 2007. From that year, the trends varied considerably, especially in those states with the highest marginalization rate (figure 3a). This finding is consistent with what is shown in figure 3b, which suggests a decreasing trend in BC mortality in women aged 25 years or older as the marginalization rate increases (2012).

Discussion

Nationally, a growing trend of hospital discharges was observed, particularly in UW, whereas mortality rates standardized by age in 25-year-old or older women remained constant. However, these rates decreased in IW from 2009, while in UW, rates increased from 2007. In addition, mortality rates were higher in federative states with low marginalization levels than in states with high marginalization levels.

The results of this study show an increase in the number of hospital discharges for BC from the inclusion of the comprehensive BC treatment into the FPGC. This result is consistent with the findings of an initial assessment of the SPSS impact conducted by Gakidou and colleagues.²¹21. Gakidou M, Lozano R, González-Pier E, Abbot-Klafter J, Barofsky JT, Bryson-Cahn C, et al. Assesing the effect of the 2001-06 Mexican health reform: an interim repord card. Lancet 2006;368(9550):1920-1935. They reported that municipalities with high levels of SPSS affiliation had higher rates of hospitalization, and the impact was greater when it accounted for conditions included in the FPGC. However, higher increases in the states of Michoacan and Jalisco were noted, which could result from a difference from the other states in terms of the hospitalization criteria. Similarly, other studies have shown an increase in the use of public hospital services associated with an increased SPSS affiliation,²²22. González-Block M, Sauceda-Valenzuela A, Santa Ana-Téllez Y. Factores asociados a la demanda de servicios para la atención del parto en México. Salud Publica Mex 2010;52(5):416-423.^,2323. Sosa-Rubi S, Galarraga O, Harris J. Heterogeneous impact of the "Seguro Popular" program on the utilization of obstetrical services in Mexico, 2001-2006: a multinomial probit model with a discrete endogenous variable. Nber Working Paper Series No. 13498, 2007. which is more pronounced when the condition is included in the FPGC.²⁴24. Navarrete-López M, Puentes-Rosas E, Pineda-Pérez D, Martínez-Ojeda H. El papel del Fondo de Protección contra Gastos Catastróficos en la cobertura de atención a pacientes con cataratas. Salud Publica Mex 2013;55(4):394-398. This finding is consistent with studies stating that when removing financial barriers to access the health services, there is an increased utilization of hospital health services, particularly in populations that did not use these services previously.²⁵25. Rashidian A, Joudaki H, Khodayari-Moez E, Omranikhoo H, Geraili B, Arab M. The impact of rural health system reform on hospitalization rates in the Islamic Republic of Iran: an interrupted time series. Bull World Health Organ 2013;91(12):942-949.^,2626. Xu K, Evans D, Kadama P, Nabyonga J, Ogwal PO, Nabukhenzo P, et al. Undestanding the impact of eliminating user fees: Utilization and catastrophic health expenditures in Uganda. Soc Sci Med 2006;62:866-876.

The number of deaths and the mortality rates experienced growing trends nationwide, which contrasts with expected results given the greater availability and access to health services.²⁷27. Wheeler S, Carpenter W, Peppercorn J, Schenck A, Weinberger M, Biddle A. Sctructural/organizational characteristics of health services partly explain racial variation in timeliness of radiation therapy among elderly breast cancer patients. Breast Cancer Res Treat 2012;133(1):333-345.^,2828. Gerend M, Pai M. Social determinants of black-white disparities in breast cancer mortality: a review. Cancer Epidemiol Biomarkers Prev 2008;17(11):2913-2923. Studies in other countries have suggested, after a reform in the health system, that the health coverage improvement increases the use of services and decreases mortality.²⁹29. Cheng S, Chiang T. The effect of universal health insurance on health care utilization in Taiwan. JAMA 1997;278(2):89-93.

30. Arroyave I, Cardona D, Burdorf A, Avendano M. The impact of increasing health insurance coverage on disparities in mortality: health care reform in Colombia, 1998-2007. Am J Public Health 2013;103(3):e100-e106.^-3131. Sommers B, Long S, Baicker K. Changes in mortality after Massachusetts health care reform. Ann Intern Med 2014;160:585-593. However, this reduction is hampered by inequalities in education³⁰30. Arroyave I, Cardona D, Burdorf A, Avendano M. The impact of increasing health insurance coverage on disparities in mortality: health care reform in Colombia, 1998-2007. Am J Public Health 2013;103(3):e100-e106.^,3232. Bautista-Arredondo S, Serván-Mori E, Colchero A, Ramírez-Rodríguez B, Sosa-Rubí S. Análisis del uso de servicios ambulatorios curativos en el contexto de la reforma para la protección universal en salud en México. Salud Publica Mex 2014;56(1):18-31. and socioeconomic levels.²⁹29. Cheng S, Chiang T. The effect of universal health insurance on health care utilization in Taiwan. JAMA 1997;278(2):89-93.^,3232. Bautista-Arredondo S, Serván-Mori E, Colchero A, Ramírez-Rodríguez B, Sosa-Rubí S. Análisis del uso de servicios ambulatorios curativos en el contexto de la reforma para la protección universal en salud en México. Salud Publica Mex 2014;56(1):18-31. Thus, in Mexico, Bautista-Arredondo et al.³²32. Bautista-Arredondo S, Serván-Mori E, Colchero A, Ramírez-Rodríguez B, Sosa-Rubí S. Análisis del uso de servicios ambulatorios curativos en el contexto de la reforma para la protección universal en salud en México. Salud Publica Mex 2014;56(1):18-31. found that people with lower education levels and who are poorer are less likely to access outpatient medical services, even if the service is a beneficiary of SPSS. This finding suggests that the coverage of social health protection is a necessary but insufficient condition to reduce inequalities in access to primary outpatient care. This factor may be one reason why such a result in this study was not found, as most members of the SPSS are located in groups with social inequalities. Another possible explanation is that breast cancer in women is detected at an advanced clinical stage; thus, improvements should be incorporated in terms of access, screening by mammography, and the timeliness of diagnosis and treatment. Another explanation could correspond to the fact that FPGC covers only the costs of the disease; however, the infrastructure, equipment and the number of available spots may not be sufficient to provide the treatment with the required timeliness and quality.³³33. Consejo Nacional de Evaluación de la Política de Desarollo Social. Indicadores de acceso y uso efectivo de los servicios de salud afiliados al Seguro Popular. México, DF: Coneval, 2014. Subsequent studies could deepen these hypotheses, with the additional advantage that the period of inclusion of breast cancer in the FPGC would be higher.

In Mexico, there is a legal and regulatory framework for universal access to BC treatment; however, this framework needs to be translated into effective and timely access to a health services infrastructure and sufficient human resources to meet the demand of such services.¹⁴14. Knaul F, Nigenda G, Lozano R, Arreola-Ornelas H, Langer A, Frenk J. Cáncer de mama en México: una prioridad apremiante. Salud Publica Mex 2009;51(Suppl 2):S335-S344. However, increasing the available information about the benefits of using FPGC through awareness campaigns about the existing regulations to both health care providers and women would be advisable.

The nationwide breast cancer mortality rates in women aged 25 years or older presented here are similar to those reported in other studies.³3. de la Vara-Salazar E, Suárez-López L, Ángeles-Llerenas A, Torres-Mejía G, Lazcano-Ponce E. Tendencias de la mortalidad por cáncer de mama en México, 1980-2009. Salud Publica Mex 2011;53(5):385-393.^,3434. Lozano-Ascencio R, Gómez-Dantes H, Lewis S, Torres-Sánchez L, López-Carrillo L. Tendencias del cáncer de mama en América Latina y El Caribe. Salud Publica Mex 2009;51(Suppl 2):S147-S156.^,35) However, this study is one of the first that takes into account the insurance scheme, which gives an added value to generate an hypotheses about the differential impact of the inclusion of comprehensive BC treatment between FPGC populations with and without social security.

One limitation of this study is that it does not measure BC prevalence and incidence because the number of hospital discharges is different from the number of patients. Moreover, for some years (2005 and 2011), no reliable data at the national and federative state levels were available on the number of hospital discharges for BC per age group. To resolve this issue, some populations for which the number of hospital discharges for BC was not available were estimated; therefore, the results may not reflect actual trends for these years. This estimation is a limitation of this study because of the lack of population information disaggregated by age groups and the lack of access to original source data (i.e., medical records). Another limitation of the study is not upholding the correlations between mortality rates and some determinants of health inequalities because they were not part of the objectives of this study. However, this analysis attempts to establish the foundations to perform other studies in greater depth that could identify the factors that limit the effects of including comprehensive BC treatment in the FPGC.

In conclusion, the results of this study suggest that trends in mortality rates among women are heterogeneous according to insurance scheme and are higher for UW than for IW, who showed a decreasing trend. These findings could be a reflection of differences in socioeconomic status or could be because the coverage of mammography screening is higher among IW than among UW.⁷7. Unger-Saldaña K, Infante-Castañeda C. Breast cancer delay: a grounded model of help-seeking behaviour. Soc Sci Med 2011;72(7):1096-1104. This difference results in BC treatment beginning at an earlier stage for IW than for UW. Although the current FPGC operation has not yet shown the desired change in the health indicator, improvements in access, strengthening the mechanisms to recruit women to the SPSS, and ensuring the implementation of regulations and consolidating systems for training, evaluation, monitoring and compliance of operating regulations and treatment guides for BC systems is necessary. The adaptation of the established capacity to the demand for services is necessary, as is the development of a leadership capacity of health authorities to fulfill the roles of coordination and regulation. These changes would improve equity in access to BC treatment care and would inform on population-wide results.

References

Publication Dates

History