Towards Integrated Oncology Care: A Qualitative Study of Providers’ Perspectives on Service Quality within the Chilean National Oncology Network

Technical Summary: Towards Integrated Oncology Care: A Qualitative Study of Providers' Perspectives on Service Quality within the Chilean National Oncology Network

Problem Statement
Despite the implementation of national oncology policies in Chile, including the "Explicit Health Guarantees" (GES) system and the National Cancer Law (2020), significant inequalities persist in the availability, coordination, and quality of cancer care across the country's diverse territories. The Chilean public health system, organized into 29 decentralized Health Services, faces challenges in translating centralized policy designs into effective local implementation. While the system formally adopts Integrated Health Service Networks (IHSNs), gaps remain between the formal design of these networks and their operational reality, particularly regarding territorial adaptation, resource distribution, and the continuity of care. This study addresses the need to understand how organizational, territorial, and sociocultural factors shape the implementation and functioning of oncology services from the perspective of those managing and coordinating care.

Methodology
The study employs an exploratory-descriptive qualitative design grounded in a systemic-constructivist paradigm. This approach posits that perceptions of quality and sufficiency are socially constructed through interactions within the health system, shaped by specific contexts.

• Data Collection: The researchers conducted 19 semi-structured interviews with key providers involved in oncology management and coordination. The sample was selected using a purposive, maximum variation strategy to capture diverse perspectives across six macro-regions of Chile (Northern, North Central, Central, South Central, South, and Extreme South).
• Participants: The sample included professionals from seven Health Services (Antofagasta, Coquimbo, Central Metropolitan, Maule, Biobío, Araucanía Sur, and Magallanes) holding three specific roles: cancer care coordinators, local technical council representatives, and case managers.
• Analysis: Data were analyzed using thematic content analysis with QDA Miner Lite®. An initial deductive coding framework, based on WHO health system building blocks and the interview guide, was expanded through inductive coding to capture emergent themes. Rigor was ensured through Lincoln and Guba's criteria for trustworthiness (credibility, transferability, dependability, and confirmability).

Key Results
The analysis identified four interrelated themes describing the state of oncology care in Chile:

1. Access to Services: Participants reported persistent structural limitations, including shortages of specialized human resources (physicians and non-medical staff) and limited access to diagnostic and therapeutic technologies (e.g., PET/CT, MRI, radiotherapy). These gaps are exacerbated by geographic dispersion, where patients in remote areas face significant travel burdens and delays. Furthermore, the fragmentation of information systems—where different Health Services operate on incompatible platforms—hinders patient traceability and continuity of care, often forcing reliance on manual record-keeping.
2. Governance and System Organization: A central tension exists between centralized policy design and local implementation capacity. Participants noted that standardized national guidelines often fail to account for territorial, cultural, and organizational diversity. While the GES system provides legal guarantees, operational constraints (resource scarcity, workforce turnover) create gaps between policy and practice. Governance challenges also manifest as institutional fragmentation, with weak coordination between primary, secondary, and tertiary levels of care, and a lack of unified referral protocols.
3. Sociocultural and Territorial Conditions: Access is heavily influenced by sociocultural factors, including paternalistic care models that limit patient autonomy, gender norms affecting preventive screening, and cultural beliefs among Indigenous, rural, and migrant populations. Providers highlighted the difficulty of implementing standardized strategies in contexts with distinct worldviews and high levels of distrust toward institutions. Additionally, territorial conditions, such as environmental exposures (e.g., mining regions) and geographic isolation, shape the cancer burden and access trajectories.
4. Perceptions of Quality and Adequacy: Providers define quality not merely as technical compliance with standards but as a relational and experiential condition. Key dimensions include timeliness, continuity of care, and the "humanization" of care (psychosocial support, empathy). Participants expressed that delays in diagnosis and treatment, along with insufficient psychosocial support, fundamentally undermine the perceived quality of services, even when clinical interventions are technically adequate.

Key Contributions

• Provider-Centered Governance Analysis: The study shifts the analytical lens to healthcare providers as active institutional agents who navigate the tensions between policy guidelines and local realities. It highlights how providers assume informal coordination and mediating roles to bridge gaps in service integration, effectively sustaining continuity of care in the absence of formal structural support.
• Territorial Adaptation: The research documents how centralized oncology policies often fail to adapt to the specific demographic, epidemiological, and sociocultural conditions of Chile's diverse macro-regions, leading to persistent territorial inequities.
• Reconceptualizing Quality: The findings suggest that perceptions of quality in oncology care are socially and institutionally constructed. Quality is inextricably linked to the ability of the system to provide timely, continuous, and culturally responsive care, rather than just technical efficacy.
• Role of Primary Health Care (PHC): The study identifies a critical gap in the integration of PHC within oncology networks, noting that while PHC is rhetorically prioritized, its operational role in coordination and longitudinal follow-up remains underdeveloped.

Significance and Claims
The paper claims that the challenges facing oncology care in Chile are not solely due to resource scarcity but are fundamentally shaped by systemic fragmentation, limited territorial adaptation, and insufficient integration across healthcare networks. The authors argue that improving oncology care requires moving beyond a capacity-oriented approach toward models that prioritize organizational coherence and territorial responsiveness.

Specifically, the study asserts that:

• Strengthening oncology care necessitates improving coordination across levels of care and reinforcing the role of primary healthcare.
• Governance processes must incorporate the "situated knowledge" of providers to advance more integrated, equitable, and context-sensitive cancer care.
• The transition toward patient-centered, interdisciplinary care requires organizational conditions (continuity, coordination, sustained support) that are currently lacking in resource-constrained settings.
• Community support networks and intersectoral collaborations, while currently reliant on informal efforts, are essential complementary mechanisms for addressing unmet patient needs and should be formally recognized and supported.

The study concludes that achieving equitable oncology care depends on strengthening the relational integration of the health system and adapting governance models to the diverse realities of Chilean territories.