Background There is well-established variation in cancer survival and, despite general improvements over time, differential progress has been made across high-income countries with seemingly similar health systems. Research has explored the source of these differences in outcomes, but the role of leadership in cancer care systems has been under-researched. Leadership is one of the WHO ‘building blocks’ that underpin a functioning health system. It is variously defined as including governance, stewardship, responsibility and accountability.

As part of the International Cancer Benchmarking Partnership, this study looked at these diverse aspects of leadership to identify drivers of change and improvement across a range of high-income countries.

Methods Cancer strategy documents were analysed from 22 jurisdictions: Australia (3 states), Canada (10 provinces), Denmark, Ireland, New Zealand, Norway and UK (4 countries). Key informants in 15 of these jurisdictions, representing a range of stakeholders at the different tiers of the system, were recruited: hospital managers; regional and/or government officials; representatives from arms’ lengths bodies, professional bodies and patient associations; experts within the cancer field and with wider health policy expertise. Key informants were identified through a combination of purposive and ‘snowball’ strategies. They participated in semi-structured interviews held in English, using online conferencing software. Documents and interview transcripts were analysed using a thematic approach using a framework based on the WHO health systems framework and previous work analysing national cancer control programmes.

Results Different facets of leadership emerged: diffused across health boards vs centralised (including the central role of a cancer agency in some places); the interplay between national, regional and local leadership structures; the establishment of links between primary and secondary care. The study demonstrated a central role of sustained leadership and political commitment, crucial for initiating and maintaining progress, as was a coherent vision that supported the implementation of national policies locally. Clinical leadership of the cancer care system emerged as vital for translating policy into action.

Conclusion Certain aspects of cancer care leadership emerged as underpinning and sustaining improvements. Improving cancer outcomes is challenging and complex, but it is unlikely to be achieved without effective leadership and sustained political commitment that can create effective co-ordination of care. These lessons can be applied to jurisdictions which are struggling to achieve the progress they might otherwise be able to, and to a variety of conditions.