Assessing Country Capacity Scaling up a Comprehensive ......Section 5 – Monitoring 33 Section 6...

AssessingCountry Capacityand Preparednessfor Introducing orScaling up a ComprehensiveCervical CancerPrevention andControl ProgrammeBaseline ReportDecember 2014

World Health OrganizationRegional Office for Africa

Assessing Country Capacity and Preparedness for Introducing or Scaling up aComprehensive Cervical Cancer Prevention and Control Programme

Baseline Report

December 2014

ASSESSING COUNTRY CAPACITY AND PREPAREDNESS FOR INTRODUCING OR SCALING UP A COMPREHENSIVECERVICAL CANCER PREVENTION AND CONTROL PROGRAMME. BASELINE REPORT, DECEMBER 2014

ISBN : 978-929023326-8

© WHO Regional Office for Africa 2017

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Baseline Report7


Sommaire

Acknowledgements 9

List of Tables 11

Abbreviations 13

Executive summary 15

Introduction 17

Objective 18

Methodology 18

PART 1 – Overall results 21

Section 1 - Demographics 21

Section 2 – Burden of disease 21

Section 3 – Governance and management 22

Section 4 - Laboratory services 32

Section 5 – Monitoring 33

Section 6 – Financing 35

PART 2 – Assessment of country capacity and preparedness 37

Discussion 49

Baseline Report9


Acknowledgements

The World Health Organization (WHO) Regional Office for Africa would like toexpress its deep appreciation to the ministries of health of Member States of theWHO African Region for supporting this programme of work. Thanks are due to KofiMensah Nyarko (Ghana), Namory Keita (Guinea), Nakato Jumba (Kenya), HenriRaharivohitra (Madagascar), Phiri Twambiline (Malawi), Rahmatu Hassan (Nigeria),Serigne Niang (Senegal), Angel Mwiche (Zambia), Bernard Madzima (Zimbabwe)and Dr Sulaiman Gbonnie Conteh (Sierra Leone) for their contribution.

Special thanks go to the following staff who contributed to data organization,implementation and analysis: Jean-Marie Dangou, Prebo Barango, Mary-Anne Landand the WHO country office focal points for the BMGF project on the Reduction ofCervical Cancer Burden, notably Ohene, Sally-Ann(Ghana), Diallo, Saliou Dian(Guinea),Oyelade Taiwo Adedamola (Nigeria), Tall Fatim (Senegal), Ganda Louisa(Sierra Leone), Nato Joyce (Kenya), Ramiliarijaona, Adele Benedicte (Madagascar),Msyambosa Kelias (Malawi), Malumo Sarai ( Zambia) and Kanyowa Trevor(Zimbabwe).

WHO also wishes to express sincere gratitude to the Bill & Melinda Gates Foundationfor providing the funding for this assessment, as part of the Reducing Cervical CancerBurden in Selected High-Burden Countries in the African Region programme grant.

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List of tablesPart 1 : Overall results

Table 1 : Population data

Table 2A : Cervical cancer case definition

Table 2B : Burden of disease

Table 3A : National health policies

Table 3B : Cervical cancer prevention and control guidelines and policies

Table 3C : National immunization coverage

Table 3D : Management of cervical cancer prevention and control programmes

Table 3E : Referral system programmes

Table 3F : Clinical guidelines

Table 3G : National targets for screening coverage

Table 3H : Screening tests

Table 3I : Training offered to health professionals performing cytology

Table 3J : Human resources and facilities

Table 3K : Screening services delivered as part of various health services

Table 3L : Treatment services: cryotherapy, LEEP, conisation and hysterectomy

Table 3M : National cervical cancer screening coverage for women aged 30-49 years

Table 3N : HPV vaccination management

Table 4A : Laboratory services

Table 4B : Human resources and facilities

Table 5A : National monitoring capacity

Table 5B : Laboratory information monitoring

Table 5C : HPV vaccination monitoring

Table 6A : Funding of health programmes

Table 6B : Funding of cervical cancer prevention and control

Part 2 : Assessment of country capacity and preparedness

Table 7 : A checklist for a comprehensive cervical cancer prevention and control programme - Ghana

Table 8 : A checklist for a comprehensive cervical cancer prevention and control programme - Guinea

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Table 9 : A checklist for a comprehensive cervical cancer prevention and control programme - Kenya

Table 10 : A checklist for a comprehensive cervical cancer prevention and control programme -Madagascar

Table 11 : A checklist for a comprehensive cervical cancer prevention and control programme - Malawi

Table 12 : A checklist for a comprehensive cervical cancer prevention and control programme - Nigeria

Table 13 : A checklist for a comprehensive cervical cancer prevention and control programme - Senegal

Table 14 : A checklist for a comprehensive cervical cancer prevention and control programme – Sierra Leone

Table 15 : A checklist for a comprehensive cervical cancer prevention and control programme -Zambia

Table 16 : A checklist for a comprehensive cervical cancer prevention and control programme -Zimbabwe

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Abbreviations Yes

No

CHW Community Health Worker

DK Don’t know

DTP3 3rd dose of Diphtheria, Tetanus, Pertussis vaccine

GAVI Global Alliance for Vaccines and Immunization

HepB3 3rd dose of Hepatitis B vaccine

HIV Human Immunodeficiency Virus

HPV Human Papilloma Virus

LEEP Loop Electrosurgical Excision Procedure

MoH Ministry of Health

N/A Not applicable

NCD Noncommunicable disease

ND No data

No. Number

RH Reproductive Health

QA Quality assurance

VIA Visual inspection with acetic acid

WHO World Health Organization

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Executive summaryVaccinating young girls against the Human Papilloma Virus (HPV) before sexual debut andscreening women for cervical cancer have been identified as priority interventions to reduce theburden of cervical cancer. Awareness strategies for these interventions have existed for someyears, and many countries are in various stages of developing and implementing programmesto vaccinate, screen for and treat cervical cancer. This is the first comprehensive overview toassess country capacity and preparedness to introduce or scale up comprehensive cervical cancerprevention and control programmes in sub-Saharan Africa. The policies, resources and systemsreported here build on the growing body of literature about practical aspects of cervical cancerprevention and control by documenting existing programmes and their core characteristics. Assuch, it makes an essential contribution to the understanding of the several components that areimportant in effective cervical cancer prevention and control programming.

Ten countries (Ghana, Guinea, Kenya, Madagascar, Malawi, Nigeria, Senegal, Sierra Leone, Zambiaand Zimbabwe) were selected to participate in this survey. A six-section questionnaire wascompleted by non-communicable diseases, cancer control or reproductive health nationalprogramme coordinators between June and July 2014, except Sierra Leone, for which data wasreceived in May 2015 due to the country’s prioritization of resources toward responding to theEbola outbreak which, for most of last year, had a devastating effect on the country. The surveyprovides an assessment of country capacity and preparedness to introduce or scale up cervicalcancer prevention and control programmes.

In line with the WHO recommendation on cancer control, most but not all countries either have anational cancer or cervical cancer prevention and control policy/strategic plan. All countries havesome level of a cervical cancer prevention and control programme, with a responsible office oragency leading and coordinating the programme. Clinical practice guidelines exist for severalaspects of cervical cancer screening in most countries. National targets for screening coverageare established in half of the countries, screening services are delivered in primary, secondaryand tertiary settings as part of routine preventive health, maternal and child health and specialcampaigns for cervical cancer prevention.

The number of health professionals, facilities and laboratories offering screening, treatment and thereporting of tests were recorded in most of the countries, but the degree of completeness variesconsiderably from country to country. All countries use VIA and cytology services for screening.Continuing training for health professionals performing screening and within laboratories reportingresults is organized occasionally. National cervical cancer screening coverage for women duringthe past year was reported by half of the countries. A referral system with a unique identificationnumber is used for women who need treatment for precancerous lesion and cervical cancer andpalliative care in some countries. The number of women who received preventive therapy duringthe past year was reported by two countries. Only one country completes a national coverage surveyon a regular basis. While an existing cancer registry was reported by most countries (half of whichalso have a cervical cancer registry), the proportion of the population covered by the registrationsystem was low.

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HPV vaccination programmes are being implemented in school and community settings in half ofthe countries as demonstration projects and there are plans for implementation in a further twocountries. Most countries have national funding for health programmes, mainly adolescent andreproductive health programmes. Few countries, however, have funding for cancer preventionand control. International and local private assistance programmes exist in most countries but onlytwo countries have health insurance covering treatment and associated diagnostic tests, excludingscreening.

This review summarizes the components of existing cervical cancer programmes and highlightscharacteristics most likely to impact programme efficacy. For most countries, strengthening currentprogrammes may be one of the most cost-effective approaches for improving public health.

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IntroductionCervical cancer is the second most common cancer in women in sub-Saharan Africa, accountingfor 20.4% of all women’s cancers and 12% of all newly diagnosed cancers in men and womenevery year. Nearly 90% of cervical cancer deaths in 2012 occurred in developing parts of theworld : 60 100 deaths in Africa; 28 600 in Latin America and the Caribbean, and 144 400 in Asia1.In Africa, cervical cancer is most common in East, Southern and Central Africa with respectiveage-standardized rates (ASRs) of 42.7, 31.5 and 30.6 per 100 0002 . Patients are often diagnosedat advanced stages of the disease, resulting in poor prognosis.

Cervical cancer is a preventable disease, yet it remains the most common cause of cancer deathamong women in the African Region. In sub-Saharan Africa, 34.8 new cases of cervical cancer arediagnosed per 100 000 women annually and 22.5 per 100 000 die from the disease. These figurescompare with 6.6 diagnosed and 2.5 deaths per 100 000 women in North America.

WHO recommends a comprehensive approach to cervical cancer prevention and control that followsa life course approach based on the mode of transmission of the causative pathogen (HPV) andthe progression of the disease with a prolonged precancerous stage before progression to cancer.This approach spans the continuum of interventions, from prevention including vaccination ofyoung girls against HPV and sexual reproductive health strategies, screening to detect and treatprecancerous lesions, diagnosis and treatment of cervical cancer and palliative care3 .

The vast difference in cervical cancer incidence in developing versus developed regions is areflection of the absence of effective national cervical cancer screening and treatment programmesin the majority of developing countries. Where national organized screening and treatmentprogrammes have been implemented, data demonstrates that cervical cancer incidence andmortality are significantly reduced. There are numerous barriers to setting up national cervical cancerprevention and control programmes in developing countries, although, in the last 15 years, newapproaches and technologies have made the possibility of implementing primary and secondaryprevention programmes in these countries more feasible. The barriers include :

(a) Rare or weak cervical cancer prevention and control policy, strategies and programmes. (b) Lack of recent and comprehensive data. (c) Heavy economic and psychosocial burden of cervical cancer. (d) Insufficiency or lack of information and skill as well as scarce local, effective and

sustainable research. (e) High cost of immunization against HPV.(f) Unavailability of secondary prevention for cervical cancer.(g) Unaffordability of therapeutic resources and neglect of palliative care. (h) Lack of collaboration and coordination of interventions among stakeholders and donors.

1 Torre, L. A., Bray, F., Siegel, R. L., Ferlay, J., Lortet-Tieulent, J. and Jemal, A. (2015), Global cancer statistics, 2012. CA : ACancer Journal for Clinicians. doi : 10.3322/caac.21262.2 GLOBOCAN 2012 (IARC), Estimated age-standardized rates (World) per 100,000;http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx.3 World Health Organization, Comprehensive cervical cancer prevention and control: a healthier future for girls and women. Geneva, 2013. (http://apps.who.int/iris/bitstream/10665/78128/3/9789241505147_eng.pdf?ua=1)

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Recent research into alternative approaches for the secondary prevention of cervical cancer offersnew possibilities for more affordable and implementable programmes, particularly the ‘screenand treat’ approach. This has been tested in randomized trials in some African countries where ithas been demonstrated that Visual inspection methods and HPV–based screening, coupled withimmediate treatment using cryotherapy, significantly reduces both cervical cancer precursors andcervical cancer4 . In addition to new approaches to secondary prevention of cervical cancer, therecent availability of two highly effective vaccines against HPV infection has major implicationsfor future prevention: the bivalent vaccine and the quadrivalent vaccine. Furthermore, a considerableamount of current research is towards molecular detection of cervical cancer precursors which shouldovercome many of the deficiencies associated with visual methods or cervical cytology-basedscreening programmes.

It is in the light of these challenges and the opportunity to reduce the burden of cervical cancer inthe Region that the WHO, with support from the BMGF, is implementing a four-year project in tenhigh-burden countries in the Region to reduce the burden of cervical cancer. However, to enablethe documentation of real progress made in these countries and assess their capacity to implementthe project, WHO is collecting baseline information on the state of cervical cancer prevention andcontrol interventions in the countries as well as assessing their state of preparedness to implementcost-effective high-impact interventions to reduce cervical cancer burden.

Objectives

The objectives of the assessment are to :

(a) collect baseline information on the cervical cancer prevention and control interventions in the countries involved in the BMGF project;

(b) better understand the selected countries’ context and readiness to develop country-specific operational plans to implement primary and secondary cervical cancer prevention interventions;

(c) collect baseline information that will inform programme implementation and be used to assess progress in the implementation of the BMGF project.

Methodology

Ten countries (Ghana, Guinea, Kenya, Madagascar, Malawi, Nigeria, Senegal, Sierra Leone, Zambiaand Zimbabwe) that are part of the BMGF-funded project to reduce the burden of cervical cancer wereselected to participate in this survey. A six-section questionnaire was completed by noncommunicablediseases, cancer control and/or reproductive health national programme coordinators between Juneand July 2014, except Sierra Leone, for which data was received in May 2015 due to the country’sprioritization of resources toward responding to the Ebola outbreak that, for most of last year, hada devastating effect on the country. Although the questionnaire was designed through expert consul-tation, pilot testing was not completed to evaluate the questions and responses. Consequently,additional information was provided post-hoc through country consultation and by extracting datafrom pre-existing surveys.

4 WHO. Prevention of cervical cancer through screening using visual inspection with acetic acid (VIA) and treatment witcryotherapy. A demonstration project in six African countries: Malawi, Madagascar, Nigeria, Uganda, United Republic of Tanzaniaand Zambia. World Health Organization 2012.

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5 World Health Organization, Comprehensive cervical cancer prevention and control : a healthier future for girls and women.Geneva, 2013(http://apps.who.int/iris/bitstream/10665/78128/3/9789241505147_eng.pdf?ua=1)..

The results of the data are presented in two parts. First, as an overall summary of the results,enabling country comparisons and highlighting several important considerations relating toburden of diseases, infrastructure and human resources. The second part used the Checklist fora Comprehensive Cervical Cancer Prevention and Control Program5 as a framework for assessingindividual country capacity and preparedness to introduce or scale up a Comprehensive CervicalCancer Prevention and Control Programme.

Baseline Report21


PART 1 – OVERALL RESULTS

Section 1 - Demographics

All the countries concerned reported their total female population. The estimated number of womenaged 30-59 years and girls aged 9-12 years in each of the countries that reported the informationis more than 1.3 million and 470 thousand respectively. Primary school completion rate amonggirls ranged from 33% to 90% (Table 1).

TABLE 1. POPULATION DATA

Section 2 – Burden of disease

The definition of cervical cancer differed between countries; definitions are presented in Table 2A.

TABLE 2A. CERVICAL CANCER CASE DEFINITION

Country

Ghana

Guinea

Kenya

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

12 633 978

5 927 600

22 072 281

10 652 965

8 055 276

86 805 213

6 445 412

3 226 000

6 638 019

6 780 700

2010

2010

--

2013

2014

2014

2013

2013

2010

--

3 435 607

No data

++

2 081 687

1 471 574

20 233 297

1 650 987

802,737

1 326 864

1 671 839

2010

ND

--

2013

2014

2012

2013

2013

2010

--

1 191 351

No data

++

--

--

++

476 521

306559

582 437

538 182

2010

ND

--

--

--

--

2011

2013

2010

--

90+

77

52

33.05

--

85

70.1

71

76

--

2010

2010

2012

2010/11

--

2012

2013

2014

2013

--

Total Female Population

No. Year

No. Women aged30-59 years

No. Year

No. Girls aged9-12 years

No. Year

Primary school completion rate

among girls(%) Year

-- no information reported++ disaggregated population age range different. + MoH estimate

Country Definition

Ghana

Guinea

Kenya

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

Cancer of cervix confirmed by histology.

Cancer of cervix confirmed by histology.

Histologically diagnosed malignancy following positive lesion identified by cytology.

Malignant tumour of the cervix with histologic evidence.

Cauliflower-like growth or ulcer fungating mass.

Cancer that forms in tissues of the cervix (the organ connecting the uterus and vagina).

Cervical tumour whose histological diagnosis establishes a malignancy.

A disease that affects the cervix in the female reproductive system due to the abnormal growth of the cells

that have the ability to invade or spread to other parts of the body.

Pathology of squamous cell or adenocarcinoma.

--

-- no information reported

Baseline Report22


The incidence and mortality rate, number of cervical cancer cases and deaths per year are shownin Table 2B.

TABLE 2B. BURDEN OF DISEASE

Section 3 – Governance and management

The guidelines and policies in place for cervical cancer prevention and control are shown in Charts3A and 3B below. There is a national cancer prevention and control policy in four countries (Ghana,Guinea, Madagascar and Zimbabwe) and a national cervical cancer prevention and control policyin five countries (Ghana, Guinea, Kenya, Madagascar and Nigeria). No country has a nationalHPV vaccine policy and only two countries (Madagascar and Malawi) participating in HPVdemonstration projects have a national guideline on HPV immunization service delivery.

There is a national guideline on health promotion/communication for cervical cancer preventionand control in three countries (Ghana, Malawi and Nigeria). National policies on reproductive,maternal and child health are reported by all ten countries. Policies on women and gender arereported to be available in eight countries (Ghana, Guinea, Madagascar, Malawi, Nigeria, Senegal,Sierra Leone and Zimbabwe) while availability of noncommunicable diseases policy is reportedby seven countries (Ghana, Guinea, Madagascar, Malawi, Nigeria, Senegal and Zimbabwe).

There are guidelines for screening in eight (Ghana, Guinea, Kenya, Madagascar, Malawi, Nigeria,Senegal and Zimbabwe), diagnostics in six (Ghana, Guinea, Kenya, Madagascar, Malawi, andZimbabwe), laboratories in four (Guinea, Kenya, Madagascar and Zimbabwe), treatment optionsfor precancerous lesion and cervical cancer in seven (Ghana, Guinea, Kenya, Madagascar, Malawi,Nigeria and Zimbabwe) countries.

Pays

Ghana

Guinea

Kenya

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

32,7

56,3

20,5

DK

33,6

0,04

21,9

ND

32

33,2

2012

2008

2012

ND

2010

2012

2012

--

2013

--

28,2

25

16,3

ND

--

12,8

17,70

ND

38/100000

--

2012

2008

2012

ND

--

2012

2012

--

2007

--

--

1736

245

ND

2316

14550

1482

36*

665

--

--

2008

2012

ND

2010

2010

2012

2014

2013

--

--

--

1676

ND

1621

9659

858

ND

ND

--

--

--

2012

ND

2010

2012

2012

--

ND

--

Incidence

(%) Year

Mortality rate

(%) Year

Cases per year

No. Year

Deaths per year

No. Year

-- no information reported* no formal data collection system for cervical cancer

Baseline Report23


Chart 3A. NATIONAL HEALTH POLICIES

Chart 3B. CERVICAL CANCER PREVENTION AND CONTROL GUIDELINES AND POLICIES

Baseline Report24


National immunization coverage for measles, DTP3 and HepB3 is shown in Table 3C below.

TABLE 3C. NATIONAL IMMUNIZATION COVERAGE

The management of cervical cancer prevention and control programmes is shown in Table 3Dbelow. There is a cervical cancer prevention and control programme in seven countries (Ghana,Guinea, Kenya, Madagascar, Malawi, Nigeria and Zimbabwe). Cervical cancer prevention andcontrol programmes are organized at the national level in five countries (Ghana, Kenya, Malawi,Nigeria and Zimbabwe), in selected areas in six countries (Ghana, Guinea, Madagascar, Nigeria,Zambia and Zimbabwe) and through opportunistic screening in six countries (Ghana, Guinea,Madagascar, Nigeria, Senegal and Zambia). All nine countries have a responsible office or agencyleading and coordinating the programme, and five countries (Kenya, Malawi, Nigeria, Senegal andZimbabwe) have a steering committee for the programme.

TABLE 3D. MANAGEMENT OF CERVICAL CANCER PREVENTION AND CONTROL PROGRAMMES

Country

Ghana

Guinea

Kenya

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

89

62

86

86

88

59

84

89

84

79

2013

2012

2013

2013

2013

2013

2013

2014

2010

--

90

47

84

90

89

58

92

93

88

95

2013

2012

2013

2013

2013

2013

2013

2014

2010

2013

90

90

83

90

89

63

92

93

79

95

2013

2013

2012

2013

2013

2013

2013

2014

2010

2012

Measles

(%) Year

DTC3

(%) Year

HepB3

(%) Year


Country

Ghana

Guinea

Kenya

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

Cervical cancerpreventionand controlprogramme

Nationallevel

N/A

Selectedareas

N/A

--

NCDs Control Programme

PNL Cancer/Maternal Health Services

Division of Reproductive Health

DLMNT/SLMV*

MoH Reproductive Health*

National Cancer Control Programme FMoH*

Transmitted Diseases Division*

-

MCDMCH/MOH

MoH and child care/RH *

Opportunisticscreening Name of office or agency

-- no information reported, † No national level programme but partners have programmes,* countries with steering committees for the programme.DLMNT Direction de Lutte contre les Maladies Non Transmissible / SLMV Service de Lutte contre les Maladies Liées aux Modesde Vie.

Baseline Report25


A referral system is available for women who need treatment for precancerous lesion and cervicalcancer in eight (Ghana, Guinea, Kenya, Malawi, Madagascar, Nigeria, Senegal and Zimbabwe)and palliative care in eight (Ghana, Guinea, Malawi, Madagascar, Nigeria, Senegal, Sierra Leoneand Zimbabwe) countries. One country (Zambia) reported no available formalized referral system(very weak formalized referral system) (Table 3E). There is a unique identification number fortracing or calling and recalling women who use screening services in six countries (Guinea,Madagascar, Malawi, Nigeria, Zambia and Zimbabwe).

TABLE 3E. REFERRAL SYSTEM PROGRAMMES

There are clinical practice guidelines on the age at which to initiate screening, coverage goals,screening interval, tests to be used, use of standard terminology, health care professionals per-mitted to conduct screening and methods of managing women with precancerous lesions in sixcountries (Guinea, Kenya, Madagascar, Malawi, Nigeria and Zimbabwe). One country (Ghana)reported no available clinical guidelines. However, Ghana has a national cancer plan outlining na-tional strategies for control of priority cancers, including cervical cancer. The plan specifies theage at which to initiate screening, the screening test to be used, the screening interval as well asthe health care cadres that can conduct screening. Zambia is currently developing a tool that willdefine standard terminology, the health care cadres that are permitted to perform screening andprovide treatment, and methods of managing precancerous lesions (Table 3F).

Country

Ghana

Guinea*

Kenya

Madagascar*

Malawi*

Nigeria*

Senegal

Sierra Leone

Zambia*

Zimbabwe*

Precancerous lesion treatment

Cervical cancer treatment

Palliative care

* Countries which have a unique identification number for tracing or calling and recalling women who use screening services

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TABLE 3F. CLINICAL GUIDELINES

TABLE 3G. NATIONAL TARGETS FOR SCREENING COVERAGE

Country

Ghana*

Guinea

Kenya

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

Ag

e at

wh

ich

to in

itia

tesc

reen

ing

Co

vera

ge

go

als

Scr

een

ing

inte

rval

Scr

een

ing

test

s to

be

use

d

Sta

nd

ard

ter

-m

ino

log

y

Pro

fess

ion

als

per

mit

ted

to

test

/tre

at

Met

ho

ds

of

man

agin

gw

om

en w

ith

pre

can

cero

us

lesi

on

*There are no clinical guidelines; however, all indicators such as the age at which to initiate screening, coverage goals andscreening intervals are provided in the National Cancer Plan (NCCP)

National targets for screening coverage were reported by the seven countries shown in Table 3G.

Clinical practice guidelines

--no information reported* no national cervical cancer screening policy. Screening is organized by CSO/NGOs.

Country National screening target

Ghana

Guinea

Kenya

Madagascar

Malawi

Nigeria

Senegal*

Sierra Leone

Zambia

Zimbabwe

30% of the eligible population within 5-year span of the plan

--

70% coverage for 18-69 year olds (target year not provided)

5% coverage by 2013 for 25-49 year age group.

80% coverage for 30-45 year olds by 2016

80% coverage for HIV+ women prescribed ART

--

--

N/A

1.3 million women to be screened in 5 years (target year not provided)

25% coverage for 18-59 year olds by 2016

Baseline Report27


A summary of where cytology and VIA services are delivered and by whom is presented in Table3H. No country reported the use of cytology services in primary health facilities. Cytology servicesare delivered in secondary health facilities in two countries (Ghana and Nigeria) and in tertiaryfacilities of all countries but Sierra Leone. Cytology services for screening are performed byOB-GYNs in all but two (Senegal and Sierra Leone), general practitioners in five (Ghana, Madagascar,Malawi, Zambia and Zimbabwe), nurses in two (Ghana and Madagascar), midwives in four(Ghana, Guinea, Madagascar and Zambia) and cytopathologists in three (Madagascar, Nigeriaand Senegal) countries. VIA services are delivered in primary health services of all but two countries(Senegal and Sierra Leone), as well as in secondary facilities of nine countries and tertiary facilitiesin all but two countries (Ghana and Sierra Leone). VIA services for screening are performed byOB-GYNs and midwives in nine countries, general practitioners in all but two countries (Nigeriaand Sierra Leone; while Senegal reported `don’t know`), nurses in all countries (other than Senegalreporting `don’t know` and Sierra Leone) and oncologists in one country (Madagascar). SierraLeone is the only country that reported non-availability of cytology and VIA services at any levelof its health service delivery system.

TABLE 3H. SCREENING TESTS

Special training is offered to health professionals performing cytology in six countries (Ghana, Kenya,Madagascar, Nigeria, Zambia and Zimbabwe), refresher training courses are offered `occasionally`in four countries (Ghana, Kenya, Madagascar and Zimbabwe) and training is planned in the nearfuture in six countries (Ghana, Guinea, Kenya, Nigeria, Zambia and Zimbabwe) (Table 3I).

Country

Ghana

Guinea

Kenya

Madagascar*†

Malawi

Nigeria*

Senegal*

Sierra Leone

Zambia

Zimbabwe

Pri

mar

y

Sec

on

dar

y

Ter

tiar

y

OB

GY

Ns

Gen

eral

P

ract

itio

ner

s

Nu

rses

Mid

wiv

es

Pri

mar

y

Sec

on

dar

y

Ter

tiar

y

OB

GY

Ns

DK

Gen

eral

P

ract

itio

ner

s

DK

Nu

rses

Mid

wiv

es

* Cytologists also perform cytology, † oncologists also perform VIA screening

Cytology servicesare delivered at : Cytology is performed by : VIA services are

delivered at : VIA is performed by :

Baseline Report28


TABLE 3I. TRAINING OFFERED TO HEALTH PROFESSIONALS PERFORMING CYTOLOGY

The number of health professionals providing screening is reported in four countries (Guinea,Madagascar, Zambia and Zimbabwe). The number of facilities which offer routine screening testsis reported in six countries (Ghana, Guinea, Madagascar, Malawi, Nigeria, Senegal, Zambia andZimbabwe) (Table 3J). Sierra Leone was the only country to report no available data on healthprofessionals carrying out screening. It, however, reported that screening tests are delivered aspart of maternal and child health services in tertiary health facilities.

TABLE 3J. HUMAN RESOURCES AND FACILITIES

Country

Ghana*

Guinea

Kenya

Madagascar*

Malawi

Nigeria*

Senegal*

Sierra Leone

Zambia

Zimbabwe*

N/A

Special training incytology

N/A

Refresher courses

N/A

Future training

* Frequency of training courses - occasionally

Country

Ghana**

Guinea

Kenya

Madagascar†

Malawi*

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

--

10

ND

3

--

--

NA

--

--

25

ND

156

--

--

NA

--

--

52

ND

42

250

--

NA

--

--

--

ND

--

--

--

NA

--

--

93

N/A

199

--

--

NA

--

10

34‡

ND

76

104

DK

NA

--

8

5

ND

5

37

60

NA

--

OB

-GY

Ns

Gen

eral

P

ract

itio

ner

s

Nu

rses

Mid

wiv

es

Hea

lth

Car

eW

ork

ers

Routine screening tests Cryotherapy

Total No. health professionals providing screening tests No. health facilities offering

20

10

23

32

58

93

45

74

13

0

32

31

17

25

--no information reported; Total No. health professional providing screening test † VIA only* In Malawi VIA is integrated in FamilyPlanning Clinics and is provided by nurses. ** In public facilities there about 25 health professionals offering the screening service.However, there are other private facilities that offer pap smears. ‡ 34 centres offer screening during campaigns but only 5 arefunctional for routine screening

Screening services delivered as part of various health services are shown in Table 3K. Screeningservices are delivered as part of routine preventive health services for women in primary healthfacilities in seven countries (Ghana, Guinea, Kenya, Madagascar, Malawi, Nigeria and Zimbabwe)and in secondary and tertiary facilities in all but three countries (Ghana, Sierra Leone and Zambia),maternal and child health services in primary health facilities in six countries (Ghana, Guinea,Kenya, Madagascar, Malawi and Zimbabwe), secondary health facilities in seven countries(Ghana, Guinea, Kenya, Madagascar, Malawi, Senegal and Zambia) and tertiary health facilitiesin all but two countries (Ghana and Zambia) and special campaigns for cervical cancer preventionare conducted in primary and secondary health facilities in seven countries (Ghana, Guinea,Kenya, Nigeria, Malawi, Zambia and Zimbabwe) and in tertiary health facilities in five countries(Guinea, Kenya, Nigeria, Zambia and Zimbabwe).

TABLE 3K. SCREENING SERVICES DELIVERED AS PART OF VARIOUS HEALTH SERVICES

Baseline Report29


Country

Ghana

Guinea

Kenya

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

Pri

mar

y

Sec

on

dar

y

--

Ter

tiar

y

Pri

mai

re

Sec

on

dar

y

Ter

tiar

y

Pri

mar

y

Sec

on

dar

y

Ter

tiar

y

--

--


As part of the routine preventivehealth services at :

As part of maternal and childhealth services at :

As a special campaign for cervical cancer prevention at :

Cryotherapy for treating precancerous cells is offered in some of the health facilities in all thecountries except Sierra Leone which indicated that a cryotherapy service was not available incountry. Cryotherapy services are delivered at the primary level in five(Madagascar, Malawi, Nigeria,Zambia and Zimbabwe), secondary level in five(Ghana, Guinea, Kenya, Madagascar and Zambia)and tertiary level in three (Guinea, Kenya and Senegal) countries. Treatment services for LEEPare delivered at the primary level in one country (Nigeria), at the secondary level in six countries(Ghana, Guinea, Kenya, Malawi, Zambia and Zimbabwe) and the tertiary level in five countries(Guinea, Kenya, Malawi, Madagascar and Nigeria). Treatment services for conisation are notdelivered at the primary level in any country, but are delivered at the secondary level in threecountries (Kenya, Madagascar and Nigeria) and tertiary level in six countries (Guinea, Kenya,Madagascar, Senegal, Zambia and Zimbabwe). Treatment services for hysterectomy are notdelivered at the primary level in any country, but are delivered at the secondary level in threecountries (Ghana, Guinea, Madagascar and Nigeria) and tertiary level in all the countries exceptSierra Leone. (Table 3L).

Baseline Report30


TABLE 3L. TREATMENT SERVICES : CRYOTHERAPY, LEEP, CONISATION AND HYSTERECTOMY

National cervical cancer screening coverage for women during the past year was reported by fourcountries (Kenya, Madagascar, Malawi and Zimbabwe). The number of women who receivedpreventive therapy for cervical cancer during the past year was only reported by two countries (Nigeria(538-cryotherapy) and Zimbabwe (4703)) (Table 3M).

TABLE 3M. NATIONAL CERVICAL CANCER SCREENING COVERAGE FOR WOMEN AGED 30-49 YEARS

Country

Ghana

Guinea

Kenya

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

*

*

Pri

mar

y

**

Sec

on

dar

y

DK

DK

+

DK.

--

--

--

‡

•

‡

Ter

tiar

y

--no information reported, *District, †Sub-national, ‡National, • Referral facilities** some offer

Cryotherapy

Pri

mar

y

Sec

on

dar

y

Ter

tiar

y

LEEP

Pri

mar

y

Sec

on

dar

y

Ter

tiar

y

Conisation

Pri

mar

y

Sec

on

dar

y

Ter

tiar

y

Hysterectomy

Country National cervical cancer screening coverage for women aged 30-49 years during the past year

Ghana

Guinea

Kenya

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone

Zambia†

Zimbabwe

--

ND

3,2 % (18-69)

3,21 % (25-49)

37 493 (22 %) en 2014

DK

N/A

N/A

DK

46 288

+ Information from different partners not reported to the central government -- no information reported

Baseline Report31


There is a funded HPV demonstration vaccination programme in five countries (Kenya, Madagascar,Malawi, Zambia and Zimbabwe). One country (Senegal) is planning to start a vaccination pro-gramme in November 2014 while another country (Ghana) has completed a feasibility study. Twocountries (Guinea and Nigeria) reported no plans to start a vaccination programme. The currentprogrammes, where available, are funded by government partners and GAVI. The HPV vaccinationprogramme is delivered in schools by five countries (Ghana, Kenya, Madagascar, Malawi andZambia) and in community health centres by two countries (Madagascar and Zambia). Commu-nication strategy packages are available for clinicians and service providers, the community, targetgroups, parents and teachers in countries implementing the GAVI demonstration projects andGhana. There is a training structure/model for clinicians and vaccinators in five (Ghana, Kenya,Madagascar, Malawi and Zimbabwe) and communicators in three (Ghana, Madagascar andMalawi) countries. Vaccination is performed by general practitioners in three countries (Ghana,Kenya and Madagascar), nurses in five countries (Ghana, Kenya, Madagascar, Zambia andZimbabwe) and community health workers in one country (Malawi). The total number of generalpractitioners and nurses providing HPV vaccination was reported in one country (Madagascar).At least two teachers were reported to be providing the vaccination in one country (Malawi).

A cold chain is available in each health facility at the national level in all countries, district level innine countries (Ghana, Guinea, Kenya, Madagascar, Malawi, Nigeria, Senegal, Sierra Leone andZambia) and community level in five countries (Ghana, Madagascar, Malawi, Sierra Leone andZambia) (Table 3N).

TABLE 3N. HPV VACCINATION MANAGEMENT

Country

Ghana•

Guinea

Kenya†

Madagascar†

Malawi*

Nigeria

Senegal‡

Sierra Leone

Zambia†

Zimbabwe*

N/A

--

--

DK

Sch

oo

ls

--

N/A

--

--

--

DK

Co

mm

un

ity

hea

lth

cen

tres

--

--

--

Clin

icia

ns

--

--

Com

mun

ity

--

--

Tar

get

g

rou

ps

--

--

Par

ents

--

--

Teac

hers

--

--

Clin

icia

ns

--

--

Vac

cin

ato

rs

--

--

DK

Co

mm

un

ica-

tors

N/A

--

--

Gen

eral

P

ract

itio

ner

s

N/A

--

--

Nu

rses

--

N/A

--

--

CH

W

Com

mun

ityle

vel

--no information reported, *funded HPV vaccination programmes, † countries with demonstration projects, ‡programme expectedto commence in Nov 2014, •a feasibility project has been completed.

HPV vaccinationdelivered

Communication packages available for Training model Vaccination is

performed byCold

Chain

Baseline Report32


Section 4 – Laboratory services

Laboratory services are offered in all the countries except Sierra Leone. Centralized laboratorysystems are reported in all but three of the countries (Ghana, Kenya and Nigeria) and a nationalreference library in all but one of the countries (Zambia). Regular external quality assessment ofcytology and histopathology is conducted in three countries (Ghana, Guinea and Malawi) andpathologist reports are evaluated and monitored in two countries (Ghana and Zambia) anddependent on facility ownership in a third country (Kenya). The use of standard internationalterminology for reporting cytologic results was reported in three countries (Guinea, Madagascarand Nigeria). There is a programme in place for training and evaluation of cytotechnicians in onecountry (Nigeria). Negative cytologic smears are only re-scanned by a cytologist/pathologist inthree countries (Ghana, Nigeria and Zambia) (Table 4A).

TABLE 4A. LABORATORY SERVICES

The data on the number of laboratory specialists available in each country for cervical cancerservices are shown in Table 4B.

TABLE 4B. HUMAN RESOURCES AND FACILITIES

Country

Ghana

Guinea

Kenya*

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

Centralizedsystem

Nationalreferencelaboratory

DK

DK

DK

QA forcytology/

histopatho-logy

DK

DK

DK

DK

DK

QA for pathology

DK

DK

DK

DK

Standardizedterminology

DK

N/A

DK

DK

Training

DK

N/A

DK

DK

DK

Re-screeningof negative

smears

* QA for pathology is dependent on facility ownership, but not always conducted in pubic

Country

Ghana

Guinea

Kenya

Madagascar*

Malawi

Nigeria†

Senegal

Sierra Leone

Zambia‡

Zimbabwe

3

1

ND

9

1

39

3

ND

1

1

Laboratories

3000

ND

ND

4500

--

DK

ND

--

150

--

Cytology smears

8

3

ND

13

--

DK

3

--

2

1

Cytopathologists

20

3

ND

10

3

DK

5

1

3

12

Pathologists

12

2

ND

16

--

DK

ND

--

4

0

Cytotechnicians

-- no information reported, *Madagascar reported at a sub-national level; 2 labs, 1500 smears, 3 cytopathologist and 4 cyotechnicians.†Nigeria reported at a sub-national level; 37 labs., ‡Zambia reported at a sub-national level; 3 labs, 30 smears and 5 pathologists.

Baseline Report33


Section 5 – Monitoring

All countries, except Sierra Leone, reported that enumeration for target population screening waspossible. Only one country (Malawi) reported that national coverage surveys are performed on aregular basis in a standard survey. An available cancer registry was reported by seven countries(Ghana, Kenya, Madagascar, Malawi, Nigeria, Senegal, Zambia and Zimbabwe). Kenya is in theprocess of developing a national cancer registry. Currently, there are regional cancer registries(hospital-based) for two regions. The proportion of the population covered by the registrationsystems was reported by five countries (Kenya (23%), Malawi (<10%), Madagascar (0.6%), Nigeria(7%), and Zimbabwe (13%)).There is a central health information system on cervical cancer infive countries (Ghana, Guinea, Madagascar, Nigeria and Zimbabwe). National, sub-nationaland district cervical screening registries with a public health professional, e.g. epidemiologist,responsible for monitoring cervical cancer screening data were reported in four countries(Guinea, Madagascar, Malawi and Zimbabwe) (Table 5A).

TABLE 5A. NATIONAL MONITORING CAPACITY

In all countries, except Sierra Leone, there are measures in place to ensure confidentiality. Thereis a system that links the cervical cancer smears to the biopsy slides in two countries (Madagascarand Nigeria). A central list of women with abnormal screening results is available in four countries(Guinea, Madagascar, Malawi and Zimbabwe) and the purpose of the list in all countries where itis available is to track and follow up clients. It is possible to access laboratory records for eachwoman so that data are available by woman screened over time in four countries (Guinea, Mada-gascar, Nigeria and Senegal) and data are available on a cross-sectional basis in three countries(Guinea, Nigeria and Senegal). Statistical reports on the cervical cancer screening programmeare produced routinely by four countries (Guinea, Malawi, Nigeria and Zimbabwe). These reportsare available to policy-makers in three countries (Malawi, Nigeria and Zimbabwe) (Table 5B).

Country

Ghana**

Guinea

Kenya

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone***

Zambia*

Zimbabwe

Enumeration

--

--

National coverage surveys

--

Availablecancerregistry

Central healthinfo system

--

Cervical cancer registry

National Sub-national District

--

--

--no information reported, *the cancer registry is hospital-based, **the national level receives reports from the various screeningcentres, ***The hospital register is used to gather information which is scanty

Rapport de référence34


TABLE 5B. LABORATORY INFORMATION MONITORING

The size of the target population for HPV vaccination can be identified in five countries (Kenya –target group is Year 4 class, approximately 20 943 girls in the GAVI demonstration project, Ma-dagascar- seven per cent of girls aged 9 -13 years, Senegal - approximately 162 401 girls andZambia - 250 000 girls aged 9 – 14 years and Sierra Leone). Three countries (Kenya, Madagascarand Malawi) have a HPV vaccination registry available with a public health professional, e.g.epidemiologist, responsible for monitoring vaccination data. These three countries have a standardvaccination record for use by all immunization providers, and information on vaccine dose number,date of birth, the place where the vaccine is distributed and a system for reporting adverse eventsof vaccines by the public and health professionals to a national centre. However, case definitionfor adverse events of vaccines is only being identified in two countries (Madagascar and Malawi)(Table 5C). Information is transferred between screening and vaccination by mail in one country(Kenya), and by email in another country (Malawi). No country reported using disk or web accessfor the transfer of information.

TABLE 5C. HPV VACCINATION MONITORING

Country

Ghana

Guinea*

Kenya

Madagascar*

Malawi⁾

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe*

--

N/A

DK

DK

System linkingsmears to

biopsy slides

--

DK

Central list for abnormal

screening

DK

Lab. record access over

time

DK

Lab. recordaccess on a

cross-sectionalbasis

--

DK

Stats. reportsproduced

--

Results available to

policy-makers

--no information reported, Systems for tracking and following up abnormal screening are both *electronic and paper,⁾ paper only.

Country

Ghana**

Guinea

Kenya*†

Madagascar*

Malawi*‡

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

Vaccinationregister

--

--

--

Std vaccination

record

--

--

--

Vaccinedose No.

--

--

--

Placedistributed

--

--

--

Date ofbirth

--

--

--

Misseddose

--

N/A

--

Syst. forreportingadverse

events ofvaccines

--

N/A

--

Adverseevent

defined

--

--

--

DK

--

--

--

DK

--

--

--

DK

--

--

--

DK

--

--

--

DK

--

--

--

DK

--

--

--

DK

--no information reported, * Health professional responsible for monitoring data, Information is transferred between screening andvaccination by mail† and by email‡** Ghana has implemented a demonstration project for HPV and all the data is available.

Baseline Report35


No country reported if the background rates of relevant diseases are known for the target age group.Only one country (Kenya) reported that it is possible to link to other health data sets to monitor diseaserates.

Section 6 – Financing

Specific budgets for cancer prevention and control were reported in three countries (Malawi, Nigeriaand Zimbabwe); however, no country reported the specific annual appropriation for cervical cancer.Specific budgets for adolescent health services, noncommunicable diseases and reproductivehealth were reported by eight countries (Ghana, Madagascar, Malawi, Nigeria, Senegal, Sierra Leone,Zambia and Zimbabwe), five countries (Malawi, Nigeria, Senegal, Sierra Leone and Zimbabwe)and eight countries (Ghana, Kenya, Madagascar, Malawi, Nigeria, Senegal, Sierra Leone andZimbabwe) respectively. Three countries (Malawi, Senegal and Zimbabwe) have a budget for allfour programmes, while one country (Guinea) does not have a budget for any of the programmes.Funding for the purchase of HPV vaccine and operational costs was reported in three countries(Malawi, Kenya and Madagascar) where demonstration projects are currently under way and in athird country (Senegal) (Table 6A).

TABLE 6A. FUNDING OF HEALTH PROGRAMMES including HPV Vaccine

International assistance supporting cervical cancer is reported by six countries (Ghana, Kenya,Madagascar, Nigeria, Zambia and Zimbabwe); six countries reported receiving local private assis-tance (Kenya, Madagascar, Nigeria, Zambia, Malawi and Zimbabwe). Three countries reportedno assistance (Guinea, Senegal and Sierra Leone). Health insurance is reported to cover cervicalcancer screening in Kenya and cancer diagnosis, treatment and palliative care in Ghana. HPVvaccination is not currently included in health insurance of any country. Women are required topay the total cost for cervical screening in five countries (Ghana, Guinea, Madagascar (Papsmear), Senegal and Sierra Leone) and partial cost in two countries (Kenya and Nigeria), while

Country

Ghana

Guinea

Kenya*

Madagascar

Malawi

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

Can

cer

pre

ven

tio

n

and

co

ntr

ol

Ad

ole

scen

th

ealt

h

NC

Ds

Rep

rod

uct

ive

hea

lth

DK

Vac

cin

s

DK

Op

erat

ion

alco

sts

* HPV funding for a demonstration project

Specific budgets for health programmes Specific budget for HPV

Baseline Report36


five countries (Kenya, Madagascar (VIA), Nigeria, Zambia and Zimbabwe) reported free screening.Only one country (Madagascar) categorized the cost for different screening methods (Table 6B).

TABLE 6B. FUNDING OF CERVICAL CANCER PREVENTION AND CONTROL

Country

Ghana

Guinea

Kenya†

Madagascar‡•

Malawi

Nigeria

Senegal

Sierra Leone

Zambia

Zimbabwe

Inte

rnat

ion

al

Lo

cal/p

riva

te

N/A

N/A

Scr

een

ing

N/A

N/A

Dia

gn

osi

s

--

N/A

Tre

atm

ent

and

Pal

liativ

eca

re

N/A

DK

HP

Vva

ccin

atio

n

--

N/A

To

tally

--

--

Par

tial

ly

--

Fre

e

-- no information reported, Screening cost to women † screening for cervical cancer in Kenya is free in all public health facilities,payments are only done at private facilities, ‡Yes- PAP, • Yes –VIA

Assistancesupporting cervical

cancerHealth insurance covers cervical cancer Screening cost to women

Baseline Report37


PART 2 – ASSESSMENT OF COUNTRY CAPACITY AND PREPAREDNESS

This section summarizes the countries’ capacity and preparedness to start or scale up comprehensivecervical cancer prevention and control interventions, using the Checklist for a ComprehensiveCervical Cancer Prevention and Control Program6 as a framework for assessing the capacityand preparedness to scale up cervical cancer prevention and control programmes.

6 World Health Organization, Comprehensive cervical cancer prevention and control : a healthier future for girls and women. Geneva, 2013. (http://apps.who.int/iris/bitstream/10665/78128/3/9789241505147_eng.pdf?ua=1).

Baseline Report38


TABLE 7 : A CHECKLIST FOR A COMPREHENSIVE CERVICAL CANCER PREVENTION AND CONTROL PROGRAMME - GHANA

Component Comment/Recommendation

1 A functional multi-disciplinary platform to foster partnership and collaboration in setting the national agenda.

2 A comprehensive national policy or plan on cervical cancer prevention and control.

3 National guidelines for health workers for all components of comprehensive cervical cancer prevention and control.

4 Financial and technical resources to implement the policy or plan and ensure that services are accessible and affordable to girls and women.

5 Communication strategies to educate the community andadvocate for support of national policies.

6 A training plan is in place, as well as a supervisory mechanismfor quality control and assurance of the programme.

7 HPV vaccination as a population-based strategy for anappropriate cohort in the target age group of 9-13 years old girls.

8 Cervical cancer programme to ‘screen and treat’ every womanbetween 30-49 years old at least once in her lifetime.

9 A functioning referral system that links screening services with the treatment of precancerous lesions and invasivecancer.

10 Functioning monitoring systems to track coverage of HPV vaccination, screening, and follow-up treatment.

11 Existence of a cancer registry as part of the health informationsystem to monitor cervical cancer incidence and mortality.

There is a National Cancer Steering Committee. A functionalmulti-disciplinary platform that will involve education, social mo-bilization, vaccination, screening, treatment and palliative carewith representatives from these groups is recommended.

There is a National Cancer Strategic Plan that outlines thenational strategies for control of the priority cancers, includingcervical cancer.

Development of guidelines for screening tests, diagnosticstests, laboratories, treatment options for precancerous lesionsand cancer treatment, as well as clinical practice guidelines isrecommended.

Most of the recommendations in the Cancer plan have not beenimplemented due to lack of resources. There is no specific budgetfor cancer prevention and control or HPV. There is a budget forreproductive health. There is international but no local assistancesupporting cervical cancer. A specific MoH budget for cancercontrol at the MoH is recommended.

There are national guidelines on health promotion/communicationfor cervical cancer prevention and control.

Development of a training plan is recommended.

Development of a HPV vaccination policy is recommended.

There is a programme for cervical cancer prevention.Development of a national coverage target is recommended.

A referral system is available for women who need treatmentfor precancerous lesion and cervical cancer and palliative care.Recommend strengthening of this system with clearly definedroles and responsibility at each level of the referral system.

Development of monitoring systems and strengthening cancer/cervical cancer registries at the national, sub-national and districtlevels is recommended.

Development of health information system and registries isrecommended.

Baseline Report39


TABLE 8 : A CHECKLIST FOR A COMPREHENSIVE CERVICAL CANCER PREVENTION AND CONTROL PROGRAMME- GUINEA








7 HPV vaccination as a population-based strategy for an appro-priate cohort in the target age group of 9-13 years old girls.

8 Cervical cancer programme to ‘screen and treat’ every woman between 30-49 years old at least once in her lifetime.

9 A functioning referral system that links screening services with the treatment of precancerous lesions and invasive cancer.


11 Existence of a cancer registry as part of the health informationsystem to monitor cervical cancer incidence and mortality

A functional multi-disciplinary platform that will involve education,social mobilization, vaccination, screening, treatment and pallia-tive care with representatives from these groups is recommended.

There is a national cancer and cervical cancer prevention andcontrol policy.

There are guidelines and policies for cervical cancer preventionand control, including clinical guidelines.

There is no specific budget for cancer prevention and controlor other health programmes. There is no international or localassistance supporting cervical cancer prevention.

Development of national guidelines on health promotion/communication for cervical cancer prevention and control isrecommended.



There is a programme for cervical cancer prevention.Development of a national coverage target is recommended.

A referral system is available for women who need treatmentfor precancerous lesion and cervical cancer and palliative care. Recommend strengthening of this system with clearly definedroles and responsibility at each level of the referral system.

Development of monitoring systems is recommended

There is a central health information system and a cervical cancerregistry at the national, sub-national and district levels.

Baseline Report40


TABLE 9 : A CHECKLIST FOR A COMPREHENSIVE CERVICAL CANCER PREVENTION AND CONTROL PROGRAMME - KENYA







6 A training plan is in place, as well as a supervisory mecha-nism for quality control and assurance of the programme.







There is a national cervical cancer prevention and control policy.


There is no specific budget for cancer prevention and control. There is a budget for reproductive health and HPV programmes.There is international or local assistance supporting cervicalcancer prevention.




There is a programme for cervical cancer prevention.

A referral system is available for women who need treatmentfor precancerous lesion and cervical cancer. Recommendstrengthening of this system with clearly defined roles and res-ponsibility at each level of the referral system.

Development of monitoring systems is recommended.

Development of monitoring systems and strengtheningcancer/cervical cancer registries at the national, sub-nationaland district levels is recommended.

Baseline Report41


TABLE 10 : A CHECKLIST FOR A COMPREHENSIVE CERVICAL CANCER PREVENTION AND CONTROL PROGRAMME - MADAGASCAR








7 HPV vaccination as a population-based strategy for an appropriate cohort in the target age group of 9-13 years old girls.





A functional multi-disciplinary platform that will involve education,social mobilization, vaccination, screening, treatment and palliativecare with representatives from these groups is recommended.

There is a national cancer and cervical cancer prevention andcontrol policy that expires in 2015. Recommend the develop-ment/update of the national cervical cancer prevention andcontrol policy.


There is no specific budget for cancer prevention and control.There is a budget for reproductive health and HPV program-mes. There is international or local assistance supporting cervicalcancer prevention.

Development of national guidelines on health promotion/commu-nication for cervical cancer prevention and control is recommen-ded.



There is a programme for cervical cancer prevention.

A referral system is available for women who need treatmentfor precancerous lesion and cervical cancer and palliative care.Further detail is required on the functionality of the system.


Development of monitoring systems and strengtheningcancer/cervical cancer registries at the national, sub-nationaland district levels is recommended.

Baseline Report42


TABLE 11 : A CHECKLIST FOR A COMPREHENSIVE CERVICAL CANCER PREVENTION AND CONTROL PROGRAMME - MALAWI













There is a multi-disciplinary national steering committee to over-see the implementation of HPV vaccine. The MoH plans tobroaden the scope of this committee to cervical cancer.

Development of a comprehensive cancer/cervical cancercontrol plan/strategy is recommended.

There are guidelines and policies on cervical cancer prevention andcontrol, including clinical guidelines; guidelines for laboratories arerecommended.

There is a specific budget for cancer prevention and control,reproductive health and HPV operational costs. There is nointernational but local assistance supporting cervical cancerprevention.

There are national guidelines on health promotion/communicationfor cervical cancer prevention and control.



There is a programme for cervical cancer prevention and control.

A referral system is available for women who need treatmentfor precancerous lesion and cervical cancer and palliative care;further detail is required on the functionality of the system.



Baseline Report43


TABLE 12 : A CHECKLIST FOR A COMPREHENSIVE CERVICAL CANCER PREVENTION AND CONTROL PROGRAMME - NIGERIA








7 HPV vaccination as a population-based strategy for an appropriate cohort in the target age group of 9-13 years old girls.

8 Cervical cancer programme to ‘screen and treat’ everywoman between 30-49 years old at least once in her lifetime.





There is a national cervical cancer prevention and control policy.

There are guidelines and policies on cervical cancer preventionand control, including clinical guidelines; guidelines for labora-tories and diagnostics are recommended.

There is a specific budget for cancer prevention and control andreproductive health. There is no budget for HPV. There is inter-national and local assistance supporting cervical cancer pre-vention.

There are national guidelines on health promotion/communica-tion for cervical cancer prevention and control.



There is a programme for cervical cancer prevention and control.Development of a national coverage target is recommended.




Baseline Report44


TABLE 13 : A CHECKLIST FOR A COMPREHENSIVE CERVICAL CANCER PREVENTION AND CONTROL PROGRAMME - SENEGAL






5 Communication strategies to educate the community and advocate for support of national policies.







A functional multi-disciplinary platform that will involve education,social mobilization, vaccination, screening, treatment and palliativecare with representatives from these groups is recommended.

Development of a comprehensive cancer/cervical cancercontrol plan/strategy is recommended.

Development of guidelines for laboratories, diagnostics andtreatment is recommended. Clinical guidelines for coveragegoals, standard terminology and professionals permitted to testand treat are recommended.

There is no specific budget for cancer prevention and control.There is a budget for reproductive health and HPV programmes.There is no international or local assistance supporting cervicalcancer prevention.




Development of a programme for cervical cancer prevention andcontrol, including a national coverage target is recommended.




Baseline Report45


TABLE 14 : A CHECKLIST FOR A COMPREHENSIVE CERVICAL CANCER PREVENTION AND CONTROL PROGRAMME – SIERRA LEONE













A functional multi-disciplinary platform that will involve education,social mobilization, vaccination, screening, treatment andpalliative care with representatives from these groups isrecommended.

There is no national cancer and cervical cancer prevention andcontrol policy. It is recommended that these policies should bedeveloped and implemented.

Development of guidelines for laboratories, diagnostics andtreatment is recommended. Clinical guidelines for coveragegoals, standard terminology and professionals permitted to testand treat are recommended.

There is no specific budget for cancer prevention and control.There is no international or local assistance supporting cervicalcancer prevention. Development of cervical cancer advocacyto increase support for cervical cancer prevention and controlinterventions is recommended.


Development of a programme for cervical cancer prevention andcontrol including a national coverage target is recommended.


Development of a programme for cervical cancer prevention andcontrol, including a national coverage target is recommended.

A referral system is available for women who need palliative care.Development of a referral system for treatment of precancerouslesions and cervical cancer is recommended. Also recommendedis the strengthening of this system with clearly defined roles andresponsibilities at each level of the system.



Baseline Report46


TABLE 15 : A CHECKLIST FOR A COMPREHENSIVE CERVICAL CANCER PREVENTION AND CONTROL PROGRAMME - ZAMBIA








7 HPV vaccination as a population-based strategy for an appro-priate cohort in the target age group of 9-13 years old girls.





A functional multi-disciplinary platform that will involve education,social mobilization, vaccination, screening, treatment and pallia-tive care with representatives from these groups is recommended

Development of a comprehensive cancer/cervical cancer controlplan/strategy is recommended.

Development of guidelines for screening tests, diagnosticstests, laboratories, treatment options for precancerous lesionsand cancer treatment, as well as clinical practice guidelines isrecommended.

There is no specific budget for cancer prevention and controlor HPV. There is a budget for adolescent health. There is inter-national and local assistance supporting cervical cancer.





Development of a referral system is recommended.



Baseline Report47


TABLE 16 : A CHECKLIST FOR A COMPREHENSIVE CERVICAL CANCER PREVENTION ANDCONTROL PROGRAMME - ZIMBABWE






5 Communication strategies to educate the community and advocate for support of national policies.

6 A training plan is in place, as well as supervisory mechanism for quality control and assurance of the programme.


8 Cervical cancer program to ‘screen and treat’ every woman between 30-49 years old at least once in her lifetime.





Development of a comprehensive cervical cancer control plan/strategy is recommended.


There is a specific budget for cancer prevention and control,reproductive health and HPV. There is international and localassistance supporting cervical cancer.





A referral system is available for women who need treatmentfor precancerous lesion, cervical cancer and palliative care;further detail is required on the functionality of the system.


There is a central health information system and cervical cancerregistry at the national, sub-national and district level.

Baseline Report49


DiscussionThe baseline survey highlights several programmatic gaps in cervical cancer preventionand control programmes across the countries. It reveals several potentials for improve-ment to deliver efficient and effective comprehensive interventions for cervical cancerprevention and control. Key among these is the need to develop a robust monitoringand evaluation system to monitor programme performance, ensure that marginalizedgroups are appropriately reached by interventions, assess service uptake trendsand incorporate feedback for better programme performance.

The assessment also highlights the need to develop a screen and treat approachthat is responsive to the peculiarity of the individual country context. However, thedevelopment of relevant policy and costed strategic plans should be prioritized in orderto establish a sustainable framework for implementation of the various componentsof a comprehensive cervical cancer programme. In the same vein, it is crucial for countriesto explore innovative models of delivery of cervical cancer screening services inorder to generate a significant impact on coverage.

The components of a comprehensive cervical cancer prevention and control programmeadopted in all the countries vary. However, the three key areas which were identifiedas limited across all countries were training, referral systems and monitoring systems.Future work should explore these components through a more in-depth analysis soas to further inform and guide scale-up and implementation.

The assessment also highlights the need for appropriate funding for NCD preventionand control activities in general and cervical cancer programmes in particular. Thoughall the countries receive significant support from external partners and donors forcervical cancer prevention and control activities, there is a need for improved governmentfunding for NCD, cancer and cervical cancer prevention and control interventions.A budget line in the annual national budget of countries for these interventions will goa long way towards complementing external support, ensuring programme sustainabilityand, thus, reducing morbidity and mortality from cervical cancer..

Assessing Country Capacity Scaling up a Comprehensive ......Section 5 – Monitoring 33 Section 6...

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