National Cancer Control Strategic Plan 2019-2029

Objectives

Malawi’s National Cancer Control Strategy 2019–2029 establishes a multisectoral framework for systematic cancer control across the continuum of prevention, early detection, diagnosis, treatment, follow-up, palliation, survivorship, financing and research. Its mission is to provide strategic leadership for a coordinated and responsive cancer control framework through partnerships and collaboration, reducing cancer incidence and mortality while improving patients’ quality of life.[1][2]The strategy aims to advance Universal Health Coverage by 2029 through equitable access to effective, sufficiently high-quality services without undue financial hardship.[2][3]

• Reduce exposure to cancer risks by addressing tobacco use, harmful alcohol consumption, unhealthy diets, physical inactivity and obesity, and by preventing cancer-causing infections through human papillomavirus and hepatitis B vaccination and HIV control.[3][4][5]
• Strengthen screening and early diagnosis by expanding cervical cancer services, ensuring timely referral, diagnostic evaluation, staging, treatment and follow-up, and improving pathology, laboratory, imaging, endoscopy and blood-analysis services.[6][7][8]
• Improve treatment quality and access through surgery, radiotherapy, chemotherapy, hormone therapy, multidisciplinary care, specialist outreach, referral pathways and strengthened district and tertiary capacity.[9][10][11]
• Provide palliative, supportive, rehabilitative and survivorship care for people with progressive, life-threatening or terminal cancer and their families, including pain relief, psychosocial, nutritional, emotional and spiritual support.[12][13][14]
• Strengthen governance, sustainable financing, affordable access to essential medicines and technologies, cancer research, monitoring, evaluation, registration and surveillance.[15][16][17]

Action is organised across six thematic areas: prevention; screening and early diagnosis; treatment and follow-up care; palliative care and survivorship; governance and financing; and cancer control research, monitoring and evaluation.[18][3]Priority cancers are cervical cancer, Kaposi sarcoma, breast cancer, non-Hodgkin lymphoma and oesophageal cancer, selected for their potential impact on Malawi’s cancer burden.[19][20]

The prevention agenda combines population-level policy measures with health promotion and immunisation. It seeks stronger tobacco control through legislation, taxation, smoke-free environments, warnings, cessation support, school education and alternative livelihoods for tobacco farmers.[4][21][22]It also promotes alcohol-policy implementation, advertising restrictions, taxation and drink-driving enforcement, alongside healthier diets, physical activity and obesity prevention.[5][23][24]

Early detection is intended to make treatment more effective, less complex and more affordable.[5]The strategy prioritises nationwide Visual Inspection with Acetic Acid screening and treatment of screen-positive women, national human papillomavirus vaccination, pathology and laboratory strengthening, and quality-assured referral systems.[25][6][8]Population-based mammography for women aged 50 years is not proposed because it is considered neither cost-effective nor feasible in Malawi; clinical breast examination during cervical screening is presented as a more feasible alternative.[7]

Treatment priorities include stabilising the National Cancer Treatment Centre in Lilongwe, developing regional matrix cancer centres, establishing specialist services and strengthening the oncology workforce.[10][12]The Centre is intended to provide surgery, radiotherapy, chemotherapy, hormone therapy, palliative care, pathology, diagnostics, medical records and a hospital cancer registry.[10]

Implementation

Implementation is designed as a coordinated, resource-appropriate programme embedded within the existing health-sector framework and delivered across all levels of governance.[1][14]It is guided by equity, national ownership, primary health care, human rights, gender sensitivity, ethical practice, evidence-based decision-making, decentralisation, accountability, sustainability, community participation and multisectoral collaboration.[2]Health service delivery is to align with devolved local-government structures under the Local Government Act 1998.[2]

• Coordinate national implementation through the Ministry of Health and Population’s cancer control unit and national cancer control coordinator, advised by a Cancer Control Advisory Committee chaired by the Secretary for Health.[14]
• Review implementation quarterly through the advisory committee and recommend mid-course corrective action.[14]
• Establish coordination frameworks, multisectoral Technical Working Groups, partnership forums and district cancer-control focal persons, including a dedicated group for childhood cancers.[15][16][26]
• Engage government departments, tertiary and district facilities, the National Cancer Treatment Centre, the Christian Health Association of Malawi, private providers, civil society, communities, training institutions, professional and regulatory bodies, research institutions and cooperating partners.[27][14][28]
• Develop public-private partnership arrangements, service standards, key performance indicators and common audit mechanisms across cancer services.[15]

Service delivery combines population prevention, primary health care, screening, diagnostics, treatment, follow-up, palliation and survivorship.[2]Prevention interventions are to integrate with sexual and reproductive health, HIV and AIDS programmes, national immunisation, occupational and environmental health, and lifestyle-modification initiatives.[18][3]Cervical screening expansion is supported by provider training, referral, treatment of precancerous lesions, thermocoagulation and loop electrosurgical excision procedure capacity.[6][29][30]

Diagnostic implementation includes needs assessments; workforce training and retention plans; equipment procurement, maintenance and quality-assurance policies; three regional pathology laboratories; regional imaging and endoscopy services; a national cancer reference laboratory; and interoperable medical information systems linked to the District Health Information System, cancer registration and surveillance.[8][31]The strategy seeks pathology reporting within seven days of specimen reception and use of International Agency for Research on Cancer tools and standards for data collection and quality assurance.[8]

Treatment delivery includes infrastructure development, staff training, national treatment and referral guidelines, patient and caregiver accommodation, supply-chain strengthening, cancer-specific patient education and specialist oncology outreach.[32][33][34]Palliative care is to operate through health-centre and community, district or rural hospital, and central hospital or hospice levels, using home visits, hospital visits and outreach clinics and supporting access to immediate-release oral morphine after clinical assessment and follow-up.[13]

Monitoring and evaluation are to use implementation and monitoring matrices, cancer registries, medical-record review, surveys, survival studies, mortality registration and research data.[1][28][17]Priorities include strengthening the Blantyre and Lilongwe population-based registries, the National Cancer Treatment Centre hospital registry, data completeness, cancer reporting systems, breast and cervical survival data, annual progress reports and legislation to make cancer a notifiable disease.[17]The evaluation plan is expected to track risk factors, screening, new cases, deaths, stage at diagnosis, treatment, clinical management and survival, although numerical targets and reporting frequencies are not comprehensively specified.[28]

Financing measures include increased government allocations, a cancer control fund, levies on products linked to cancer risk, local-government budget lines, government research funding and efforts to reduce service and medicine costs through generic medicines.[16]The strategy also identifies costed implementation activities, including 1,820 million Kwacha for treatment infrastructure, equipment and consumables, but the supplied material does not provide a consolidated budget, funding gap or complete financing plan.[33]

Monitoring & Evaluation

The strategy establishes monitoring, evaluation, research, cancer registration and surveillance as a thematic area and envisages an implementation matrix and a monitoring and evaluation matrix. It seeks to improve programme monitoring through standardised data collection, modernised systems, better indicators, a cancer reporting database, mandatory cancer reporting legislation and annual progress reports.[1][17]

• Use population-based and hospital-based cancer registries, medical-record reviews, cross-sectional surveys, survival studies, mortality registration, World Health Organization STEPwise surveillance surveys, household surveys and researcher-led studies as sources for monitoring and evaluation.[25][17]
• Monitor cancer risk factors, screening and early detection, new cases, deaths, stage at diagnosis, treatment, clinical management and survival, and disseminate findings to public-health agencies and scientists.[28]
• Strengthen the Blantyre and Lilongwe population-based registries, the National Cancer Treatment Centre hospital registry and other hospital registries, using International Agency for Research on Cancer tools, International Classification of Diseases compliance and links with the Health Management Information System.[17]
• Improve diagnostic and registry data quality to address under-reporting, noting that only 18% of reported cancers had pathological confirmation in the cited evidence.[19][20]
• Require accurate diagnostic documentation and reporting, including processing and reporting tissue specimens within seven days of receipt.[35][8]

Specific operational indicators include cancer incidence; lung-cancer prevalence and incidence; tobacco-use prevalence; alcohol-consumption frequency; obesity and physical-activity measures; vaccination coverage; screening volume and coverage; referral and treatment completion; diagnostic turnaround time; service capacity; workforce numbers; and palliative-care access.[4][5][36][37][13]

Targets include human papillomavirus vaccination coverage above 85% of target girls and hepatitis B vaccination coverage above 90% of the target population.[5]The human papillomavirus vaccination pilot achieved 82.7% final-dose coverage among 23,381 girls aged 9 to 13 years.[4]Cervical-screening performance rose from 75 sites and 15,331 women screened annually in 2011 to 130 sites and 49,301 women screened annually in 2015.[36]

Accountability is intended through the national cancer control coordinator and cancer control advisory committee, which should review implementation quarterly and recommend corrective action.[25][14]Public-private service standards should include key performance indicators and common audits, while the national cancer control programme should establish an evaluation protocol and produce regular reports.[15][28]Detailed indicator definitions, reporting frequencies, targets and sanctions are not consistently specified in the supplied extracts.[28]

Costing & Financing

The strategy identifies governance and financing as a thematic area and calls for sustainable financing, efficient resource use, cost-effective technology, and protection from financial hardship under Universal Health Coverage.[2][3]It also seeks to avert catastrophic cancer costs for households and the health system.[27]

• Establish planned budget outlays and dedicated budget lines for implementation and evaluation.[25]
• Increase government allocations for cancer activities and research, create a cancer control fund, use levies on products linked to cancer, and establish local-government budget lines for prevention, screening and early diagnosis.[16]
• Mobilise adequate Government of Malawi resources for the National Cancer Treatment Centre and seek global, regional and other sustainable financing mechanisms.[14][15]
• Use taxation of tobacco and alcohol both as prevention measures and as potential sources of cancer-control financing.[38][21][24]
• Reduce service and product costs and increase use of generic medicines.[16]

Costed implementation tables include allocations for prevention, early diagnosis, treatment, infrastructure, rehabilitation, coordination and registry activities, generally expressed in Kwacha and in some cases distributed across years 1–2, years 3–5 and years 5–10.[39][40][33][41]The extracts do not consistently identify the activities corresponding to every tabulated value or provide a consolidated total plan budget.[39][40]

Major resource needs include infrastructure, diagnostic and treatment equipment, medicines, consumables, supply chains, workforce training and retention, patient accommodation, blood products, information systems and operational funding.[8][10][12]The National Cancer Treatment Centre, regional cancer centres, nuclear medicine facilities, positron emission tomography capacity and cyclotron equipment are identified as substantial investment requirements.[10]

Economic considerations include the finding that population-based mammography for women aged 50 years is not cost-effective or feasible in Malawi, whereas clinical breast examination integrated with cervical screening may offer a more cost-effective alternative.[7]The source also cites an annual global economic cost of cancer of 1.16 trillion United States dollars.[20]Financing sources, quantified funding gaps, expenditure ceilings and underlying economic assumptions remain incompletely specified across the supplied material.[16][17]