Plan National De Lutte Contre Le Cancer (PNLCC) 2018-2022

Objectives

The National Cancer Control Plan for 2018 to 2022 sets out an integrated national response to reduce cancer-related morbidity, mortality and wider social and economic burdens, while improving quality of life during and after treatment. Its vision is a Mauritania in which cancer is no longer a public-health problem, supported by prevention, early detection, diagnosis and treatment adapted to the country’s socio-economic and cultural context.[1][2][3][4]

• Organise action across five intervention areas: primary prevention; screening and early diagnosis; cancer care, including palliative care; training, research and epidemiological surveillance; and programme coordination, advocacy and management.[1][5]
• Reduce exposure to tobacco, unhealthy diets, obesity, physical inactivity, pollution, occupational hazards, aflatoxin and chronic infections, including sexually transmitted infections, human papillomavirus and hepatitis B.[6][7][8][9]
• Strengthen cancer information through an institutionalised national population-based registry and facility registries, to assess incidence, trends, survival, geographical distribution, risk factors, service needs and intervention outcomes.[10][11]
• Expand screening and timely treatment for cervical and breast cancer, while promoting early diagnosis of prostate, colorectal, childhood, oral and other relevant cancers.[12][13]
• Improve diagnostic, surgical, medical and radiotherapy care, psychosocial support, pain management and palliative care across hospital, outpatient and home settings.[13][14][15]
• Build the oncology workforce, develop national diagnostic and treatment standards, support operational research, strengthen partnerships and ensure programme monitoring and evaluation.[16][4][15]

Key stated targets include reducing cancer mortality by 15%; reducing tobacco-smoking prevalence by 30%; informing half the population about physical activity and unhealthy diets; and detecting and treating more than half of precancerous lesions and early cervical and breast cancers in time.[4]Additional targets seek to sensitise more than 80% of women aged over 20 to breast self-examination and more than 80% of women aged over 40 to systematic mammography; train 50% of doctors, midwives and other health workers in cancer control; provide international-standard care to all patients; cure 50% of patients receiving care; and ensure that more than half of women aged over 40 receive cervical screening at least once in their lifetime.[5]

The plan’s guiding principles emphasise access to information on cancer risks, prevention and treatment; political commitment; international cooperation, technology transfer and financial assistance; multisectoral action; and participation by communities, private providers and civil society.[5]These priorities respond to an established cancer burden, including cancer’s reported position as the leading cause of medical evacuation abroad, accounting for 28% of evacuations.[17]

Implementation

Implementation is intended to be multisectoral and multidisciplinary, led through the Ministry of Health, the Directorate for Disease Control and the integrated non-communicable disease plan. Delivery builds on the National Oncology Centre as the national referral institution, alongside health centres, regional hospitals, specialist and private providers, and decentralised referral facilities.[2][18][19]

• Formalise the cancer registry by ministerial order, provide dedicated premises, equipment and operating resources, and appoint registry focal points in reference facilities.[10]
• Mobilise health services, schools, media, relevant ministries, consumer bodies, professional associations, non-governmental organisations, civil society, religious and community actors, technical and financial partners, and private-sector providers.[7][5][19]
• Implement tobacco-control legislation, smoke-free measures, restrictions on promotion, cessation consultations, public awareness and targeted education for young and vulnerable groups in collaboration with the national tobacco-control programme and PNLCC.[9]
• Deliver breast and cervical screening through awareness, clinical and self-examination promotion, mobile screening, active case-finding, referral, visual inspection with acetic acid or Lugol’s iodine, screen-and-treat services, and treatment of higher-grade lesions at regional hospitals.[12][13]
• Consider a pilot human papillomavirus vaccination project for girls aged 10, 11 or 12 years, with potential later expansion to other regions with GAVI Alliance support.[7]
• Develop integrated diagnostic and treatment pathways, referral and counter-referral algorithms, multidisciplinary consultation meetings, decentralised pathology and laboratory services, and patient access to medical records when transferring between public and private care.[16][20]
• Expand oncology capacity through specialised hospital services, day hospitals, centralised chemotherapy preparation, surgery, imaging, radiotherapy, brachytherapy, supportive medicines and affordable palliative-care provision.[20][14]
• Institutionalise pain management and develop palliative-care and psychological-support units, multidisciplinary support teams, family and social support, carer accommodation and home-based care.[3][15]

Governance arrangements include a technical steering committee chaired by an adviser to the Minister of Health, involving health directorates, the National Oncology Centre, the World Health Organization and other institutions. Technical thematic groups cover prevention, early detection, diagnostic and therapeutic management, and palliative care.[21][22]The source also identifies the National Health Insurance Fund, medicines-regulation and supply bodies, social-affairs institutions, traditional practitioners, parliamentary groups and cancer associations among relevant stakeholders.[16][3]

Monitoring is to combine programme performance indicators, cancer-registration systems, annual dissemination of registry data, behavioural risk-factor studies, knowledge-attitudes-and-practices studies, research and integration with the wider non-communicable disease monitoring and evaluation system.[2][11]Proposed indicators include trained palliative-care workers, palliative-care units created, functional registries, people trained, research activities undertaken and funded, resources mobilised, authority and health-worker commitment, and improved coordination.[21]The available material does not specify a complete reporting timetable, indicator definitions, evaluation methodology or formal accountability framework.[4][21]

Financing priorities include mobilising human, material and financial resources, creating a cancer-research support fund, securing an operating budget for the registry and supporting non-governmental organisations involved in cancer control.[10][8][19]No numerical plan budget, financing envelope, allocation schedule or quantified funding gap is provided.[16][4]

Monitoring & Evaluation

Monitoring and evaluation are integral to the National Cancer Control Plan, which combines performance-based annual review, cancer surveillance, operational research, quality assurance and information systems.[2][4][14]The framework seeks to generate evidence on cancer burden, trends, risk factors, service performance and outcomes, but several extracts identify incomplete institutionalisation, coordination and documentation of monitoring arrangements.[23][24]

• Implement annual monitoring and evaluation using performance indicators, alongside programme monitoring and evaluation as an explicit strategic objective.[2][4]
• Use outcome targets to track a 15% reduction in cancer mortality, a 30% reduction in tobacco-smoking prevalence, information on physical activity and unhealthy diets reaching half the population, and timely screening and management of more than 50% of precancerous lesions and early cervical and breast cancers during 2015–2019.[4]
• Track further service targets, including awareness of breast self-examination and mammography, health-worker training, care delivered to international standards, cure among treated patients, and lifetime cervical screening among women over 40.[5]
• Institutionalise a population-based national cancer registry and hospital registries in cancer-care facilities, supported by registry focal points, trained personnel, dedicated premises, equipment and operating resources.[10][11]
• Address registry weaknesses, including its status as a co-ordination committee rather than an institutionalised service, and the absence of dedicated data-collection and data-entry staff, logistics and financial support.[23]
• Use registry and facility-recording data to assess incidence, trends, survival, geographical distribution, risk factors, emerging cancers, service needs and the effectiveness of preventive and curative interventions.[11]
• Conduct regular behavioural risk-factor studies, annual analysis and dissemination of registry data, and knowledge, attitudes and practices studies in populations and workplaces to assess information, education and communication activities.[11]
• Strengthen epidemiological, clinical, biological, genetic, diagnostic, therapeutic, organisational and implementation research, while monitoring activities, processes, standards and services in accordance with ethical and good-practice requirements.[11][19]
• Monitor diagnostic and therapeutic care, implement quality assurance across treatment modalities, use multidisciplinary consultation meetings to agree treatment strategies, and strengthen referral, counter-referral and patient-record continuity between public and private services.[20][14]
• Address data-quality and follow-up constraints, including inadequate cancer data collection, limited epidemiological information, delayed pathology reporting, poor documentation of early-detection activities and substantial loss to follow-up.[6][24][18][7]
• Measure palliative-care and coordination progress through numbers of trained workers, palliative-care units, functional registries, people trained, research activities and funding, resource mobilisation, authority and staff commitment, and improved activity coordination.[21]

Available baseline evidence includes cancer accounting for 28% of medical evacuations abroad, 1,300 new cases recorded at Nouakchott Hospital between January 2000 and December 2004, and 1,115 new cases including 112 deaths reported in 2016.[17]Reported service figures include more than 98% reduction in overseas chemotherapy evacuations, 100% reduction in overseas radiotherapy evacuations, 50 to 60 new cases monthly, and about 2,080 patients treated by 30 August 2012.[25][26]The supplied material does not consistently specify indicator definitions, reporting timetables, evaluation methods, responsible reporting bodies or formal accountability arrangements.[4][5][21]

Costing & Financing

Financing information is limited: the plan identifies important resource requirements and constraints, but does not provide a complete costed implementation plan, numerical budget, financing envelope, funding-gap estimate or economic assumptions.[1][16][4]Cancer control is presented as requiring domestic resource mobilisation, international cooperation and financial assistance, partner support and, where appropriate, public-private purchasing partnerships.[5][19]

• Recognise the estimated 2008 cost of overseas cancer-care evacuations as 1.5 billion Ouguiyas, also reported as 4 million euros.[25]
• Maintain free local cancer treatment for indigent patients at the National Oncology Centre, whose reported patient coverage was approximately 94% indigent patients and 6% patients covered by the National Health Insurance Fund.[25][26]
• Establish a dedicated budget line and operating resources for the cancer registry and cancer control, as their absence is identified as a weakness.[10][16]
• Provide premises, equipment, logistics and financial support for registry operations and data management.[23][10]
• Mobilise human, financial and material resources, support non-governmental organisations involved in cancer control, and establish a cancer-research support fund.[8][19]
• Address affordability and supply barriers, including costly early-detection examinations, expensive morphine and consumables, medicine and single-use-material stock-outs, equipment-maintenance difficulties and the illicit market in medicines and consumables.[18][16][3]
• Resource diagnostic, laboratory, imaging, surgical, chemotherapy, radiotherapy, supportive-care and palliative-care capacity, including specialised personnel and affordable quality medicines.[20][14]

Early-detection activities have mainly relied on support from the United Nations Population Fund, the World Health Organization, civil society and professional associations, while palliative-care training has included bilateral cooperation with Italy and Morocco.[24][27]The material identifies international cooperation, technology transfer, knowledge transfer and financial assistance as guiding financing-related principles, but does not quantify partner contributions, domestic allocations or anticipated resource needs.[5]