Plan Stratégique de Lutte Contre le Cancer du Col de l’Utérus et les Autres Cancers Gynécologiques et Mammaires au Bénin

Objectives

The 2019–2023 Strategic Plan for the Prevention and Control of Cervical, Other Gynaecological and Breast Cancers seeks a Benin in which women are free from the burden of these cancers. It is integrated within national cancer and non-communicable disease action, aligns with the National Health Development Plan, and aims to improve equitable access to quality prevention, diagnosis, treatment and palliative care while reducing morbidity and mortality.[1][2][3]

• Reduce morbidity and mortality from gynaecological and breast cancers by 30% by 2023.[4]
• Reduce invasive cervical-cancer incidence by 50%, from 13.6 to 6.8 new cases per 100,000 inhabitants, by 2023.[5]
• Achieve early diagnosis for 75% of cervical, breast, ovarian, vaginal, fallopian-tube and endometrial cancers, defined through diagnosis at International Federation of Gynecology and Obstetrics stages I or II.[5]
• Provide adequate care for all women screened or diagnosed with gynaecological or breast cancer, and palliative care for all patients with incurable disease or a need for such care.[4][6]
• Reduce oncogenic human papillomavirus prevalence among girls aged 18 to 25 by 30%, while promoting research, coordination, monitoring and evaluation.[4][6]

The plan is structured around four strategic areas: primary prevention; early diagnosis and treatment; tertiary and quaternary prevention; and leadership, governance and research promotion.[4]It gives particular attention to young women and adolescents, women living in remote areas or with limited resources, vulnerable and marginalised groups, and women aged 21 to 65 years.[3]For cervical cancer, screening and treatment of precancerous lesions target women aged 25 to 65 years; for breast cancer, mammography every two years is reserved for women aged 50 years and over.[7][3]

• Strengthen primary prevention through social and behavioural change communication, healthy behaviours, risk-factor reduction, human papillomavirus vaccination for girls aged 9 to 13 years, and community awareness of symptoms and screening.[3][8]
• Expand early detection through cervical screening, including visual inspection with acetic acid, treatment of precancerous lesions, breast awareness, clinical examination, mammography and breast-lesion microbiopsy.[9][10]
• Improve tertiary and quaternary care through pathology, surgery, chemotherapy, radiotherapy, nuclear medicine, referral systems and palliative care.[11][12]
• Advance equity and universal access by strengthening peripheral services, involving midwives in cervical and breast screening, and prioritising vulnerable groups.[13]

Implementation

Implementation is organised across the central, intermediate and peripheral levels of Benin’s health-system pyramid, coordinated nationally by the National Programme for the Fight against Non-Communicable Diseases. Departmental Health Directorates operate at intermediate level and health-zone bureaux at operational level, with designated focal persons intended to coordinate and guide activities at each level.[14]The plan favours integration of activities into existing health services to support sustainability and proposes piloting activities in one southern and one northern health zone for six months before evaluation and national scale-up.[8][15]

• Coordinate cervical-lesion screening through maternity services and integrate visual inspection with acetic acid into the national minimum maternity-service package.[9][16]
• Establish a joint gynaecological and breast-cancer screening sub-programme through the National Programme for the Fight against Non-Communicable Diseases and the Directorate of Maternal and Child Health.[16][15]
• Deliver human papillomavirus vaccination through the National Vaccination Agency and decentralised structures, linked to the Expanded Programme on Immunisation and supported by education, social-affairs and youth sectors.[16][17]
• Designate the National University Hospital Centre, the Mother and Child Teaching Hospital, Parakou Departmental Hospital, Tanguiéta Hospital and Abomey Departmental Hospital as expert centres, with other departmental hospitals acting as relay centres for straightforward surgery and follow-up.[11][18]
• Build specialist capacity through pre-service and continuing education for midwives, general practitioners, gynaecologists, radiologists, surgeons, pathologists, oncology personnel, anaesthesia staff, palliative-care staff and epidemiology personnel.[19][12]

The delivery model combines public-sector service provision, community participation, multisectoral collaboration and partnerships with private actors, civil society, development partners and international training or research institutions.[13][20]Community and religious leaders, municipal authorities, men, women’s associations, peer educators, traditional practitioners, teachers, journalists and community relays are expected to support communication, behaviour change and appropriate care-seeking.[21][8]Other ministries have proposed roles in social protection for indigent patients, school-based communication, specialist recruitment, legal protection, media sensitisation and regulation of tobacco, alcohol, early marriage, pesticides and related risks.[22][23]

• Establish national referral and counter-referral arrangements to enable patients to move from primary care to diagnostic and treatment centres.[11]
• Develop oncology capacity through pathology laboratories, imaging, chemotherapy day hospitals, radiotherapy, nuclear medicine, surgical equipment and six palliative-care units with mobile teams.[11][12]
• Subsidise anticancer medicines and provide a State chemotherapy subsidy of at least 50%.[11][14]
• Mobilise resources through a dedicated budget line, technical and financial partner round tables, telethons and proposed earmarking of 5% of selected health-related taxes for cancer control.[20][24]

Governance arrangements include quarterly health-zone meetings, six-monthly departmental meetings and annual national review sessions.[12][14]Monitoring relies on facility screening registers, Cotonou and Parakou cancer registries, standardised data-collection forms and the District Health Information Software 2.[23][25]The plan schedules a mid-term evaluation in the second half of 2021 and a final evaluation in the first half of 2024.[23]Its gross budget is 28,203,556,100 CFA francs, of which 22,249,800,000 CFA francs was identified as acquired financing and 5,953,756,100 CFA francs remained to be mobilised.[24]

Monitoring & Evaluation

The plan establishes a multi-level monitoring, evaluation and accountability system for gynaecological and breast cancer control, combining routine facility and registry data, District Health Information Software 2 (DHIS2) reporting, performance indicators, coordination reviews, and independent periodic evaluations.[23][25]

• Collect standardised data through facility forms, cervical and breast screening registers, the Cotonou and Parakou cancer registries, and DHIS2. Facility data are transmitted through health zones to the Ministry of Health’s Health Information Management Service, while registry data are centralised and periodically analysed by the National Programme for the Fight against Non-Communicable Diseases.[23][25]
• Strengthen surveillance by maintaining the Cotonou and Parakou cancer registries with operational inputs, recruiting four epidemiology technicians, and using lessons from existing registries to consider expansion to other departments.[23][25]
• Monitor indicators continuously for implementation and short- and medium-term results, including prevention communication, human papillomavirus vaccination, screening capacity and uptake, positivity rates, early diagnosis, treatment coverage, mortality, palliative-care access, referral-centre capacity, medical evacuations, partnerships, publications and the programme-budget share allocated to these cancers.[26][27][28][5][29][30]
• Measure key prevention indicators annually, including the proportion of facilities offering communication or human papillomavirus vaccination packages, completion of two vaccine doses among girls aged 9 to 13, adverse events following immunisation, and proportions of trained midwives and specialists. Awareness sessions are monitored quarterly at facility level.[31][32][33]
• Measure screening and clinical-service indicators annually, including facilities and maternity units offering cervical screening, breast examination practices, mammography and microbiopsy availability, women screened and testing positive, treatment of precancerous lesions, invasive-cancer treatment completion, radiotherapy availability and palliative-care coverage.[34][35][36][37][38][39][40][41][42][43][44][45][46][47]
• Track outcome targets, including a 50% reduction in invasive cervical-cancer incidence from 13.6 to 6.8 new cases per 100,000 inhabitants, early diagnosis at International Federation of Gynecology and Obstetrics stages I or II for 75% of specified cancers, comprehensive care and palliative care for all eligible patients, and a 30% reduction in oncogenic human papillomavirus prevalence among girls aged 18 to 25 by 2023.[5][6]
• Review implementation through quarterly zone meetings, six-monthly departmental meetings and annual national reviews. Financial performance is monitored quarterly by the programme accounting officer through fiduciary expenditure controls and detailed financing reports.[14][25]
• Conduct a mid-term evaluation in the second half of 2021 and a final evaluation in the first half of 2024. Evaluators are to agree evaluation questions with the programme monitoring and evaluation service while retaining independence.[23][25][48]

Costing & Financing

The plan has a gross budget of 28,203,556,100 West African CFA francs, of which 22,249,800,000 West African CFA francs is identified as acquired financing and 5,953,756,100 West African CFA francs remains to be mobilised from the national budget.[24]

• Finance acquired activities through 4,080,000,000 West African CFA francs from projects funded through the national budget and 18,169,800,000 West African CFA francs from technical and financial partners. Costly vaccination and radiotherapy interventions are described as already covered by funded projects or programmes.[24]
• Allocate 18,389,093,000 West African CFA francs to primary prevention during 2019–2023, including communication, awareness, social mobilisation, media programming and advocacy for financial and material resources.[48][49]
• Fund early diagnosis and treatment, with 17,800,000,000 in the source’s unspecified currency assigned to selecting and financing a human papillomavirus vaccine suited to prevalent genotypes, and 1,514,735,600 assigned to Strategic Axis 2.[17][10]
• Resource tertiary and quaternary prevention through investments in screening and treatment equipment, specialist training, chemotherapy units, diagnostic imaging, nuclear medicine, radiotherapy and palliative care. The extracts give several allocations but do not consistently identify their currency or financing source.[50][18][51][52]
• Mobilise additional resources through a dedicated budget line, a round table with technical and financial partners, telethons, a cancer-control fund, and proposed earmarking of 5% of taxes on tobacco, alcohol, sugary drinks, high-salt products and fats.[20][53][14][24]
• Provide financial protection by making primary and secondary prevention free, subsidising tertiary prevention, subsidising anticancer medicines nationally and providing a minimum 50% State subsidy for chemotherapy.[20][11][14]
• Sequence expenditure by prioritising cost-effective interventions during the first two years and postponing financially intensive activities until the third year onwards because of substantial resource gaps.[15][25]
• Recognise broader fiscal constraints: public health expenditure represented 4.03% of the national budget in 2017, while mobilisation of State contributions for non-communicable disease activities fell from 96% in 2013 to 26% in 2018.[54]