National Cervical Cancer Prevention Program Strategic Plan 2012-2015

Objectives

Kenya’s National Cervical Cancer Prevention Strategic Plan provides a national framework to reduce cervical cancer incidence, prevalence, morbidity and mortality, lower associated costs, and improve the quality of life of patients, pursuing a vision of Kenyan women being free from cervical cancer.[1][2][3]It aligns cervical cancer prevention and control with national reproductive health policy and strategy, which identify reproductive-organ cancers as priorities.[1][4]

• Expand equitable access to quality prevention, screening, diagnosis, treatment, referral and palliative-care services across all levels of the Kenya Essential Package for Health.[3][5]
• Achieve at least 70% screening coverage among women in the age group with the greatest risk-benefit ratio, principally women aged 25 to 49 years, while screening women outside this group where requested or clinically indicated.[6][7][8]
• Strengthen community awareness, reduce fear and stigma, promote symptom recognition and informed care-seeking, and mobilise support for screening, treatment and home-based or palliative care.[6][9]
• Promote primary prevention of human papillomavirus infection and related cofactors through safer sexual practices, tobacco-use prevention, male circumcision and human papillomavirus vaccination.[6][10]
• Deliver human papillomavirus vaccination mainly to girls aged 9 to 13 years before sexual debut, preferably through upper-primary school delivery, while using health facilities or outreach to reach girls who are out of school.[10]
• Provide prompt treatment for precancerous lesions, preferably in a single visit, and ensure diagnosis, stage-specific management and palliative care for women with invasive or advanced disease.[7][11][5]
• Build an enabling environment for programme expansion through leadership, coordination, quality assurance, workforce development, partnerships, resource mobilisation, referral systems and stronger health information.[3][12][13][14]

The strategy responds to a substantial burden of disease and low screening coverage. Cervical cancer is described as a major cause of morbidity and mortality among Kenyan women despite being preventable and curable when detected early, while reported screening coverage among women aged 18 to 69 years was 3.2%.[15]It seeks to address barriers including fragmented project-based delivery, limited community awareness, inadequate provider skills, shortages of equipment and supplies, limited treatment capacity, weak screening-to-treatment linkages, outdated guidelines and weak data management.[4]

Priority action therefore spans behaviour change and advocacy; vaccination; screening and early detection; diagnosis and treatment of precancer and overt cancer; referral; palliative care; community partnerships; service delivery by level of care; data use; and resource mobilisation.[1][16][17]

Implementation

Implementation combines Ministry of Health leadership and national standards with integrated, decentralised delivery through routine reproductive-health, maternal and child health, family-planning, HIV, obstetric and gynaecology services, outreach and campaigns.[7][8][18]The Division of Reproductive Health coordinates the prevention programme, including policy and guideline development, quality assurance, monitoring and evaluation, while provincial and district health management teams support subnational coordination; established cancer management is linked to Ministry of Medical Services hospitals.[4][18][19]

• Integrate screening into existing routine and outreach services, including maternal and child health and family-planning clinics, comprehensive care clinics, obstetric and gynaecology services, reproductive-health camps and mass-screening campaigns, to improve reach in underserved areas.[7][8]
• Use visual inspection with acetic acid, visual inspection with Lugol’s iodine, conventional Pap-smear cytology and human papillomavirus testing as recommended screening methods.[7][8]
• Apply a five-year screening cycle for the general programme and intensified screening for women living with HIV, including screening at diagnosis, six-monthly in the first year and annually thereafter where results remain normal.[8]
• Use a single-visit see-and-treat model where feasible to reduce repeat visits and loss to follow-up; where primary facilities lack supplies, equipment or trained personnel, refer screen-positive clients for reassessment, diagnosis and treatment.[7][11]
• Make cryotherapy available at lower levels of care, provide loop electrosurgical excision procedure at county hospitals and national referral sites, and use cold-knife conisation where appropriate expertise is available.[11][5]
• Strengthen referral networks, records, referral forms, communication between facilities, referral directories and access to blood transfusion from level 4 facilities upwards.[3]
• Develop regional radiotherapy capacity, refer patients requiring radiotherapy to level 6 hospitals, and strengthen hospices, facility-based services, home-based care, palliative-care medicines and supplies.[5]

Community mobilisation is intended to use Community Health Units, community health workers, community midwives, schools, youth and women’s groups, elders’ councils, professional bodies, workplaces and county health committees.[6]Community health workers are expected to mobilise communities, follow up screen-positive clients and support home-based care, while successfully treated clients may act as programme champions.[9]The programme also engages women, men and male partners, community and religious leaders, civil authorities, policymakers, media, schools, private and faith-based providers, professional associations, universities, research institutions, development partners and nongovernmental organisations.[6][17][19]

Workforce and facility readiness are operational priorities. Facilities should be assessed before commencing screening, with findings used for resource mobilisation.[5]Training is to be competency-based and delivered through regional and district workshops, on-site learning, mentorship and supportive supervision; trained providers should, where feasible, remain in their service units for at least two years.[5][13]Infrastructure, maintenance, equipment, medicines, supplies, electricity, sterilisation capacity, specimen handling and records systems are required for safe screening and treatment delivery.[20]

Governance includes technical working groups, partner coordination and a partner database recording organisational activities and geographical coverage.[5][19]Monitoring arrangements include standard data tools, facility registers, monthly summaries, routine supervision, reporting by providers to the Division of Reproductive Health, a national programme database and linkage with the national cancer registry.[5][9][17]Indicators cover screening coverage, positivity, referral, immediate treatment, treatment completion, complications, service availability and provider retention.[20][21][22]Accountability is supported through quarterly and annual reviews, coordination meetings, periodic evaluations and supportive supervision.[18][19]

Resource mobilisation seeks national, provincial, district and facility budget allocations, donor support and external funds to supplement internal budgets.[3][17]Start-up financing is prioritised for training and equipment, while recurrent personnel and supply costs are expected to draw on existing budgets and cost-recovery funds.[17]The supplied material does not provide a costed implementation plan or total programme budget.[2][17]

Monitoring & Evaluation

The strategy establishes a comprehensive monitoring, evaluation and accountability approach for cervical cancer prevention and control, centred on routine service data, programme databases, cancer registries, supportive supervision, periodic evaluation and performance review. It aims to measure programme coverage, service quality, treatment and referral outcomes, workforce capacity, and longer-term effects on cervical cancer incidence and mortality.[5][18][19]

• Monitor screening coverage, with a stated programme ambition to reach at least 70% of women in the priority age group, while baseline national screening coverage was reported as 3.2% among women aged 18 to 69 years.[6][15]
• Track outcome and impact measures including annual screening coverage, new cervical cancer cases, prevalence, case-fatality rate, incidence and mortality.[22][18]
• Measure service performance through indicators on screening positivity, referrals for large lesions or suspected cancer, immediate treatment of eligible women, completion of deferred treatment, loss to treatment, complications and completion of Loop Electrosurgical Excision Procedure among referred clients.[21][22]
• Apply an expected screening-positivity range of 5% to 10% in general-population programmes, recognising that positivity may be higher among women living with HIV, and disaggregate results where possible by HIV status, visit type, facility and provider.[21]
• Target immediate treatment for at least 80% of eligible women and review treatment and referral measures through monthly summary forms, registers, screening maps and assessment tools.[21][22]
• Introduce standard data tools, including screening forms, daily registers or log books, monthly facility summaries and routine health information system tools containing cervical screening and precancer-treatment indicators.[5][17][18]
• Require facilities and practitioners providing screening services to maintain records and submit reports to the Division of Reproductive Health, alongside routine reporting through the District Health Information System.[5][9]
• Maintain a Division of Reproductive Health programme database to support planning, scale-up and reporting against global indicators, and link programme information with the national cancer registry in line with the National Cancer Control Strategy.[5][9]
• Strengthen hospital and regional cancer registries, data management and a national database to support planning, resource allocation and training.[18]
• Undertake supportive supervision covering staff performance, supplies, quality of care, coverage and client satisfaction, and use findings for strategic and operational decisions. National support supervision is envisaged twice yearly.[18][22]
• Conduct periodic evaluations, including an interim evaluation two years after programme initiation, mid-term and end-of-programme assessments, supplemented by surveys, observation visits, client interviews and special studies on satisfaction, community support and cost-effectiveness.[18][19]
• Use quarterly and annual reviews, coordination meetings and formal evaluations for accountability, with the Head of the Division of Reproductive Health responsible for convening these processes; recognise facilities annually through a service-based monitoring and recognition approach.[18][19][22]
• Support implementation oversight through the national reproductive tract cancer technical working group and quarterly technical working-group meetings.[5][12]
• Address previously identified weaknesses in monitoring and evaluation, particularly data collection and management in existing programmes.[4][2]

Costing & Financing

Financing provisions focus on resource mobilisation, use of existing budgets, advocacy for dedicated allocations and external support, rather than a quantified costed implementation plan. The supplied material provides no overall programme budget, funding gap, unit-cost schedule, financing envelope or formal economic assumptions.[17][12]

• Mobilise financial, human, material and technical resources under Ministry of Health leadership, with external funds intended to supplement internal budget allocations.[17]
• Finance recurrent personnel and supply costs through existing budgets at different levels and through cost-recovery funds, while prioritising start-up financing for training and equipment.[17]
• Advocate for dedicated national, provincial, district and facility budget allocations for the cervical cancer programme, as well as additional donor support.[3][17]
• Use facility readiness assessments to identify implementation needs and guide resource mobilisation.[5]
• Seek resources for infrastructure, equipment, maintenance, supplies, trained personnel, cryotherapy equipment, palliative-care medicines and radiotherapy capacity appropriate to each level of care.[2][3][5][17]
• Advocate for investment in human papillomavirus vaccination, corporate social responsibility support for radiotherapy equipment, and increased support from bilateral organisations and other stakeholders.[12]
• Recognise that integrated prevention within existing reproductive health, maternal and child health, family-planning and HIV services is considered more cost-effective and efficient to manage.[7]
• Prioritise outpatient management for precancerous lesions where appropriate, as this is preferred over costly inpatient procedures such as cone biopsy or hysterectomy, which may also result in over-treatment.[8]
• Use cryotherapy as a comparatively inexpensive option suitable for low-resource settings, while recognising that Loop Electrosurgical Excision Procedure requires more costly equipment, electricity, local anaesthesia, skilled personnel and emergency backup.[11]
• Recognise the high costs associated with late presentation and anticipate that prevention may reduce future government expenditure on gynaecology ward and clinic cancer care, while supporting women’s economic and social contribution.[1][23]
• Include cost-effectiveness among topics for special evaluation studies and use advocacy materials on cost-benefit results and deaths averted to support policy engagement.[18][17]
• Note that the government included a financial-year 2011/2012 budget line for cervical cancer treatment equipment and allocated funds for procurement of cryotherapy equipment, but the supplied material does not provide allocation amounts.[1][7]