Accelerated Plan for Elimination of Cervical Cancer in Rwanda

Objectives

Rwanda’s National Strategy for the Elimination of Cervical Cancer 2024–2027 seeks to eliminate cervical cancer as a public health problem through equitable, accessible and high-quality prevention, screening, diagnosis, treatment, rehabilitation and palliative care.[1][2]It is aligned with the World Health Organization elimination threshold of fewer than 4 age-standardised cases per 100,000 women-years and adopts a life-course, rights-based and multisectoral approach.[3][4][2]The strategy responds to a substantial disease burden, including an estimated 866 new cases and 609 deaths in 2022, with many women diagnosed at advanced stages.[5]

• Maintain human papillomavirus vaccination coverage above 90%, principally among 12-year-old girls, while sustaining vaccine supply and considering updated guidance and newer-generation vaccines.[3][6][7]
• Increase screening coverage among eligible women to 70% by 2027, using high-performance human papillomavirus DNA testing where feasible and ensuring treatment for 90% of screen-detected pre-cancerous lesions.[8][3][7]
• Improve diagnosis, staging, invasive cancer treatment, rehabilitation and palliative care, with a target of effective treatment coverage for 90% of women diagnosed with pre-cancer or cancer by 2027.[2][9][10]
• Strengthen awareness, information, education, community mobilisation, programme governance, coordination, sustainable financing, data systems, monitoring and research across the cervical cancer continuum.[11][2][12]
• Reduce inequities by prioritising equitable access and recognising the elevated risk among women living with HIV, who may develop cervical cancer at a younger age.[13][5]

Implementation

Implementation is led by the Ministry of Health and Rwanda Biomedical Centre, including the Cancer Diseases Unit and Cancer Programme, with support from a Technical Working Group, a proposed National Cervical Cancer Elimination Task Force, district coordination structures, health facilities, civil society, communities, development partners and private-sector partners.[14][3][2][6]Delivery is intended to be decentralised, integrated and community-oriented, linking cervical cancer services with primary healthcare, maternal and child health, HIV services, laboratory systems and community health workers, with referral to hospitals for specialist diagnosis and treatment.[15][2]

• Deliver routine school-based vaccination for girls aged 12 years, complemented by community outreach for eligible girls not attending school, public education to address misconceptions, and coordination with education, local-government and gender institutions.[16]
• Expand screening through facility-based services, mass campaigns, mobile units and community self-sampling, progressing towards population-based screening.[7][9]Integrate sample collection at community health centres with molecular testing at district hospitals, recall human papillomavirus-positive women for visual inspection with acetic acid triage and treatment, and maintain patient navigation and results-feedback systems.[17][9]
• Apply differentiated screening and treatment pathways, including more frequent screening and treatment attention for women living with HIV, thermal ablation or loop electrosurgical excision procedure according to lesion characteristics, and updated national screening and pre-cancer treatment guidance.[18][7]
• Strengthen diagnostic services through specimen transport, histopathology supplies, medical imaging, tele-radiology and picture archiving and communication systems.[9]Harmonise care through clinical protocols, regular mentorship, coordination meetings and multidisciplinary tumour boards.[7][9]
• Expand invasive-cancer capacity through oncology theatres and beds, surgical services, chemotherapy, a radiotherapy centre with two linear accelerators and a brachytherapy unit, strengthened systemic-therapy supply chains, and additional gynaecological oncology and radiotherapy staff.[9][10]
• Integrate palliative, rehabilitative and support services into facility, community and home-based care, including psychosocial, nutritional, housing and financial support and reliable supplies of pain medicines such as oral morphine.[12][19]
• Strengthen accountability through an indicator framework covering incidence, mortality, vaccination, screening, pre-cancer treatment, diagnosis, staging, invasive-cancer treatment, palliative care and programme coordination.[20][21][19]Use quarterly to annual reporting, with data drawn from immunisation and health-management information systems, screening registries, electronic medical records, laboratory information systems, the National Cancer Registry, civil registration and vital statistics, facility reports and surveys.[21][19]
• Improve data quality and evidence use through supportive supervision, data-quality audits, regular reviews, interoperability across vaccination, screening, treatment and registry platforms, an annual national symposium, and research on implementation, clinical, economic and financial questions.[12][22]
• Mobilise sustainable resources through domestic financing, health-sector budgets, insurance coverage including Community-Based Health Insurance, public-private partnerships, international donor and technical support, and a proposed cervical cancer fund.[6][22][23]The plan was costed at approximately US$38.4 million, including US$4.5 million for primary prevention and US$33.9 million for screening and treatment of pre-cancerous and invasive disease.[22]

Monitoring & Evaluation

The plan establishes a monitoring and evaluation framework spanning impact, outcome and output indicators across cervical cancer incidence and mortality, human papillomavirus (HPV) vaccination, knowledge and practices, screening, treatment of pre-cancerous lesions, diagnosis, staging, invasive-cancer treatment, palliative care and programme coordination.[20][21][19]Its principal elimination measures are maintaining HPV vaccination coverage above 90%, achieving 70% screening coverage among eligible women and treating 90% of pre-cancerous lesions by 2027, alongside the longer-term goal of reducing incidence below four cases per 100,000 women.[2][21]

• Track impact through cervical cancer incidence and mortality data generated by the National Cancer Registry and civil registration and vital statistics systems.[12][21]
• Monitor prevention and early detection through immunisation systems, screening registries, health-management information systems, health-facility reports and population knowledge, attitude and practice surveys.[21][19]
• Measure service quality and timeliness through indicators for biopsy reporting within 15 days, staging imaging within 30 days of pathology results, treatment initiation within 60 days of diagnosis, treatment-plan completion and oral morphine stock-outs.[19]
• Assess system readiness through indicators on facilities meeting screening standards, patient navigation, specimen transport, digital tracking, oncology theatres and beds, radiotherapy and chemotherapy capacity, trained providers and palliative-care availability.[10][23]

Data-system strengthening is a central implementation mechanism. Planned actions include linking HPV vaccination, screening and treatment platforms with electronic medical records, District Health Information Software 2, the National Cancer Registry and the civil registration and vital statistics mortality module; strengthening data quality, interoperability and use of evidence for decision-making; and promoting implementation, economic, financial and clinical research.[12]The strategy also calls for provider and data-officer training, clinical mentorship, supportive supervision, regular data-quality audits and data reviews.[12]

Reporting frequencies range from quarterly to annual depending on the indicator. A population knowledge, attitude and practice measure is scheduled every five years, while the post-2027 sustainability-plan indicator is assessed in 2027.[21][19]Annual Ministry of Health and Cancer Programme reports, health-management information system reports, facility-readiness surveys, quality-assurance reports, training reports, radiotherapy commissioning reports, research-conference reports and website updates are identified as reporting vehicles.[10][23]

Accountability is intended to operate through Ministry of Health leadership, the Rwanda Biomedical Centre and its Cancer Diseases Unit, supported by a National Cervical Cancer Elimination Task Force, district coordination committees and multisectoral partners.[2][6][19]An annual national cervical cancer symposium is intended to review and share progress, while a high-level multisectoral committee is proposed to coordinate action across sectors.[12][22]Where specified, indicators should be disaggregated by age, HIV status, residence, disease stage, sex, treatment type, staging examination and health-facility type.[21][19]

Costing & Financing

The accelerated cervical cancer elimination plan is costed at approximately US$38.4 million over a five-year period.[24]The costing covers primary prevention through HPV vaccination, secondary prevention through screening and treatment of pre-cancerous lesions, and tertiary prevention through diagnosis, treatment and palliative care.[25][24]

• Allocate US$4.5 million in economic costs and US$1.8 million in financial costs to HPV vaccination.[24]
• Estimate US$16.63 million in economic costs and US$13.1 million in financial costs for screening and treatment of pre-cancerous lesions, including programme costs.[24]
• Estimate US$16.57 million in economic costs and US$14.03 million in financial costs for diagnosis, treatment and palliative care for invasive cancer, including programme costs.[24]
• Identify a US$4.5 million primary-prevention allocation and US$33.9 million for screening and treatment of pre-cancerous and invasive cervical cancer.[22]

The costing used the World Health Organization Cervical Cancer Prevention and Control Costing Tool and a bottom-up method that distinguishes economic resource use from financial monetary outlays, categorises service-delivery and programme-support costs, annualises long-term resources and applies a 3% discount to economic costs.[22]The plan assumes a single-dose HPV vaccination approach for girls aged 12 years as a cost-optimisation measure.[24][22]

Unit-cost estimates include US$7.25 in economic costs and US$2.87 in financial costs per girl vaccinated; US$13.20 and US$10.20 respectively per woman for initial screening; US$37.90 and US$33.60 per pre-cancer treatment service; and US$2,640.10 and US$2,234.70 respectively per woman treated for invasive cancer.[24]HPV vaccination coverage is projected to average 93.2% between 2024 and 2027, with existing GAVI subsidies supporting the current vaccination financing model.[22]

Resource mobilisation and sustainable financing are framed as priorities, including domestic funding, a proposed cervical cancer fund, public-private partnerships, international donor and technical assistance, and incorporation of prevention, screening, care and treatment into Community-Based Health Insurance, known as Mutuelle de Santé, and private insurance.[2][6][22]The source identifies potential financing risks from the high cost of comprehensive care, competing health-sector priorities and possible reductions in external funding.[1]It does not provide annual budgets, funding-gap estimates, financing shares by government or donor, or named allocations beyond the cost estimates reported above.[1][22]