Accelerated Plan for Elimination of Cervical Cancer in Rwanda

Objectives

Rwanda’s Accelerated Plan for Elimination of Cervical Cancer 2024–2027 aims to eliminate cervical cancer as a public health problem through equitable, accessible and high-quality prevention, screening, diagnosis, treatment, rehabilitation and palliative care. Elimination is defined as sustaining an age-adjusted incidence rate below four cases per 100,000 women-years.[1][2][3]The plan responds to cervical cancer being Rwanda’s second most common cancer among women and a leading cause of cancer-related deaths among women.[4]

• Achieve the World Health Organization 90-70-90 targets by 2027: maintain human papillomavirus vaccination coverage above 90% among girls aged 12 years, screen 70% of eligible women, and provide effective treatment to 90% of women diagnosed with pre-cancerous lesions or cervical cancer.[3][5][6]
• Strengthen primary prevention through culturally appropriate awareness, information, education and sustained human papillomavirus immunisation.[7][5]
• Increase screening and treatment of pre-cancerous lesions, prioritising high-risk human papillomavirus deoxyribonucleic acid testing and treatment approaches matched to screening capacity.[8][5]
• Improve access to diagnosis, stage-appropriate invasive cancer treatment, rehabilitation, palliative care and patient support.[9][10]
• Enhance monitoring, evaluation, data systems and research, while promoting intersectoral collaboration, partnerships and sustainable resource mobilisation.[7][11]

The strategy applies a life-course approach, combining adolescent vaccination with screening of adult women, treatment of detected pre-cancerous lesions and management of invasive disease.[4][2]It gives particular attention to women living with HIV, who face a substantially higher risk of cervical cancer and require earlier and more frequent screening.[12][13]

Screening targets include women aged 30–49 years in the general population, previously unscreened women aged 50–65 years, and women living with HIV aged 25–49 years.[13]The general population is scheduled for screening every 10 years, while women living with HIV are scheduled every five years, with annual follow-up after human papillomavirus-positive results and after treatment.[13]

Implementation

Implementation is led by the Ministry of Health and the Rwanda Biomedical Centre, which coordinate resource mobilisation, delivery, monitoring and evaluation with the Technical Working Group and a wide range of public, private, civil-society, community and development partners.[1][14]The delivery model integrates cervical cancer interventions with primary healthcare, maternal and child health, HIV, laboratory and routine immunisation services to reduce missed opportunities and improve sustainability.[3][15]

• Deliver vaccination through the routine age-based programme for 12-year-old girls, using school registers and community outreach to reach girls who are not in school.[2]
• Integrate human papillomavirus deoxyribonucleic acid screening into primary healthcare, with collection at health centres, testing at district hospitals with molecular platforms, and visual inspection with acetic acid triage and treatment for women with positive results.[13]
• Expand access through facility-based services, targeted mobile units and mass screening campaigns using screen-and-treat approaches.[13][5]
• Provide treatment of pre-cancerous lesions through thermal ablation or large-loop excision of the transformation zone according to lesion characteristics and national guidance.[13][5]
• Refer suspected invasive cancer to hospitals with histopathology services and provide surgery, chemotherapy, radiotherapy, rehabilitation and palliative care according to disease stage.[16][10]
• Strengthen workforce capacity through provider training, mentorship, specialist oncology fellowships, multidisciplinary tumour boards and patient-navigation systems.[16][9][10]

Governance actions include establishing a national cervical cancer elimination task force supporting the Cancer Diseases Unit, district coordination committees and a strengthened coordinating team within the Rwanda Biomedical Centre.[7]A high-level multisectoral committee is intended to provide a platform for dialogue, cross-sector coordination and political support.[17][18]Community health workers, local and faith leaders, schools, media, cancer survivors and civil society organisations support awareness, demand creation, outreach and linkage to screening and care.[8][5]

The monitoring framework uses facility-level data aggregated nationally by the Rwanda Biomedical Centre, covering vaccination, screening, test and triage positivity, treatment, post-treatment follow-up, referrals, biopsy processes, invasive cancer diagnosis and staging.[6][19][20]Data systems include mUzima, screening registers, the health management information system, the national electronic medical record, District Health Information Software 2 trackers, pathology laboratories and the National Cancer Registry.[19][20]Most screening, treatment, referral and follow-up indicators are reported monthly, while immunisation and invasive cancer indicators are generally reported annually.[19][20]

Planned data-strengthening measures include linked digital systems for vaccination, screening and treatment; interoperability between electronic medical records, District Health Information Software 2, the National Cancer Registry and mortality records; routine data-quality audits; supportive supervision; annual stakeholder symposia; and research partnerships.[11]The plan also proposes an online information platform to share implementation progress with the public and stakeholders.[17][18]

The plan was costed using the World Health Organization Cervical Cancer Prevention and Control Costing Tool, using a bottom-up approach and a 3% discount rate for economic costs.[17]Total investment for 2024–2027 is estimated 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.[17]Financing actions include increasing domestic funding, developing an investment case and post-2027 sustainability plan, incorporating services into insurance and health budgets, establishing a pooled cervical cancer fund, and mobilising public-private and international support.[7][17]

Monitoring & Evaluation

The monitoring and evaluation framework is designed to track progress towards cervical cancer elimination through impact, outcome and output indicators, linking vaccination, screening, diagnosis, treatment, palliative care, data systems, research and accountability.[7][11][21]The Ministry of Health and Rwanda Biomedical Centre lead implementation monitoring, with facility-level data aggregated for national and global reporting.[1][6][19]

• Monitor the core 2027 elimination targets of at least 90% human papillomavirus vaccination coverage among girls aged 12 years, 70% screening coverage among eligible women aged 30–49 years, and 90% treatment coverage for precancerous lesions and invasive cervical cancer.[3][6][22]
• Track annual screening expansion from a 2024 baseline of 21% to targets of 35% in 2025, 55% in 2026 and 70% in 2027, while maintaining treatment of eligible precancerous lesions at 92%.[22]
• Measure vaccination performance, first-time screening with high-performance human papillomavirus deoxyribonucleic acid testing, test and triage positivity, precancer treatment, post-treatment follow-up, suspected cancer referrals, referral compliance, biopsy collection, results feedback, invasive cancer confirmation and staging imaging.[19][20]
• Monitor incidence and mortality through the National Cancer Registry, which provides nationwide cancer incidence and mortality data for planning and evaluation.[23]Baseline reporting records 612 crude cervical cancer cases, an age-standardised incidence rate of 18.9, 609 crude deaths and an age-standardised mortality rate of 13.8.[22]
• Disaggregate service indicators by HIV status and age, and disaggregate vaccination indicators by age.[19][20]
• Report most screening, treatment, referral, biopsy and follow-up indicators monthly, while reporting immunisation, confirmed invasive cancer and staging imaging indicators annually.[19][20]Treatment and palliative-care indicators are collected annually, whereas morphine availability for pain management is assessed quarterly.[21]
• Use mUzima, screening registers, health management information system reports, the national electronic medical record, District Health Information Software 2 immunisation and oncology trackers, pathology laboratories, the National Cancer Registry and civil registration and vital statistics systems as data sources and operational platforms.[19][20][21][22]
• Strengthen data quality through provider and data-officer training, supportive supervision, clinical mentorship, regular data-quality audits and reviews, linked digital systems, and annual national cervical cancer symposia.[11]
• Ensure interoperability between electronic medical records, District Health Information Software 2, the National Cancer Registry and mortality reporting systems, and use data for programme decisions.[11]
• Track service readiness and quality, including laboratory diagnosis, access to computed tomography or magnetic resonance imaging for staging, guideline-concordant treatment, patient navigation, sample transport, oncology theatre capacity and functional palliative care.[24][25][26]
• Publish implementation progress through an online cervical cancer elimination information platform for the public and stakeholders.[17][18]

Governance mechanisms include a proposed national task force supporting the Cancer Diseases Unit, district coordination committees, a high-level multisectoral committee and an expanded Rwanda Biomedical Centre coordinating team.[7][18]The framework supports accountability, but some indicator targets, including incidence, mortality and population knowledge measures, remain to be determined.[21][22]

Costing & Financing

The plan applies a costed investment approach for 2024–2027, estimating approximately 38.4 million US dollars for cervical cancer elimination.[17]Costing used the World Health Organization Cervical Cancer Prevention and Control Costing Tool and a bottom-up method to estimate both economic resource use and financial outlays, annualise long-term resources, and apply a 3% discount rate to economic costs.[17]

• Allocate an estimated 4.5 million US dollars to primary prevention and 33.9 million US dollars to screening and treatment of precancerous and invasive cervical cancer.[17]
• Estimate human papillomavirus vaccination at 4.5 million US dollars in economic costs and 1.8 million US dollars in financial costs.[27]Economic vaccination costs are principally associated with vaccines and supplies, supervision and microplanning.[27]
• Mobilise domestic and international resources through an investment case, increased domestic funding, a pooled cervical cancer fund, public-private partnerships, donor resources, technical assistance and high-level political support.[17]
• Incorporate cervical cancer services into Community-Based Health Insurance and private insurance packages, routine health services, long-term national health budgets and policies, supported by a post-2027 sustainability plan.[7]Community-based health insurance covers more than 90% of the population and includes cervical cancer treatment in its benefits package.[23]
• Monitor annual increases in the domestic budget allocated to cervical cancer interventions using the health sector budget and expenditure framework, the Health Resource Tracking Tool and reported funding sources.[26][18]
• Resource vaccine procurement and delivery, human papillomavirus deoxyribonucleic acid test kits, consumables, equipment, workforce training, digital tools, mobile and mass screening, pathology, surgery, radiotherapy, chemotherapy, patient navigation and palliative care.[5][9][10][6]
• Address sustainability risks arising from high costs of screening, diagnosis and advanced treatment, shortages of trained personnel and dependence on external funding.[15]

The strategy identifies prevention through vaccination, screening and precancer treatment as cost-effective, and indicates that vaccination combined with screening is more cost-effective than either intervention alone.[12][16]Early-stage treatment is less complex, less expensive and more effective than advanced-stage treatment, while mobile screen-and-treat approaches may reduce procurement requirements compared with conventional approaches.[13][16]No quantified funding gap, financing shares, budget allocations by implementing institution or detailed economic assumptions beyond the costed investment methodology are specified.[17][27]