Plan Stratégique pour la Prévention et le Contrôle du Cancer du Col de l’Utérus 2017–2022

Objectives

Togo’s Strategic Plan for the Prevention and Control of Cervical Cancer 2017–2022 provides a national framework to coordinate previously fragmented activities, reduce cervical-cancer morbidity and mortality, and improve survival and quality of life for patients and families. It is aligned with the National Health Policy 2012–2022, the National Health Development Plan 2016–2022 and the wider non-communicable disease response.[1][2][3]

• Increase public awareness, advocacy and community mobilisation so that at least 90% of the population receives information, education and communication on cervical cancer by 2022.[4][5]
• Prevent human papillomavirus infection through behaviour-change communication, tobacco control and routine vaccination, reaching at least 70% of girls aged 9 to 13 years annually in every district.[6][7]
• Strengthen secondary prevention by screening women aged 25 to 49 years, diagnosing and treating precancerous lesions, and providing diagnostic and treatment services to at least 80% of the target population by 2022.[4][8]
• Improve tertiary care by expanding early diagnosis, surgery, chemotherapy, radiotherapy, referral systems and specialist capacity, with targets to provide surgery to at least 50% of women with invasive cancer and chemotherapy and radiotherapy to at least 70%.[9][4]
• Establish integrated, equitable and sustainable palliative care, including pain control and physical, psychosocial and spiritual support, for at least 50% of women with cervical cancer and their families.[10]
• Develop cancer information and surveillance capacity, including a national population-based cancer registry, to support incidence measurement, research, programme management and evaluation.[11]

Implementation

Implementation uses a phased, health-system-wide model across community, peripheral, district, regional and national referral levels. The Ministry of Health and Social Protection leads the response through the National Steering Committee for Cancer Control, while regional and district teams incorporate interventions into annual workplans, supervise delivery and address local needs.[12][13]The approach combines community mobilisation, school- and health-centre-based vaccination, integrated screening and treatment, strengthened referral hospitals, and partnerships with civil society, development partners and private or faith-based providers.[14][15][3]

• Coordinate governance through the National Steering Committee, responsible for strategic-plan implementation, supervision, provider training, quality assurance, stakeholder meetings and periodic policy updates in response to new evidence.[4][12]
• Integrate cervical-cancer activities into reproductive health, family planning, HIV testing and treatment, postnatal care, breast-cancer screening, immunisation and school programmes.[12][15][16]
• Scale up human papillomavirus vaccination from the Gulf and Tchamba demonstration districts to all districts, supported by micro-planning, vaccine logistics, cold-chain strengthening, operational training and incorporation of vaccination data into the health information system.[7][17]
• Deliver vaccination through schools and health centres, targeting girls before sexual debut, while engaging teachers, parents, community leaders, district authorities and non-governmental organisations in communication and mobilisation.[14][18]
• Provide screening and precancer treatment through a progressive expansion from university and regional referral hospitals to district hospitals, peripheral facilities and eligible private and faith-based providers.[15][19]
• Use a screen-and-treat model where feasible, combining visual inspection with acetic acid and Lugol’s iodine, optionally with human papillomavirus testing, and same-visit cryotherapy for eligible positive cases to reduce loss to follow-up.[8][20]
• Train nurses and midwives in screening, biopsy and cryotherapy; train doctors in colposcopy, loop electrosurgical excision and conisation; and use cascade training to expand capacity at peripheral and district levels.[14][8]
• Strengthen referral-level services through colposcopy, surgery, anaesthesia, chemotherapy, radiotherapy and palliative-care capacity, including specialist gynaecological oncology training, equipment, medicine supply and patient databases for follow-up.[12][21][22]
• Build palliative-care networks across all levels of care, including community providers and family carers, supported by standards, referral mechanisms, essential analgesics including oral morphine, provider training and public education.[23]
• Conduct monitoring through existing health-sector mechanisms, routine data collection, formative supervision, joint field visits with technical and financial partners, surveys, research, annual reviews and mid-term and end-of-plan evaluations.[24]New service sites are to receive monthly supervision during the first three months, quarterly supervision until one year, and six-monthly supervision thereafter.[15][25]
• Track targets for communication reach, vaccination, screening, treatment, diagnostic access, survival, service availability and palliative care, while using the planned cancer registry and cervical-cancer data integrated into the health information system to support surveillance and evaluation.[4][15][24]
• Mobilise resources through State and local-authority budgets, national and international non-governmental organisations, bilateral and multilateral partners, insurance schemes and household contributions.[3]Advocate for dedicated cancer and cervical-cancer budget lines, government co-financing of vaccines, and partner support, including Gavi support for human papillomavirus vaccine procurement and some operational costs.[12][26]

Monitoring & Evaluation

The plan establishes a monitoring, evaluation and accountability architecture intended to track cervical cancer prevention and control across national, regional and district levels. It combines routine health-information reporting, supportive supervision, surveys and research, performance reviews, and planned mid-term and final evaluations.[24]

• Assign oversight of implementation to the National Steering Committee for Cancer Control, coordination and partnerships to the Division of Non-Communicable Disease Surveillance, regional oversight and corrective action to regional teams, and local integration, indicator recording and intersectoral collaboration to district teams.[13]
• Use existing health-sector mechanisms, including committee meetings, joint field visits with technical and financial partners, periodic evaluations, surveys, studies and supervision.[24]
• Define in a dedicated monitoring and evaluation plan the institutional organisation, actors, responsibilities, mechanisms, indicators, information sources, and pathways for producing and disseminating information for decision-making.[24]
• Integrate cervical cancer data into the existing health information system and establish a national population-based cancer registry to generate incidence data for surveillance, research, programme implementation and evaluation.[15][11]
• Conduct a mid-term evaluation in 2019 and undertake evaluations at both the mid-point and end of the 2017–2022 implementation period.[19][24]
• Review performance through annual and mid-term health-sector reviews, using survey, research and study data to identify barriers to achieving cervical-cancer objectives.[24]

Monitoring is linked to quantified 2022 targets spanning communication reach, human papillomavirus vaccination, screening, treatment of precancerous lesions, diagnostic access, surgery, radiotherapy and chemotherapy, and palliative care.[4]The plan also identifies process, outcome and impact measures across communication, primary prevention, and secondary and tertiary prevention.[24]

• Track vaccination scale-up through vaccine availability, cold-chain and logistics capacity, workforce training, district coverage, government co-financing and annual access for at least 70% of target girls.[17]
• Measure vaccination effects through reduced human papillomavirus infection and, over 10 to 20 years, reduced precancerous lesions, with reduced cervical-cancer prevalence and mortality identified as impact measures.[17][26]
• Monitor secondary prevention through coverage of target women, verification of positive cases, treatment of women screening positive, trained staff, equipped facilities, treatment recovery and reductions in precancerous lesions and invasive cancer.[25][27]
• Maintain patient databases for surgical, radiotherapy and chemotherapy services, recording cancer stage, treatment details and one- and five-year survival to support follow-up and outcome monitoring.[28][22][29]
• Assess palliative care through the number of women receiving services, facility provision, pain and symptom control, and quality of life for women and families.[23]

Accountability mechanisms include National Steering Committee supervision and quality assurance, Ministry of Health monitoring and evaluation responsibilities, regular meetings with stakeholders and decision-makers, evidence-informed policy review, and incorporation of actions into annual regional and district workplans.[4][12]New screening and treatment sites are to receive monthly supervision for their first three months, quarterly supervision until one year, and six-monthly supervision thereafter, before integration into routine formative supervision.[15]

Some implementation details remain unspecified, including standard reporting schedules, detailed indicator definitions, data-quality procedures, independent evaluation methods and formal sanctions or enforcement arrangements.[4][26]

Costing & Financing

The financing approach combines public funding, partner support, local-authority and non-governmental resources, and household contributions through insurance and direct payments.[3]The plan calls for stronger resource mobilisation and dedicated cancer-control budget lines, but the supplied material does not provide a consolidated programme budget, unit costs, expenditure allocations, quantified financing gap or detailed economic model.[12]

• Advocate for a dedicated budget line for cancer control and cervical cancer, including financing for the National Cancer Institute and prevention and control activities.[12]
• Mobilise innovative financing and bilateral and multilateral partner resources for implementation.[12]
• Increase public investment in advocacy and communication, vaccine procurement and cold-chain systems, screening and treatment equipment, health-worker training, health-information systems and operational research.[9]
• Increase the budget line for human papillomavirus vaccines and the cold chain, and establish budget lines for cryotherapy, excision procedures, colposcopy, operating-room equipment and radiotherapy materials.[9]
• Seek State subsidies and partner-supported procedures to reduce anticancer medicine costs and improve financial access to treatment.[3]
• Support palliative care through facility budgets for medicines and supplies, including analgesics and oral morphine, alongside training and appropriate storage for controlled medicines.[23][13]

Human papillomavirus vaccination scale-up assumes subsidy from the Gavi Alliance for vaccine procurement and part of operational costs, alongside increased government co-financing for newly introduced vaccines.[26]The plan also identifies resource needs for vaccine supply, injection materials, cold-chain storage, transport, computers, laboratory equipment and supervision without monetary costing.[7]

Financial constraints are substantial. State health-sector allocations represented 4% to 6% of the national budget from 2010 to 2015, below the 15% Abuja benchmark, while direct household payments accounted for 53.03% of health expenditure in 2008 and 40.53% in 2013.[30]Cancer diagnosis and treatment are described as costly, with patients and families meeting costs for medicines, complementary examinations and other treatment-related needs; chemotherapy is not systematically available because of high cost.[31][32][33]

Investment priorities include two radiotherapy units, specialist equipment and workforce recruitment and training, alongside development of radiotherapy, chemotherapy, surgical oncology, referral, information and palliative-care capacity.[16][21][22][29]The source provides no monetary values for these inputs other than contextual economic figures and the number of radiotherapy units proposed.[16]