Plan Nacional De Prevención Control Y Seguimiento De Cáncer De Cuello Uterino

Objectives

Bolivia’s National Plan for Prevention, Control and Follow-up of Cervical Cancer 2009–2015 aims to reduce cervical-cancer morbidity, incidence, prevalence and mortality among women by strengthening prevention, timely detection, diagnosis, treatment and follow-up within the National Health System. It frames health as a right, aligns with the National Development Plan and the Family, Community and Intercultural Health policy, and seeks culturally respectful action that addresses the disease’s substantial social, health and economic burden.[1][2][3]

• Promote health, prevent cervical cancer and inform adolescents, women, families, service providers, authorities and social organisations about risk, vaccination, screening, timely detection, control and follow-up.[4][5]
• Improve access to annual Papanicolaou testing and treatment of premalignant lesions through carcinoma in situ, including services within the Universal Maternal and Child Health Insurance package.[6][7]
• Prioritise women aged 25 to 64 for screening and seek total coverage above 50% over the five-year period where women receive no more than two Papanicolaou tests.[8][9]
• Expand annual Papanicolaou coverage from a projected 10% in 2009 to 40% in 2015, while recognising that increased screening will require corresponding capacity for colposcopy, histology, treatment and human resources.[10][11]
• Develop qualified personnel, equip facilities, strengthen cytopathology and referral services, improve health information, establish surveillance and evaluation, support research, and enable social oversight and community surveillance.[4][12][13][14][15]
• Reduce economic, cultural, social and geographical barriers that limit women’s access to prevention, detection, treatment and follow-up services.[3][16]

Implementation

Implementation uses the plan as an operational framework for National Health System establishments, applying the Family, Community and Intercultural Health model and continuous care across the life course through health-service and municipal networks. The Ministry of Health and Sports provides national policy direction, regulation, planning, control and coordination, while the Directorate General of Health Services and Directorate for the Development of Health Services are responsible for implementation and compliance.[1][2][6]

• Coordinate public providers, short-term social security funds, private providers, non-governmental organisations, churches, voluntary organisations, universities, health schools, departmental health services, municipal authorities, laboratories, health networks and social and community organisations.[7][5][12][13]
• Produce and disseminate culturally appropriate information and education materials in different formats and languages, train personnel to communicate effectively, and convene periodic national discussions with social organisations.[5]
• Update and implement national standards, protocols and procedures; train providers in sample collection, Papanicolaou testing, visual inspection with acetic acid, cytology, colposcopy and treatment of precancerous lesions; and incorporate relevant detection and control methods into curricula and clinical practice through agreements with universities and health schools.[12]
• Provide supplies, infrastructure and equipment for Papanicolaou and visual-inspection sampling in health facilities, and for colposcopy, biopsy and treatment in referral hospitals; develop referral and counter-referral arrangements for invasive carcinoma.[13]
• Strengthen data systems by incorporating cervical-cancer variables into the National Health Information System, registering screened women in family records, requiring networks and laboratories to collect, analyse and transmit data, and locating and supporting patients with positive biopsy results.[14]
• Establish monitoring and evaluation instruments for all plan activities, conduct periodic analysis of results, undertake a mid-term evaluation, and complete a final evaluation in 2015.[14]
• Track implementation through indicators covering information materials and meetings, trained personnel, updated standards, trained providers, educational institutions incorporating relevant methods, equipped facilities and referral hospitals, and women with invasive carcinoma referred for care.[5][12][13]
• Measure screening coverage among women aged 25 to 64, sample adequacy, high-grade and low-grade squamous intraepithelial lesion results, and positive visual-inspection results; stated quality standards include no more than 10% inadequate smears, 1% to 5% high-grade lesions and 5% to 25% positive visual-inspection tests.[17]
• Monitor diagnostic, treatment and impact outcomes through colposcopy-histology correlation, biopsy after positive screening, treatment and follow-up of lesions and cancer, post-treatment complications, cervical-cancer incidence and mortality, and incidence of high-grade lesions.[8]
• Promote research, including human papillomavirus research and a strategy for incorporating vaccination into the health system, and form community-surveillance networks that participate in analysis, prioritisation, planning, supervision and evaluation.[15][17]

Monitoring & Evaluation

The plan establishes a national monitoring, surveillance and evaluation framework for cervical-cancer prevention, detection, diagnosis, treatment and follow-up. It seeks to strengthen the National Health Information System, register women screened in family records, improve follow-up of women in at-risk age groups, and use information to guide intervention strategies.[4][14]Earlier assessments identified weak recording, referral and follow-up systems, insufficient data for decision-making, and inadequate collection, analysis and use of service information.[16]

• Develop a monitoring and evaluation instrument covering all activities in the National Strategic Plan; analyse implementation and results periodically; conduct a mid-term evaluation; and complete a final evaluation in 2015.[14]
• Integrate cervical-cancer variables into the national information system; record screened women in family records; and require health-service networks, facilities and laboratories to collect, analyse, use and transmit information.[14]
• Establish mechanisms to locate and support patients with positive biopsy results through trained personnel using relevant protocols.[14]
• Strengthen surveillance, monitoring and evaluation of plan activities and results, including those of the National Cervical Cancer Programme Component.[4]
• Promote social oversight and community surveillance through local community-surveillance networks and community participation in analysis, prioritisation, planning, programming, supervision and evaluation.[15][17]

The framework includes implementation indicators for communication, workforce development, service capacity, information systems and community participation. These include numbers of information materials produced and disseminated, personnel trained in communication, meetings organised, training workshops delivered, and educational institutions incorporating cervical-cancer methods into curricula and clinical practice.[5][12]Service indicators cover the number and proportion of facilities equipped for Papanicolaou testing and visual inspection with acetic acid, referral facilities equipped for colposcopy and biopsy, invasive-carcinoma patients referred, and referral hospitals equipped to treat precancerous and carcinoma-in-situ lesions.[13]Information-system indicators include cervical-cancer variables added, women registered, facilities and laboratories submitting analysed data, personnel supporting women with positive diagnoses, monitoring reports and completed evaluations.[14]

• Measure community and epidemiological performance through the number of community surveillance networks, the percentage of district health boards undertaking community analysis and information committees, the percentage of facilities using epidemiological forms, and the percentage of trained departmental teams.[17]
• Measure screening coverage as the proportion of women aged 25 to 64 whose cervical smear was processed during 2009–2015, against the female population of that age group.[17]
• Monitor screening quality through inadequate-smear results, for which the standard is no more than 10%; high-grade squamous intraepithelial lesion results, with a 1–5% standard; low-grade lesion results; and positive visual-inspection-with-acetic-acid results, with a 5–25% standard.[17]
• Track diagnostic quality through the colposcopy-histology correlation rate, and monitor follow-up through biopsy, treatment and post-treatment follow-up among women with positive screening results, precancerous lesions or cervical cancer.[8]
• Measure treatment quality through a post-treatment complication rate of no more than 1%, and limit Papanicolaou tests performed outside the target population to no more than 5%.[8]
• Evaluate impact using cervical-cancer mortality, incidence and incidence of high-grade lesions.[8]

Baseline evidence illustrates the monitoring challenge: national Papanicolaou sample totals rose from 190,539 in 2003 to 312,374 in 2007, but reported coverage among women aged 25–64 was 11.6% in 2007 and represented samples collected rather than women receiving cytological results.[18]An 80% coverage benchmark is cited as necessary for significant results.[18]The plan projects annual expansion of screening coverage, with total coverage intended to exceed 50% where women receive no more than two tests each during the five-year period.[9]It also projects annual departmental and national positive-test totals and links increased coverage to expanded colposcopy, histology and treatment capacity.[11][10]

Implementation and monitoring responsibilities are distributed across national health units, departmental health services, service networks, facilities, reference laboratories, local and municipal health authorities, educational institutions, social organisations and community networks.[5][12][13][17]The Ministry of Health and Sports retains responsibilities for programme evaluation and health-sector oversight, while designated health-service directorates are responsible for plan implementation and compliance.[6]The supplied material does not set out a unified reporting timetable, baseline values for all indicators, detailed evaluation methodology or a comprehensive public-accountability procedure.[5][12][13]

Costing & Financing

No explicit budget, costed implementation plan, monetary allocation, funding source, financing schedule, quantified funding gap or resource-mobilisation mechanism is provided in the supplied material.[7][4][14][15][17]

• Provide annual Papanicolaou screening and treatment of premalignant lesions through carcinoma in situ within the Universal Maternal and Child Health Insurance package for eligible patients.[6][7]
• Recognise cervical cancer as carrying substantial social and economic costs, while characterising prevention and early detection as relatively economical.[3][19]
• Address previously insufficient resource allocation, dispersed interventions and limited commitment by authorities, which were identified as constraints on earlier efforts.[3]
• Increase human-resource capacity as screening coverage expands, using a planning assumption that each cytologist reads 40 Papanicolaou tests per working day.[10][20]
• Secure supplies, infrastructure and equipment for screening, colposcopy, biopsy and treatment services, although no associated prices or funding arrangements are specified.[13]

The material indicates that existing resources should achieve improved coverage, quality and impact on morbidity and mortality, but provides no monetary estimate or economic model.[18]Although expanded screening is expected to increase demand for diagnostic assessment and treatment, the source does not quantify the financial implications of this expansion.[11]