National Cervical Cancer Prevention and Control Strategic Plan 2011–2015

Objectives

The National Cervical Cancer Prevention and Control Strategic Plan for 2011–2015 seeks to reduce cervical cancer incidence, morbidity and mortality in Tanzania, advancing a vision of women free from the burden of cervical cancer.[1][2]It translates prevention and control knowledge into equitable public-health action, particularly for rural, underserved and vulnerable women, through transparent, quality, available and accessible services.[2]

• Strengthen governance, leadership, policy and resource mobilisation for cervical cancer prevention and control at every level of the health system.[3][4]
• Prevent human papillomavirus infection through education, safer sexual behaviour, tobacco-risk reduction, community awareness and HPV vaccination for adolescent girls before sexual activity.[5][6]The plan aims for universal vaccination coverage among adolescent girls by 2017, with a logical-framework target of 90% coverage by 2015 and inclusion of girls both in and out of school.[7][8][4]
• Expand secondary prevention by providing organised screening for adult women, particularly those aged 30 years and above, with timely diagnosis and treatment of precancerous lesions.[5][9]The plan targets 50% access to and use of screening and early treatment by 2015, and treatment for 80% of women with positive screening results by that year.[9][4]
• Provide tertiary prevention through accessible diagnosis, surgery, radiotherapy, chemotherapy, care and palliative care for women with invasive or advanced cervical cancer.[6][10]It targets 50% access to and use of quality cancer treatment by 2015.[10]
• Integrate essential palliative care, including symptom management, pain medicines and opiates, provider and community-carer training, and physical, psychological, spiritual and emotional support for terminally ill patients.[11]
• Apply principles of integration, evidence-based action, equity, gender responsiveness, human rights, partnership, transparency, local relevance, complementarity and phased implementation.[2][3]

The strategy responds to Tanzania’s substantial cervical cancer burden, late presentation and limited access to screening, diagnosis and treatment, while recognising that persistent high-risk HPV infection can progress to invasive cancer over 10 to 20 years and therefore creates an opportunity for prevention and early treatment.[12][13]It also addresses gender-related inequalities through community education and engagement of women, men, boys and adolescents on HPV, safe sexual behaviour, vaccination, screening and health-seeking.[2][14]

Implementation

The plan uses a phased, integrated national delivery model, building on existing immunisation capacity, health infrastructure, referral arrangements, screening experience, histopathology services and the Ocean Road Cancer Institute.[15]Implementation spans national, regional, district, health-facility and community levels, with districts serving as the principal local administrative and public-service unit.[6][16]

• Coordinate implementation through the Ministry of Health and Social Welfare, including its Reproductive and Child Health Section and Cancer Unit, alongside the Prime Minister’s Office for regional and local government, district and regional health management teams, district councils and health facilities.[6][9]The Ministry is expected to define roles for implementation, monitoring and evaluation and promote accountability, stewardship and transparency.[3]
• Engage the Ministry of Education in school-based vaccination activities, the Ministry of Finance in allocating programme funds, and the Ministry of Community Development, Gender and Children in community sensitisation.[16]Involve development partners, international agencies, private organisations, professional bodies, civil-society organisations, communities, parents, religious leaders and local leaders in mobilisation, service support, training, supplies, research and fundraising.[16][10]
• Roll out HPV vaccination in phases, beginning in three regions in 2014/15, adding seven regions in 2015/16 and progressing nationwide in 2017.[9]Forecast and procure vaccine, auto-disable syringes, needles and safety boxes; strengthen cold-chain capacity and vaccine stock management; and monitor first, second and third doses.[9]
• Deliver screening through reproductive and child health, outpatient, sexually transmitted infection and care-and-treatment clinics, referral and regional hospitals, outreach services and community mobilisation.[10]Use visual inspection with acetic acid and, where indicated, cryotherapy, cold coagulation or loop electrosurgical excision procedures, including integrated ‘see and treat’ approaches.[17][10]
• Introduce HPV DNA testing at selected screening sites through a national reference laboratory, national expert group and World Health Organization operational research demonstration project.[18]Develop scale-up plans, update pre-service curricula, train clinical and laboratory cadres, supply and maintain equipment, and strengthen referral mechanisms.[19][20]
• Reduce barriers to cancer care by issuing referral guidance, training providers and requiring district councils to establish transport-support mechanisms for poor patients.[10]Improve diagnostic and treatment access outside Dar es Salaam, where capacity is concentrated.[21]
• Integrate cervical cancer activities into Comprehensive Council Health Plans, Council Management Plans and annual work plans aligned with the fiscal year.[22]Fund central work plans through the Medium-Term Expenditure Framework and incorporate district interventions into council plans.[22]

Monitoring combines routine Health Management Information System reporting, facility records, HPV registers and vaccination cards, supportive supervision, data-quality assessments, post-introduction evaluations, operational research and client exit interviews.[11][23]The plan calls for cervical cancer indicators across primary, regional and referral services, including vaccination coverage, screening, treatment, referrals, adverse events following immunisation, service quality and client satisfaction.[24][23]Available reporting sources include programme annual reports, Health Management Information System data, Council Health Management Team supervision reports, reproductive and child health annual reports, health-facility records and periodic surveys.[25][26]

Resource mobilisation is to involve government, local authorities, donors and partners, with advocacy for national allocations and a proposed five-year costing of vaccination, screening, treatment and palliative care.[7][27]No total budget, activity-level allocations, quantified financing gap or monetary cost estimates are specified in the supplied material.[7][10]

Monitoring & Evaluation

The plan establishes monitoring and evaluation as a core programme theme, intended to track cervical cancer prevention, screening, diagnosis, treatment and palliative care at all health-facility levels, strengthen accountability, and support learning through operational research.[3][11][24]It recognises that existing monitoring is limited, relying mainly on uncoordinated hospital cancer registries at three institutions and with insufficient information on prevention, control interventions and referral follow-up.[16][17]

• Integrate cervical cancer indicators into the national Health Management Information System (HMIS), harmonise reporting tools and training materials, distribute registers, vaccination cards and data-capture tools, and train providers, planners and data personnel in data collection, analysis and use.[11][24][28]
• Monitor human papillomavirus (HPV) vaccination through district, regional and national coverage tools that record first, second and third doses, alongside vaccine logbooks, post-introduction evaluations, phase reviews, data-quality self-assessments and surveillance and response to adverse events following immunisation.[9][11][23][4]
• Track high-level targets including 90% HPV vaccination coverage among adolescent girls by 2015, screening of at least 50% of eligible women at least once in the preceding five years by 2015, and treatment of 80% of women with positive screening results by 2015.[4]
• Measure service delivery through indicators on women screened, positive visual inspection with acetic acid results, referrals, referral completion, treatment of precancerous lesions, surgical treatment, chemotherapy, radiotherapy, refrigerator functionality and availability of integrated screening and early-treatment services.[26][29][30]
• Assess governance, policy and resource mobilisation through indicators such as policy documents, standard operating procedures, quality-assurance measures, advocacy meetings, leadership commitment, facilities demonstrating good governance, funds mobilised and incorporation of activities into health plans.[31][32][27]
• Conduct supportive supervision, post-training follow-up, service-quality assessment and client-exit interviews, including six-monthly exit interviews at randomly selected facilities in the logical framework.[11][24][23][4]
• Undertake operational research on prevention, screening, treatment and palliative care, including World Health Organization-supported research to pilot and assess the feasibility and cost-effectiveness of HPV deoxyribonucleic acid testing; disseminate findings to improve services.[10][11][23]
• Use reporting sources including the National Cervical Cancer Prevention Programme annual reports, HMIS, health-facility records, Council Health Management Team supervision reports, reproductive and child health annual reports, operational-research reports, demographic and health surveys, mini-surveys, cluster surveys and the Tanzania Service Provision Assessment.[4][25][26][29]

Reporting frequencies range from monthly monitoring of vaccination, screening and treatment to semi-annual, annual, biennial and five-yearly reporting and surveys.[25][26][29]Coordination mechanisms include quarterly meetings among programme, immunisation and medical-supply managers and annual stakeholder progress meetings.[7]Although responsibilities are allocated to the Ministry of Health and Social Welfare and other stakeholders, the extracts do not provide a single consolidated evaluation design, comprehensive surveillance protocol or fully specified accountability process beyond reporting, supervision and review arrangements.[3][22][24]

Costing & Financing

The plan promotes resource mobilisation, rational allocation and cost-effective cervical cancer prevention and control, but the supplied extracts do not provide a total programme budget, activity-level monetary allocations, unit costs, quantified funding gap or detailed economic assumptions.[2][9][19]Financing is expected through Ministry of Health and Social Welfare and Ministry of Finance and Economic Affairs allocations, Local Government Authority and district plans, and support from development partners, donors, private-sector organisations and civil society.[7][22][16]

• Develop and verify a five-year national costing for HPV vaccination, ‘see and treat’ screening, HPV screening, treatment and palliative care.[7][27]
• Fund annual central work plans through the Medium-Term Expenditure Framework and incorporate district interventions into Comprehensive Council Health Plans and Council Management Plans.[22]
• Advocate for national and local funding through relevant ministries, district councils, partners and private-sector organisations, while requiring transparent and accountable resource management.[7][22][27]
• Address constraints including limited finances, inadequate human resources, restricted diagnostic and treatment capacity, limited budgets for awareness campaigns and human-resource development, and insufficient funding for operational research.[5][21][15][25]
• Resource procurement and investment needs include vaccines, syringes, needles, safety boxes, cold-chain equipment and spare parts, screening and treatment equipment, radiotherapy and brachytherapy machines, laboratory capacity, training, maintenance, data tools, palliative-care medicines and transport support for poor patients.[9][10][20][33][28]
• Recognise donation-supported inputs, including Merck’s HPV vaccine donation for a three-year immunisation programme, Qiagen’s donated HPV DNA screening products, UNICEF cold rooms and Canadian International Development Agency support for vaccine-storage infrastructure.[15][21]
• Recognise sustainability risks where vaccines, screening products and wider programme resources depend on donations or where local-government resources and Ministry allocations are inadequate.[15][34]

Ocean Road Cancer Institute provides cancer treatment and palliative care without charge to patients, while the Government of Tanzania is responsible for costs of cancer diagnosis, treatment and care.[35]The plan also notes that the Ministry of Health and Social Welfare allocation had not reached the Abuja recommendation of 15% of the total national budget.[3]