Normes et Directives Nationales pour la Prévention du Cancer du Col de l’Utérus en Côte d’Ivoire

Objectives

The national norms and guidelines establish a comprehensive cervical cancer control framework for Côte d’Ivoire, intended to standardise quality services suited to national needs and to reduce preventable illness and death through prevention, early detection, treatment and palliative care.[1]Cervical cancer is identified as the most frequent cancer and leading cause of cancer mortality among women in Côte d’Ivoire, with late detection limiting treatment effectiveness.[2][3]

• Prevent human papillomavirus infection through behaviour-change communication, safer sexual practices and vaccination, with girls aged 9 to 13 years prioritised before sexual debut.[4][5]
• Expand prevention from services initially focused on women living with HIV to all women, integrating activities into reproductive-health services and promoting national scale-up.[6]
• Detect and treat precancerous lesions through screening from age 25, prioritising women living with HIV because of their elevated risk and recommending annual screening for this group.[7][8]
• Achieve screening coverage above 80% of women at greatest risk, linking accurate testing to timely and effective treatment.[7][9]
• Provide a continuum from counselling and screening to diagnosis, referral, treatment of invasive disease and palliative care, while protecting privacy and supporting patients and families.[10][11]
• Strengthen awareness, advocacy and community mobilisation to improve acceptability and access to vaccination, screening and treatment, using culturally appropriate communication.[12][13]
• Build a competent workforce through provider qualification, training of trainers, supervision and competency-based assessment for visual inspection with acetic acid, cryotherapy and related services.[14][15]

Implementation

Implementation is designed as an integrated, tiered health-system model led by the Ministry of Health and the Fight against AIDS through the National Cancer Control Programme, with development supported by national and international experts, the World Health Organization, Jhpiego and the United Nations Population Fund.[16]Services combine facility-based care, community mobilisation, structured referral and counter-referral, supply management, workforce development and a national health-information system.[17][10][18]

• Deliver communication and mobilisation through health facilities, communities, schools, places of worship, media and public spaces, engaging women, men, adolescents, leaders, policymakers, health workers, civil-society organisations and faith-based groups.[19][20]
• Integrate human papillomavirus vaccine logistics into the Expanded Programme on Immunisation, use existing coordination mechanisms, and establish a technical working group spanning immunisation, cancer control, reproductive health, school health, education, youth, and economy and finance.[5][21]
• Provide visual inspection with acetic acid and cryotherapy at all levels of the health system where appropriate, using screen-and-treat or single-visit approaches where feasible; use loop excision for lesions unsuitable for cryotherapy and refer suspected cancer.[22][23][24]
• Organise services by facility level: primary facilities provide visual inspection, cryotherapy and palliative care; secondary and tertiary facilities add loop excision, biopsy, surgery, chemotherapy, specialist diagnostics, radiotherapy and histopathology.[17][25]
• Use the national referral system and forms for suspected cancer, extensive lesions, unsuitable cryotherapy cases and second opinions, with feedback to referring facilities.[25]
• Procure and maintain equipment, supplies and cold-chain inputs through the Ministry’s Directorate of Infrastructure, Equipment and Maintenance and the Public Health Pharmacy, using the integrated logistics system and demand forecasting to avert stock-outs.[26][10]
• Train nurses, midwives and general practitioners for visual inspection and cryotherapy, while assigning specialist diagnostic, surgical, oncology and pathology tasks to appropriately qualified cadres.[27]Training combines theoretical and clinical practice, followed by continuing supportive supervision.[14][28]
• Monitor programme delivery through the National Health Information System at facility, district, regional and central levels. Facilities collect data daily and submit monthly reports, which are compiled, validated, analysed and fed back through the system before transmission to the cancer registry and senior management.[18][29]
• Track screening, positivity, referral, cryotherapy, loop excision, complications and vaccination completion, including full three-dose human papillomavirus vaccination among girls aged 9 to 13 and partial vaccination.[30][31][32]
• Use standard registers, client forms, follow-up cards, monthly reports and referral records, with data-quality checks and a progressive transition from paper-based to computerised data processing as resources allow.[18][29]

Monitoring & Evaluation

The monitoring and evaluation system is designed to determine whether cervical cancer prevention meets objectives and targets, guide corrective action and management decisions, promote efficient resource use, and assess expected results and the national strategic plan’s impact.[18]It is integrated within the National Health Information System across facility, district, regional and central levels, with information ultimately centralised through the Directorate of Planning, Information and Evaluation.[18][29]

• Collect service data daily at facilities through standard forms, registers, individual client follow-up cards, referral and counter-referral forms, and monthly reporting tools.[18][29]
• Validate and compile facility information monthly through trained teams comprising a doctor, midwife and nurse, then submit reports to districts by the fifth day of the following month.[18]
• Analyse, consolidate and provide feedback on reports at district and regional levels, with district submissions due by the tenth and regional submissions to central level by the fifteenth of the month.[18][29]
• Process national data through the National Cancer Control Programme, disseminate findings to senior management and reporting sites, and transmit relevant information to the cancer registry.[29][30]
• Compile annual health-sector reporting through the Directorate of Planning, Information and Evaluation and share findings with the ministerial cabinet and partners.[29][30]

The framework calls for valid, measurable indicators, standardised collection tools and methods, clear reporting procedures, and data-quality controls for validity and consistency.[18]Computerisation is identified as the preferred longer-term approach, but implementation is expected to start with paper-based systems because of limited resources.[18]

• Monitor screening activity through indicators for women screened by visual inspection with acetic acid, positive results, suspected cancer lesions, referrals for extensive lesions or suspected cancer, treatment by cryotherapy or loop excision, and post-treatment complications.[30][33][34]
• Measure screening coverage against a target of at least 80% of the defined population, while recognising that effective linkage to treatment is essential to programme performance.[23][22]
• Track vaccination coverage through the numbers and proportions of girls aged 9 to 13 who are fully vaccinated with three doses within six months, partially vaccinated with one or two doses, and distributed by age.[21][31][32]
• Assess HPV vaccination introduction through coverage surveys, post-introduction evaluation, monitoring of strategy implementation, financing commitments, HPV incidence in vaccinated populations, and rates of precancerous lesions among vaccinated people.[5][21]
• Monitor service readiness and quality through facility observation, supervision, reporting completeness, provider competency checklists, client follow-up cards, equipment and supply checks, and review of registers against monthly reports.[32][35][36]

Accountability is operationalised through assigned responsibilities for facility screening teams, district and regional health-information units, the National Cancer Control Programme, central planning and information structures, and management teams.[30][37][38]Continuous supportive supervision is intended to improve provider performance and service quality, with supervision scheduled twice yearly from central to regional and regional to district levels, and four times yearly from districts to facilities.[14]

Clinical follow-up requirements include annual screening for women living with HIV, three-yearly screening after a normal result for other women, and repeat assessment one year after an abnormal result or treatment before return to three-yearly screening if normal.[8][23]Formal monitoring provisions for tertiary cancer care, complication management and several communication activities are not fully specified beyond supervision, clinical documentation, service assessments and the indicator framework.[17][11][39]

Costing & Financing

The guidance identifies financing and resource availability as important conditions for cervical cancer prevention, but it does not provide an overall national budget, programme costings, funding allocations, quantified funding gap or comprehensive economic assumptions.[5][10][18]Preparation of the manual was financed by the United States President’s Emergency Plan for AIDS Relief, with technical support from the World Health Organization and Jhpiego.[16]

• Secure sustainable financing and consider cost-effectiveness before introducing routine human papillomavirus vaccination within national immunisation programmes.[40]
• Track financing commitments as part of human papillomavirus vaccination monitoring and evaluation.[5]
• Use United Nations procurement mechanisms to negotiate wholesale vaccine prices, which may generate savings relative to private-sector prices.[41]
• Limit the cost of a three-dose human papillomavirus vaccine course to no more than 25 US dollars, equivalent in the source to 12,500 CFA francs, to support target-population coverage.[42]
• Mobilise resources through advocacy to support cervical cancer prevention policies and strategies.[12]

Financial support is also identified from the United States President’s Emergency Plan for AIDS Relief for referral treatment of large lesions by loop excision and from the United Nations Population Fund for integrating and expanding prevention services within reproductive-health activities.[6]The programme identifies inadequate prevention and treatment resources as a constraint, alongside weak partnerships, limited geographical access and the absence of a coordinated national policy at the time described.[3]

Resource requirements include trained personnel, screening and treatment equipment, laboratory and pathology capacity, cold-chain inputs for vaccination, consumables including carbon dioxide for cryotherapy, emergency supplies, and reliable logistics to prevent stock-outs.[26][10][24][43]Cryotherapy is characterised as relatively inexpensive and as part of a more cost-effective immediate screening-and-treatment alternative to traditional multi-visit approaches; the source also notes that local costs, supply, equipment and logistics should inform selection of cryotherapy gas.[22][44]

No monetary values are provided for infrastructure, equipment, staff training, supervision, data systems, treatment services, transport barriers or palliative care.[26][45][14][46]