Plan Strategique De Lutte Contre Le Cancer Du Col De L'Uterus Et Les Autres Cancers Gynecologiques Et Mammaires Au Benin

Objectives

The 2019–2023 Strategic Plan for Cervical, Other Gynaecological and Breast Cancers aims to create a Benin in which women are free from the burden of these cancers, reducing related morbidity and mortality by 30% by 2023.[1]It aligns with the National Health Development Plan 2018–2022, the national non-communicable disease response and the global ambition to eliminate cervical cancer as a public-health problem by 2030.[2][3]

• Reduce invasive cervical cancer incidence by 50%, including a reduction from 13.6 to 6.8 cases per 100,000 inhabitants by 2023.[1][4]
• Ensure early diagnosis for 75% of cancers of the cervix, breast, ovary, vagina, fallopian tube, vulva and endometrium, with diagnosis at International Federation of Gynecology and Obstetrics stages I or II targeted to reach 75% by 2023.[1][4]
• Provide adequate care for all women identified with precancerous lesions or diagnosed with gynaecological or breast cancer, with full treatment coverage for precancerous cervical lesions targeted from 2021 and for invasive cancers from 2022.[1][4]
• Provide palliative care for all patients with incurable cancer or another indication for such care, including follow-up through mobile and fixed palliative-care units.[1][5]
• Reduce oncogenic human papillomavirus prevalence by 30% among girls aged 18 to 25 years by 2023.[1][6]
• Prioritise four strategic areas: primary prevention; early diagnosis and treatment; tertiary and quaternary prevention; and leadership, governance and research.[7][8]
• Promote equitable and universal access, prioritising sex workers, adolescents, girls, rural women, people with limited resources and women living far from services.[9][10]

Implementation

The plan uses a whole-of-system, multisectoral delivery model spanning national referral hospitals, departmental facilities, health zones, health centres and maternity units.[2][11]It combines prevention, screening, diagnosis, treatment, palliative care, workforce development, information systems, research and resource mobilisation, while initially prioritising cost-effective interventions and phasing more financially intensive activities from the third year.[8]

• Deliver primary prevention through behaviour-change communication, community mobilisation, school- and maternity-based education, human papillomavirus vaccination and action on tobacco, alcohol, sexual risk behaviours, obesity and physical inactivity.[12][13][14]
• Integrate human papillomavirus vaccination into routine immunisation through the National Vaccination Agency and decentralised structures, targeting girls aged 9 to 13 before sexual activity and involving boys, families, schools, community leaders and religious leaders in information activities.[10][11]
• Integrate cervical precancer screening, including visual inspection with acetic acid, into maternity-service minimum packages, and provide treatment of detected lesions at zone and referral hospitals through a screen-and-treat approach.[15][11]
• Expand breast cancer awareness, clinical breast examination, self-examination education, mammography, microbiopsy and periodic mass-screening activities, while reserving mammographic screening every two years for older women as specified in the plan.[10][13][16]
• Strengthen the workforce through continuing education and specialist training for midwives, nurses, general practitioners, gynaecologists, obstetricians, surgeons, radiologists, pathologists, oncologists, anaesthetists, palliative-care staff and epidemiologists.[15][17][18]
• Develop expert cancer centres at the National Hospital and University Centre, Mother and Child University Hospital, Parakou University Hospital and designated departmental hospitals, supported by relay centres for surgery, follow-up and systemic treatment.[17]
• Improve treatment capacity through pathology laboratories, surgical equipment, chemotherapy day hospitals, radiotherapy partnerships, referral and counter-referral systems, subsidised anticancer medicines and at least 50% support for chemotherapy costs.[17][19][20]
• Establish six palliative-care units, including mobile teams, ensure oral morphine availability at intermediate expert centres and train specialist palliative-care personnel and psychologists.[19]
• Coordinate implementation through the national non-communicable disease programme, departmental health directorates and health zones, with designated cancer focal points at each level and quarterly zone, half-yearly departmental and annual central coordination meetings.[21][20]
• Engage ministries responsible for health, education, social affairs, civil service, justice and communication; technical and financial partners; the private sector; civil society; communities; universities; professional bodies; and the World Health Organization.[9][12][3]
• Implement initially in two pilot areas, one in the south and one in the north, evaluate activities after one semester and use findings before national scale-up.[22]
• Monitor delivery through cancer registries in Cotonou and Parakou, facility screening registers and the District Health Information Software 2 system; define operational indicators in annual work plans; conduct a mid-term evaluation in the second half of 2021 and a final evaluation in the first half of 2024.[23][24][22]
• Mobilise financing through a dedicated budget line, annual provisional budgets, partner round tables, a cancer fund, telethons, government allocations and a proposed allocation of 5% of selected health-related taxes to gynaecological and breast cancer control.[24][21][20]

Monitoring & Evaluation

The plan establishes a structured monitoring, evaluation and accountability approach centred on performance and progress indicators, routine service data, cancer registries, annual work plans and scheduled evaluations. It aims to track prevention, screening, diagnosis, treatment, palliative care, research, coordination and financing performance while addressing major limitations in cancer data, registry staffing and funding.[19][23][25][11][22]

• Define operational performance indicators in annual work plans at every level of the health system and link them to implementation progress.[24][25]
• Monitor outcomes against targets to reduce overall morbidity and mortality from gynaecological and breast cancers by 30%, invasive cervical cancer incidence by 50%, and oncogenic human papillomavirus prevalence among girls aged 18 to 25 by 30% by 2023.[1][6][3]
• Track early diagnosis, including the target for 75% of relevant cancers to be diagnosed at International Federation of Gynecology and Obstetrics stages I or II by 2023, alongside treatment coverage for precancerous lesions and invasive cancers.[26][4]
• Measure service availability and uptake through indicators covering awareness sessions, trained personnel, human papillomavirus vaccination completion and adverse events, screening provision and participation, diagnostic capacity, lesion treatment, invasive cancer care, radiotherapy and palliative care.[14][27][28][29][16][30][31]
• Collect facility data using standard forms submitted through health zones for inclusion in District Health Information Software 2, and include cancer indicators in half-yearly health-zone monitoring.[23]
• Maintain cervical and breast screening registers in facilities and strengthen the population-based cancer registries in Cotonou and Parakou, including recruitment of four epidemiology technicians.[23]Population-based registries have operated in Cotonou since 2014 and Parakou since 2017 but face staffing and financing constraints.[32]
• Centralise and periodically analyse registry data through the National Programme for the Fight against Non-Communicable Diseases, while transmitting peripheral data through zone offices to the Ministry of Health Health Information Management Service.[22]
• Conduct quarterly coordination meetings at health-zone level, six-monthly departmental meetings and annual central reviews, with progress and follow-up considered across the system.[19][20]
• Undertake a mid-term evaluation in the second half of 2021 and a final evaluation in the first half of 2024.[23]
• Assess financing performance periodically and apply fiduciary control, supported by detailed quarterly financing reports prepared by the accounting officer of the National Programme for the Fight against Non-Communicable Diseases.[22]

Costing & Financing

The plan identifies substantial resource needs and proposes a mixed financing strategy combining increased domestic allocations, technical and financial partner support, dedicated funding mechanisms, taxes, subsidies and resource-mobilisation activities. However, the available text does not provide an overall quantified plan budget, activity-level costs, committed funding amounts or a quantified financing gap.[24][21][20][8]

• Prepare an annual provisional budget for gynaecological and breast cancer control and increase allocations to the national non-communicable disease programme and the directorate responsible for maternal and child health.[21]
• Mobilise financing through a round table with technical and financial partners, a dedicated cancer budget line, a cancer fund, telethons and advocacy for increased government support.[24][21][20]
• Allocate a proposed 5% of taxes on tobacco, alcohol, sugary drinks, salt-producing products and fats to gynaecological and breast cancer control.[24]
• Finance the proposed cancer fund through health-related taxes, including those on tobacco, alcoholic and sugary drinks, frozen food products and mobile telecommunications networks.[20]
• Subsidise anti-cancer medicines and cover at least half of chemotherapy costs nationally to improve affordability.[17][20]
• Prioritise interventions with favourable cost-effectiveness during the first two years and phase more financially intensive interventions from the third year onwards because resources are limited.[8]
• Increase domestic health financing, as public health expenditure represented 4.03% of the national budget in 2017, below the 15% Abuja Declaration target, while State-contribution mobilisation for non-communicable disease activities fell from 96% in 2013 to 26% in 2018.[32]
• Recognise the financial burden of invasive cervical cancer care, which may require radiotherapy, chemotherapy, targeted therapy and surgery, compared with the relatively low cost of screening and treatment for precancerous lesions.[33]
• Use autonomous budgets by strategic area and activity to help technical and financial partners finance relevant interventions.[3][34]
• Maintain external and in-kind support where available, including World Health Organization support for plan development, Gavi support for the human papillomavirus vaccination demonstration project and expected Care4Afrique thermocoagulation equipment.[35][36][37]