Rwanda National Cancer Control Plan: 2020-2024

Objectives

Rwanda’s National Cancer Control Plan 2020–2024 seeks to reduce cancer incidence, morbidity and mortality, improve quality of life, and provide comfort through palliative care where cure is not possible.[1][2]It aims to achieve this through an integrated framework covering prevention, early detection and screening, diagnosis, treatment, pain management, palliative care, cancer information, research, coordination, partnerships, financing, and monitoring based on reliable statistical data.[1][3]

• Reduce preventable cancers by addressing tobacco, harmful alcohol use, unhealthy diets, physical inactivity, overweight and obesity, cancer-related infections, radiation, and environmental and occupational carcinogens.[4][5][6]
• Prevent infection-related cancers by sustaining human papillomavirus vaccination, hepatitis B immunisation, prevention messaging, and diagnosis and treatment of relevant infections.[7]
• Increase early detection and screening, particularly for cervical, breast, childhood, colorectal, prostate and other priority cancers, while promoting timely consultation and referral.[8][9][10]
• Achieve cervical cancer targets of screening at least 70% of eligible women and treating at least 90% of women with precancerous lesions by 2024.[8]
• Reduce the proportion of breast cancers diagnosed at stages III and IV from 77% to 25% by 2024.[9]
• Improve equitable access to safe, timely and quality diagnosis, staging and treatment through stronger pathology, imaging, surgery, systemic therapy and radiotherapy services.[11][12]
• Establish a comprehensive National Cancer Referral Centre in Kigali and expand treatment capacity in tertiary and teaching hospitals.[11][12]
• Provide quality pain management, psychosocial and nutritional support, and palliative care integrated across facilities, communities and home-based services.[12][13]
• Strengthen population-based and hospital cancer registries, cancer-data quality, research capacity, evidence use and dissemination for planning and evaluation.[14][15]
• Strengthen coordination, partnerships and sustainable domestic and private-sector financing, reducing duplication across cancer-control activities.[14][3]

Implementation

The plan uses an integrated and decentralised health-system approach, combining community prevention and awareness, primary-care screening, structured referral, district-level services, and specialised diagnosis and treatment at referral, teaching and cancer hospitals.[16][10][17]The Cancer Diseases Unit within the Non-Communicable Diseases Division of the Rwanda Biomedical Centre coordinates national cancer control as the Ministry of Health’s implementing agency, while cancer interventions are integrated with district health programmes and other relevant health services.[18][19]

• Coordinate delivery through the National Cancer Technical Working Group, functioning as a steering committee and meeting quarterly, while broadening participation to civil society, non-governmental organisations and cross-sectoral bodies.[18]
• Collaborate with relevant ministries, development partners, private providers, insurers, professional associations, patient groups, media, research institutions and international cancer-control organisations.[3][15]
• Integrate cancer education into health facilities, community programmes, school health, social-sector ministries, civil-society activities, HIV services, maternal and child health services, and non-communicable disease programmes.[4][7][8]
• Engage communities through Community Health Workers, local leaders, churches, mass media, information technology, Umuganda community actions, car-free-day activities and awareness campaigns.[4][5]
• Deliver cervical screening through women’s cancer screening clinics and existing HIV and maternal and child health services, introducing human papillomavirus DNA testing, annual campaigns, electronic monitoring and validated innovations.[8][9]
• Provide breast early detection through clinical examination, self-examination education, district-hospital ultrasound, referral-hospital mammography, and genetic testing for high-risk populations.[9]
• Strengthen referral and diagnostic capacity through specimen transport, pathology algorithms, laboratory upgrades, immunohistochemistry, molecular testing, flow cytometry, telepathology, imaging, nuclear medicine and laboratory quality assurance.[17][11]
• Expand treatment through oncology units, infusion centres, upgraded surgical oncology, systemic-treatment procurement and insurance access, radiotherapy and brachytherapy, multidisciplinary tumour boards, national guidelines and electronic links between cancer centres.[12][20][21]
• Develop the workforce through specialist fellowships, university partnerships, tailored curricula, continuing medical education and training for multidisciplinary oncology, pathology, radiotherapy and palliative-care personnel.[12][21][22]
• Integrate palliative care in public and private facilities, strengthen access to essential medicines including oral morphine, train health workers and community personnel, and develop sustainable home-based care.[13][15]
• Use cancer registries, the Health Management Information System and District Health Information Software 2 to improve data completeness, timeliness and use in planning, surveillance and evaluation.[14][15]
• Monitor local and national implementation using indicators on incidence and mortality, stage at diagnosis, service access, pathology turnaround time, medicine availability, workforce, palliative-care coverage, registry functionality and research outputs.[23]
• Prepare annual implementation reports through the Cancer Control Unit, with Technical Working Group endorsement and submission by the Rwanda Biomedical Centre Director General to the Ministry of Health; undertake a mid-term review and final evaluation.[24]
• Finance implementation through increased domestic resources, partner support, public-private partnerships, innovative financing and insurance-based universal health coverage, while recognising that the plan’s 2020–2024 implementation estimate excludes many diagnosis and treatment costs.[3][23]

Monitoring & Evaluation

The plan establishes a national monitoring and evaluation system for cancer control, combining performance indicators, routine reporting, cancer registration, health information systems, quality assurance and periodic review. Monitoring is intended to support implementation at local and national levels and inform adjustments to the 2020 to 2024 plan.[23][24]

• Monitor outcomes through indicators covering cancer incidence and mortality, stage at diagnosis, access to diagnosis and treatment, pathology turnaround time, medicine and reagent availability, trained personnel, palliative-care coverage, registry functionality and cancer research outputs.[23]
• Target pathology diagnostic turnaround of less than five days and measure the proportion of newly diagnosed patients receiving surgery, radiotherapy or chemotherapy in accordance with national guidelines.[23]
• Track prevention targets, including a 5% reduction in overweight and obesity, a 20% increase in fruit and vegetable consumption, and a 10% reduction in harmful alcohol use by 2024.[5][6]
• Measure cervical screening coverage among eligible women, with a target of at least 70% screened by 2024, and treatment coverage for pre-cancerous lesions, with a target of at least 90% treated.[8]
• Monitor reduction in breast cancers diagnosed at stages III and IV from 77% to 25% by 2024.[9]
• Use 2019 baselines and 2024 targets in action matrices, with implementation activities scheduled across five years and responsibility allocated to named institutions.[25][26][27][20]
• Generate baseline information during the first two years where registry data are incomplete, and review indicators during the 2021 mid-term review to establish reliable baselines and targets.[23]

Cancer surveillance is centred on population-based and hospital-based registration, complemented by aggregate facility reporting and mortality records. The Rwanda Biomedical Centre established the national cancer registry in July 2018, using International Agency for Research on Cancer guidance for population-based registries, to collect cancer cases presenting at facilities and cancer deaths in communities.[2]Health facilities report aggregate cancer data through the Ministry of Health Health Management Information System, while the National Institute of Statistics of Rwanda provides mortality information from vital records and the death registry.[28]

• Expand registry coverage through the Kigali Population Based Cancer Registry, hospital registries in referral and teaching hospitals and the Butaro Cancer Centre of Excellence, linked through a nationwide National Cancer Registry and integrated with health surveillance.[14]
• Digitise registration, enable automated hospital reporting, strengthen pathology laboratory information systems and report registry information through District Health Information Software 2.[14][15]
• Use Electronic Medical Records to monitor and evaluate cervical screening, and use electronic links between cancer centres to support coordinated care.[9][12]
• Apply laboratory accreditation, quality control and external quality assurance, alongside imaging safety and quality-assurance guidelines, standardised pathology reporting and telepathology.[11]
• Integrate palliative-care indicators into facility accreditation and monitor access to pain management and quality palliative-care services.[13]

Accountability arrangements assign the Cancer Diseases Unit within the Rwanda Biomedical Centre responsibility for implementation monitoring, supported by the Cancer Technical Working Group. Annual reports are prepared by the Cancer Control Unit, endorsed by the Technical Working Group, submitted to the Ministry of Health by the Rwanda Biomedical Centre Director General and disseminated to stakeholders.[24]A mid-term review was scheduled for the end of 2021 and a final evaluation for the end of 2024.[24]The plan also envisages cancer-data dissemination for policy decisions, including an annual cancer symposium and research dissemination channels.[14]

Costing & Financing

The National Cancer Control Plan implementation requirement for 2020 to 2024 is estimated at 36,525,222,844 Rwandan francs, stated as equivalent to 38,856,620 United States dollars.[23]Costing used prices and tariffs available in 2019 and annual allocations are intended to vary by activity and funding source.[23]

• Finance implementation through Government of Rwanda resources, cancer-control partners, increased domestic allocations, public-private partnerships, private-sector investment and continued international technical and financial support.[29][3][23]
• Strengthen sustainable financing through prudent resource management, value for money, effective use of partner resources and innovative financing models, including health-insurance coverage for cancer services.[3][23]
• Recognise limited financial resources and competing health priorities as implementation risks, and use advocacy and partnerships with development partners, insurers and the private sector to mobilise resources.[14][24]
• Identify resource gaps and promote domestic and private financing, although no quantified funding gap or financing target is provided.[14]

The cost estimate mainly covers service establishment and excludes diagnosis and treatment costs, including medicines, radiotherapy, surgery, consumables and diagnostic tests. These costs are expected to be met through existing health-financing mechanisms, including patient payments and insurance arrangements.[23]Cancer financing is integrated into Ministry of Health and Rwanda Biomedical Centre budgets, with allocations made by the Ministry of Finance; no separate earmarked cancer budget is identified.[30]

• Provide approved health services through public and private insurance, with patients contributing between 10% and 15% of service costs according to insurance and socioeconomic arrangements.[16]
• Maintain community-based health insurance alongside civil-service, military and private insurance schemes; in September 2019, 80% of the population was enrolled in community-based insurance and 11% in other schemes.[30]
• Support chemotherapy at the Butaro Cancer Centre of Excellence free of charge through Partners In Health, while recognising that the centre cannot provide all cancer services or meet all patient demand.[18]
• Address affordability because cancer diagnosis and treatment costs exceed the reported gross domestic product per capita of 740 United States dollars and may entail additional out-of-pocket expenditure at other centres.[19]

Priority resource needs include medicines, reagents, consumables, laboratory and imaging equipment, maintenance, infrastructure upgrades, workforce development, screening technologies, palliative-care medicines and service expansion.[17][11][12]The source does not provide activity-level budgets, annual expenditure profiles, funding shares, unit costs or a quantified financing gap beyond the overall implementation estimate.[29][23]