Key points
Development of any national cervical cancer prevention and control programme should be done in accordance with the WHO framework of the “six building blocks” to strengthen the overall health system.
Cervical cancer prevention and control programmes are developed and designed to decrease cervical cancer incidence, morbidity and mortality.
There are large inequities in access to effective cervical cancer screening and treatment; invasive cervical cancer predominantly affects women who lack access to these services.
A comprehensive programme should include primary, secondary and tertiary prevention activities (including treatment), and access to palliative care.
Screening services must be linked to treatment and post-treatment follow-up.
Monitoring and evaluation are essential components of cervical cancer prevention and control programmes.
About this chapter
This chapter is based on the following WHO guidelines:
A strategic approach to strengthening control of reproductive tract and sexually transmitted infections: use of the programme guidance tool. Geneva: WHO; 2009. (http://www.who.int/reproductivehealth/publications/rtis/9789241598569/en/).
Cancer control knowledge into action: WHO guide for effective programmes: diagnosis and treatment (module 4). Geneva: WHO; 2008. (http://www.who.int/cancer/publications/cancer_control_diagnosis/en/).
Cancer control knowledge into action: WHO guide for effective programmes: palliative care (module 5). Geneva: WHO; 2007. (http://www.who.int/cancer/publications/cancer_control_palliative/en/).
Cervical cancer prevention and control costing tool (C4P): user's guide. Geneva: WHO; 2012. (http://www.who.int/immunization/diseases/hpv/cervical_cancer_costing_tool/en/).
Everybody's business: strengthening health systems to improve health outcomes: WHO's framework for action. Geneva: WHO; 2007. (http://www.who.int/healthsystems/strategy/everybodys_business.pdf).
Global action plan for the prevention and control of NCDs 2013–2020. Geneva: WHO; 2013. (http://www.who.int/nmh/publications/ncd-action-plan/en/).
Human papillomavirus vaccines: WHO position paper, October 2014. Wkly Epidemiol Rec. 2014;89(43):465–92. (http://www.who.int/wer/2014/wer8943.pdf) [PubMed: 25346960].
Monitoring national cervical cancer prevention and control programmes: quality control and quality assurance for visual inspection with acetic acid (VIA)-based programmes. Geneva: WHO; 2013. (http://www.who.int/reproductivehealth/publications/cancers/9789241505260/en/).
New vaccine post-introduction evaluation (PIE) tool. Geneva: WHO; 2010. (http://www.who.int/immunization/monitoring_surveillance/resources/PIE_tool/en/).
Prevention of cervical cancer through screening using visual inspection with acetic acid (VIA) and treatment with cryotherapy: a demonstration project in six African countries: Malawi, Madagascar, Nigeria, Uganda, the United Republic of Tanzania, and Zambia. Geneva: WHO; 2012. (http://www.who.int/reproductivehealth/publications/cancers/9789241503860/en/).
WHO guidance note: comprehensive cervical cancer prevention and control: a healthier future for girls and women. Geneva: WHO; 2013. (http://www.who.int/reproductivehealth/publications/cancers/9789241505147/en/).
The aim of this chapter is to give an overview of how a national cervical cancer prevention and control programme is developed by national decision-makers, and to provide the basic information needed by health-care managers and providers for implementing such a programme at the patient and community levels.
This chapter has two main sections. Section 2.1, What is a comprehensive cervical cancer prevention and control programme?, describes the overall purpose of a comprehensive cervical cancer prevention and control programme and how it should be organized in order to have an impact on the burden of this disease. To be successful, a national programme should include the following key components: primary, secondary and tertiary preventive services, including treatment for pre-cancer and cancer, and palliative care.
Section 2.2, National cervical cancer prevention and control programmes, describes the phases of a national programme: (1) national policy development and establishment of a programme management structure, (2) programme planning and preparation, including an effective referral system, (3) programme implementation, and (4) programme monitoring and evaluation, which must operate across all levels of care. This section provides operational guidelines on the various interventions needed at each level to achieve the goal of reducing the burden imposed by cervical cancer at the individual, community and national levels.
Included in this chapter are tables summarizing commonly encountered challenges to programme planning and implementation and possible options for reducing or eliminating their negative effects. This chapter also includes a list of further reading and useful websites, and links to two practice sheets: a planning and implementation checklist, and descriptions of key performance and impact indicators for national cervical cancer prevention and control programmes.
2.1. What is a comprehensive cervical cancer prevention and control programme?
Any specific national health programme is embedded within a national health system. According to WHO, a strong health system should be built on six building blocks (see Box 2.1). Programme planners should be encouraged to use the WHO framework as a basis for building a national cervical cancer prevention and control programme.
The WHO Health System Framework. Source:
Everybody's business: strengthening health systems to improve health outcomes: WHO's framework for action
Geneva
World Health Organization2007.
A cervical cancer prevention and control programme comprises an organized set of activities aimed at preventing and reducing morbidity and mortality from cervical cancer. It is part of the priority actions as stated in the Global action plan for the prevention and control of NCDs 2013–2020.1 The programme provides a plan of action with details on what work is to be done, by whom and when, as well as information about what means or resources will be used to implement the programme. The achievement of the programme is assessed periodically using a set of measureable indicators. A comprehensive programme includes the principal evidence-based interventions needed to reduce the high and unequal burden imposed on women and health systems in less developed countries by cervical cancer.
The goal of any comprehensive cervical cancer prevention and control programme is to reduce the burden of cervical cancer by (i) reducing human papillomavirus (HPV) infections, (ii) detecting and treating cervical pre-cancer lesions, and (iii) providing timely treatment and palliative care for invasive cancer, as depicted in .
The WHO comprehensive approach to cervical cancer prevention and control: Overview of programmatic interventions over the life course to prevent HPV infection and cervical cancer. * Tobacco use is an additional risk factor for cervical cancer. Source (more...)
2.1.1. Key components of comprehensive cervical cancer prevention and control
A comprehensive programme includes three interdependent components: primary, secondary and tertiary prevention (see ). The interventions included in each component are described in this section.
a. Primary prevention: reduce the risk of HPV infection
The public health goal is to reduce HPV infections, because persistent HPV infections can cause cervical cancer.
Interventions include:
vaccinations for girls aged 9–13 years (or the age range referred to in national guidelines) before they initiate sexual activity;
healthy sexuality education for boys and girls, tailored as appropriate to age and culture, with the aim of reducing the risk of HPV transmission (along with other sexually transmitted infections, including HIV) – essential messages should include delay of sexual initiation, and reduction of high-risk sexual behaviours;
condom promotion or provision for those who are sexually active;
male circumcision where relevant and appropriate.
For further details on HPV vaccination, see Chapter 4, and for information on HPV infection, see Chapter 1, section 1.3.4.
b. Secondary prevention: screening for and treating pre-cancer
The public health goal is to decrease the incidence and prevalence of cervical cancer and the associated mortality, by intercepting the progress from pre-cancer to invasive cancer.
Interventions include:
counselling and information sharing;
screening for all women aged 30–49 years (or ages determined by national standards) to identify precancerous lesions, which are usually asymptomatic;
treatment of identified precancerous lesions before they progress to invasive cancer.
Even for women who have received an HPV vaccination, it is important to continue screening and treatment when they reach the target age.
For further details about screening and treatment of cervical pre-cancer, see Chapter 5.
c. Tertiary prevention: treatment of invasive cervical cancer
The public health goal is to decrease the number of deaths due to cervical cancer.
Interventions include:
a referral mechanism from primary care providers to facilities that offer cancer diagnosis and treatment;
accurate and timely cancer diagnosis, by exploring the extent of invasion;
treatment appropriate to each stage, based on diagnosis:
- –
Early cancer: If the cancer is limited to the cervix and areas around it (the pelvic area), treatment can result in cure; provide the most appropriate available treatment and offer assistance with symptoms associated with cancer or its treatment.
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Advanced cancer: If the cancer involves tissues beyond the cervix and pelvic area and/or metastases, treatment can improve quality of life, control symptoms and minimize suffering; provide the most effective available treatment and palliative care in tertiary facilities and at the community level, including access to opioids.
palliative care to relieve pain and suffering.
For further details about diagnosis and treatment of invasive cancer, and palliative care, see Chapters 6 and 7, respectively.
d. The context for delivering the prevention components
The above three prevention components are planned and implemented in conjunction with:
a structured national approach to community education and mobilization strategies (see
Chapter 3 for details); and
a national monitoring and evaluation system (described in this chapter,
section 2.2.3).
2.2. National cervical cancer prevention and control programmes
The objective of a national programme will be to decrease the incidence and prevalence of cervical cancer and associated mortality in the country.
The development and implementation of a national cervical cancer prevention and control programme includes the following phases:
national policy development and establishment of a programme management structure
programme planning and preparation
programme implementation
programme monitoring and evaluation.
2.2.1. National policy development and establishment of a programme management structure
a. National policy development
The policy development phase involves deciding on nationally appropriate and feasible options for prevention and control, giving careful consideration to scalability and sustainability, and developing national guidelines based on these policy decisions.
This phase needs to use a cyclical process, since policies need to be updated regularly, as new evidence-based data become available. Service delivery, training, and monitoring and evaluation (M&E) all need to be adapted to the updated policies.
Decisions on national priorities
Vital policy decisions should be carefully drafted based on the national burden of disease, availability of financial and human resources, and the existing structure, quality and coverage of the health-care and education systems. All decisions need to be examined and tailored to make them sustainable and applicable to the real situation in the country. Participants in this phase include national-level policy-makers and decision-makers and political and technical personnel from the country's Ministry of Health (MOH), as well as representatives of professional medical associations, such as the obstetric/gynaecology association, medical oncology association, nurses association, etc.
Areas for policy discussions and decisions may include the following:
Review and, if necessary, update existing national guidelines and protocols for health workers at all levels.
Conduct policy dialogue and build consensus with stakeholders, including health-care providers, public health authorities, health insurance executives and medical professional associations, among others.
Gather and review country data to answer these key questions:
Where is the problem?
- –
What should the priority areas be in addressing the problem?
- –
What are the costs of delivering the services and how will they be financed?
Assess the affordability, cost-effectiveness and sustainability of introducing HPV vaccines and the screen-and-treat approach to cervical cancer prevention and control, as well as of a referral system for treatment at the national level.
Determine whether existing services have the capacity to add cervical cancer prevention and control services (including introduction of HPV vaccination), and plan how to address any shortcomings or deficiencies.
Consider strategies for programme introduction, including when, how (phased or not) and where (if not nationwide) to introduce HPV vaccine and screening and treatment services; if not nationwide initially, include a tentative future expansion plan for reaching all at-risk women and girls in the country.
Choose service-delivery strategies and possible venues for HPV vaccine delivery, and for screening.
Select which HPV vaccine is to be used in the country.
Determine which methods will be used for screening and treatment of pre-cancer.
Determine which hospitals will serve as reference centres for cervical cancer treatment.
Determine the age range, frequency, coverage level, time frame for achieving the coverage, and the health-care level for service delivery for each of the selected interventions.
Establish a training plan for health-care providers and community health workers.
Establish a plan for information, education and communication (IEC) on cervical cancer, including training for managers and providers on how to implement IEC initiatives targeting consumers and the media.
Plan ahead for M&E; determine the key indicators, frequency of data collection and methods for recording and analysing data.
To facilitate decision-making on cervical cancer prevention and control strategies, programme managers and policy-makers need information on the projected programmatic costs of introducing cervical cancer interventions. The WHO cervical cancer prevention and control costing tool (C4P) has been developed to assist governments to estimate the costs of cervical cancer interventions over a five-year planning horizon.2 Module 1 of the tool focuses on HPV vaccine introduction while Module 2 focuses on cervical cancer screening and treatment.
Scalability and sustainability considerations
Two important factors that should be taken into consideration when setting up or improving a cervical cancer prevention programme are sustainability and scalability.
The costs of the cervical cancer prevention and control programme should be included in the national health budget. Planning for sustainability should include determining what is feasible in terms of available financial resources, human resources and infrastructure, with a view to equitable implementation of the various components of cervical cancer prevention and control. Sustainability planning may also include the search for external support from bilateral and multinational agencies and large foundations with proven records. For example, for HPV vaccine introduction, support from the GAVI Alliance is available for five years, with the requirement that the country must plan for long-term sustainability beyond the initial five years.
For countries with limited resources that initially can only implement a cervical cancer programme with limited coverage, future scalability is an important consideration. Wide coverage can be achieved using a step-wise incremental approach over a defined time period, based on the feasibility and availability of resources. Plans for scale-up should prioritize women who have not had access to health services and those groups with the greater burden of cancer deaths and suffering. Programme managers have to set realistic targets depending on the number of providers, the available hours of work and the size and sociocultural characteristics of the target population in the geographical area being considered.
Development of national guidelines
The above decisions will inform the development of guidelines for national cervical cancer prevention and control. This activity needs to be conducted collaboratively by national policy-makers and MOH representatives in consultation with key stakeholders, such as health-care providers, medical professional associations and women's groups. It is also important to include national and international cervical cancer experts and representatives of nongovernmental organizations with experience with cervical cancer prevention and control.
Guidelines must include information on clinical and public health requirements for a successful programme. The elements that should be defined in the guidelines are listed below.
Clinical requirements:
HPV vaccination: age range, schedule and clinical procedures
Screening: age range, screening test(s), screening interval, diagnostic criteria, follow-up recommendations and clinical procedures
Treatment of precancerous lesions: treatment methods and clinical procedures
Treatment of invasive cancer: treatment methods, clinical procedures and palliative care
Referral system.
Public health requirements:
HPV vaccination: vaccination strategy, coverage, safety standards, reporting on adverse events following immunization (AEFI)
Screening: infrastructure, equipment and supply requirements, quality assurance and quality control approach, coverage
Treatment of precancerous lesions and invasive cancer: infrastructure, equipment and supply requirements, timeliness of treatment, quality assurance and quality control approach
M&E: key performance and impact indicators for each service component, plan for incorporation of necessary data into a management information system (MIS).
b. Establishment of a programme management structure
To facilitate planning, implementation and monitoring of a national cervical cancer prevention and control programme, it is important to establish a national cervical cancer management team, with clear responsibilities and accountability for the programme.
As shown in , two key groups should be developed at the national level, led by a designated national coordinator:
Proposed structure of a national cervical cancer management team.
A multidisciplinary management team responsible for the programme and composed of representatives from various national departments and programmes;
A stakeholder advisory group composed of representatives of appropriate segments of civil society.
Members of both groups would be selected and invited to participate by the MOH.
Role of the national coordinator
The role of the national coordinator would include the following activities and responsibilities:
Raise awareness within the MOH at different levels of the health system on the seriousness of national cervical cancer morbidity and mortality, and the potential to prevent most deaths with relatively few resources.
Advocate to make cervical cancer prevention and control a priority within the MOH, including allocation of a continuous and sustainable supply of resources to the programme.
With input and advice from senior MOH administrators and managers, establish and develop representative membership, roles and responsibilities for the multidisciplinary management team (in accordance with the structure shown in ).
In collaboration with the team, organize and schedule regular team meetings.
In consultation with the team and with senior MOH administrators and managers, identify and invite key stakeholders from civil society to form the stakeholder advisory group (in accordance with the structure shown in ), and establish group functions and responsibilities.
In collaboration with the stakeholder advisory group, organize periodic meetings to update them on the status of the cervical cancer prevention and control programme and seek their input on the key steps.
Be the principal link and coordinator between and within all service levels in the national cervical cancer prevention and control programme, as well as with other national programmes (such as cancer control, immunization and adolescent health) and with other partners.
Prepare a proposal to ensure that all necessary elements for programme implementation will be in place at all health-care facilities, including equipment, supplies, and trained and supervised staff. This process should involve regional management personnel, and proposals may need to be adapted for different regions.
Produce annual reports on the performance of the cervical cancer prevention and control programme, based on the established programme indicators.
Role of the national multidisciplinary management team
For the national multidisciplinary management team to be effective, the MOH needs to provide it with the appropriate mandate, decision-making authority, autonomy and resources to direct the planning, implementation, monitoring and evaluation of the national programme.
As the national cervical cancer prevention and control programme has several key components, the management team will involve representatives from other national programmes, including community education and social mobilization, immunization, reproductive health, adolescent and school health, sexually transmitted infections and HIV, oncology, M&E, etc. Local and regional representation is important. The overall size of the team may range between approximately 10 and 25 people, depending on the size of the country and the structure of the national programme.
Key responsibilities of the national multidisciplinary management team (MMT):
Develop national plans for the various components and elements of the programme.
Develop a detailed budget for planning, implementation, monitoring and evaluation of the programme.
Establish systems for various elements of the programme including: recording data in the existing management information system (MIS); periodic reports (frequency, content and audience); distribution and maintenance of equipment and supplies, among others.
Through monitoring and evaluation (M&E) activities, assess whether services are functioning effectively and ensure the implementation of corrective action in a timely manner, as needed.
Using a multipronged, evidence-based approach, build awareness of programmatic components at the primary and secondary levels and ensure that health-care providers are kept up-to-date with technical information.
Document and address any misinformation and misconceptions among health-care providers and communities.
Conduct regular M&E of programme activities.
Principal functions of the stakeholder advisory group
Provide support and input to the MOH multidisciplinary management team (MMT) to create a cervical cancer prevention and control programme and/or expand, update or strengthen an existing one.
Attend regular meetings to review past activities, plan new ones and document planned achievements and/or lack of them.
In collaboration with the MMT, form and delegate working groups to focus on specific elements of the national programme, including (but not limited to) those shown in .
Advise and participate in national, regional and local meetings with the MMT as necessary to define the programme.
c. Challenges to the development of effective cervical cancer prevention and control strategies
As with all new programmes, challenges can be expected to arise at all levels of the health system pyramid when a national cervical cancer prevention and control programme is first contemplated and developed. There are actions that can be taken at all levels to mitigate the negative effects of these challenges.
describes the most common challenges and suggests possible actions to address these at the appropriate levels of the health system. Many additional actions can be developed as appropriate in each country based on careful review of the updated contents of all chapters of this second edition of the guide.
Potential challenges at the policy and managerial levels, and suggested actions for addressing them.
2.2.2. Programme planning and preparation
A cervical cancer prevention and control programme requires detailed planning and preparation because:
it requires involvement, commitment and close coordination between and within several existing ministries (e.g. MOH, Ministry of Education, Ministry of Gender Equality, among others) and multiple programmes within them (e.g. within the MOH, relevant programmes include cancer control, immunization, reproductive health and adolescent health, among others);
it requires consideration of the various responsibilities and linkages between the structures at different levels of the health system: national, regional, clinic and community (see );
it involves collaboration with nongovernmental organizations, women's groups and professional associations, such as paediatricians, gynaecologists, oncologists, primary care physicians and nurses; and
it requires active participation of key local stakeholders.
Examples of programmatic considerations at different levels of the health system.
a. Planning: key programmatic considerations
Based on policy decisions that have been made regarding the programme, to move forward with planning and designing an organized programme, the key programmatic considerations include:
providing an opportunity for health-care providers to provide input on programme planning and preparation, in line with national guidelines;
assessing the service delivery needs at all service delivery facilities and building on what is already available at each, with the aim of sharing resources;
developing an action plan for community education and mobilization, and developing appropriate materials;
procuring and distributing equipment and supplies and setting up local repair/maintenance and distribution systems for them;
establishing and maintaining an effective referral system;
establishing a health management information system (paper-based or computerized) to enable monitoring and evaluation;
developing a monitoring and evaluating strategy to regularly assess the programme and institute corrective action in a timely manner;
assuring a well-designed and implemented provider training programme including post-training follow-up and periodic refresher training;
providing for supportive supervision to detect and correct any problems with health services, to keep them in line with national standards; and
establishing implementation strategies with district managers and local decision-makers.
b. Steps in preparing to launch a new national cervical cancer prevention and control programme using a strategic approach
A strategic approach to implementing a new national cervical cancer prevention and control programme requires several activities to be completed prior to launching services. The four main steps are described in this section.
Determine the target population
It is crucial to having a clear definition of the target populations for HPV vaccination and cervical cancer screening, and to know the location and size of these populations. This information can be obtained relatively easily in countries where population records are kept and updated routinely as part of health services or by using census data from the national statistics authorities. In countries where this is not done, regional population estimates from the United Nations can be used. 4
Determining the target population is important for the following reasons:
to provide the denominator for calculating coverage as a core performance indicator
to estimate the needed supplies, staff numbers and time, and other resources
to assist development of the action plans for delivering and monitoring services.
Conduct a needs assessment
A needs assessment involves visiting, observing, interviewing key informants and stakeholders and documenting existing resources. The following information needs to be obtained:
the location and condition of all facilities in the selected implementation area, including details about the infrastructure, equipment and supplies;
the capacity of all cadres of providers for adding cervical cancer prevention and control services;
the quality of general services provided at each facility from the point of view of clinic personnel at all levels (from managers to cleaning staff) and from community representatives, including women and girls in the target age groups (both users and nonusers of services);
the schedule of service hours per day and per week, and out-of-pocket costs for all or selected services, if any;
the existence and functionality of a referral/counter-referral system;
the existence of an adequate system for adding data on cervical cancer services, as these data will be needed for monitoring and evaluating the new programme;
space available for cold chain storage of new vaccines, to determine whether expansion is needed to provide dedicated space for this purpose in the immediate future.
Map and leverage support from additional local contributors
As cervical cancer prevention and control involves collaboration among various public and private organizations, mapping their locations in the area of implementation, as well as their infrastructure and human resources, can be very useful. It is important to identify and personally contact all potential local contributors, and leverage their collaboration. These potential contributors would include organizations identified for their experience and expertise in provider training, community sensitization and mobilization, design and implementation of vaccination programmes, monitoring and supportive supervision, and establishment and monitoring functionality of the cold chain, among others.
Decide on and design an introduction strategy
Countries with limited resources can consider initiating cervical cancer prevention and control as a demonstration project in a selected geographic area. This strategy can be very valuable as a way of monitoring elements that may need to be modified or improved before services can be scaled up.
Geographic expansion can be planned using a step-wise approach, applying lessons learnt in the demonstration project and incorporating, if applicable, emerging new evidence-based technology. Scale-up can proceed gradually until the programme serves the entire country.
2.2.3. Programme implementation
An operational framework must be developed for the activities that need to be undertaken at different levels of the health care system. See and .
Example of organization of screening, referral and treatment services. Source:
Prevention of cervical cancer through screening using visual inspection with acetic acid (VIA) and treatment with cryotherapy: a demonstration project in six African countries: (more...)
At the community level, activities include creating awareness, providing education, and outreach efforts targeting girls aged 9–13 years and women aged 30–49 years (see Chapter 3, and sections 4.3 and 4.4 in Chapter 4). For patients with advanced disease, the family and community are the principal contributors to palliative care after a woman is discharged from hospital (see Chapter 7: Palliative care).
At the primary- and secondary-level health-care facilities, the screening test or tests that have been selected at the policy development stage can be performed, and clients who screen positive can be treated with cryotherapy or loop electrosurgical excision procedure (LEEP). For lesions that do not meet the eligibility criteria for these treatments, women must be referred to the tertiary level of health services for further evaluation and treatment (see Chapters 5 and 6 on diagnosis and treatment of pre-cancer and invasive cancer, respectively).
Training of health-care providers, supervision, and monitoring and evaluation of services are required, and must be performed continuously at all levels.
a. Role of health-care providers in programme implementation
Health-care providers at all levels, as well as managers, supervisors and training facilitators, contribute to the effectiveness of a national cervical cancer prevention and control programme.
Health-care providers' key roles in implementing an effective programme include all of the following:
delivering relevant preventive, curative and rehabilitative health services to the eligible population, as determined by the national guidelines and service protocols;
participating in relevant training and refresher training to keep knowledge and skills up-to-date;
keeping informed of any changes to service recommendations or interventions and adapting clinical practices accordingly;
providing correct information to the community in clear terms using the local language so that people in the target populations will make use of (and benefit from) these services;
ensuring that services are provided in a timely manner and that referral services are working efficiently;
maintaining meticulous records and registers, which are needed to calculate the monitoring indicators as a basis for assessing whether the goals of the programme are being achieved; and
assuring and continuously improving the quality of services at all levels.
b. Integrating cervical cancer services with other health services
Integrating services or, at a minimum, informing and arranging linkages between services enables holistic health management for women. The introduction of new cervical cancer prevention and control services provides an opportunity to take a comprehensive approach to women's health.
Integrating cervical cancer screening and treatment with other reproductive health services
Links are needed between the demand for and the supply of health services. On the demand side, many women visit health-care facilities seeking advice on a variety of ailments, especially those related to reproductive health. But they may not be aware of the importance of cervical cancer screening and treatment in particular.
On the supply side, primary care facilities often have only one mid-level health-care provider who is tasked with managing all reproductive health care for women (i.e. family planning, STI management, antenatal care and behaviour change communication). Often this primary care provider does not have the training and/or the necessary equipment to provide pre-cancer screening for women over the age of 30, and might therefore miss the only opportunity to offer this service to a particular client. If screening is not possible at the primary care facility, the provider can, at least, determine the need for this service, educate the client and refer her to the secondary-level facility.
Integrating HPV vaccination into other primary prevention services
The HPV vaccination strategy offers valuable opportunities for integration with other school health services and adolescent-friendly primary health care services. Interventions can include screening for common nutritional deficiencies, physical disabilities and illnesses, as well as providing preventive health information, such as information on the dangers of tobacco use, on contraception to prevent unplanned pregnancies, and on condom use for the dual purpose of preventing pregnancies and STIs, including HIV/AIDS.
Integrating HIV and cervical cancer screening and treatment services WHO strongly recommends that in countries with a high prevalence of HIV any contact between a client (or patient) and a health worker be used as an opportunity for HIV counselling and testing (HCT) and provision of appropriate education and care. The integration of cervical cancer and HIV services can occur in two ways:
Women attending HCT services should be encouraged to seek cervical cancer screening if they are aged 30 years and above; if they are living with HIV and have never had cervical screening, they should be encouraged to get screened immediately regardless of their age, or to get screened within three years if they have previously had a negative cervical screening result.
Women attending for cervical cancer screening in countries with a high prevalence of HIV should be encouraged to attend HCT services if they have not been tested for HIV recently.
c. Integrating services with screening for other cancers: the case of breast cancer
The same principles for implementing a successful and high-quality cervical cancer screening programme apply to screening for other cancers, such as breast cancer. The experience and lessons learnt organizing and implementing a programme for cervical cancer could provide the basis for developing a programme for breast cancer. Differences in the target age range for breast cancer screening (usually women aged 50 years and older) need to be considered when approaching women at cervical cancer screening services. At a minimum, cervical cancer services offer an opportunity for building awareness about breast cancer and linking with breast cancer screening services. Similarly, women undergoing breast cancer screening should be asked about cervical cancer screening if they are in the recommended age range for cervical cancer screening, and those who have never been screened should be particularly encouraged to do so.
d. Challenges to programme implementation
Challenges are not only found at the policy development level, but also arise during programme implementation at the level of the health-care facility and the community, in addition to barriers affecting families and individuals. summarizes these challenges and provides suggestions for reducing any negative effects of these challenges.
Potential challenges in the implementation phase, and suggested actions for addressing them.
e. Develop an action plan for information and education, training and supportive supervision
As with other programme components, the action plan for IEC, training and supportive supervision should be developed based on the needs assessment and mapping exercises described earlier, in section 2.2.2.
This action plan should include the following activities:
Conduct focus group discussions and/or interviews with women and girls in the target age groups to better understand their knowledge, perceptions and needs; this information will help programme managers to tailor the training curricula for health-care providers, so that they can provide the appropriate information and support to clients, thus assuring high levels of participation in screening and compliance with treatment and follow-up services.
Based on available information about existing service capacity and local needs, develop and implement staff training curricula, as well as IEC materials and patient education tools.
Prepare records and registers for documentation of services provided; this is important not only for patient management and programme evaluation, but also for supervision and evaluation of provider performance.
Provide training for all health-care providers and programme managers to enable them to explain clearly to patients what they can expect when they undergo certain procedures (see
Chapters 3–
7 for information on counselling messages and mobilization plans for HPV vaccination, and screening and treatment of pre-cancer and invasive cancer).
Provide training to data operators, equipment maintenance staff, programme supervisors and laboratory technicians on the technical details of their tasks.
Educate primary- and secondary-level providers about treatment of invasive cancer and palliative care, so that they are knowledgeable about the services provided at the tertiary level.
The duration of training courses should be sufficient to achieve proficiency in the majority of learners and should include theoretical components, simulation using anatomical models, and hands-on clinical training. Training on methodologies that will be used in services should be flexible to permit integration of new technologies as they emerge.
Common challenges encountered in training include:
insufficient hands-on (practical) training due to a small case load
lack of focus on competency-based training
insufficient post-training follow-up and supportive supervision
lack of refresher courses
training centres not reflective of resources available at service delivery sites.
When facing some of these challenges, it may help to bear the following points in mind. While some participants acquire new knowledge and skills quickly, others may need additional time. Extension of practical training beyond the training course can be arranged by having experienced providers take on trainees as apprentices at their facilities on a weekly or rotational basis after they have completed the basic course. It is crucial to ensure that all providers are confident in their ability to provide the service to the established standard before they commence service provision. Post-training supervision, the use of job aids, algorithms and other relevant learning tools to reinforce quality performance should be built into the training plan and subsequent programme management.
f. Other components that must be in place for efficient and safe service delivery
Procurement and maintenance of equipment and supplies
The needs assessment during the planning and preparation phase will provide vital information about the essential equipment and supplies that need to be procured. Strategies for distributing and storing equipment and for regular replenishment of supplies (including consumables, spare parts and reagents) must be established. In addition, an efficient local system for repair and maintenance will be needed, in order to avoid interruption of services or the need to reschedule patients due to broken or malfunctioning equipment. Such interruption of service may discourage clients from returning, and may damage the image of the service quality for actual or potential patients.
An infection prevention strategy
Proper management of medical waste items and decontamination and sterilization of reusable equipment is necessary to minimize the spread of infection and harm to clinic personnel, patients and the local community (see Annex 3).
The strategy should provide clear instructions on the following points:
proper management of medical waste, including sorting, transportation and disposal;
a system for disposal of used vials and syringes used for HPV vaccination (see
Practice Sheet 4.4 for the essential elements of injection safety for quality services);
processing of contaminated reusable equipment according to international standards, including decontamination with a bleach solution, rinsing and washing, high-level disinfection or sterilization; and
use of proper protective gear by health-care staff responsible for the management of contaminated waste and/or reusable equipment, including protective clothes, heavy gloves and masks if necessary.
A national reference laboratory
This will be necessary for quality assurance and quality control when HPV tests are introduced in a programme.
The checklist in Practice Sheet 2.1 may be helpful in planning and implementing the cervical cancer control programme. Also, please consult the list of further reading at the end of this chapter for useful publications and websites containing up-to-date evidence-based information on strategic approaches to programme planning and implementation.
2.2.4. Programme monitoring and evaluation
Monitoring and evaluation (M&E) in any health programme is conducted to ensure that the processes and systems are developed and adhered to in such a way that the deliverables are of good quality and maximize the benefits to the target population. The key indicators to use for M&E for a cervical cancer prevention and control programme can be found in the WHO/PAHO 2013 publication Monitoring national cervical cancer prevention and control programmes: quality control and quality assurance for visual inspection with acetic acid (VIA)-based programmes.5
Stakeholders should be involved from the strategic planning stage to ensure that the necessary results will be obtained from the programme and that appropriate corrective measures will be applied as needed. Basic health information systems, either manual (using records and registers), computerized or a combination of both, should be put in place and the data required for M&E should be collected regularly.
Cancer registries are important tools for collecting information on cancer cases and deaths. These data can be analysed to obtain information on the occurrence and trends of cancer in a defined population and to assess the impact of the cervical cancer prevention and control programme. If it is too difficult initially to implement cancer registries across the entire country, sentinel sites representative of different populations can be established and, as lessons are learnt, can be modified and scaled up until there is nationwide coverage. For more information on cancer registration, consult the website of the Global Initiative for Cancer Registry Development (GICR) of the International Agency for Research on Cancer (IARC).6
a. Monitoring
According to the WHO Health Systems Strengthening Glossary,7 monitoring is the continuous oversight of an activity to assist in its supervision and to see that it proceeds according to plan. It involves the specification of methods to measure activity, use of resources, and response to services against agreed criteria.
Monitoring with appropriate corrective action requires a functioning system for gathering, storing and disseminating health information, a supervisory system to ensure adherence to standards, participatory and continuous quality improvement, and local problem-solving methods implemented with the involvement of providers and community members. This sub-section provides further details on health information systems, suggests tools for self-assessment and local problem-solving, and gives information on supportive supervision used for cervical cancer prevention.
Two specific activities in a cervical cancer prevention and control programme that rely heavily on monitoring are continuous quality improvement of service provision and monitoring adverse events following immunization (AEFIs) (see Chapter 4 and Practice Sheet 4.6 for specific issues related to M&E for an HPV vaccination programme).
Continuous quality improvement of service provision should be carried out periodically with remedial action instituted in a timely manner. Improving quality is a responsibility of all staff and should involve all cadres. Methods that can be adapted and used to monitor and improve the quality of services are:
b. Evaluation
Evaluation is defined by the WHO Health Systems Strengthening Glossary as the systematic and objective assessment of the relevance, adequacy, progress, efficiency, effectiveness and impact of a course of actions, in relation to objectives and taking into account the resources and facilities that have been deployed.
An evaluation plan, developed with the active participation of stakeholders, needs to define the following:
the person or persons in the multidisciplinary management teams who will be responsible for evaluating the services;
the resources and services that will be evaluated and the methods of the evaluation;
the data that will be collected, and the definition of the key performance and impact indicators for cervical cancer prevention and control (see
Practice Sheet 2.2 for the key indicators);
the manner in which corrective action will be taken wherever gaps are detected; and
the budget for implementing the evaluation.
c. Core indicators
Core indicators to use for monitoring and evaluating services of a comprehensive cervical cancer prevention and control programme include performance and impact indicators. The core indicators are those that every country is strongly encouraged to adopt, as they provide fundamental information for monitoring and evaluating programme progress and impact as well as global information for intra- and intercountry comparisons (for examples, see Chapter 1, section 1.1.2, which presents data on the global epidemiology of cervical cancer).
Performance indicators for HPV vaccination
Performance indicators for cervical cancer screening and treatment
Coverage of the target population:
percentage of women aged 30–49 years who have been screened at least once since age 30 (this can be assessed using a survey of women aged 30–49 years that includes a question about whether they have been screened at least once)
percentage of women aged 30–49 years who have been screened that year (information can be obtained from service logbooks, taking care to disaggregate first screen from repeat screen)
Note: For both of the above indicators, the denominator is the number of women in the population aged 30–49 years, and it is important to disaggregate the data in five-year groups.
Screening test positivity: percentage of screened women aged 30–49 years with a positive result in the previous 12-month period (information can be obtained from logbooks)
Treatment rate: percentage of screen-positive women completing appropriate treatment for pre-cancer and treatment for invasive cancer in the previous 12-month period (information can be obtained from logbooks).
Impact indicator
Refer to Practice Sheet 2.2 for the definitions of the core performance and impact indicators, the methods of calculation and the cut-off level for instituting corrective action (other indicators are also described in the same practice sheet).
For more information, refer to the WHO/PAHO document Monitoring national cervical cancer prevention and control programmes: quality control and quality assurance for visual inspection with acetic acid (VIA)-based programmes (2013). 9
2.3. Achieving cervical cancer prevention and control
Cervical cancer prevention and control can be achieved if:
a national policy and national guidelines on cervical cancer control are developed and disseminated, based on the natural history of the disease and data about the prevalence and incidence in different age groups;
financial and technical resources are allocated to support the implementation of the policy and guidelines, making services accessible and affordable to women and girls;
public education programmes and advocacy for prevention are in place to support the national policy;
women and girls in the target age groups participate widely in screening and HPV vaccination;
HPV vaccine is administered as a population-based strategy to adolescent girls between the ages of 9 and 13 years;
screening is organized, rather than opportunistic;
screening services are linked to treatment of pre-cancer and invasive cancer;
a health management information system and a monitoring and evaluation plan are in place to monitor achievements, identify gaps and provide feedback regularly to managers and health-care providers, such that appropriate corrective action can be implemented in a timely manner;
a functioning referral system is established and maintained; and
an overall strengthened health system is in place.
Further reading
Useful websites
International Agency for Research on Cancer (IARC) – Global Initiative for Cancer Registry Development (GICR):
http://gicr.iarc.fr.
