FEDERAL MINISTRY OF HEALTH

NATIONAL STRATEGIC PLAN

PREVENTION AND CONTROL OF CANCER OF THE CERVIX IN NIGERIA

FOR

2017-2021

National Strategic

Plan for Prevention

and Control of Cancer

of the Cervix in

Nigeria

2017 -2021

1

PREFACE

2

ACKNOWLEGEMENTS

3

TABLE OF CONTENTS

4

Preface .........................................................................................................................................................................2

Acknowlegements....................................................................................................................................................3

Table of Contents......................................................................................................................................................4

List of Acronyms......................................................................................................................................................5

1.0 Introduction.........................................................................................................................................................6

1.0 Current Situation in Nigeria..........................................................................................................................8

2.1 Burden of Cervical Cancer in Nigeria........................................................................................................8

National Response....................................................................................................................................................9

2.2.1 Primary Prevention.....................................................................................................................................9

2.2.1 Secondary Prevention..................................................................................................................................9

2.2.3 Tertiary Care.................................................................................................................................................10

1.0 Vision; Goaland Specific Objectives.......................................................................................................12

4.0 Strategic Approaches....................................................................................................................................13

4.1 HPV Mass Immunization Campaigns.....................................................................................................13

4.2 'screen and Treat' Approach......................................................................................................................13

4.3 Establishing and Maintaining a Treatment Referral Network.................................................... 14

4.4 Palliative Care...................................................................................................................................................14

4.5 Mass Mobilization...........................................................................................................................................14

4.6 Monitoring and Evaluation ........................................................................................................................14

4.7 Capacity Building.............................................................................................................................................15

4.8 Mobilization Of Resources.........................................................................................................................15

5.0 Road Map For Cervical Cancer Prevention And Control In Nigeria...........................................16

6.0 Monitoring & Evaluation .............................................................................................................................25

6.0 Monitoring And Evaluation Framework................................................................................................27

7.0 References..........................................................................................................................................................29

LIST OF ACRONYMS

5

1.0 INTRODUCTIONCervical Cancer is the leading cause of cancer mortality among women . In 2012, there were 528,000 new cases and 266,000 deaths worldwide. In the same year, there were 92,400 new cases and 56,600 deaths in the African Region alone. It is estimated that if the current situation continues, there would be 135,000 new cases of cervical cancer and 83,000 deathsin Africa by 2030(1, 2).

The high burden of cervical cancer and resultant huge number of deaths occurring in womenin the African Region has been attributed to poor access to effective screening and identification of precancerous lesions, latepresentation in the health facilities and inadequate treatment services. The inequity in access to services have been attributed to competing health care priorities, insufficient financial resources, weak health systems, and limited numbers of trained providers(2).

The WHO comprehensive approach to cervical cancer prevention and control over the life course provided an overview of programmatic interventions under three interdependent components: primary, secondary and tertiary prevention (Figure 1). The core principle of a comprehensive approach to cervical cancer prevention and control is to act across the life course using the natural history of the disease to identify opportunities in relevant age groups to deliver effective interventions

The public health goal of primary prevention is to reduce HPV infections, because persistent HPV infections can cause cervical cancer. Secondary prevention: screening for and treating pre-cancerous lesions aims at decreasing the incidence and prevalence of cervical cancer and the associated mortality, by intercepting the progress from pre-cancer to invasive cancer, whilst tertiary prevention: treatment of invasive cervical cancer has the goal of decreasing the number of deaths due to cervical cancer (3).

The World Health Organization recommends a comprehensive multidisciplinary approach to cervical cancer prevention and control at the national level. The approach is made up of several key components ranging from community education, social mobilization, vaccination, screening, and treatment to palliative care. Involvement of various disciplines and national health programmes

second most common cancer in women globally and thein developing countries

Cervical cancer prevention and control programmes situates well under the Sustainable Development Goals 3 and 5; ensuring healthy lives and promoting wellbeing of all ages and achieving gender equality and empowering all women and girls. The two goals contribute by ensuring universal access to sexual and reproductive health services to improve women's health. In addition, the updated UN Secretary-General's Global Strategy for Women and Children's Health and the 2011 “Political Declaration of the High-level Meeting of the UN General Assembly on the Prevention and Control of Non-communicable Diseases” as well as the “comprehensive global monitoring framework” under development include key indicators, and a set of global targets for the prevention and control of non-communicable diseases including cervical cancer (2, 3).

Furthermore,W.H.O has developed several guidance documents that givebroad vision of what a comprehensive approach to cervical cancer prevention and control means. The documents outline complementary strategies for comprehensive cervical cancer prevention and control, and highlight the need for collaboration across programmes, organizations, and partners. They also emphasize the core principle of a comprehensive approach to cervical cancer prevention and control which is to act across the life course using the natural history of the disease to identify opportunities in relevant age groups to deliver effective interventions.

6

such as immunization, reproductive health, cancer control and adolescent health are very significant for the success of the programme.

7

1.0 CURRENT SITUATION IN NIGERIA2.1 Burden of Cervical Cancer in NigeriaCancer of the cervix is the commonest cancer in women globally and leading cause of cancer mortality in Nigeria. With a total population of about 170 million people, Nigeria has about 40 million women aged 15 years and older who are at risk of developing cervical cancer.Available data indicate that the incidence of cervical cancer in Nigeria is about 33/100,000 and an estimated 14,089 are diagnosed every year, eight out of every ten of them presenting at an advance stage with mortality rate of about 25%.Nigeria is responsible for about 50% of new cases and deaths from cervical cancer in West Africa. The majority of women with cervical cancer die in an undignified and painful manner after many months of ill health characterised by intractable pain, urinary or faecal incontinence, and severe anaemia among others. Late presentation at the health facility is responsible for the death of about 8,000 women from cancer of the cervix annually in Nigeria. If this trend continues, annual number of cases of cancer of the cervix and deaths from the condition could rise to 19,000 and 15,000 respectively by 2025(4).

Current research has revealed that most cases of cancer of the cervix are caused by the Human Papilloma Virus (HPV). Currently In Nigeria, about 3.5% of women in the general population are estimated to harbour cervical HPV-16/18 infection at a given time, and 70% of invasive cervical cancers are attributed to HPVs 16 or 18 (5).This is a very common sexually transmitted infection which occurs in young girls within two years of sexual debut. In most cases the infection is cleared by natural body immunity, but some persist, leading to development of abnormal cells in the cervix that could over time transform into cancerous cells. Available data on the sexual and reproductive behaviour patterns of young people in Nigeria have shown that early onset of sexual activity and early marriages are highly prevalent as evidenced by the median age at first sexual intercourse at 17.6 years for women and 21.1 years for men age 25-49, with wide variation between zones, with the lowest of 15.4 and 16.2 respectively in the North East and North West respectively. The most notable pattern is the increasing median age with increasing education among women. The median age rises steadily from 15.6 years among women with no education and those in the lowest wealth quintile(6).

Capacity for prevention, early detection, diagnosis and treatment of precancerous and cancerous lesions of the cervix in Nigeria is weak. There is currently no national immunization programme for HPV and the screening campaigns are currently conducted mainly by individuals and community based organizations.

Although tertiary care takes place in tertiary facilities, NGOs facilities and private facilities all over the country, available services are grossly inadequate. PAP smear, colposcopy and histopathology services essential for diagnosis of cervical cancer are only available in some tertiary facilities and most clinics are not equipped to do Biopsy because required equipment are not readily available. Average waiting time for histology report can be up to 3weeks to months and ancillary investigations for complete work up of suspected cancer cases are not readily available in most hospitals

Electrosurgical excision procedures such as LEEP)/LLETZ (Large loop excision of transformation zone) and cold coagulation are only available in few centers. In addition only few centers have the capacity to perform trachelectomy, radical hysterectomy and pelvic exenteration.

Radiotherapy is only available in 10 centers all over the federation with only two machines functioning at any given time. Most of the cobalt machines are more than 15years old and no longer functioning optimally.

8

Palliative care need awareness came into Nigeria with the HIV epidemic and increasing prevalence of cancer. With late presentation and diagnosis of cancer cases, research evidence suggests that these patients need palliative care. Palliative care is a holistic care and an approach to care given to persons with life limiting disease that focuses on pain and symptom control for patients and family support throughout the course of illness until death and even in their bereavement. Available data indicate that each year about 181,600 Nigerians die in pain, while opioid consumption from 2008-2010 was2.6kg, enough to treat only 266 people. This translates to only average opioid coverage rate was 0.2% during the period(7).

Nigeria developed a National Cancer Control Policy in 2008 to provide strategic direction for the national programme. It includes guidance on how to increase awareness on cancer of the cervix screening and prevention, training of health care providers, vaccination against Human Papilloma Virus, treatment of pre-cancerous lesions as well as monitoring and evaluation. It also defines roles and responsibilities of stakeholders and steps for integrating cancer of the cervix prevention into reproductive health services at primary health care level.Despite, this effort, implementation of the policy has at best been sporadic and limited to hospitals and research settings. This is mainly due to factors such as inadequate public awareness of the problem, lack of capacity for population screening and preventive programmes, limited access to treatment for advance conditions, inadequate financial and policy support.

Primary prevention of cancer of the cervix through awareness creation, health promotion and vaccination with HPV vaccine has been very limited in Nigeria. Although Nigeria has approved the two available prophylactic vaccines for the prevention of HPV infections, there is currently no immunization programme for HPV in Nigeria. Both bivalent and quadrivalent vaccines are approved for use and are only provided on request from some private secondary and tertiary institutions. The bivalent vaccine is effective against HPV 16 and 18, the strains that cause 70% of all cervical cancer cases worldwide while the quadrivalent vaccine on the other hand has an added advantage over the bivalent vaccine with demonstrated efficacy against HPV6, 11, 16 and 18 that cause 90% of all genital warts cases. The vaccines are targeted at girls 9-15 years, using 3 doses over 6 months (at 0, 1 and 6 months).The delivery strategies recommended include School Based, Health Centre Based, and Outreach /community options. The government is engaging pharmaceutical companies to reduce the cost of the vaccine and continue to evaluate and endorse other vaccines available for prevention of cancer of the cervix for use in Nigeria.

Nigeria is currently in the process of introducing HPV vaccination in the country to protect women against developing cervical cancer. The Global Alliance for Vaccine and Immunization (GAVI) are supporting developing countries to introduce the vaccine in the country following a successful implementation of a demonstration/pilot project amongst an eligible 20,000 population of girls aged 9 to 13 years. Countries are expected to select at least 2 districts (LGAs) in the country representing the two major regions of the country namely Northern and Southern zones.

Secondary prevention through screening for precancerous lesions and early diagnosis followed by adequate treatment is also being promoted in Nigeria, but largely currently implemented by individuals, institutions and community based organizations without a national programme. The visual inspection with acetic acid/lugos are non-invasive, cheap, simple and easy to conduct, requires very little expertise and no sophisticated equipment. Above all, it provides instant result

NATIONAL RESPONSE

2.2.1 PRIMARY PREVENTION

2.2.1 SECONDARY PREVENTION

9

which can be interpreted on the spot. The cryotherapy component offers opportunity for instant treatment of pre-cancerous lesions after confirmationthus, fulfilling the “see & treat” strategy. This public health approach will enhance capacity of the primary health care system to detect and support treatment of cancer of the cervix early. Capacities of different cadres of health care providers and NGOs have been built to implement the visual inspection and cryotherapy strategy.

There are multiple opportunities to integrate cervical cancer prevention and control into existing health care delivery systems, such as reproductive health and HIV/AIDS programmes. National cervical cancer prevention and control programmes offer a model for collaboration among several programmes, including reproductive health, NCD and cancer, immunization and adolescent health. These national programmes could thus catalyse changes in the planning and delivery of health care, supporting a transition from vertical approaches to horizontal systems.

Integration of cervical cancer prevention activities into other sexual and reproductive health programmes in order to improve coverage has proved to be more complex than expected. Experience with integration has been mixed, not enough is known about how integrated interventions can best be configured and what effect they have on prevention of infections, cancer of the cervix and women's health in general. This is basically due to the inadequate funding of cervical cancer prevention programme resulting in paucity of data, lack of programmatic experience and local lessons learned from research and policy actions.

Government continues to upgrade Hospitals and provide equipment such as, Mammography machines, Colposcopes, MRIs, linear Accelerators and other radiotherapy equipment. In addition, several staff are currently undergoing training in cancer radiotherapy and cancer Registry respectively.

Federal Government plans to establish in the next 8 years, 10 new Radiotherapy/Nuclear medicine facilities across the country. While technical partnership with IAEA is continuing, the Federal Ministry of Health is engaging other partners towards successful cancer prevention efforts in Nigeria.

Palliative care has been recognized as an important aspect of cancer control in Nigeria and was contained in the Federal Ministry of Health Cancer Control Plan 2003-2008. Individuals, groups-Local and International Organizations have collaborated and worked with FMOH Cancer Control Unit to create awareness about Palliative care in Nigeria and establish enabling Laws and Policy to make Oral Morphine available and dispensed to Palliative patients in Nigeria. Noteable groups in the collaborative process include: Centre for Palliative Care Nigeria (CPCN) Ibadan, Oyo State; Hospice and Palliative Care Association of Nigeria (HPCAN); Hospice Uganda; African Palliative Care Association (APCA); Treat the Pain.org Group, etc.

Palliative Care is at infancy stage in Nigeria compared to Eastern/Southern Africa regions. Although Nigeria is the most populous country in Africa, the palliative care access is far from adequate but some progress has been made. There has been increasing awareness among health professionals especially those involved in HIV and Cancer care and pain management on the need for palliative care for Nigerian patients with life limiting diseases. Notable results include increasing number of emerging sites of palliative care across the country and availability of morphine for pain management.

2.2.3 TERTIARY CARE

10

From only two known facilities in 2004, there is increasing awareness of palliative care needs and sites over the years in all the six geopolitical zones of the Federation(8). The sites are mainly in Southwest, North central and southeast geopolitical zones, few in the Northeast, North West and South-south zones. The sites are mostly located in tertiary health institutions, few established freelance NGOs and faith-based organizations. Viable ones are about 10 with only one paediatric hospice.

Services provided include: Hospital in-patient pain and other palliative care services in collaboration with the Primary Physician, Home-based care/visitation; and bereavement support; Day care and tele consultation through phones.

In hospitals, the services are provided by few volunteer Palliative Care trained multidisciplinary staff through team work. Except for the Nurses, all other groups do not offer fulltime services. Only UCH centre currently offers short certificate course in palliative care for healthcare providers, minimal research and advocacy activity.

The Federal Ministry of Health has madeMorphine available at Central Medical Stores Oshodi Lagos and encouraging institutions and states to collect.The number of tertiary Health care institutions and states Ministry of health collecting varying quantities of Morphine sulphate powder for compounding and distribution to the public have been increasing steadily since 2013.

11

1.0 VISION; GOALAND SPECIFIC OBJECTIVES

3.1 Vision3.2 Goal

To free Nigeria from the burden of cervical cancer-To reduce incidence, morbidity and mortality from cervical cancer by one-third from

2015 levels by 2020

3.3 Specific Objectives

3.3.1 To immunize 80% of girls 9-13years with HPV vaccine by 2020

3.3.2 To increase screening coverage of eligible women by 2020 by 80%

3.3.3 To provide adequate and effective treatment of precancerous lesions for 100% detected

cases

3.3.4 To establish an effective referral pathway across all levels of care

3.3.5 To ensure that all referred cases of cancerous lesions have access to prompt diagnosis and

that management is initiated within one week of presentation

3.3.6 To improve palliative care facilities

3.3.7 To ensure availability of quality data on cervical cancer programme

3.3.8 To ensure adequate and sustainabel funding for cervical cancer programs

12

4.0 STRATEGIC APPROACHES

4.1 HPV MASS IMMUNIZATION CAMPAIGNS

4.2 'SCREEN AND TREAT' APPROACH

The national strategy for the prevention and control of cancer of the cervix in Nigeria will utilize a

public health approach - employing a combination of vaccination, education, screening, treatment

and linkages with other sexual and reproductive health programmes.

HPV vaccination, a primary prevention approach will be targeted at girls 913 years of age in and out

of school. The immunization campaign will be conducted using mixed delivery strategies including

School Based, Health Centre Based, and Outreach /community based strategies targeting 9-13 year

old girls at primary schools and junior secondary school classes. Girls out of school will be identified

and reached in places such as their homes, on the street, in markets and other places they can be found

according to states peculiarities. The national programme will utilize lessons learned from ongoing

pilot project in the country to improve the programme and provide other health services and

information to the targeted age group.

Bivalent Vaccine and Quadrivalent vaccine which acts against HPV genotypes 6, 11, 16 and 18

responsible for over 90% of infections and with potential for cross protection from other strains are

recommended for use in Nigeria. They have safety profile similar to other EPI vaccines and the three

doses are delivered over 6 months (0, 1 and 6 months) for full protection. Because the vaccines do

not protect against all HPV types that can cause cervical cancer, girls vaccinated against HPV will

still require cervical cancer screening later in their lives.Immunocompromised individuals,

including those who are living with HIV, and females aged 15 years and older should also receive the

vaccine and need three doses (at 0, 115 years and older should also receive protected(2).

Early detection of asymptomatic precancerous lesions and prompt treatment can prevent the

majority of cervical cancers. In order to reach more women in the target age group, screening

services will be integrated into other sexual and reproductive health services including family

planning and HIV services. At a minimum, screening is recommended for every woman 3049 years

of age at least once in a life time and at an interval not less than 5 years. The national programme will

promote different types of screening tests currently available including: Visual inspection with

Acetic Acid (VIA),and HPV DNA testing.HPV DNA testing may be considered as a primary

screening method where feasible, and VIA/VILLI as a secondary test for those identified as HPV

positive through HPV testing. Otherwise use of VIA/VILLI will be encouraged at the primary health

care level.HPV DNA testing will occur at PHCs where the kits will be issued to,and received from

clients. VIA/ VILLI will be made available at PHC and secondary care levels.

Using a screening test that gives immediate results (like visual methods, VIA) followed by “on the

spot” treatment (e.g. using cryotherapy) of detected lesions, without any further tests unless a

suspected cancer is found is recommended for the public health approach to prevention of cervical

cancer. The visual inspection with acetic acid Acid/Lugol's Iodine (VIA/VILI) technique is sensitive

13

and can be implemented by PHC workers. It is non-invasive, cheaper, simple/easy to conduct,

requires very little expertise and no sophisticated equipment. Positive cases will be referred to

gynaecologist, who confirms and treats with cryotherapy, thus, fulfilling the “screening and treat”

strategy.In clinical settings, the treatment of choice for precancerous lesions is loop electrosurgical

excision procedure (LEEP) other techniques include cold knife conisation.

Cryotherapy will be available at primary, secondary and facilities. It will be provided by trained

nurses and midwivesý.LEEP will be made available at secondary care levelý, and will be done by

trained medical officers & gynaecologists where available HIV puts women with the virus at a

higher risk of having persistent HPV infections, and a higher risk of developing pre-cancer. They are

also more likely to develop cervical cancer earlier and to die from it sooner. They are advised to

follow a different screening schedule because most develop pre-cancer at a younger age and the time

for pre-cancer to progress to cancer can be shorter. Women living with HIV should be: re-screened

within three years after a negative screening test result. VIA, HPV test or cytology screening tests

can be used for women living with HIV and cryotherapy and loop electrosurgical excision procedure

(LEEP) can also be sued for treatments.

A national referral protocol and functioning communication system will be established at national

and state levels to ensure an effective referral system and overcome the challenge faced in the

provision of chemotherapy and radiotherapy. There will also be effective linkages to enable timely

access and continuity of care between health facilities, laboratory, diagnostic and referral treatment

centres for cervical cancer.

Government will continue to expand access to palliative care to ensure that patients with life-

threatening cervical cancer are provided with relief from pain and suffering (both physical and

psychological). Teams of health care providers including doctors, nurses, other specialists, and

community members will be trained to provide services and support palliative care in each state.

Nationwide awareness campaigns will be led by high level policy makers at the national and state

levels. Local Government Areas, the private sector including pharmaceutical companies and

hospitals are expected to collaborate to ensure that individuals, families and communities get

appropriate information, education and communication to increase community awareness about

cervical cancer prevention and control.

Monitoring and evaluation of progress of the objectives and targets set for prevention and control of

cancer of the cervix in Nigeria will be strengthened to ensure that quality data are available for

4.3 ESTABLISHING AND MAINTAINING A TREATMENT REFERRAL NETWORK

4.4 PALLIATIVE CARE

4.5 MASS MOBILIZATION

4.6 MONITORING AND EVALUATION

14

planning and monitoring of progress. As much as possible, national HMIS tools and mechanisms

will be utilized for cervical cancer data collection and analysis. Each level of government and

supporting stakeholders will play crucial roles in ensuring availability of essential data elements.

Essential impact indicators such as incidence and mortality of cervical cancer will be collected from

sentinel facilities and cancer registries to monitor long-term trends in disease incidence and

mortality rate. This will enable the country to assess the long-term impact of both HPV vaccination

and cervical cancer screening and treatment programmes.

Health care providers at all levels will be trained to competency in appropriate skill for prevention

and control of cancer of the cervix. Capacity for visual inspection and cryotherapy will be expanded

to cover majority of the primary health care centres in the country. More gyneacologist, oncologists,

radiotherapists, histolopathologist and laboratory technologists, oncology nurses, palliative care

specialists will be trained to ensure availability of teams to provide tertiary care in all states of the

federation.

he national and state programmes will embark on extensive resource mobilization drive to ensure

that funds are available for implementation of the strategy. Programme budget and funding gaps will

be determined at each level. Resource mobilization will be data driven and is expected to be

supported by stakeholders at international, regional, national, state, local government and

community levels.

4.7 CAPACITY BUILDING

4.8 MOBILIZATION OF RESOURCES

15

5.0 ROAD MAP FOR CERVICAL CANCER PREVENTION AND CONTROL IN NIGERIA

Objective Milestone Strategie

s

Outcome

indicators Activities Indicators

Verification

method

2016

2017

2018

2019

2020 Responsible

To immunize

80% of girls 9-

13years with HPV vaccine by 2020

2016: 2%

2018 : 30%

2019: 50% 2020: 80%

Immunization of

girls between the ages of 9-13

with the HPV

vaccine facility based- linked with

screening -

School based

vaccination

programme-

HPV coverage

rate

Create partnership with and undertake awareness creation for the use of HPV vaccine through the use of targeted IEC material and other social mobilization platforms( traditional rulers, social media, CBOs,NGOs,organising a walk, private sector)

IEC materials disseminated

Annual Records Reports

of Surveys

FMOH/ NPHCDA/ NGO/ Media/SMOH/MOI/MWA/NOA and other MDAs( including ALGON and Youths )

Partner with global organizations and others critical actors to work with manufacturers to reduce prices of HPV vaccine

% reduction in the price of HPV vaccines

FMOH/ PECA/ NPHCDA/CHAI

Integrate HPV into the routine immunization schedule and enlist the support of education and women affairs MDAs integrate schools and women groups into the immunization programmes.

% of states in which HPV vaccines has been introduced

State & Fed Education MDAs, LGA Health Depts, PECA,FMOH/NPHCDA

16

HPV house to

house vaccinati

on campaig

ns

Training of health care workers,auxilaries and volunteers on HPV delivery, handling and vaccination.

% planned HCW that have received training on HPV

State & Fed Education MDAs, LGA Health Depts, PECA,FMOH/NPHCDA

Secure donations and support to expand cold chain and delivery systems . Strengthening cold chain and delivery systems for HPV

% of LGA with cold chain equipment Average breakdown time for CCE % of HFs with stock out of HPV vaccines

FMOH/NPHCDA /UNICEF/ Private sector

Sensitize and vaccinate girls in schools and Organization of outreach sessions to vaccinate girls who do not attend schools .And partner with communication and mobile telephone companies to rebroadcast messages on cervical cancer vaccination.

% of planned outreach sessions conducted

State and Fed. MDAs in Education & Health,/NPHCDA /WHO /CSOs

Sexual and

reproductive

health education of girls

% of girls with

increased

knowledge of

HPV ( As

Partner with ministry of education to include cervical cancer prevention, education and vaccination of pupils in the school curriculum and programme

% of planned education centres using revised curriculum

State & Fed. MDAs in Education,FMOH/NPHCDA/MOE/CSO

17

defined by a pre and post

test )

sensitize parents and community leaders on importance of HPV Vaccination and Develop and disseminate health education material to communities and schools

% of states in which health education materials have been distributed

FMOH/NPHCDA/MOE/CSO

Mobilize resource

s from private sector, public sector

and donors to fund

HPV procure

ment and programs ensuring

fund transpar

ency

% increase

in funding for HPV related

programs

Develop advocacy material and lobby legislature, private sector, state governments etc. for increased funding for HPV related vaccines and programs

% change in funding from government in appropriation

CSOs/PECA/FMOH/ NPHCDA

Create a basket fund for HPV procurement and programs

Operationalized Basket fund

CSOs/PECA/FMOH/ NPHCDA

PARTNER with NCC to operationalize a Short code for donation and create online platforms to collect donations toward immunization of HPV Vaccines

Operationalized short code and online donation platforms

CSOs/PECA/FMOH/ NPHCDA

Develop M&E

systems to track

HPV vaccine

delivery,HPV

incidence

partner with the DPRS team of the FMOH to include HPV incidence tracking and immunization tracking into the NHMIS tool

HPV indicators included in the NHMIS

FMOH/NPHCDA/IHVN/CSOs/ CHAI

Produce biannual survey reports and undertake verification of HPV related data

number of surveys conducted

FMOH/NPHCDA/IHVN/CSOs/ CHAI

18

and HPV prevalen

ce

1stYr: 20%

2nd

Yr:40%

3rd r:60%

4thYr:70

5thYr:80%

Provide screening services at all levels

with emphasis on PHCs : Fixed and

mobile screening

% of eligible women

screened with

cervical screening test in the last

12 month period

%of PHCs

providing

screening

services

Baseline survey

Baseline survey conducted

Survey report

FMoH, SMoH, NPHCDA,Partners (CSOs),

donors, SPHCDA

Conduct sensitization and awareness campaign

Sensitization and awareness campaign conducted

Program report

Develop screening guidelines, SOPs and job aids

Screening guidelines, SOPs and job aids completed

Facility registers

Procurement and maintenance of equipment and supplies for screening : 40million HPV test kits, 7,000litres of 99.9% acetic acid, 42,000 sprayers, 7.2million specula, 8000 examination couches, 5 % of budget to cover consumables( gauze, stationary, torch light with LED bulbs)

% of equipment procured

HMIS forms

Training of 3 health workers per facility

Number of health care workers trained

Training Report

Establish mobile outreach teams

% of LGAs with at least one

To increase

screening coverage of eligible women by 2020 by 80%

19

mobile outreach team

% of detected cases that are treated 2020: 100%

Provide necessary drugs

and treatmen

t for precance

rous lesions

% of screen-positive women

with lesions eligible

for cryother

apy treated during

the same visit

% of

facilities that

provide treatme

nt for precance

rous lesions

Training of health workers

% of PHCs with trained providers

Facility reports

Develop treatment guidelines and manuals

Treatment guidelines created and disseminated

Procurement of equipment and materials: 17,000 Cryoguns and 30kg cylinders with connectors, consumables(CO2 gas)

% planned equipment procured

To provide adequate and effective treatment of precancerous lesions for 100% detected cases

To establish

an effective referral

Proportion of states

with referral

pathways

Establish a robust referral system

% of screen-positive women

with

Conduct service availability mapping

Service availability mapping conducted

Monthly reports

*

20

pathway across all levels of

care

for manageme

nt of cervical cancer

established

lesions not

eligible for

cryotherapy

referred to

colposcopy

% of patients that are

continually

tracked

Develop referral directory Referral directory developed

Develop referral guidelines and SOP

Referral guidelines and SOP created

Develop appointment system using appointment diaries etc.

Appointment system created

Identification and training of referral focal persons

List of referral focal persons available Training of referral focal persons

To ensure that all

referred cases of

cancerous lesions have

access to prompt

diagnosis and that

management is

% of cancer of cervix patients receiving treatment within 1 week

Provision of

necessary drugs

and treatmen

t for cancerous lesions

% of positive women

who receive treatme

nt

Training of relevant staff Staff trained

Provision of additional Facilities for diagnostic & treatment (surgery, Chemo, Radiotherapy & Palliative)

Number of additional diagnosis and treatment facilities

21

initiated within

one week of

presentation

Provision and dissemination of necessary equipment and drug

number of procured equipment and drugs

Creation and dissemination of treatment guidelines

disseminated treatment guideline

To improve palliative

care facilities

Proportion of tertiary facilities offering palliative care Ensure

the availabilit

y of palliative

care

% of cervicalc

ancer patients

that receive

palliative care

Develop a palliative care strategy in collaboration with HIV/AIDS, Sickle cell and other key programs

Pallaitive care strategy completed

Increase the number of palliative care centres

Number of palliative care centres

Expand access to palliative care drugs including morphine

% of cervical cancer patients that receive palliative care

To ensure availability of quality data on cervical cancer programme

Proportion of states contributing to the annual national cancer of the cervix

Establish tracking , follow up and feedback mechanism

Completion of a tracking system

Baseline data collection Conduct tracking and follow up using paper tools, Use of M-health technology and community resource persons

Establishment of a tracking system

DHIS?

22

programme report 2016: 30% 2017: 50% 2018: 80% 2019: 100% 2020: 100%

Ensure that there is adequate and sustainabel funding for cancer programs

% increase in the funding available for cancer of the cervix programme 2016-20% 2017-40% 2018-60% 2019-80% 2020-100%

Costing , resource mapping of cancer program

funding gap determined

conduct comprehensive costing of resources required for the procurement of cancer specific drugs, consumables, devices and program costs

Costing of required resources completed

Develop and implement sustainable financing strategy

% of funding from governement

Conduct a landscape analysis of available resources for cancer program

resource mapping completed

Conduct resource mobilization

develop advocacy tool advocacy tool developed

23

Conduct advocacy visits

advocay visits conducted

Develop sustainable financing strategy including the use of basket funds etc.

strategy developed

Implement developed strategy

strategy Implemented

24

The Monitoring and Evaluation process

Log frame

developed

Baseline and

targets set

Performance

reviews

conducted

Tracking sheet

and dashboard

developed

Key performance

indicators

determined

Data collection

An important component of this strategic plan is the monitoring and evaluation of progress of the

objectives and targets set for prevention and control of cancer of the cervix in Nigeria. The M&E

structure will be based on the following core principles:

ｷ Provision of data that meets the reporting requirements of the relevant stakeholders

ｷ Utilization of national tools and methods for data collection to ensure timeliness of reporting

ｷ Independent assessments of the M&E process, to reduce bias and provide an impartial

appraisal

ｷ Clearly defined roles and responsibilities for data collection, analysis, and usage to ensure

accountability

ｷ Data dissemination process that allows all stakeholders to easily access data and make

decisions based on the data

This sectionoutlines the monitoring and evaluation matrix including key outcome performance indicators; targets, timelines and means of verification. Essential impact indicators such as incidence and mortality of cervical cancer will be collected from sentinel facilities and cancer registries to monitor long-term trends in disease incidence and mortality rate. This will enable the country to assess the long-term impact of both HPV vaccination and cervical cancer screening and treatment programmes.

Step 1 Develop a log frame that outlines key objectives, outcomes, outputs, and activities for the

year: Log frame development is the first step in the performance management process; it will outline

key outcomes, objectives, outputs, and activities.

Step 2 Determine KPIs: Once the log frame has been completed, key performance indicators will be

set for all outcomes, outputs, and activities. Metrics should be measurable, specific, and relevant to

what is being measured.

6.0 MONITORING & EVALUATION

25

Step 3 Set baselines and targets for all indicators: Once metrics have been determined, baselines and

targets are to be set. Baselines should equate to values from the last month of the previous calendar

year, while targets should be ambitious but take into account baseline values.

Recommended process for monitoring and evaluation of cervical cancer prevention and control

process at all levels in Nigeria is as indicated in the schema below.

Step 4 Develop a tracking sheet and dashboard: Once baselines and targets have been determined,

the M&E group will create data tracking sheets and dashboards that will contain information such as

definition of data, who is responsible for collecting data, etc.

Step 5 Ongoing data collection: Data collection should be done monthlyusing the national NHMIS

tools and reported through the existing national framework. Data from sentinel sites and registries

will be forwarded directly to the National Cancer control programme in the Federal Ministry of

Health.

Step 6 Conduct performance reviews: Discussions on performance based on tracked metrics should

be institutionalised. These present an opportunity to discuss indicators that have seen improvements

and those that have not; clear action items should be identified during these meetings and deadlines

should be set for completion.

The federal team shall conduct quarterly supervision of the states, while the states are expected to

supervise the local governments on a quarterly basis. The local governments in turn are expected to

conduct supportive supervisory visits to each primary health care facility on a monthly basis.

Reports of supervisory visits should inform planning at all levels with adequate feedback given to all

facilities and institutions visited in the course of supervision.

Key programme indicators for primary, secondary and tertiary prevention within the cervical cancer

prevention and control approach are: Vaccination coverage, by year of age and by dose, screening

coverage, screening test positivity rate, and treatment rate, proportion of curable Cancer patients

who get adequate treatment and survival rates and opioid access for women with advanced cervical

cancer.

Baseline metrics for the national and state cancer of the cervix prevention and control programmes

would be collected to ascertain where we are at the inception of implementation of this strategy. This

will form basis for measurement of progress towards the set targets by 2020.

26

6.0 Monitoring and Evaluation Framework

Objective Indicator

Baseline Targets – derived from milestones Verification

Result

Year Source 2016 2017 2018 2019 2020

To immunize 80% of girls 9-13years with HPV vaccine by 2020

HPV coverage rate NA 2015 - 2% 5% 10% 30% 50%

Annual Records Reports of Surveys

To increase screening coverage of eligible women by 2020 by 80%

% of eligible women screened with cervical screening test in the last 12 month period

NA 2015 - 20% 40% 60% 70% 80% Program report Facility Records

To provide adequate and effective treatment of precancerous lesions for 100% detected cases

% of screen-positive women with lesions eligible for cryotherapy treated during the same visit NA 2015 - 100% 100% 100% 100%

100% Programme Report

To establish an effective referral pathway across all levels of care

Proportion of states with documented referral pathways

0 2015 FMOH 100% 100% 100% 100% 100% Programme Report

27

for management of cervical cancer established

To ensure that all referred cases of cancerous lesions have access to prompt diagnosis and that management is initiated within one week of presentation

% of cancer of cervix patients receiving treatment within 1 week

NA 2015 - 50% 80% 100% 100% 100% Programme Facility records

To improve palliative care facilities Proportion of tertiary facilities offering palliative care

20%

2015 FMOH 50% 80% 100% 100% 100% Facility Records

To ensure availability of quality data on cervical cancer programme

Proportion of states

contributing to the

annual national

cancer of the cervix

programme report

0% 2015 FMOH 50% 80% 100% 100% 1005 National Programme Annual Report

Ensure that there is adequate and sustainabel funding for cervical cancer programs

% increase in the funding available for cancer of the cervix programme

NA 2015 - 30% 40% 60% 80% 100%

Budgetary allocation Programme Report

28

7.0 References

1. National Cancer of the cervix control draft policy, Federal Ministry of Health Nigeria, 2006

2. WHO, Comprehensive cervical cancer control: a guide to essential practice 2nd ed,2014

3. WHO guidelines for treatment of cervical intraepithelial neoplasia 23 and adenocarcinoma

in situ: cryotherapy, large loop excision of

4. the transformation zone, and cold knife conization, 2014

5. WHO guidelines for screening and treatment of precancerous lesions for cervical cancer

prevention,2013.

6. Bruni L et al . ICO Information Centre on HPV and Cancer (HPV Information Centre).

Human Papillomavirus and Related Diseases in Nigeria. Summary Report 2015- 12-23.

7. National Demographic and Health Survey 20137. International Narcotics Control Board.

Dataset: Opioid consumption statistics 2007-2012. 2014

8. Olaitan A. Soyannwo; Palliative Care and Public Health, a Perspective from Nigeria

Journal of Public Health Policy Vol. 28, No. 1 (2007), pp. 56-58

29