by Rakshika Bhana, Programme Manager
The Cervical Cancer Prevention, Access and Control (CCPAC) Programme funded by the Bristol Meyers Squibb Foundation (BMSF) aims to identify and explore barriers and facilitators to policy and programme implementation, and to design evidence-informed interventions for improving cervical cancer treatment and care in the Zululand District in KwaZulu-Natal (KZN).
The project is led by a consortium of partners comprising the Health Systems Trust (HST), the Cancer & Infectious Diseases Epidemiology Research Unit (CIDERU) of the University of KwaZulu-Natal (UKZN), Genius Quality (GQ), and the Zululand Department of Health (ZDoH).
This three-year project forms part of the BMSF Global Cancer Disparities Africa (GCDA) programme to build knowledge on focal cancers, and to create awareness and understanding of care and support pathways in different cultural and resource settings. The cancers of focus under the GCDA programme include lung, cervical, paediatric cancers and blood disorders, and multiple myeloma. The countries currently implementing the programme are Eswathini, Ethiopia, Lesotho, Kenya, South Africa, Tanzania and Zimbabwe (Figure 1).[1]
Embedded within a health systems strengthening approach and informed by a defined theory of change model, the GCDA programme's investment areas include: health infrastructure, resourcing cancer units, human resource and capacity-building, outreach, education and awareness, cancer care service delivery, transport and funding for treatment access, and research and documentation.1
HST's CCPAC Project is implemented at community, sub-district and district levels, using a phased implementation approach. Service delivery is directed at HIV-positive women, and guided by the population and scale of need which is assessed via stakeholder engagements, baseline and post-intervention assessments ‒ including a knowledge, attitudes and perceptions (KAP) survey. The project focuses on implementing evidence-based interventions for: education and awareness; building on and harnessing existing resources for cervical cancer early diagnosis and prevention; community and stakeholder involvement; strengthening health system structures; healthcare worker capacity-building, and integration with existing Primary Health Care services to support sustainability beyond the programme's lifespan.
BMSF hosted their Global Cancer Disparities Africa Learning and Sharing Meeting from 4 to 7 November 2024 in Cape Town, which was attended by members of the HST Health Systems Strengthening (HSS) and Research and Implementation Science (RIS) Units. HST was invited to present on the CCPAC programme's health systems strengthening spotlights and lessons learnt over the implementation period. Figure 2 outlines the CCPAC health systems strengthening approach. The key findings of 2023 South African Health Review (which focused on strengthening cancer services within the South African healthcare system) were also presented and well received.
Figure 2: CCPAC systems strengthening approach
Health systems strengthening ‒ CCPAC project spotlights
The project has helped to achieve increased and sustained improvement in the Pap smear adequacy rates for Zululand District through targeted capacity-building interventions for clinicians at community and facility level. The district's Pap smear adequacy rates rank as the highest in KZN from December 2022 to date.
To reach under-screened populations, the project has delivered targeted cervical cancer screening services at community level to improve access for early screening. This is achieved through two mobile clinics, customised for delivery of cervical cancer screening services within communities. The mobile team comprises a Nurse Clinician and a Driver Mobiliser.
The cervical cancer screening coverage rate for Zululand ranks the highest in the country, as reported in the District Health Information System (DHIS) for 2023/24.
The CCPAC mobile unit with its tailor-made bed for gynaecological examination.
Lessons learnt
Continuous quality improvement and change management strategies should be adopted for sustained clinical outcomes in priority programmes.
A systems approach should be adopted in the provision of technical support and monitoring the implementation of the cervical cancer treatment cascade.
Mentorship and coaching of facility staff on continuous quality improvement strategies is central to ensuring ownership and sustainability of interventions.
The CCPAC mobile clinic demonstration project highlights the need for integration of services rendered at community level for women.
Regular and proactive screening of all eligible women including women living with HIV (WLHIV) is required as part of their comprehensive and holistic treatment plan.
Raising awareness about early cervical cancer screening at both facility and community levels empowers women to be more proactive in seeking screening services.
Capacity-strengthening on cervical cancer screening is required for healthcare cadres across priority health programmes.
Recommendations
The National Indicator Data Set (NIDS) should be reviewed to include indicators for monitoring the cervical cancer treatment cascade.
Sharing lessons and good practices across districts for scaling up focused interventions towards meeting the World Health Organization's cervical cancer elimination targets for 2030 can be conducted by using existing platforms and developing relevant networks.
To inform evidence-based cervical cancer services, capacity-building models for undertaking implementation science research should be applied.
Culturally relevant communications approaches should be used to increase and sustain efforts to raise awareness of cervical cancer screening among under-screened populations.
Human papillomavirus (HPV) vaccination campaigns can be leveraged as an opportunity to educate young women about comprehensive cervical cancer prevention, including the need for regular screening.
Quality improvement processes should be implemented at various levels to address barriers in the cervical cancer prevention and treatment programme.
For more information on the CCPAC Programme, please email hst@hst.org.za or communications@hst.org.za
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[1] Global Cancer Disparities Africa Programme: Catalyzing sustainable responses to cancer. Bristol Meyers Squibb Foundation. September 2024.