Quick Facts

Cervical Cancer – Leading cause of cancer deaths in women and the 2nd most prevalent after Breast Cancer.

•  Kenya is one of Africa's highest CaCx burden countries, with an HPV prevalence of 39% (and 31.6% globally).
• Nine women die of cervical cancer every day.
• Six times higher risk of acquiring HPV amongst HIV +ve (immunocompromised) women.
• It's only cancer that is 100% preventable
• Extremely favourable prognosis if diagnosed and treated early.

Overall Goal

MOH/NCCP has aligned with the global WHO targets of 90:70:90, i.e., 90% HPV vaccination, 70% of women screened and 90% of screened +ve women treated. CHAI has been supporting MOH at both levels to realize these targets by having every eligible woman screened (at least 1.6M annually), every screened positive client to receive an accurate diagnosis and treatment (or linked to care) and subsequently to receive appropriate follow-up/care. All preferably in a single visit approach.

Actual Screen and Treat Cascade Yellow bars represent ideal situation). Source: KHIS

Problem

Limited access to screening, diagnosis, and linkage to care and treatment services in LMICs like Kenya increases the healthcare burden in an already constrained health system with limited resources. Baseline assessment results demonstrated considerable gaps in access and utilization of these services citing limitations in HR capacity, systemic and infrastructural inadequacies, supply chain challenges and demand generation limitations. This inevitably translates to higher morbidity and mortality rates for cancer that is 100% preventable, resulting from limited access to these critical services at the PHC level.  The National Cancer Control Program (NCCP) aims to reduce morbidity and mortality and increase the survival rate in Kenya by exploring interventions that promote access to prevention strategies, early detection, quality, accurate diagnosis, treatment, and palliative care services.

In collaboration with both levels of government (i.e., national and county) for policy and implementation, CHAI positioned itself to support MOH in realizing and achieving transformational impact in exploring these critical interventions to reduce morbidity and mortality.

1.      Service Delivery

Demand generation gaps existed at all levels of care as very few facilities employed the community strategy to raise awareness of the availability of these services. Few (12%) HCWs have ever been trained to offer CaCx S&T fewer (8%) deployed at the appropriate Service Delivery Point (SDP). This results in fewer facilities being able to provide these services limiting access to Screen and Treat (S&T) services. Inadequate supplies and consumables necessary and critical for screening (and treatment) services at the PHC level also inhibited eligible clients from getting the services they need, e.g., speculums and acetic acid completely lacking in almost all facilities rendering the provision of services impossible. In addition, very few facilities were equipped with appropriate and functional HPTs for S&T, i.e., the use of recommended white light for screening (41%) and cryotherapy (8%), thereby affecting the quality of screens and reducing access to treatment, respectively. Pathology services are almost non-existent in most counties as they rely on regional MOH facilities that offer pathology or private entities. As a result, issues of sample referral, costs of sample transportation and costs of testing become an impediment to accessing these services. Integration of CaCx services with FP in most PHC facilities has proven beneficial in accessing services. However, it was observed that facilities with a dedicated CaCx room and HCW (17%) reached more clients, especially for treatment.

2.      Supply Chain

Pre-CHAI HPV kits were unavailable in the public sector as limited quantities were available for research purposes by NGOs and research institutions. HPV testing has also just been adoted as the primary screening method by MOH. Almost all facilities lacked HPV and PAP kits, including all the other related consumables and reagents necessary for screening. In addition, there were also limited supplies for screening through VIA/VILI, i.e., acetic acid, speculums etc. This has resulted from issues with not ordering the required supplies, ad-hock ordering from KEMSA and orders. This is because none of the supplies has been listed in the KEMSA supply list for routine distribution alongside other supplies.

1.      Data and Data Use

Routinely CaCx data has been captured as an addendum on the FP registers, only recorded as "done" or "not done", and this was inadequate data to make any programmatic decisions as it missed critical data points. The assessment revealed only 19% of facilities were using updated registers; 45% had an alternative way to capture it (improvised registers), and 36% didn't have any reporting tools. Also, there was inconsistent use of routine data for planning and management. (Lack of processes and systems). In addition, limited coordination, training and standardization of data collection and reporting practices resulted in low-quality data. (Multiple Cervical cancer data collection tools existed/still exist). All these factors contributed to a low reporting rate (18%) on cervical cancer making it difficult to track critical indicators for progress.

Comparison reporting for CaCx services before transition (green) and after transition to using the new tools (red).

 2.      Health Financing

CaCx screening and treatment are not under any insurance scheme, thereby limiting access to these services by the majority. It was also evident that screening and treatment services are charged, especially in L4 and L5. Furthermore, additional costs related to pathology services are charged in the L5, L6 and private sector facilities (referral costs of samples and clients) and must be footed by the client. Most counties did not have a dedicated budget for procurement of screening supplies and consumable for facilties providing the service.

Solutions employed and progress to date

1.      Service Delivery

Capacity building and targeted training of clinical HCWs/SPs of various carders on CaCx screening and treatment at the different levels ensures quality service provision (TA, LEEP, LAB pieces of training, ongoing colposcopy). This was done as a cascade training through partnering with NCCP and County TOTs to implement the training and subsequently carry out follow-up and mentorships to ensure quality services are rendered. This has increased the training coverage, screening coverage and treatment coverage, thereby improving access to these services. Subsequently, distribution and placement of donated HTPs, i.e., TA, LEEP and Colposcopy devices, ensured efficient access and utilization as clients now can access treatment at various levels of care, unlike before. Training of institutions, e.g. KDF, to widen the scope of S&T to the armed forces and their families (by extension, the communities/civilian population served by these facilities). Also, the inclusion of the CaCx training into the KMTC curricular targeting pre-service HCWs through their lecturers.

Screening Coverage increasing from 23.7% (2019) to 42.7% (2022); Positivity rates remaining constant at 2% and treatment rates declining to 38% to 18% (Source, KHIS).

2.      Supply Chain

During the implementation phase of training, supply chain was the biggest challenge. HPV resource constraints resorted to implementing the project with VIA/VILI as the primary method in most facilities to ensure that eligible women access screening services. CHAI supplied commodities and supplies to facilities during and post-training to ensure continuity. In addition, advocating for counties' resources (including facilities) to procure additional supplies to complement donations. This was through local partners in the same space also contributing to support the counties ensuring critical supplies are constantly available. CHAI also offered technical assistance to counties for the quantification of commodities required, and MOH/NCCP has also been supplying different sites with items. Leveraging on counties with vital HIV initiatives for extra support from their partners as they procured commodities.

3.      Data and Data Use

Technical assistance in reviewing existing and developing new reporting tools. Mobilizing resources to print, disseminate and distribute the new updated tools. – joint effort from CHAI, NCCP and Partners through mobilization of resources. CaCx data has almost fully transitioned to the new reporting tools i.e., MOH 412 and MOH 745 previous tools being passed out. Reporting rates are still rising. Data points for reporting 412 and 745 on KHIS-2 have been implemented.

Integration with LMIS (inclusion of HPV) – HPV samples are now being reported on the LMIS (this is an integration with the VL/EID platform). Use of data for Analytics and decision making – training HCWs including HRIOs on data use, and monitoring and evaluation into clinical skills training for service providers has helped inculcate the importance of data use in making programtic decision that save lives. Partner mapping – Implementing partners are now working together to support DQAs and support supervision activities. Collaboration with development partners to sensitize and train HRIOs in all counties on the use of the new tools and data points on KHIS-2.

LMIS platform is up and running – HPV data is now recorded and relayed through this integrated system.

Sustainability Post – CHAI

• Continued resource mobilization to train and mentor more HCWs/SPs of different carders through county governments and partners – GF supporting MOH.
• Conversations with county governments in retaining HCWs post training at their respective SDPs to ensure continuity of services.
• Enforce the use of treatment directory to be in all facilities to facilitate better referrals and follow up (minimizing LTFU)
• Procurement of additional TA devices by other partners for more sites e.g., CIHEB, CHAK, USAID. These were accessed through the CHAI negotiated price. And informing the strategic placement of these devices in beneficiary counties
• Post Training mentorship of institutions: KDF, KMTC
• NCCP working with different stakeholders in advancing their objectives as the key partners continue to support the key areas like trainings, procurement, advocacy, demand generation etc.
• Inclusion of CaCx screen and treat commodities procurement into county budgets and national budgets
• Push for inclusion of CaCx commodities to be included on the KEMSA list
• Follow up and support as necessary GF and NASCOP plan to procure CaCx screening commodities
• F&Q will be included in the AWP for NCCP and counties
• Leverage partner and GOK resources to enhance pathology services.