Liberia makes a leap in cervical cancer control by establishing screening centres in public health facilities
After years of conflict, Liberia’s health system faces a vast array of challenges. The Ebola outbreak has had a devastating effect on the population’s health. Consequently, efforts to address other essential services and public health concerns, including the growing cancer burden, have significantly lagged behind.
It is estimated that over 3500 women in Liberia died of cervical cancer in 2020, accounting for almost one in three of all female cancer deaths, followed by breast cancer which claimed one in five cancer deaths. Approximately 118 000 new cases were diagnosed in the same year with an age-standardized rate of 40.8 per 100 000 women. WHO’s Cervical Cancer Elimination Strategy provides the basis for accelerating action in Liberia. Human papillomavirus (HPV) vaccinations were introduced within the national immunization programme with limited coverage; 42% and 18% for first and second doses, respectively, with support from Gavi, the Vaccine Alliance (Gavi), focusing only on nine-year-old girls. For secondary prevention, national screening programs have yet to be established, leading to missed cases and late detection. Further, management and supportive care has been negatively affected by shortages in radiotherapy, commodities and shortages in staff, including surgeons. The International Atomic Energy Agency (IAEA) mission in 2018 drew attention to the urgent need to rebuild and train Liberia’s much-depleted health workforce following the Ebola crisis.
The National Cancer Control Policy (NCCP) was developed in 2018 by the Ministry of Health with support of WHO and other technical partners. WHO has responded through its technical expertise by introducing a cost-effective comprehensive training to provide screening services in two centres established in two different catchment areas. This was followed by the introduction of HPV vaccines into the national programme in 2019.
However, resources to establish the basis for screening is a requirement to save lives and to achieve the goal of the WHO Global strategy to accelerate the elimination of cervical cancer as a public health problem worldwide by 2030. In 2021, WHO supported the Liberian Ministry of Health with funding and technical support to organize a three-phase pilot project that trained national trainers and service providers in cervical cancer screening and to set up pilot centres in two geographical zones out of five areas in Liberia (Redemption Hospital, Montserrado County and Phebe Hospital in Bong County). The project focused on comprehensive quality services for early detection and treatment of precancerous lesions.
An integrated health system-based approach was used to introduce health staff to a screening and treatment technique associated to cervical and breast examination for early detection of cancers, its equipment and safe use. A national training and service provision manual was developed which was used for clinical on-the-job training that took place in secondary care settings for three days and covered 20 medical staff, nurses and paramedical staff. This was followed by training on data collection and monitoring and evaluation without causing extra burden to medical staff. It is anticipated that the resulting data would be used in decision making and for monitoring purposes. In addition, part of the training enables the health facilities and environment to offer the services required. Two national senior consultants were trained as trainers to support the scale up in the future. As part of the continuum of care, 12 community health assistants were trained to be able to provide the necessary sensitization and awareness aiming to empower women. Furthermore, the training module will be included in pre-service curriculum at the University of Liberia and the School of Midwifery.
The model was established to reach 140 000 women of reproductive age and enroll 15 000 women in 2022. From total visits since December 2021, seven women have been diagnosed with cervical cancer while three women have precancerous lesions and have received treatment. Three women were detected as having stage IV cancer and were referred to a specialist hospital for treatment.
A monitoring system will be put in place as part of the series of activities by the government to follow up with community awareness activities to ensure optimal impact of the training on staff knowledge. Even though the government is planning to reach all 15 counties over the next three years, the focus currently is on prioritizing the full setup of the screening and treatment centres in the two counties before moving to other regions of the country.
A health system-based approach to pilot the introduction of a screening service could be a successful model even in areas with no experience and low resources. Developing a comprehensive cervical cancer training module was instrumental in achieving the desired results of increased awareness, early detection, and saved lives.
Photo Credit: © Ministry of Health, Liberia