Scaling Up of Cervical Cancer Screening at Primary Health Care Level in Rwanda

Background: Rwanda is a high cervical cancer-burden country, with an age standardized rate (ASR) of cervical cancer incidence of 41.8 cases per 100,000 people in 2012. In the same year, cervical cancer mortality lay at 26.2 deaths per 100,000 people. Aim: To address this burden, Rwanda initiated the vision inspection with acetic acid (VIA) screening-based strategy in 2013 in line with WHO recommendations for low- and middle-income countries. The target audience of the program was set for women between the ages of 30 and 49 and remains today. Here, we describe the implementation status of the program at the primary health care level; health centers and district hospitals in Rwanda. Methods: Integrating into Rwanda's existing health system, the program was purposefully rooted in health centers, with a pathway designed for women who screen positive to be referred to the district hospital for cryotherapy or LEEP, according to the lesions' size. Nurses, midwives and medical officers from health centers and district hospitals are trained through a 10-day curriculum (5 days for theory and 5 days for practice) before initiating the provision of services to clients in routine care. Monitoring of the program is conducted through both quarterly, on-site mentorship and screening indicators that are integrated into Rwanda's Health Management Information System (HMIS), through which facilities report on monthly basis. Results: Since its initiation in August 2013, Rwanda's cervical cancer screening program has been established in 21 of 38 (55%) district hospitals and 256 health centers in their catchment area. Training has been an integral component as well, with at least two nurses/midwives trained at implementing health centers and a medical officer with two nurses/midwives trained on cervical cancer screening and the treatment of precancerous lesions at district hospital. In addition, district hospitals have been equipped with cryotherapy, LEEP, and colposcopy machines. Over this program's implementation three-and-a-half-year course, 38,000 women have been screened for cervical cancer. Conclusion: Using a simple VIA-based strategy, Rwanda has been able to swiftly and effectively increase the number of health facilities implementing cervical cancer screening program. Though additional innovative implementation strategies are still needed to proportionally increase women's screening coverage, these initial steps hold great promise in Rwanda's ability to effectively implement a sustainable cervical cancer screening program.