The document summarizes Morocco's national program for cervical cancer prevention and control. It discusses (1) the magnitude of cervical cancer in Morocco, (2) the national framework and leadership under Princess Lalla Salma, (3) components of the program including screening, diagnosis, treatment, communication and information systems, (4) challenges in widespread screening and increasing participation, and (5) lessons learned and plans to mainstream and strengthen the integrated strategy.

1. Kingdom of Morocco ‫المملكة المغربية‬
WORKING MEETING ON COMPREHENSIVE
CERVICAL CANCER PREVENTION AND
CONTROL IN UNFPA EECARO AND ASRO
COUNTRIES
Antalya, Turkey 18-20 May 2011

2. MAGNITUDE AND BURDEN OF
CERVIVAL CANCER IN MOROCCO
• 30 000 new cancer cases/year, 1 200 childhood cancer
(4%)
• Cancer causes of 7,2% deaths
• Women : breast cancer (36%), cervical cancer (13%)
• Men : lung cancer (24%), prostate cancer (8%)
• Reproductive health is a priority program of the Ministry of
health
• Early detection for cervical cancer is main component

3. NATIONAL PROGRAMME FOR
CERVICAL CANCER
PREVENTION AND CONTROL

4. LEADERSHIP / GOUVERNANCE
• National Framework :
National Cancer
Prevention and Control
Plan 2010 - 2019
Early detection of breast and cervical
cancer: main priority
• Under the leadership of
HRH Princess Lalla
Salma
• Government
comitement

5. NATIONAL FRAMEWORK
National Cancer Prevention and Control Plan 2010 -
2019
Communication Prevention Legislation
National and
Palliative international Screening
cares mobilization Early diagnosis
Diagnosis
Social support Research / Training
and treatment
Equity Solidarity Quality

6. GOUVERNANCE
• Standards development at different levels of
intervention of the health system
 HPV immunization : will be fully integrated in the
national immunization program : measure 14 of
the NCPCP
 Early detection for cervical cancer : measures 31
to 43 of the NCPCP
 Treatment and palliative care : measures 44 to
74

7. GOVERNANCE
• Implementation of a reproductive health
strategy
• Creation of a department of fight against
cancer
• Integration of early detection for breast
cancer of and cervical cancer in reproductive
health
• Financial resources mobilized for
comprehensive cervical prevention and
control, annually: $ 5 million (HR non
included)

8. PARTNERSHIP
• Under the leadership of MOH
– Civil Society
– Universities
– WHO, UNFPA
– Private sector

9. PILOT PROJECT
• 5 regions among 16
• Target population 40% of national
population
• Target population 910 000 women (30 –
49 years)

10. PROGRAM COMPONENTS
• Organise the screening
• Organise the early diagnosis
• Organise the therapeutic support
• Implement a communication plan
• Establish a computerized information
system.

11. STRATEGIC AXIS
• Integrate into the PHC
• Develop the circuit of the
1. Services participant
Availability • Strengthen the technical
plateau at all levels
• Capacity building
• Research program on cervical
2. Quality cancer control program
matter • Implement quality matter
standards in terms of diagnosis
and treatment
• Implement an information
system to enhance the
surveillance

12. STRATEGIC AXIS
• Promote the early detection of
cervical and breast cancer in
3. Utilization of the general public
RH services • Develop partnerships with
local NGOs
• Ensure political advocacy in
local, regional and national
levels
• Follow up and monitor the evolution
of the screening
4. Follow up • Follow patients in terms of timing,
Evaluation diagnosis, treatment and follow up
• Ensure better planning of screening

13. FINANCEMENT
• Morocco is middle income country
• Health insurance
– AMO + private insurance : 30%
– RAMED : 70%
• Comprehensive cervical prevention and
control
– Screening program : free of charge
– Diagnosis : colposcopy, pathology : free of
charge
– Loop electrosurgical excision procedure (LEEP) :
free of charge
– Treatment and palliative care: AMO + RAMED

14. FINANCEMENT
MOH ALSC United
Nations
(UNFPA,
WHO)
Immunizati +++ +
on
Screening +++ +++ ++
Diagnosis +++ +++ ++
Treatment +++ +++
Research / +++ +++ +++
Training

15. SERVICE DELIVERY
Intervention levels
• Immunization : Health centers (should be integrated in national
immunization program in 2013)
• The screening level: health centers
 Reception and Information on the program
 Gynecological examination : VIA
 Counselling
Physician (general practitioner) or nurse
• The diagnosis level : Reproductive health centers
 Reception, IEC, Colposcopy, biopsy, …), Pathologic analysis, LEEP,
Counselling
Specialist practitioners : gynecologist, biologist, cytologist …
• Treatment level: oncology centers
 Reception, treatment, Counselling,
Multidisciplinary staff
• Palliative care

16. SERVICE DELIVERY
• Cervical cancer
 Women between 30 and 49 years old
 VIA in the health centers
 Every three years
• Exclusion criteria
 Women with cervical cancer

17. ORGANIZATION CHART
Organisation chart DPCC
Oncology centers
Third Level
Treatment
Multidisciplinary staff
Invasive Cytology Confirmation of CIN or
micro invasive cancer
Cancer
health Centers
Follow up/
Reproductive
RAD/CONISATION 1Colposcopy
2th level
Biopsie /year
Suspicion of CIN or
Suspect lesion of non-invasive cancer.
invasive cancer
Colposcopy Normal Next
examination
Négative +
First level PHC
Health centers
3 years
JSP Positive Négative
invisible
Participant Screening / VIA
Non
Recruiting women
participant
aged 30-50

18. SERVICE DELIVERY
Guide pratique de détection précoce des cancers
du sein et du col utérin

19. HUMAN RESOURCES
• Use of available human resources
• Development of a global training plan
– Practical aspects of early detection of cervical
cancer and LEEP
– Programmatic and managerial aspects of the
early detection for cervical cancer and his
integration in the reproductive health
– Communication aspect
– Information system

20. HUMAN RESOURCES
Training achievement
Nurses Physicians Gynecologists Managers
Practical 337 213 36
aspects of
early detection
of cervical
cancer and
LEEP
Programmatic 337 213 36 100
and
managerial
aspects
Communicatio 337 213 36 100
n aspect
Information 271 165 20 06
system

21. TECHNOLOGY AND EQUIPMENT
• PHC :
– Salle de vaccination
• Immunization – Matériel de
vaccination
• Screening
– Salle d’examen
• Communication
– Table d’examen
• Information – Source de lumière
– Spéculum
– Acide acétique…
– Matériel audio visuel
– Matériel informatique

22. TECHNOLOGY AND EQUIPMENT
• Reproductive Health
centers
– Mammography and
ultrasound (breast cancer)
• Diagnosis – Salle d’examen
• LEEP – Table d’examen
– Colposcopy
– Biopsy equipment
– LEEP equipment

23. TECHNOLOGY AND EQUIPMENT
• Treatment • In the oncology
centers

24. INFORMATION SYSTEM
Each HC has its own database
Health Centers (HC)
Orientation
The HRC contains all
Health reproductive CS + HRC database
centers (HRC)
Normal
circuit
Oncology Centers

25. INFORMATION SYSTEM
First quarter 2011 (2 regions)
Screening (Primary Health centers)
Pop.Target Goal # Participation # Reference Achievement
2011 participants Rate referred rate (%)
(%) IVA + (%)
160,000 44,000 2,900 1.8 500 17.0 6.6
Diagnosis (Reproductive health centers)
# examined # CIN LEEP Pathology Biopsy Invasive
/ IVA + Colposcopy cervical
cancer
420 212 05 03 03 02 04

26. OPERATIONAL RESEARCH
• 2 studies :
 Acceptability of HPV vaccine : ongoing
 Research on Standardization acts and the evaluation of the
system of reference and feedback : ongoing
• Objectives
– Studying adequacy of the context and the organization
process at different level of the health system
– Assess prospectively the efficiency of the national early
detection program for cervical cancer

27. ADVOCACY AND COMMUNICATION
• Objectives
 Increase awareness of the interest of prevention,
screening and early diagnosis
 Promote the availability of the immunization, screening and
treatment for the target population
 Strengthen skills in interpersonal communication technics/
counseling for the health workers
 Increase target women participation in the cervical cancer
screening program

28. ADVOCACY AND COMMUNICATION
Strategic axis
• Advocacy of the decision makers and partners
• Strengthening the skills of health professionals
• Communication on cancer perceptions

29. HEALTH SYSTEM STRENGTHENING
APPROACH for CERVICAL CANCER
PREVENTION AND CONTROL
CHALLENGES ACTIONS TAKEN
Widespread cervical cancer screening to Mobilization of decision makers and partners
the whole country to mobilize resources for pilot area
Achieve a target of 60% among women Implementation of a clear communication
participating in screening program strategy to raise awareness
Mobilization of civil society and private
Extend the strategy of early detection of sector pharmacist and health professional
cervical cancer in the private sector
Validate national guidelines of HPV
Implementation of HPV vaccination strategy vaccination and acquire HPV vaccine ( on
going)
Sustainability of the program

30. HEALTH SYSTEM STRENGTHENING
APPROACH for CERVICAL CANCER
PREVENTION AND CONTROL
Lessons learned
• Unanimity on the relevance of the program
 Political level: commitment of the Government
 Strategic level: commitment of national and regional
leaders
 Operational level: mobilization of care providers
• Commitment of partners: UNFPA, ALSC,
• Feasible training strategy
• Integration of early detection for cervical cancer
in Reproductive Health program at different level
of the national health system

31. HEALTH SYSTEM STRENGTHENING
APPROACH for CERVICAL CANCER
PREVENTION AND CONTROL
Ways forward/ future plans
• Mainstreaming integrative Strategy for the
program (operational plan and budget 2019)
• Training of trainers at national level on
Standardize and finalize pedagogical package
• Operational researches on health system
strengthening (integrative reproductive health
services )
• Integrative information system for monitoring
evaluation