Bridging the cancer care gap for women in Rwanda
Harmful gender norms mean that women often face limited access to quality health services and are more exposed to noncommunicable diseases (NCDs) and their risk factors, resulting in a range of health, economic and social consequences, especially in low-resource settings. Rwanda’s recently launched Patient Navigation initiative is trying to change this by improving access to cancer screening, diagnosis and care.
Like other NCDs, the cancer burden in Rwanda is increasing. However, data covering the 2007-2018 period from the country’s newly established cancer registry strongly suggests that the majority of cancer cases in Rwanda are never diagnosed or treated. For example, WHO’s Global Cancer Observatory estimates breast cancer cases in Rwanda at 1,131 new cases annually, whereas annual cases recorded in the national registry are just 217. This indicates that only 20 percent of new cases are receiving medical attention.
The Patient Navigation initiative aims to save women’s lives by bridging this gap. It is being implemented by the Rwanda NCD Alliance in the City of Kigali, in close collaboration with the Rwanda Ministry of Health, Rwanda Biomedial Center (RBC), International Cancer Institute (ICI), Rwanda Military Hospital and Masaka District Hospital.
The aim is to decrease morbidity and mortality from breast and cervical cancers through greater access to screening and early detection, as well as improved diagnosis and treatment of benign and malignant conditions.
Community Health Workers (CHWs) play a substantial role in mobilising women in their communities to get cervical and breast cancer screenings by also directing to screening sites. Screening is done at all health centres in Kicukiro District, and abnormal findings are referred to Masaka District Hospital for further management, including breast ultrasound core needle biopsy, and Large Loop Extra Excision Procedure). Patients with highly breast or cervical cancer-suspicious results as well as breast biopsy samples taken at Masaka District Hospital, are then referred for cancer confirmation and treatment to the Rwanda Cancer Centre, which was inaugurated in 2020 by His Excellency President Paul Kagame at Rwanda Military Hospital in Kanombe, as the first step in ultimately providing a full-service cancer treatment.
Previously, the government of Rwanda had to send patients requiring radiotherapy treatment abroad on exorbitant costs. Currently, this radiotherapy cancer centre facility complements existing prevention, diagnosis, and treatment services including a chemotherapy unit.
In addition, Rwanda Cancer Centre allows full scale-up of screening and early detection for cancers such as cervical and breast. This cancer centre gradually added diagnostic and inpatient services to provide comprehensive cancer treatment and palliative care to those with late‑stage diagnosis.
Encouraging results in just six months
Numbers have demonstrated that the approach is working. From the launch of the Patient Navigation initiative in September 2022 until March 2023, a total of 14,435 women were screened: 5,014 for cervical cancer and 9,421 for breast cancer. Of these, 302 patients were diagnosed and treated, also receiving social support and follow-up treatment and monitoring.
Along with improving diagnosis and care, training health care professionals is a core component of the initiative. As of March 2023, 761 community health workers received training on breast and cervical cancer awareness. 61 health care providers were trained on Women’s Cancer Early Detection (WCED), and 20 health care professionals including medical doctors, nurses, midwives, clinical officers, and medical imaging technicians were trained on breast ultrasound and ultrasound guided core needle biopsy.
The initiative follows the WHO Guide to Early Cancer Diagnosis Framework, and addresses challenges such as low health literacy, myths and stigma, poverty, and reliance on traditional healers.
Universal Health Coverage in Rwanda
Rwanda has become a regional leader in healthcare and UHC. The percentage of the population with some kind of health insurance increased from 43.3% in 2005 to 90.5% in 2020. Insurance also known as Community-Based Health Insurance (CBHI)has also reduced out-of-pocket expenses, in particular for the poorest and most vulnerable people.
Rwanda has also been leading the way with its decentralised NCD services, and implementation of the WHO PEN- Plus strategy to address NCDs such as cancer, type 1 diabetes, sickle cell disease and rheumatic heart disease at primary health facilities in rural and peri‑urban areas.
In addition to early diagnosis and training, Rwanda NCD Alliance is planning to add a more holistic approach to the initiative including mentorship on women’s cancer screening and responding to HPV results; monitoring, evaluation and data management; informing public authorities to reduce the financial burden of the diagnostic pathway for people living with cancer; and creating a palliative care and health education centre to facilitate self-rehabilitation.
Civil society has been integral to the commitments that governments have made to pursue a whole-of-society approach to NCDs at the UN High-Level Meetings on NCDs, particularly in 2018 where the UN Political Declaration included a commitment for the meaningful engagement of civil society in supporting national NCD plans and amplifying the voices of people living with NCDs.
Civil society organisations, people living with NCDs, women, young people and other vulnerable populations, ought to be meaningfully involved and have an active role in the NCD response. The proximity of civil society organisations to the communities and people living with and affected by NCDs position them to play an important role in NCD decision-making, raising public demand for policies and ensuring that services reach communities.