CHAPTER ONE

INTRODUCTION

1.1 Introduction

This chapter introduces the study on monitoring and evaluation systems and the performance of cervical cancer units in Uganda, with particular reference to selected units in Wakiso District. It presents the background to the study, the problem statement, the study objectives, research questions, and hypotheses. The chapter also outlines the conceptual framework, significance and justification of the study, as well as the operational definitions of the key concepts used in the research.

The study is organized into five chapters. Chapter One provides the introduction and background to the study. Chapter Two reviews relevant literature and findings from previous studies related to the subject under investigation. Chapter Three describes the methodology that will be employed to collect and analyse data in order to answer the research questions. The remaining chapters present the findings, discussion, conclusions, and recommendations of the study.

1.2 Background of the Study

The background to the study is discussed from historical, theoretical, conceptual, and contextual perspectives.

1.2.1 Historical Perspective

Cervical cancer is a malignant disease affecting the cervix, which is the lower part of the uterus that connects to the vagina. Its history has been characterized by continuous medical research, improvements in prevention, and advances in treatment. Although the disease is believed to have affected women for centuries, ancient societies lacked the scientific knowledge and medical technologies necessary to diagnose or treat it effectively (Escobar & Plugge, 2020).

During the nineteenth century, advances in medical science enabled physicians to recognize cervical cancer as a distinct disease. By the early twentieth century, researchers had begun investigating possible causes of the disease. In the 1920s, scientists proposed a possible association between cervical cancer and human papillomavirus (HPV), although the relationship was not fully understood until several decades later. A major breakthrough occurred in the 1940s and 1950s when Dr. George Papanicolaou developed the Pap smear, a simple and affordable screening method that allowed early detection of precancerous and cancerous cervical cells. This innovation significantly reduced cervical cancer mortality in countries where screening became widely available (Bouvard et al., 2021).

In the 1970s, scientific evidence conclusively established HPV as the primary cause of cervical cancer, and specific high-risk HPV strains were identified. This discovery stimulated extensive research into preventive strategies, including vaccine development (Lin et al., 2021). During the 1980s and 1990s, HPV vaccines such as Gardasil and Cervarix were introduced, marking an important milestone in the prevention of cervical cancer by protecting against HPV strains responsible for most cases of the disease (Vu et al., 2018).

Further advances in medical technology and surgical procedures, including loop electrosurgical excision procedures (LEEP) and laser therapy, have improved treatment outcomes for women with cervical cancer. At the same time, many countries introduced screening programmes and public awareness campaigns promoting regular Pap smears and HPV vaccination. These initiatives contributed to reductions in cervical cancer incidence and mortality in several parts of the world (Ciapponi et al., 2021).

Research continues to focus on developing improved treatment options, enhancing early detection methods, and addressing other HPV-related cancers. Despite substantial progress in prevention and treatment, cervical cancer remains a major global public health challenge, particularly in countries with limited access to healthcare services and vaccination programmes. Continued investment in screening, HPV vaccination, and public health interventions remains essential for reducing the burden of the disease (Bhatla et al., 2021; Schulte-Frohlinde et al., 2022).

Globally, cervical cancer caused more than 311,000 deaths in 2018. By 2020, it had become the fourth most common cancer among women, with an estimated 604,000 new cases worldwide. Approximately 342,000 women died from the disease in 2020, with nearly 90% of these deaths occurring in low- and middle-income countries. Women living with HIV are about six times more likely to develop cervical cancer than those without HIV, and HIV-related cervical cancer disproportionately affects younger women (Hagiya et al., 2022; Bouvard et al., 2021; Wilailak et al., 2021).

Sub-Saharan Africa, parts of South Asia, and some regions of Central and South America experience some of the highest cervical cancer mortality rates, largely because of limited access to screening and treatment services. In response to this burden, the World Health Organization launched a global initiative in 2018 aimed at eliminating cervical cancer as a public health problem through expanded HPV vaccination, screening, and timely treatment (Kjaer et al., 2021; Jalil et al., 2021).

The development of monitoring and evaluation (M&E) as a discipline has largely been influenced by the American tradition. The United States is widely regarded as a pioneer in the field because of its contributions to evaluation theory, professional practice, legislation, institutionalization, methodological development, professional standards, academic training, conferences, and publications (Basheka, 2016).

In Uganda, cervical cancer remains one of the leading causes of cancer-related illness and death among women. Available estimates indicate that thousands of women are diagnosed with the disease each year, while many others die from it (Obol et al., 2021). Uganda’s high disease burden is associated with widespread infection with high-risk HPV strains and inadequate access to preventive interventions such as HPV vaccination and screening services.

Screening services, including Pap smears and HPV testing, remain inaccessible to many women, particularly in rural areas. Consequently, many cases are diagnosed at advanced stages when treatment is less effective (Rawat et al., 2021; Namuli et al., 2021).

Uganda’s cervical cancer screening guidelines are based on the “See and Treat” approach. Women aged 25–49 years are screened using visual inspection with acetic acid (VIA), and eligible precancerous lesions are treated using cryotherapy. Nurses and midwives provide most screening and treatment services. However, screening remains inconsistent because of limited resources and inadequate financial support, resulting in very low screening uptake in many rural communities (Nakisige et al., 2017).

Although the Ministry of Health and development partners have trained health workers to provide cervical cancer screening, many women continue to present at the Uganda Cancer Institute with advanced disease. This situation highlights the need to examine how monitoring and evaluation systems influence the performance of cervical cancer units. The present study therefore focuses on selected cervical cancer units in Wakiso District.

1.2.2 Theoretical Perspective

The study is guided by General Systems Theory, originally developed by Bertalanffy. The theory views an organization as a collection of interconnected components that work together to achieve common objectives. Changes in one component can influence the functioning of other components and ultimately affect the performance of the entire system (Chatterjee, 2021; Clark, 2014).

According to the theory, systems transform inputs into outputs through internal processes. Inputs may include financial resources, information, equipment, and human resources, while outputs consist of goods or services delivered to the environment. Feedback from the environment enables the system to make adjustments and improve performance (Pihal et al., 2022).

In this study, cervical cancer units are viewed as systems composed of interconnected components, including human capacity for M&E, routine programme monitoring, and data dissemination. Effective interaction among these components is expected to improve the overall performance of the units.

1.2.3 Conceptual Perspective

Monitoring and evaluation are essential processes used to assess and improve the effectiveness and efficiency of programmes, projects, and policies across various sectors, including healthcare (Burke et al., 2020).

Monitoring refers to the continuous and systematic collection, recording, and analysis of information about programme implementation. Its purpose is to track progress, identify challenges, and support timely corrective action (Forti et al., 2020).

Evaluation is a systematic and objective assessment of an ongoing or completed programme, policy, or project. It examines relevance, efficiency, effectiveness, impact, and sustainability to determine whether intended objectives have been achieved and to support informed decision-making (World Health Organization, 2019).

Effective M&E depends on the availability of relevant data collected through methods such as surveys, interviews, observations, and document reviews. Analysis of these data helps determine whether activities are being implemented as planned and whether adjustments are necessary (Zall Kusek & Rist, 2014).

Human capacity for M&E refers to the knowledge, skills, and expertise of individuals responsible for conducting monitoring and evaluation activities. This includes competence in research methods, data collection and analysis, evaluation design, data management, and communication of findings to stakeholders (Markus et al., 2021; Gray et al., 2021).

Data dissemination involves systematically communicating research findings and programme information to relevant stakeholders through reports, publications, presentations, and digital platforms. Effective dissemination promotes evidence-based decision-making and accountability (Aaltio, 2022).

Routine programme monitoring is the continuous collection and interpretation of data concerning programme implementation. It enables managers to determine whether activities are progressing according to plan and to identify problems requiring corrective action (Boswell & Cannon, 2022; McKenzie et al., 2022).

1.2.4 Contextual Perspective

Cervical cancer develops gradually following persistent infection with high-risk HPV types, particularly types 16 and 18. Uganda continues to experience a substantial burden of the disease, with thousands of women diagnosed annually and many deaths attributed to late diagnosis and limited screening uptake.

A significant proportion of women present to the Uganda Cancer Institute with advanced-stage cervical cancer, reducing the likelihood of successful treatment. Improving screening services therefore requires a coordinated approach involving health workers, adequate resources, supportive supervision, and effective monitoring and evaluation systems.

Health worker performance has remained a challenge despite health sector reforms. Factors such as inadequate supervision, shortages of medicines and equipment, poor working conditions, absenteeism, limited skills, inadequate remuneration, and staffing shortages have all contributed to reduced performance. Since individual health worker performance directly affects the quality of healthcare services, examining the role of M&E systems is important for identifying gaps and improving cervical cancer screening and treatment services.

1.3 Problem Statement

Monitoring and evaluation is not merely concerned with collecting data; it involves using evidence to guide decision-making, improve programme implementation, promote accountability, and ensure efficient use of resources. In cervical cancer care, the effective performance of health units is critical because these facilities provide life-saving screening and treatment services.

Despite efforts to strengthen cervical cancer services in Uganda, the disease remains a major public health concern with high incidence and mortality rates. Monitoring and evaluation systems have been introduced in health facilities to improve service delivery and identify implementation challenges.

However, there remains a significant gap in the effectiveness of M&E systems within cervical cancer units. Existing systems do not adequately assess the performance of these units or provide sufficient evidence to support timely improvements in screening, treatment, and prevention services. Consequently, weaknesses in M&E may contribute to delayed interventions, reduced quality of care, and continued high morbidity and mortality among women.

There is therefore a need to examine the extent to which monitoring and evaluation systems influence the performance of cervical cancer units. This study seeks to address this gap by investigating the relationship between M&E systems and the performance of selected cervical cancer units in Wakiso District, Uganda.

1.4 General Objective

To examine the relationship between monitoring and evaluation systems and the performance of cervical cancer units in Uganda.

1.4.1 Specific Objectives

1. To examine the relationship between human capacity for monitoring and evaluation and the performance of cervical cancer units in Uganda.
2. To determine the relationship between routine programme monitoring and the performance of cervical cancer units in Uganda.
3. To examine the influence of data dissemination on the performance of cervical cancer units in Uganda.

1.5 Research Questions

1. What is the relationship between human capacity for monitoring and evaluation and the performance of cervical cancer units in Uganda?
2. What is the relationship between routine programme monitoring and the performance of cervical cancer units in Uganda?
3. What is the influence of data dissemination on the performance of cervical cancer units in Uganda?

1.6 Hypotheses of the Study

H01: There is no significant relationship between human capacity for monitoring and evaluation and the performance of cervical cancer units in Uganda.

H02: There is no significant relationship between routine programme monitoring and the performance of cervical cancer units in Uganda.

H03: Data dissemination has no significant influence on the performance of cervical cancer units in Uganda.