Cervical cancer screening is used to identify any changes within the cervical cells that could result in cancer. Cervical cancer screening is offered to all women living with HIV who seek medical care from public health facilities.

Monitoring and Evaluation system is the process that involves the definition, selection, collection, analysis and use of information during and after a project life.

Performance is the action or process of carrying out a task.

Availability is the physical presence to carry out an action

Responsiveness is the ability to react quickly and in a positive manner.

Productivity is the measure of output against the input of performance.

Competence is the ability to perform a task effectively.

CHAPTER ONE

INTRODUCTION

1.1 Introduction

The study examines the performance of Monitoring and Evaluation systems in cervical cancer units with M&E Functions, Human Capacity for M&E, Routine program monitoring and Data dissemination and use.

The dependent variable is performance of cervical cancer units in selected facilities in Wakiso district while the independent variables are the components of the monitoring and evaluation system. Performance of the cervical units shall be measured by the effectiveness, timeliness, accuracy, competence, productivity, knowledge, efficiency, responsiveness, and target management of the health workers.

This chapter covers the thematic area of the study such as the background description, the statement of the problem, the objectives of the study, the research questions and hypothesis of the study. Furthermore, the chapter also describes the conceptual framework, study significance, justification as well as operational definitions and selected terms and concepts.

Overall, the study is organized into five chapters: the first chapter is introduction and background to the study, the second chapter is the literature review which reviews other findings from studies and other settings in relation to this study, chapter three describes the methodology that shall be used to answer to collect and analysed data so as the answer the research question.

1.2 Background of the study

This subsection discusses back ground under historical, theoretical, conceptual and contextual perception of the study variables where the M&E systems is the independent variable and the performance of cervical cancer units as the dependent variable. Performance of employees towards screening of cervical is critical in curtailing morbidity and mortality due to cervical cancer not only in Uganda but the world at large.

1.2.1 Historical background

Cervical cancer is the fourth most common cancer among women globally, with an estimated 604,000 new cases and 342,000 deaths in 2020 (World Health Organization/International Agency for Research on Cancer). The burden of cervical cancer is quite high in developing countries where it constitutes a major health problem with Sub-Saharan Africa leading with the highest incidence of cervical cancer in the world affecting women at a relatively young age (WHO, 2021). In 2012, there were an estimated 527,624 new cases and 265,672 deaths due to cervical cancer. 85% of these deaths occurred in sub-Saharan Africa (Ferlay et al., 2015). The onset of the HIV/AIDS epidemic has exacerbated the incidence of cervical cancer among HIV-positive women due to compromised immunity. In May 2018, the World Health Organization (WHO) called for a global initiative to eliminate cervical cancer as a public health problem. To achieve this goal, global scale-up of effective vaccination against the human papillomavirus (HPV) as well as screening for and treatment of cervical cancer were launched (WHO, 2020).

In Uganda, cervical cancer is the leading cause of death among women. According to the World Cancer Research Fund international, in 2020 Uganda was ranked in 7^th position having registered 6,569 new cases and 6^th position with 4,607 deaths globally. The ICO/IARC information centre on HPV and cancer indicated that currently 6959 women are diagnosed with cervical cancer every year and 4607 die from the disease.

In 2014, the World Health Organization estimated a total of 3915 Ugandan women had been diagnosed with cervical cancer and that 2160 died from the disease (WHO, 2021). Cervical cancer screening guidelines in Uganda are based on a “See and Treat” algorithm (Ministry of Health & Strategic Plan for Cervical Cancer Prevention and Control in Uganda 2010–2014, 2010). The target age group are women 25 to 49 years old. Women in Uganda are screened using VIA and those with positive findings and eligible precancerous lesions are treated using cryotherapy. Screening occurs every 3 years for both HIV-negative women and HIV-positive women. Midwives and nurses are the primary providers of cervical cancer screening as well as treatment. Unfortunately, screening in Uganda is erratic, opportunistic, and in some places absent due to a lack of resources or lack of financial commitment. This translates to a staggeringly low screening uptake of about 4.8% in rural Uganda (Nakisige et al., 2017). Consequently, the Ministry of Health with support from its development partners have trained and deployed health workers to provide cervical cancer screening to all HIV-positive women seeking health care services. The performance of health workers in regard to this screening is believed to play an important role in the early detection of cancerous cells. However, inspite of this, many women are still reporting to Uganda Cancer institute with advanced stage of cervical cancer. It is for this reason that the study seeks to study intends to study the monitoring and evaluation systems and performance of cervical cancer units in Uganda within of selected units in Wakiso district as a case study.

1.2.2 Theoretical background

Theoretical background can be defined as the structure that can hold or support a theory of a research study. The theoretical framework introduces and describes the theory which explains why the research problem under study exists. Therefore, the theory of change will be used in this study because it contributes to chain of early, intermediate and long term outcomes. The strength of this theory is that change occurs gradually in a procedural, attitudinal and behavioural aspects.

According to Vogel, 2012 a theory of change is therefore “an outcomes-based approach which applies critical thinking to the design, implementation, and evaluation of initiatives and programmes intended to support change in their context” (Vogel, 2012). A theory of change therefore, describes, and often visually presents, how an initiative or programme, through specific intermediate outcomes summarized in ‘pathways of change’, brings about long-term outcomes. In addition, assumptions on what is required for changes to occur (including external conditions beyond programme control) and contextual factors that influence the theory of change are made explicit (De Silva et al., 2014). Using a Theory of change can help study monitoring and evaluation systems and describe performance of health workers in cervical cancer to plan, implement, monitor and evaluate complex interventions (Breuer et al., 2015).

However, many theories suggest job satisfaction underpins performance and is influence by different factors. For example, Herzberg’s motivation-hygiene theory also known as the two-factor theory argues that job satisfaction and dissatisfaction exist on two different continua, each with its own set of factors which is contrary to the traditional view of job satisfaction, which posits that job satisfaction and dissatisfaction are interdependent.

Herzberg and his collaborators classified satisfaction as either hygienic or motivational factors. Motivation factors increase job satisfaction while the presence of hygiene factors prevent job dissatisfaction. This theory of motivation points out that employee motivators for example, challenging work, recognition, and responsibility give positive satisfaction, and hygiene factors such as status, job security, salary, fringe benefits, and work conditions are factors that decrease job dissatisfaction. Self-motivated employees tend to exhibit good performance even if they are never provided with much external motivation, but their performance increases if they are provided with motivation.

McGregor’s in his theory explains that there are two types of management theory i.e. A and Y theory. Management that uses X theory assumes that employees dislike work and therefore, closely supervises them, with clearly defined tasks and the promise of higher pay or the threat of punishment as means of motivation. This type of management affects performance of employees and can result in mistrust and resentment among employees. However, theory Y management establishes a conducive work environment where the organisation’s objectives correlate with the employees’ personal objectives. This kind of management creates a more cooperative relationship between managers and employees. Although McGregor acknowledged that this theory isn’t the perfect mind set for every managerial position. Instead, he presented it as an alternative that persuades managers to abandon the limiting assumptions of Theory X and consider a more positive mind set.

Therefore, this study assumes that monitoring and evaluation systems and performance of cervical cancer units is affected by the management style used. Additionally, its acknowledged that good performance by staff is enabled via a supportive working environment. This encompasses more than just having sufficient equipment and supplies. It also includes system issues, such as decision-making and information-exchange processes, and capacity issues such as workload, support services and infrastructure (Potter & Brough, 2004).

1.2.3 Conceptual background

Employee performance can be defined as the job-related activities expected of a worker and how well those activities were executed. Uganda health systems have been decentralized in the 1990s and therefore, monitoring and supervisions of health workers are performed by the district health teams headed by the district health officer. In this study, assessing the monitoring and evaluation and performance of cervical cancer units shall be measured shall be determined. Performance shall focused on the knowledge, efficiency, effectiveness, responsiveness, availability, timeliness and productivity among others.

Over the years, Ministry of health through its health partners have trained and deployed health workers to conduct screening of all HIV positive women aged 25 – 50 years for cervical cancer. This screening is key in early detection and treatment of the disease among women since its one of the leading cause of cancer in the country. This intervention was expected to lower the number of women presenting with advances stage of the disease at the Uganda cancer institute, thereby reducing the economic burden to both the family and country. As such, this study will examine cervical cancer units M&E Functions, Human Capacity for M&E, Routine program monitoring and Data dissemination and Use as illustrated in the conceptual framework.

1.2.4 Contextual background

Cervical cancer is a slow growing malignancy following infection with the human papillomavirus (HPV) in the cervical cells resulting in growth of abnormal cells. In Uganda the persistent infection with oncogenic HPV type 16 and 18 has contributed to 6959 women being diagnosed with cervical cancer every year and 4607 succumbing to the disease. The morbidity and mortality due to cervical cancer can be attributed to the high prevalence of 33.6% of human papillomavirus (HPV) among women in Uganda coupled with low screening utilization. This low utilization has resulted in the country having one of the highest cervical cancer incidence rates in the world of 47.5 per 100,000 per year (ICO Information Centre on HPV and Cancer (HPV Information Centre), 2016). Relatedly, the Uganda Cancer Institute (UCI), receives 80% of the women with cervical cancer in advanced stage disease. In order to prevent deaths due to cervical cancer in Uganda, a multidisciplinary approach must be taken to deliberately improve on the uptake of cervical cancer screening services. One of these approaches is ensuring the health workers have the required job satisfaction and motivation at the cervical cancer units so as to performance to the best of their abilities.

Health workers performance have since remain poor even after the health sector reforms in the early 90s. The poor performance of health workers is believed to be attributed to inadequate support supervision from both the districts and from the Ministry. Additionally, limited facilitation of medicines, equipment, working environment have all contributed to the decimal performance. Several factors such as absenteeism, inadequate skills, poor remuneration and low staffing levels have all been blamed for the poor performance. Whatever the case, the inadequate performance of individual health workers leads to poor health sector performance. It is therefore, imperative that monitoring and evaluation and performance of cervical units be examined to identify gaps that be filled to improve the cervical screening at health facilities.

1.3 Problem statement

Cervical cancer is a slow-growing malignancy following infection with the human papillomavirus (HPV) in the cervical cells resulting in the growth of abnormal cells over some time ((Kelkboom. S et al., 2021, WHO, 2020). In Uganda, the persistent infection with oncogenic HPV is mostly HPV-16 and HPV-18 (Nakisige et al., 2017). Detection of Cervical Intraepithelial Neoplasia (CIN) in the cervical cells also known as high-grade squamous intra-epithelial lesion (HSIL) among women of 25-49 years of age is key in the prevention and treatment of cervical cancer.

A 33.6% prevalence of human papillomavirus (HPV) among women in Uganda combined with low screening uptake has resulted in the country having one of the highest cervical cancer incidence rates in the world at 47.5 per 100,000 per year (ICO Information Centre on HPV and Cancer (HPV Information Centre), 2016). Therefore, screening of all vulnerable women is critical in prevention of the disease and death. As such, the Ministry of health and its implementing partners have trained and deployed health workers to conduct secondary prevention of cervical cancer through screening of all asymptomatic HIV positive women across all health facilities.

This group is considered a priority due to their higher risk for cervical pre-cancers and cancers, there is an obvious need to make preventive services more accessible to these patients (Bukirwa et al., 2021). However, there is limited data and undocumented performance of cervical cancer units. It’s against this background that this study seeks to evaluate the performance of cervical cancer units based on functional M&E systems, Routine program monitoring, Human Capacity for M&E and data dissemination and use as reports from Uganda Cancer Institute (UCI) indicate that most women still report with advanced stage of the disease.

1.4 Purpose of the study

To purpose of this study is to examine the performance of cervical cancer units in regard to existence of M&E functions, Human capacity for M&E, Routine program monitoring, and Data dissemination and Use. The results will be used to establish functional M&E systems to closely monitor the performance of the unit and be able to design appropriate to rectify the gaps to reduce the burden of cervical cancer. The finding can also be used to inform policy making to improve on health services so that health performance indicators can be improved in general.

1.5 General objective

To examine the performance of cervical cancer units using monitoring and evaluation systems in selected facilities of Wakiso district.

1.5.1 Specific objectives

To examine cervical cancer units with M&E Functions.
To examine the Human Capacity for M&E in cervical cancer units.
To examine existence of Routine program monitoring in cervical cancer units.

To examine Data Dissemination and Use within and outside the cervical cancer units.

1.6 Research questions

How the structure of monitoring and evaluation at the cervical cancer units organized?

What is capacity of M&E human resource at the cervical cancer units?

How is routine program monitoring conducted at the cervical cancer units?

How is cervical cancer data disseminated and used?

1.7 Hypothesis of the study

There are no functional M&E structures in the cervical cancer units.

There is no human capacity for M&E in cervical cancer units.

There is some routine program monitoring done at cervical cancer units.

The dissemination of data and its usage is observed at the facilities.

Conceptual framework of the study

Monitoring and Evaluation system (IV) Performance of cervical cancer units (DV)

M&E functions

Accountablity

Operational management

Strategic Management

Knowledge creation

Empowerment

Responsiveness

Availability

Competence

Productivity

Accuracy

Timeliness

Knowledgeable

Efficiency

Effectiveness

Target achievement

Reduced cervical cancer

Human capacity for M&E

-knowledge & skills

Routine program monitoring

Workplan

indicators

Data dissemination and use

Data collection

Data source

Data accuracy

Data analysis

The existence of the above monitoring and evaluation concepts will result in the effectiveness and efficiency of the cervical cancer units in health facilities within Wakiso district.

1.9 Scope of the study

1:9:1 Geographical scope

The study will be conducted in a total of 42 facilities within Wakiso district

1:9:2 Time scope

The study will be conducted between June and October 2023.This because the cervical cancer project which began in 2021 will be closing off.

1:9:3 Content scope

In regard to content, the study will specifically examine of performance of cancer units in relation to functional M&E structures, Human Capacity for M&E, Routine program monitoring and Data dissemination and Use.

1.10 Significance of the study

Reports from Uganda Cancer Institute (UCI) indicate that 80% of women who are admitted present with advanced-stage cervical cancer are also infected with HIV. As such, these patients can only benefit from palliative care until they succumb to the disease . It is therefore importance to determine the performance of health workers in conducting effective cervical cancer screening at health facilities. Performance of health workers in regard to cervical cancer screening is critical for early detection of precancerous lesions. Early detection of precancerous lesion means appropriate treatment can be provided to curtail the development of fully blown cancer. Therefore, this study is important in determining any gaps related to cervical cancer screening by health workers. If not conducted, many women who have precancerous cells shall go undetected and thus appropriate intervention shall not be given. This then leads to the high burden of the disease and high economic not to the

1.11 Justification of the Study

This study intends to evaluate the performance of health workers on cervical cancer screening of HIV positive women at health facilities supported by Mildmay Uganda. The finding from this study is expected to inform Wakiso district, and Mildmay Uganda to provide the necessary training of health workers to address any gaps that may be identified. The findings is also expected to help policy makers to develop policies and design appropriate strategy to incorporate routine cervical cancer screening and treatment of pre-cancer lesions into primary health care services at all levels of health facilities.

CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction

Literature reviewed in this chapter is related to the guiding objectives of the study which are; to examine cervical cancer units with M&E Functions., to examine the Human Capacity for M&E in cervical cancer units. To examine existence of Routine program monitoring in cervical cancer units. To examine Data Dissemination and Use within and outside the cervical cancer units. Literatures used in this study is obtained from textbooks, libraries, documentaries, internet and journals to fit the notes of the topic under review.

2.2 Theoretical Review

The theory of change will be used in this study because it contributes to chain of early, intermediate and long term outcomes. The strength of this theory is that change occurs gradually in a procedural, attitudinal and behavioural aspects. The study will employ Kurt Lewin’s three stage change model which came into play in 1950.The model is known as unfreeze, change and refreeze which he explained using the analogy of changing the shape of an ice block.

Performance is further enhanced by the a supportive working environment which includes sufficient equipment and supplies, decision making and information processes and capacity issues such as work load, supported by infrastructure (Potter&Brough,2004)

2:3 Monitoring and evaluation functions

The term Monitoring and Evaluation system refers to the complete set of interlinked activities that must be undertaken in a coordinated way to plan for M&E,gather and analyse information,report and to support decision making and the implementation of improvement.M&E must fullfill the following purposes

2:3:1 Accountablity

Monitoring and Evaluation is often an obligation to demonstrate that contracted work has been conducted in compliance with the agreed standards.M&E for accountability to government and donors focuses on upward accountability.

This involves demonstrating to the different stakeholders like donors,beneficiaires and implemting parterners that expenditure,actions and results are as agreed or are as can reasonably be expected in a given situation.Accountablity concerns with reporting particularly to the donors and has tended to drive most M&E efforts.How ever implementors seem to regard reporting as tedious with little contribution towards their efforts and achievements.Further reporting focuses on the input and activity level.

For accountability to take traction,there needs to be material reconfigurings like evaluative measures,performance indicators,contracts,targets,ratings,rankings,assessments,guidelines and best practices (Espeland and Sauder,2007;Miller and Rose,2008;Sauder and Espeland,2009 ).

2:3:2 Supporting operational management

Operational management is the provision of basic management informationthat is needed to direct,coordinate and control the human,financial and physical resources required to achieve the set objective. Most development initiatives have informal monitoring styles to manage the operational side of the basic activity implementation and financial management.

2:3:3 Supporting Strategic Management

Strategic management is the provision of information for and facilitating the processes required to set and adjust project goals, objectives, strategies and to improve quality performance. Strategic management requires to answer questions regarding results achievement, failures and ways to mitigate challenges by involving the different stakeholders within the project.

2:3:4 Knowledge Creation

Subsequent generation of scholars have emphasized the informatance of information,many writers over the last three decades forexample Daniel Bell,Michel Porat,Alvin Toffler,Tom Stonier arriving at the conclusion that information as well as the traditional factors of land ,labour and capital also create wealth.

The generation of new insights contributes to the established knowledge base in any given field.All human actions are based on a set of underlying assumptions or thepories about how the world works.

2:3:5 Empowerment

This is building the capacity, self reliance and confidence of beneficiaries and implementing staff and partners to effectively guide,management and implement development initiatives.It involves empowering all stakeholders like beneficiaries,managers,and implementing partners to play a constructive role towards contributing to optimizing the impact of the development initiative since it is clear that knowledge is power.

Human Capacity for M&E

An effective M&E system implementation requires that there is adequateskilled staff employed in the M& E unit but also that the staff within the unit have the necessary technical know-how and experience (Bardhan,Krishnan,and Shu,2007). The level of human resource capacity is an important management tool which can be used to enhance performance of projects(Tengan et.al;2014).

The influence of human resources capacity is the driver for successful project performance since trained and competent staff contribute to quality project performance.Therefore recruitment must focus on the type of capacity required to under task a given task.

A study by Tidac and Pivac ,2014 on human resources capacity and performance of projects established that M&E program staff should be given incentives and resources that include skills,time and equipment so as to enable them play their rightful role.In a similar study by Rejaul,Huda ans Khan 2012 demonstrated that human resources contribute to various project related outcomes.

According to World Bank ( 2013) for example human capacity with proper training and experience is vital to produce M&E results.However White 2013 stated that health instituions in kenya encounter a number of challenges when implementing M&E activities due to insufficient humans resources capacity .

Routine program monitoring

In the light of the on going burden that cervical cancer poses, organized approach to cervicval cancer screening has been recommended inorder to otpimize detection of pre-cancer leisons and further reduce the incidence of cervical cancer related morbidity and mortality treatment

Previously cervical cancer screening has been conducted in an opportunistic manner depending on either the women or care provider initiative and mostly resulted into improper screening and lack of follow up of results.

Organized cervical cancer screening ensures access to a standardized approach to screen, treat and follow up of all asymptotic omen who seek medical care at all levels public health facilities.

The fuel of an M&E system is data which is determined by indicators and research questions.The indicators can be input indicators,output indicators ,outcome indicators and impact indicators.Every routine data management process under goes 6 management processes.

Data Sourcing .This is the first data management process which entails documentation either electronically or in standardized registers.

Data Collection .Data be collected regularly and collated from the various data source locations

Data Collation .This involves add up and summarize the data that can be reported either monthly or quarterly.

Data analysis.This can be performed statistically.

Dissemination and data use

Data dissemination and use is fundamental to for informed public health and effective management of public resources.

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