Lessons learned from the support of the International Atomic Energy Agency, International Agency for Research on Cancer and World Health Organization to develop National Cancer Control Plans in low- and middle-income countries

Abstract

Background

The International Atomic Energy Agency (IAEA), International Agency for Research on Cancer (IARC) and World Health Organization (WHO) assist countries in building and strengthening their cancer control capacity. This support includes guidance to Member States to set priorities for national cancer control through the development and implementation of National Cancer Control Plans (NCCPs). Our aim was to identify the lessons learned from the support United Nations (UN) agencies provide to develop NCCPs in low- and middle-income countries (LMICs) to support the development of guidance.

Methods

We developed a questionnaire based on a review of the NCCP literature and conducted semi-structured interviews with 11 Member States that received UN agency support between 2020 and 2023 and five IAEA Programme Officers who coordinated UN support. We coded the transcripts inductively and performed a thematic analysis of the data.

Results

Three main themes were identified, each with their own barriers and enablers to develop NCCPs: coordination of NCCP development; method; and governance. We discuss each of these challenges and offer recommendations for Member States and UN agencies to further improve the development process of national cancer control strategies. We selected Kenya as a case study to show an example of good practice.

Conclusion

This paper complements a sister study conducted by the International Cancer Control Partnership which assessed challenges of developing NCCPs for countries that received a different type of support. Both studies contribute to the growing body of NCCP literature following the 2025 global review of NCCPs.

Policy summary

The lessons learned from the IAEA-IARC-WHO support to develop NCCPs will inform policies, programmes and practices in cancer control planning and implementation in LMICs, as well as the development of a common methodology for UN agencies to provide NCCP support.

Highlights

• •UN agencies support LMICs to develop National Cancer Control Plans (NCCPs).
• •We assessed the experience from 11 countries in receiving UN support to develop NCCPs.
• •We highlight common barriers and enablers in coordination, method, and governance.
• •Kenya is used as an example of good practice.
• •The paper offers recommendations to improve NCCP development.

1. Background

A National Cancer Control Plan (NCCP), is “a strategic document that outlines strategies and resources to respond to a country’s cancer burden based on the socio-economic environment and healthcare system in that country.” [1]

Several United Nations (UN) agencies and organizations advocate for NCCPs to reduce the global cancer burden. World Health Assembly (WHA) resolution 58.22 (2005) urged Member States (MSs) to establish NCCPs tailored to national needs. [2] The 2006 Union for International Cancer Control (UICC) World Cancer Declaration reinforced the need for comprehensive cancer control to reduce premature deaths. [3] In 2015, Sustainable Development Goals (SDGs) 3.4 and 3.8 emphasized reducing noncommunicable disease mortality and achieving universal health coverage. [4] WHA resolution 70.12 (2017) called for inclusive, well-resourced NCCPs with accountability and integration. [5] The UN Inter-Agency Task Force (2019) highlighted multi-sectoral collaboration on noncommunicable diseases (NCDs). [6] The International Atomic Energy Agency (IAEA), through “Rays of Hope,” aids MSs in incorporating diagnostic imaging, nuclear medicine, and radiotherapy into comprehensive cancer control. [7], [8], [9], [10] The World Health Organization (WHO) supports NCCPs via the Cervical Cancer Elimination Initiative (CCEI), Global Breast Cancer Initiative (GBCI), and Global Initiative for Childhood Cancer (GICC). [11], [12], [13] The International Agency for Research on Cancer (IARC) Global Initiative for Cancer Registry Development (GICR) assists in improving cancer data quality. [14]

The IAEA, IARC and WHO together have supported MSs develop their NCCPs, [15] including 15 of them during the COVID-19 pandemic. At the time of writing this paper, there is no common methodology to provide support in NCCP development. Depending on the stage of NCCP development, countries request different types of support from a variety of partners. For this study, we focused on countries that requested NCCP support from the IAEA.

At the time of the study in 2024, out of 13 MSs that received support in the period between 2020 and 2023, three had an active NCCP; three had finalized their NCCP but it had not yet been validated by their Ministry of Health (MoH); five were still drafting the document; and one was planning a new NCCP. The status of the NCCP for one MS was unknown. The aim of this study was to review experiences, identify best practices, challenges, and lessons learned for UN agencies to support NCCP development in low- and middle-income countries (LMICs) to continue to improve the engagement and outcome. The findings from the study will help the collective of agencies develop a methodology for support to MSs in NCCP development.

2. Method

We invited 13 LMICs from two WHO regions to participate in our study. All IAEA MSs who had formally requested IAEA support to develop their NCCP and received technical assistance from UN agencies between 2020 and 2023 were contacted to be included in this study. Additionally, we interviewed five IAEA PACT Programme Officers (PPOs) who coordinated that support.

We developed a questionnaire to collect feedback from the 13 MSs identified. The questionnaire was developed from a review of the literature on NCCPs and included 29 questions covering six areas: [16], [17], [18]

• 1.Leadership and governance
• 2.Planning and costing
• 3.Stakeholder mapping and engagement
• 4.Alignment with national and international initiatives, policies, strategies, and programmes related to cancer
• 5.Evidence-based NCCP development
• 6.Challenges and best practices

The questionnaire was developed in collaboration with the IAEA, selected MSs Focal Points (FPs), experts in NCCP development, IARC, WHO Headquarters, WHO Regional Office for Africa (AFRO), Pan-American Health Organization (PAHO) and the International Cancer Control Partnership.

The scope of the study was limited to the pre-planning (i.e., preparation of NCCP development) and planning process (i.e., actual NCCP development). Questions about NCCP implementation, evaluation and monitoring were beyond the scope of the study.

The questionnaire was shared with MSs in October 2023 (Appendix 2).

In March 2024, FPs leading the NCCP development in the countries of interest were invited for a semi-structured interview to collect their feedback on the support they received from UN agencies. We used the questionnaire co-developed with UN agencies, MSs and other international organizations as our data collection tool (Appendix 2).

Additionally, interviews were conducted with IAEA PPOs who coordinated the UN agencies’ support to develop NCCPs in these countries. An interview guide was developed, informed by the country stakeholder interviews, focusing on four categories:

• 1.UN roles and responsibilities
• 2.Method or process used to develop the NCCP
• 3.Challenges for countries and UN agencies
• 4.Best practices

Ten of the 13 countries invited completed their interview, and one completed the initial questionnaire, making a total of 11 MSs included in our analyses. Two MSs were excluded from the study as they did not reply to the questionnaire or invitation for an interview. Interviews were conducted with the FP who coordinated the NCCP development and sometimes one other representative from the MoH. In total, 18 stakeholders from MSs were engaged and five PPOs interviewed.

The team conducting online interviews consisted of representatives from the IAEA, a member of the WHO Regional Office of the respective country, WHO headquarters, and a research consultant. Depending on the country and stakeholder, either English or French was used. Interviews were recorded and lasted on average 45 min.

The transcript of each interview was manually reviewed for accuracy and pseudonymized. French transcripts were translated to English using the automatic translation from Teams and reviewed by a French-native speaker, before data analysis. The pseudonymized transcripts are stored within the IAEA’s internal system with restricted access.

We followed a coding method derived from thematic analysis to identify similarities, differences, and themes across the 11 countries. [19], [20], [21] The analysis was supported by developing a matrix framework to organize the data based on categories (Fig. 1). Data were first organized by the categories from the interview guide and then coded inductively by Interviewer #2, i.e., a code book was developed from the data content as opposed to a priori. Codes were then grouped in three themes by Interviewer #1 and Interviewer #2 and both researchers read the transcripts again to capture any additional codes from the data. Saturation was reached after the second round and both researchers compared their coding for reliability and to limit bias.

Fig. 2.

Case Study, Kenya.

Fig. 1.

Thematic analysis framework, adapted from Clarke and Braun.

3. Results

Analyses of the 10 transcripts and one set of responses to the online questionnaire generated 14 codes that we grouped into three themes (Table 1). We discuss each theme below, as illustrated by selected quotes (Table 2).

Table 1.

Challenges and enablers of UN support provided to develop NCCPs.

Themes	Sub-themes (codes)	Challenges	Enablers
Management & Coordination	Coordination Mentioned: 7/11 MSs 5/5 PPOs	▪Organizing & scheduling stakeholder meetings ▪Holding stakeholders accountable for their assigned work ▪Setting realistic milestones
	Focal Point Mentioned: 4/11 MSs 4/5 PPOs	▪Training specific to the role of the Focal Point ▪Soft skills (e.g., chairing a meeting, setting agendas) ▪Experience in developing a national health plan ▪Limited time capacity
	National Focal Team Mentioned: 7/11 MSs 4/5 PPOs	▪Limited time capacity to write the NCCP ▪Uncompensated for their time
	Roles & Responsibilities Mentioned: 10/11 MSs 3/5 PPOs	▪Setting expectations between Member State and UN agencies ▪Different understanding of roles and responsibilities between the National Focal Team and international experts	▪Ownership, commitment and direction from senior leadership in Government to develop the NCCP ▪Executive role from the National Focal Team to organize workshops and consultations with relevant stakeholders
	Local Conditions Mentioned: 5/11 MSs 2/5 PPOs	▪Impact of COVID−19 and restrictions on meeting in-person ▪Poor internet connections ▪Time differences between UN agencies, international consultants, and Member States ▪Cultural differences working online versus in-person
	Stakeholder Engagement Mentioned: 9/11 MSs 4/5 PPOs	▪Struggle to meet the needs and interest of all stakeholders	▪Consultation with relevant stakeholders early on in the process (ideally starting from the evaluation of the previous national cancer strategy to identify priorities for the new NCCP) ▪Empowered civil society and public awareness of cancer as a public health issue
Developing the NCCP	NCCP Development Methodology Mentioned: 7/11 MSs 4/5 PPOs	▪No step-by-step methodology for developing an NCCP, requiring MSs to develop their own approach or rely heavily on UN agencies for guidance	▪Having a clear roadmap with a realistic timeline agreed upon by the Member State and UN agencies ▪Suggested steps from successful examples, in consultation with relevant stakeholders for each of these steps: 1) evaluation of the previous national cancer strategy; 2) evaluation informs identification of national priorities for the new cancer strategy; 3) translation of priorities into strategic goals; 4) definition of programmes and activities associated with the strategic goals; 5) costing of programmes and activities ▪Developing the NCCP closely linked to resource mobilization for implementation of activities, e.g., presenting goals and activities early on to the Government for budget allocation, having people responsible for budget allocation on the team to develop the NCCP
	Writing the NCCP Mentioned: 9/11 MSs 5/5 PPOs	▪Limited training and experience writing an NCCP ▪Distinguishing between a strategic objective and a guideline or policy objective ▪Different understanding of responsibility of ownership on whether the MS or UN agencies would write or lead the writing of the NCCP ▪Setting realistic objectives and milestones	▪Pragmatic approach to writing the NCCP: strategic goals and associated programmes should take into account resources available for implementation
	Costing the NCCP Mentioned: 4/11 MSs 1/5 PPOs	▪Not including health economists on National Focal Teams ▪Need to submit separate request for costing support	▪Planning for costing of the NCCP as part of the development process and accounting for this exercise in the timeline
	Implementation Plan Mentioned: 2/11 MSs 1/5 PPOs	▪Not including implementation planning as part of the development process
	Country’s Policy Process Mentioned: 2/11 MSs 3/5 PPOs	▪Limited engagement with in-country policy development processes to ensure alignment	▪Guidance from the Government on national process to enact health-related national strategies
Governance	Leadership Commitment Mentioned: 4/11 MSs 2/5 PPOs	▪Limited resource allocation (human and financial) to support development of NCCP ▪Competing national (health) priorities	▪Leveraging the political momentum from an imPACT Review or similar event to develop the NCCP ▪Leveraging civil society to raise awareness on cancer and increase public accountability
	Funding Mentioned: 8/11 MSs 4/5 PPOs	▪Limited funding to support development of NCCP	▪Allocation of budget from Member State for the development of the NCCP, in particular for organizing workshops and consultations with relevant stakeholders
	Changes in Government Mentioned: 3/11 MSs 2/5 PPOs	▪Changes in government impacting national health priorities and validation of NCCP

Table 2.

Quotes from semi-structured interviews with Member States that received UN support to develop their NCCPs.

Themes	Sub-themes (codes)	Quotes
Management & Coordination	Coordination	“A challenge was the coordination of the project.” (Respondent #3.12, C12)
	Focal Point	“If there were future training opportunities for coordination for all these documents, I would really embrace them because I think this is not the last document that we will produce.” (Respondent #1.8, C8) “When you give it [coordination] to someone who has got a full-time job, then to coordinate with writing as well, that was a big challenge. I think that was a mistake from our part that needs to be corrected in the future.” (Respondent #2.12, C12) “This is somebody that generally needs to have that commitment, that influence, you know, a little bit technical, but really that manager, that senior manager that's going to make things happen.” (Person #2, C3)
	National Focal Team	“For example, the plan is built around 6 pillars. So, if we had to talk about the pillar dealing with palliative care and Doctor [anonymized] wasn't there, we had to change because she was the one who knew about palliative care and we had to adapt to what we were going to discuss." (Respondent #1.10, C10) “As I said before, the people that will work on this project are people. That is a doctor that has time in the hospital and then in their free time they can meet, maybe collaborate with you. They are not paid for this, and we have the support from the IAEA but we just have one person that is online working with these seven or eight groups with ten people on it. So, we needed more like a manager that works with us in [C9] so we can call the groups, make the agenda.” (Respondent #1.9, C9) "The work, all the formatting, integration, comments and all that, fell to us, the service team [i.e., National Focal Team], and it was really a big job for us. That's really what was difficult" (Respondent #1.10, C10)
	Communication, Setting expectations, Roles & Responsibilities	“A challenge is the need to understand the process from the start. All the teams and the people that will be involved need to understand the process better and not just one virtual meeting.” (Respondent #1.9, C9) "When we had these prioritizations, we had to get down to the drawing board to actually start drafting the document and so, at the beginning, we thought that maybe… when we talked about the IAEA's support, it was them who were going to write with us […]. That's how we understood it, but at some point, as things unfolded, we realized that it was the country that was going to write." (Respondent #1.5, C5)
	Ownership	“This is why we consciously in our Terms of Reference place the drafting and development and stewardship and the actual public presentation of the document in the hands of the Ministry of Health and stakeholders because it should be their plan. […] I think we can help them a lot in drafting specific critical sections of the plan that might be technical. But even then, I think we need to be very, very careful and make sure that this is then taken on board by the Ministry of Health and that the whole document is their document.” (Person #2, C3)
	Engagement from International experts	"The consultant who was identified would have been better if it had been someone from [C2], for example. He would have better understood the expectations, […] the context and the usual functioning." (Respondent #1.2, C2) “Even though he (international expert) has all the goodwill, he was difficult to reach, and he does not know the reality here with the experts and with the groups and with the time and with the lack of money for this work.” (Respondent #1.9, C9)
	Local Conditions	“We weren’t used to working virtually, online. It was something that a lot of my colleagues had to get their head around and there was a lot of persuading. So, in terms of participation, it wasn't ideal. I know now it's become sort of the norm, people working from home, people working online. But it was very difficult for us, I think even for the experts. We had to coordinate the times and we found it very cumbersome.” (Respondent #1.7, C7) “I'll start with the internet connection … sometimes there are blackout, it’s a really big challenge.” (Respondent #1.10, C10)
	Stakeholder Engagement	“Personally, I think we've been trying to be too cautious in the development of the NCCP. Sometimes taking everyone on board and try to do a step by step protocol is good, but sometimes it delays [the process].” (Respondent #1.8, C8)
Developing the NCCP	NCCP Development Methodology	“Another challenge was about the NCCP process.” (Respondent #1.9, C9) “I think that will be very important if the local team and the local experts know what they are making because here they didn't even know what they were making in the beginning.” (Respondent #1.9, C9) “We spent a lot of time trying to define what are our priority areas, but not necessarily being informed by data because we didn’t have the situational analysis done.” (Respondent #2.12, C12)
	Writing the NCCP	“In terms of finalizing, refining, I think it didn't work too well and this is part of the reason why the NCCP is still not finalized.” (Respondent #1.7, C7) “I think at this point we need an expert […] to just look at what we have so far […]. They know exactly what needs to be in a finalized document.” (Respondent #1.7, C7) “I remember there was a time when I said we needed someone who could make this document read like a strategic document because at some point it felt like it was a guideline.” (Respondent #2.12, C12) “I remember […] we were meeting with the consultants and there were things that were being discussed and somebody was like, you know what, we are not getting a clear direction of what goes into a strategy document and what doesn't go into a strategy document.” (Respondent #2.12, C12)
	Realistic NCCP	“Sometimes you find that at the end of the day, the document is more aspirational rather than being very pragmatic in terms of available resources. […]It's not an easy challenge to manage, you know, balance between the aspirations and the resources available.” (Person #5, C4) “It's important to align the NCCP development process with the potential opportunities that exist towards implementation of the plan.” (Person #4, C4) “[The Committee appointed for developing the NCCP] in the perfect world should become at the end of the process, the Steering Committee of that plan. They also want to be the actors that monitor the implementation, that advocate for more funding, that are able to discuss or interact with both the beneficiaries of the plan and the [actors] that will allocate or not funding.” (Person #3, C5) “Although the experts knew a lot, I kept on asking them, OK, you know what, let us know what the steps are because we have no idea. We've been involved in developing these strategic plans in one form or the other during our careers, in committees, but we don't really know how it's done, right […]. So, I kept on telling them: what do we need to do? […] What's next? And I think they weren't prepared for that.” (Respondent #1.7, C7) “At this point we need an expert […] to just look at what we have so far […]. They know exactly what needs to be in a finalized document.” (Respondent #1.7, C7)
	Costing the NCCP	"The rule for plans in [C2] is not to make a plan that will be theoretical and that doesn't take into account our resource mobilization capacities. So budgeting was complicated, in the sense that needs are enormous, resource mobilization capacities are low and we really had to focus on what was essential and what could actually be sustained over 5 years. So we also had to make trade-offs." (Respondent #1.28:52, C2) “Costing of this document, that is the problem at the moment. We were not able to develop or to cost the plan, so this is where we have the delay and where we approached WHO country office for support.” (Respondent #1.13, C13)
	Implementation Plan	“As it is for now, there is no activity implementation plan.” (Respondent #1.13, C13) “It's not about developing the greatest NCCP that no one has seen. It's about the plan that you're going to implement.” (Person #2, C3)
	Country’s Policy Process	"The biggest challenge for us was to respect the different stages of developing a policy document in our country, and I think it's important that when countries draw up their plans, they respect the standards in their own countries.” (Respondent #1..2, C2)
Governance	Leadership Commitment	“When a country wants to make such a great product as an NCCP, they need to have the political power to call the people that need to be working there. […] I was running the cancer control programme and I saw the need, but I was working there. So of course, I will see that we need that NCCP, but this needs to be seen by the President, by the Ministry of Health, by the Minister of Economics […].” (Respondent #1.9, C9)
	Funding	“We didn’t have enough financial support to do all the things that we needed to do. Sometimes we didn't consult together because the funds were not there, so we ended up having fewer meetings […].” (Respondent #2.8, C8) “Because the funding was also very modest, we weren't able to lure as many people nationally to get involved. […] I found that a lot of the work was on my back (Focal Point), […] it was a huge responsibility, and I don't have all the expertise, but we tried to do our best.” (Respondent #1.7, C7)
	Changes in Government	“The time of developing the NCCP coincided with a period of political transition. And not just transition, but actually a changeover from one administration to the next. So that was both an opportunity, but also a major challenge. We had already planned some of the workshops around the time the country went into elections. […] maybe it would have been faster if not for the transition.” (Respondent #1.4, C4)
Case study: Kenya	Methodology, Priority setting, Resource mobilization	“There are things you have to prioritize now. Which one do you want the government to fund and go and pitch. […] And then there are also those that maybe you can ask [resources for] from partners. Those ones, you don't have to push through.” “We spent a lot of efforts to marry those two processes [NCCP development and resource mobilization], which I think was pragmatic and is always reassuring to donors and any development partner. The money or the resources you're looking for have that important policy backup, which in this case was the NCCP.”
	National commitment	“If [the process] gets extended beyond a year, then the whole energy really gets diluted and the initial expectations are no longer there.”

3.1. Management and coordination challenges

Seven MSs indicated they experienced challenges with coordination of the entire process at a national level to develop their NCCP, confirmed by all PPOs interviewed. This included organizing and scheduling stakeholder meetings, setting agendas, holding stakeholders accountable, and setting milestones related to completing the NCCP. Four MSs reported that their Focal Point (FP) was not trained or experienced in coordinating the process to develop a national health plan. These FPs needed not only the soft skills to be effective coordinators but also material support as most of them had full-time jobs in parallel. PPOs recognized the critical role of the FP for the success of the NCCP development. One PPO distinguished between the need for the FP to be an influential person at the MoH–someone with the power and authority to develop a new strategy for cancer control–and the need for that person to have someone assisting them in the execution of tasks such as setting up meetings and liaising with experts.

Seven MSs and four PPOs indicated that the National Focal Team (NFT) struggled to dedicate enough time to the preparation and writing of the document. Typically, NFT members were clinicians not compensated for the additional time needed to develop the NCCP. They had to attend to their full-time job, including seeing patients. Some NFT members were compensated for attending workshops, but not for the work taking place outside of these workshops, i.e., research and writing of the plan itself. Coordinating time from the NFT was also a challenge due to the busy schedule and professional commitments of these experts. This brought further challenges around different understanding of roles, responsibilities and time commitment, that aimed to set expectations on the type and level of support. From the perspective of the MSs, they request additional engagement from international experts on the development process and writing of the NCCP. The data show more focus is needed on how to develop the NCCP (through expert consultations in this field) in addition to providing support in key stages. In addition, providing support contextualized to the local cultural, economic and social conditions is challenging, and MSs expressed a desire to improve contextual expertise. Interviews with the PPOs showed the need for ownership of the NCCP development process by the MS, as this increases chances of the plan actually being implemented.

In addition to the challenges of coordination and differences in expectations, local conditions made it difficult to run the virtual meetings. Most of the support happened during the COVID-19 pandemic when travel restrictions were in place and physical meetings were prohibited. Coupled with a poor internet connection and important time differences with some of the MSs, successfully holding a series of online meetings was difficult. Working online was also a new working culture for some clinicians.

Engagement with stakeholders was an aspect of management and coordination of the NCCP development process that worked well in most MSs. Nine MSs mentioned that they identified national stakeholders early in the process and invited them to participate in initial meetings and follow-up workshops, with opportunity for more support in defining the role and contribution of each group.

3.2. Challenges related to the method of NCCP development

Seven MSs indicated that they lacked a methodology to develop their NCCP, which was confirmed by four PPOs. Most MSs developed their own approach to develop the NCCP, others relied heavily on the UN agencies for guidance. Nine MSs indicated that they struggled to write the NCCP. The FP and NFT were not trained on NCCP development: they did not know what an NCCP should look like, what should be included or excluded, and what the writing process entails. Some respondents indicated that they faced challenges to distinguish between a strategic objective and a guideline or policy. One respondent clearly indicated that they wished support included writing and editing of the NCCP document, as well as overall guidance on the steps to develop an NCCP.

From the PPOs’ perspective, they recognize the need for the NCCP to be a realistic plan that the MS can act upon once finalized. This includes making sure that objectives are tailored to the country's needs, that they are prioritized depending on available resources and within a defined timeframe. Writing a realistic NCCP also means having the right people involved in the development process with the knowledge, experience, and influence to implement.

The planned global methodology to develop the NCCP should include a methodology to cost the programmes and activities mentioned in the plan. Four MSs expressed the struggle they experienced in costing the NCCP, which led to delays in finalizing the document. NFTs did not include a health economist, which means that MSs needed to turn to external partners for additional support to cost the draft NCCP. In addition to its activities being costed, the NCCP needs an implementation plan. However, two MSs indicated that they struggled with this part of the process. At times, the NCCP development did not comply with national processes to develop a national health plan, which led to further delays in validating the plan with the MoH or the Government at large.

3.3. Governance challenges

Four MSs indicated limited leadership commitment as a factor that hindered the development of their NCCP. This translated to little to no time and resources allocated to develop the NCCP. Sometimes, the economic situation of some MSs meant that even if there was commitment, limited or no funding was available to organize workshops with stakeholders and ensure adequate human resources capacity at the MoH to develop the NCCP. Eight MSs indicated limited financial resources as a challenge, confirmed by four PPO interviews.

Leadership was also altered by changes in government in three MSs where the Minister of Health or other key high-level officials changed during the development of the NCCP. On these occasions, leadership of the NCCP development was interrupted or discontinued altogether.

Case study: Kenya

The example of Kenya illustrates many enablers in successfully developing NCCPs. [22] The country had previous experience in developing NCCPs and benefited from UN agencies support in cancer control, including IAEA support to develop a strategic funding document to mobilise resources. Bearing in mind that each process must be tailored to the country needs, we mention below a few general principles that could guide the development process in other MSs.

From the outset, the Kenyan FP and NFT had a clear roadmap to develop the NCCP. The process was led by the MoH who called on UN agencies to support targeted areas. The roadmap was aligned to the national process to develop health-related strategic plans ensuring buy-in from all actors that would later validate the NCCP.

First, Kenyan experts conducted an evaluation of their previous cancer strategy (2017–2022). [23] This exercise built on the already established monitoring mechanism for the 2017–2022 strategy implemented through a series of annual meetings that included all stakeholders responsible for implementation at national and regional levels. The evaluation of the final year was geared towards informing the priorities for the new national strategy. Secondly, the NFT ensured that the prioritization exercise for the new NCCP was pragmatic, noting that the activities and programmes presented to the MoH would be competing for limited resources. This would ensure that once a programme was accepted by the MoH, a specific budget line would be created and resources allocated towards its implementation. This process ensured that a) strategic goals were genuinely prioritized and tailored to the situation in the country; and b) programmes mentioned in the NCCP and validated by the MoH would be prioritized for funding, which increases chances of implementation.

Once the Kenyan NFT defined the priorities for the new NCCP, they called for support from UN agencies. This means that the Government and the NFT not only had a clear roadmap on how to develop their new NCCP and identify areas where UN support could focus but also had ownership of the entire process. The clear roadmap and definition of national priorities, as well as targeted UN support to these areas, were crucial to a successful government-led NCCP development process.

Support from UN agencies focused on integrating cancer registry, early detection, diagnostic imaging, pathology, and radiotherapy in the NCCP, costing of the NCCP, as well as translating national priorities into strategic goals and associated programmes of activities. Once these activities were determined, WHO supported costing the entire NCCP and IAEA provided expertise to cost radiation therapy services. The NCCP was supplemented by a Monitoring, Evaluation, Accountability and Learning (MEAL) framework to ensure implementation of the newly developed NCCP. [24] The MEAL framework itself was costed, and funding was identified for its implementation.

Key national and international stakeholders were consulted early on under the framework of the national Technical Working Group and contributed to evaluating the previous cancer strategy and defining the priorities for the new NCCP. Participation from a large array of stakeholders was facilitated by the organization of workshops by the Government and a possibility to participate virtually for those not able to travel. This people-driven process is anchored in Article 10(2)(a) of the Kenyan Constitution which states that a new policy cannot be enacted without adequate public engagement. [25] Participants included both State and non-State agencies, such as academic institutions and civil society organizations. Representatives from sub-national health management teams and several government Ministries (Agriculture, Environment, Education, and Interior) were involved to ensure coordinated activities at different levels of the health system. Participation of stakeholders in evaluating the previous and current NCCP also contributed to promoting accountability of all actors in implementing cancer programmes.

The prioritization of feasible strategic goals, participation from key implementation stakeholders, and costing of the activities contributed to make the new NCCP realistic, rather than an aspirational document. Because activities validated by the MoH had to be budgeted, the planning process was intricately linked to resource mobilization for implementation. Actors involved in the development later presented the activities to be integrated into the Kenyan joint ministerial plan to determine budget allocation.

There was a strong commitment from senior leadership in the Government to develop the new NCCP, observed through the organization of workshops and allocation of a budget to consult with stakeholders in evaluating the previous cancer strategy and defining new national priorities. While senior leadership commitment ensured that developing the new NCCP was a priority, the NFT executed the groundwork (organization of workshops, consultation with stakeholders, coordination with UN agencies).

The second imPACT Review (2016) played a role in prioritizing cancer in the national agenda, with the creation of the National Cancer Control Programme at the MoH to coordinate the development and implementation of the first NCCP. More generally, there was also a good public awareness of cancer both in Government and at population level, fueled by a vibrant civil society that raised awareness about cancer as a public health priority.

The Kenyan example highlights a few general principles that serve as enablers in successfully developing NCCPs. According to one interviewee, the three main enablers to developing the NCCP in Kenya were “(1) policy commitment (2) awareness and the (3) population itself being empowered to ask questions and then stakeholders working together to drive the agenda.” Enablers are summarised in Table 1.

4. Discussion

This study highlights experiences of LMICs in developing their NCCPs and offers opportunities for both the country teams and the respective UN agencies in future collaborations. We identified modalities of communication and engagement, country expectations, government ownership, and availability of human capacity and technical expertise at national level as key determinants of a timely and quality development of a new NCCP.

4.1. Management and coordination

The role of the FP is crucial in ensuring efficient coordination of the development of a new NCCP. They are the primary point of contact between the IAEA – coordinating UN support for MSs queried in this study – and national (or local) NCCP development process. The FP should be someone with experience, influence and decision-making power to drive high-level action, have strong skills in leading, coordinating complex projects, and managing people. As such, the success of the new NCCP development depends largely on the FP. Additionally, WHO plays a vital role in convening MSs and fostering engagement through its country offices, serving as a critical entry point for the three UN agencies to secure strong commitments from the MoH.

While members of the national team receive recognition for being part of developing their NCCP, FPs often have a full-time job, not related to their role in coordinating the NCCP. Some of them were not senior enough to have the necessary influence. Others were experts in their clinical field but lacked the experience required to manage the NCCP development team. We observed similar characteristics for the NFT, which was often composed of oncology experts who had full-time jobs, not compensated for their time, and without expertise or experience in developing or writing strategic documents. There is a need for inclusion, within the NFT, of professionals who are experienced in the national health planning process to guide the development of the new NCCP.

Additionally, the question of ownership also appeared as a crucial factor to develop a new NCCP. Most MSs expected more ownership from UN agencies, probably influenced by their previous experience of receiving an imPACT Review, for which the UN does take the lead. [26], [27] However, IAEA PPOs emphasised that developing an NCCP should be led by national authorities. A National Plan should be written by national actors leading the country’s efforts in national cancer control for the next five to ten years. Its content must be strategic, prioritized, developed and accepted by the State actors who will be responsible for its implementation. [28]

4.2. Developing the National Cancer Control Plan

The two most significant challenges that we observed when it came to developing the NCCP were the uncertainty of MSs on the steps to follow to develop a strategic policy document and the writing of the document itself. In Kenya, where we observed a strong ownership from the Government and clear alignment of internal policy processes, the NFT knew how to develop and write a strategic policy document, and they knew where the support from UN agencies would plug into that process.

At the time of writing this article, there is not a standard approach to develop an NCCP. The WHO is designing a WHO Academy course for programme managers to support NCCP development, to complement existing guidance and technical guidelines on cancer control. [29], [30], [31], [32], [33], [34], [35], [36] Further guidance and resources are available from IARC and the International Cancer Control Partnership (ICCP). [37], [38] Developing a standard document to guide the development of NCCP is a global priority. This document is under development based on the lessons learned collected from this study and other feedback. It should give enough flexibility to tailor the approach to each individual country's needs. Separate from this, each MS should align the development of an NCCP to their internal policy processes and take full ownership of the process, regardless of whether guidance is available.

4.3. Governance

Linked to the question of ownership is the governance structure of the NCCP development process. Without clear leadership and accountability from the MS, appropriate funding for the NCCP development is unlikely and the FP, NFT, and UN agencies cannot develop a new guidance document. A 2024 WHO regional assessment of breast cancer control capacity in the African region shows that of the 42 countries that have an NCCP, only 12 allocated funding for its implementation. [39]

This is particularly challenging when the NCCP development coincides with a change of government. In such situations, national health priorities may change and development of the NCCP might be delayed or no longer considered a priority for the country. In such instances, UN agencies can help mitigate the effects. For example, a briefing could be requested from the new government to give an update on the steps taken so far and what is planned next. During this briefing, national stakeholders such as professional organizations, representatives of hospital staff, researchers, patient organizations, local non-governmental organizations, the Ministry of Education, Ministry of Finance and Ministry of Science and Technology, could be invited to strengthen advocacy for developing the new NCCP.

4.4. Lessons learned

Lessons learned are organized based on phases of the development of an NCCP: 1) Country readiness; 2) Pre NCCP development (phase 1); 3) NCCP development (phase 2); and 4) Post NCCP development (phase 3). A fifth category on resources is also included (see Table 3).

Table 3.

Lessons learned for UN agencies and Member States to strengthen support to develop National Cancer Control Plans in low- and middle-income countries.

Phase of NCCP development process	Lessons learned	Responsible entity
Country readiness	Management and coordination: 1.Develop a country readiness checklist.	UN agencies
	Management and coordination: 2.Mobilize the necessary resources (financial, governance) to conduct the process and implement the NCCP. 3.Identify capacity at the MoH to develop health policy and related programmes, including possible alignment with ongoing programmes (e.g., HIV, PHC, UHC, NCDs). Governance: 4.Establish a National Cancer Control Programme and a National Cancer Committee responsible for the development, implementation, monitoring and evaluation of the new NCCP.	Member State
Pre NCCP development – Phase 1	Management and coordination: 5.Develop, in consultation with the Member State, clearly defined roles and responsibilities in the Terms of Reference of the support for NCCP development, ensuring each actor understands its role and responsibilities within an estimated timeline, including responsibility of the National Focal Team to write the NCCP document. 6.Support Member State in mapping the relevant stakeholders for the development of the new NCCP. NCCP development methodology: 7.Contribute to the elaboration of a country-contextualized action plan to develop the new NCCP, lead by the MoH. 8.Anchor the NCCP development process within the WHO Country Strategy. 9.Coordinate training of the Focal Point and National Focal Team in developing and writing strategic policy documents.	UN agencies
	Management and coordination: 10.Nominate the Focal Point and National Focal Team in alignment with the Terms of Reference signed with UN agencies. 11.Ensure the Focal Point has the necessary authority and capacity to keep a solid communication flow with UN agencies, lead the National Focal Team and coordinate the NCCP development process. 12.Ensure the Focal Point develops a schedule of meetings with stakeholders that include a defined agenda, objectives and timeline. NCCP development methodology: 13.Review previous NCCP to identify strengths and weaknesses in its implementation. 14.Prepare a country-contextualized action plan with UN agencies to develop the new NCCP based on UN guidance. 15.Ensure the agreed action plan to develop the new NCCP is feasible within the limits of national capacities and coherent with established procedures to develop national health policy. 16.Plan for the new NCCP to include an implementation plan and a monitoring and evaluation framework.	Member State
NCCP development – Phase 2	Management and coordination: 17.Coordinate development of the new NCCP in parallel of mobilization efforts for its implementation. Governance: 18.Ensure the new NCCP includes a costed governance structure for its implementation, monitoring and evaluation. 19.Develop the new NCCP in coordination with all the relevant directorates at the MoH and government levels to ensure continuity despite potential changes in government.	Member State
	NCCP development methodology: 20.Support the Member State with resource mobilization efforts for implementation of activities mentioned in the new NCCP. Governance: 21.Prepare to handle changes in government that may affect national health priorities.	UN agencies
Post NCCP development – Phase 3	Governance: 22.Anchor support for NCCP implementation within the IAEA Technical Cooperation framework and WHO Country Strategy.	UN agencies
	Governance: 23.Establish governance structure with appropriate financial and human resources for the implementation, monitoring and evaluation of the new NCCP.	Member State
Guidance	Management and coordination: 24.Provide technical guidance for planning of diagnostic imaging, nuclear medicine and radiation therapy services within the NCCP. NCCP development methodology: 25.Provide technical guidance on radiation medicine to make sure it is included in the new NCCP, and provide continuous support after NCCP endorsement to implement, monitor and evaluate radiation medicine programmes. 26.Provide technical guidance on health and NCD strategic policy development. Governance: 27.Revive the cancer leadership course as a way to enhance capacity in cancer leadership at the Ministry of Health.	UN agencies

4.5. Limitations of the study

Our sample was small, one region was overrepresented (Africa) and the selection of interviewees might have influenced the results. However, the selection of countries was limited to MSs that had formally requested IAEA support and received UN technical assistance to develop their NCCP between 2020 and 2023. Our aim was not to generalize findings to all MSs but to review MSs experience in developing NCCPs with support of UN agencies to 1) improve for future NCCP development requests, and 2) develop a common methodology for support.

5. Conclusion

We identified various challenges that country teams face while developing NCCPs, including coordination of all stakeholders, limited time capacity of experts, differing expectations, and unclear understanding of the process to develop an NCCP. We propose recommendations for the methodology under development to improve collaboration and processes by systematically assessing country readiness before engaging in NCCP development (e.g., whether sufficient financial and human resources in country are dedicated to developing a new cancer control strategy) and by targeting specific support during the pre-development, development and post-development phases. Results from this study are informing the creation of a common methodology to provide support to MSs to develop their NCCPs. NCCPs developed with UN support have informed project planning for programmatic technical support by the three organizations. In the case of IAEA, NCCPs have informed regular technical assistance, the Technical Cooperation Program and Country Programme Frameworks. In addition, for countries in the first wave of IAEA’s Rays of Hope initiative, the national level plans provided prioritized areas for support. Some of the Member States have also developed Bankable Documents to focus mobilization of support (e.g., financial) for areas included in their NCCP.

This study is complementing a companion study lead by the ICCP that assessed the experience of MSs in developing their NCCP, outside of the pool of countries for which UN support was coordinated by the IAEA. Finally, the 2025 global review of NCCPs documented a general improvement in quality and number of NCCPs globally, despite several barriers that persist, such as costing of programmes. [40] This study complements the NCCP body of literature to further inform MSs in designing effective cancer control strategies that can be implemented to decrease inequalities in access to cancer care.

Ethical considerations

Informed consent was obtained verbally from all participants and recorded during the interview. The purpose of the study and the type of data collected were described to participants. The participants were informed that they had the right to refuse or stop participation at any point. Participants were not compensated for participating in the study. No personal information or identifiers were collected. All participants had a chance to review the manuscript and agree for their data to be included.

CRediT authorship contribution statement

Mary Nyangasi: Writing – review & editing, Data curation. Issimouha Dille Mahamadou: Writing – review & editing, Data curation. Lisa M. Stevens: Writing – review & editing, Validation, Supervision, Conceptualization. John Russell: Writing – original draft, Writing – review & editing, Methodology, Formal analysis, Data curation. Mauricio Maza: Writing – review & editing. Lisa Montel: Writing – review & editing, Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization. Andre Carvalho: Writing – review & editing. Valerian Mwenda: Writing – review & editing. Alfred Karagu: Writing – review & editing. Sharon Katai Kapambwe: Writing – review & editing, Data curation. Yannick Romero: Writing – review & editing. Marianna Nobile: Writing – review & editing. Geraldine Arias de Goebl: Writing – review & editing, Conceptualization.

Declaration of Competing Interest

The authors declare that they have no competing interests.

Appendix A. Supplementary material

Supplementary material