Developing a Sustainable Programme of Cervical Cancer Screening

A Scotland-Nkhoma PartnershipWith 3 years funding from Scottish Government International

Fund for Development in Malawi, 2013-2016

• In Malawi, cervical cancer is commonest cancer in women (45.4%)

• Malawi Minister of Health estimates that if nothing is done, the number of cervical cancer cases will rise by 60% by 2025.

Partnership

Scottish team: - Co-leads: Prof Heather Cubie; Dr Christine Campbell - Gynae team: Sr Hilary Brown; Dr Graeme Walker; Dr Miriam Deeny [Oct-Dec 2013] - Academic and Support: Dr Liz Grant; Dr Isabel Bruce

Nkhoma Team: - Medical Director & Surgeon: Dr Reynier Ter Haar - Deputy Medical Director & Physician: Dr David Morton - Project co-ordinator: Mr Savel Kafwafwa - VIA: Belito Madetsa, Harriet Chirwa, Savel Kafwafwa - Laboratory- Edson Kawonga, Rose Nkhoma, Mike

First planning meeting, May 2013

‘VIA Clinic’, May 2013

Aims of Project

To reduce the burden and mortality from cervical cancer by:• Upskilling VIA in Nkhoma Hospital and its associated Health Centres• Sensitisation of healthcare professionals and local population to value of

cervical screening• Providing treatment by cold coagulation through Scottish professionals

spending time in Nkhoma • Ensuring good follow-up of all non-negative VIA patients• Increasing awareness of data collection and analysis to establish a robust

evidence base for appropriate cervical screening• Providing HPV testing for potential triage to VIA • Interacting with Colleges of Nursing through VSO nurse tutors to develop a

curriculum module based on knowledge of cervical cancer screening and prevention

Successes -1Numbers!

Awareness/ sensitisation delivered to • Hospital Clinics [VIA, ART and Family Planning] daily for 4 months reaching 5,600 males

and females• 2 Traditional Chiefs, 24 Group Village Heads, over 150 Village Heads within the 10

villages, reaching ~20,000 peopleInfrastructure• 3 clinic rooms equipped and 7 Nkhoma staff trained to deliver VIA, with clinics running

dailyScreening• In Feb 2013, 24 women presented for cervical examination while in Feb 2014, 341 were

screened. • Overall, 2336 women seen in VIA clinics between October 2013 and March 2014Roll-out• 7 Health Centre staff now trained• Clinics commenced in 2 Health centres, one Government and one CHAM , in May 2014

Successes – 2Numbers cont

• 75% of women with treatable lesions received it on same day• Monthly increase- influenced by rains and harvest• Word of mouth spread of regular service has led to women

travelling from much further afield

VIA CC

Total First

visits Neg (2) Pos (1)Suspect

cancer (3)Advanced cancer (4) Other

Done on day

Postponed Tx (P1) Other

October (from 16/10/13) 275 267 235 26 5 1 3 20 0 1November 282 212 223 19 6 3 16 12 0 0December 192 159 146 29 5 0 8 19 10 0Total Q4 749 638 604 74 16 4 27 51 10 1

2014 January 157 130 108 21 9 1 15 19 5 1

February 341 318 290 27 7 2 11 20 7 0March 1089 1047 988 53 14 5 18 42 6 0

Total Q1 1587 1495 1386 101 30 8 44 81 18 1Half year total 2320 2109 1993 175 46 12 71 132 24 2

Successes – 3Additional skills

• Treatment by cold coagulation rather than cyrotherapy has been well received by staff and women, is cheaper, more transportable

• Biopsies – can now be taken in clinic rather than in surgery, giving cost saving and greater accuracy

• Expanded surgical skill set to radical hysterectomy due to expertise in Scottish team, providing better chance of survival for more women

Challenges

• For Partnership: Recognising The magnitude of the problem e.g with population served by Nathenje

(first Government Health Centre involved) it would take 8 years of daily clinics to reach all eligible women

Success should not be measured mainly by numbers of women screened but by good clinical outcomes for women with abnormalities

• For Scottish team: Understanding thatthere are capacity pressures when staff have many different duties of which

VIA is one small partData keeping is not a strong point and considerable input is required on on-

going basis to ensure records are up to date• For Nkhoma team: Recognising the

importance of follow-up - addressed by introduction of monthly biopsy review and weekly palliative care clinics

service and skills must be maintained by consistent working practices and quality control, team work including sharing knowledge across different professional groups and by regular assessment of competence

Learning

Value of preliminary preparation- 6 months before the first woman was screenedNeed for continuing preparation for roll-out – training, competence and capacity, practical issues (Sufficient instrumentation for every clinic, adequate sterilising facilities and instruments ready for every clinic; stock taking eg vinegar)Communication – monthly, minuted skype calls with actions in addition to frequent email traffic with all members of both teams and more frequent visitsFlexibility- change from funding request for 9m each year of senior registrar level to shorter time from consultantsRecognition of time commitment – project funds part of salary of 5 permanent staff in Nkhoma; Scottish team have also invested much more time than anticipated which have resulted in

Learning -2

Enthusiasm, ownership and pride of local team – now see themselves as centre of excellence for cervical screening (commitment to quality service)likely to become additional training centre for MoHnow part of MoH Safe Motherhood Sub-Committeeword has spread not only to other parts of Malawi but beyond

International healthcare charity Founded in 1842 Works in Malawi, India, Nepal, Scotland Turnover £1 million Helping 68,000 poor and vulnerable people/year 14 staff, all in Edinburgh 3 programmes:

Maternal and Child Health Palliative Care Disease and Disability

EMMS International

PARTNER: EKWENDENI COLLEGE OF HEATLH SCIENCES

RNM AND CLINICAL OFFICER TRAINING, EKWENDENI COLLEGE OF HEALTH SCIENCES

Funded by: Scottish Government (£75,162) and EMMS International (£45,000)

July 2013 to March 2013 £120,162, of which:

£58,819 to partner to start courses £45,000 to partner for students’ fees and maintenance £13,343 for Edinburgh project management and 2 visits £3,000 for final evaluation

By 2016, Ekwendeni College of Health Sciences is running accredited 3-year RNM Diplomas and then Degrees, and 3-year Clinical Offi cer training, suffi cient to graduate

> 20 COs/year and >200 RNM/year,

with the first graduates in September 2016 (20 RNMs and 20 COs) bonded for 5 years to hospitals serving rural areas.

OVERALL OBJECTIVE

RENOVATIONS

EQUIPMENT

BOOKS FOR LIBRARY

CURRICULUM DEVELOPMENT

Working in partnership with 2 other donor-partners, Kwacha Foundation (Netherlands) and Medical Benevolence Foundation (USA) Fortnightly Skype calls Kwacha Foundation has mentored us MBF has provided additional monitoring

Renovations of hostels and classrooms are complete. Equipment and textbooks are nearly all purchased. Curricula are developed and approved by relevant

authorities. RNM course starts this month (June 2014). Clinical Offi cer course starts when Kwacha Foundation

approves its quality.

SUCCESSES WITH OUR PARTNERSHIP

Principal resigned right at project start! (Got a better job.) Replacement still not recruited. No deputy, but competent Acting Principal started immediately.

Financial management turned out to be less good than expected. We put 1-year finance training programme in place. Assistant accountant is responding well to training.

RNM courses in Malawi turned into 4 years instead of 3 Took months for College to gain accreditation for 4 th year from Mzuzu

University. Partner happy to start CO course with approvals from

Malawian authorities, while we 3 donor-partners want better quality. Potential for tempers to fray, but good relations with College chair

help smooth things over. Good relations among 3 donor-partners helps us stand firm.

CHALLENGES WITH OUR PARTNERSHIP

How to develop a curriculum in Malawi 1 year to develop each curriculum Medical Council of Malawi, Nurse and Midwife Council of Malawi Equipment, books, renovations Costs of developing a course and fees and maintenance

Many students are prepared to self-fund Partner wants to add in self-funding students in addition to those

funded by Kwacha Foundation.

All partners need some sort of financial capacity-building We contracted a Scottish accountant in Malawi to train.

Check which staff will take over if key staff leave. Know at least one board member well. Know deputies of key staff.

LEARNING FROM OUR PARTNERSHIP

Externally audited accounts If only the government would implement the requirement for all organisations to submit their annual externally audited accounts – College and Synod.

This would make a massive difference to Malawi.

Remember that many students are prepared to self-fund. Education is valued. People need it to improve their lives. People at this level of education (completed high school) are prepared to find funding for it.

HOW SCOTLAND MALAWI PARTNERSHIP CAN LEARN FROM OUR EXPERIENCES AND

STRENGTHEN BILATERAL RELATIONSHIP