United Nations Public Service Awards Case Studies

Breast cancer is the leading cause of death among women worldwide, yet, 75% of global deaths attributed to breast cancer occur in the developing world. Women in low and middle income countries are unduly undereducated, underserved and underinsured as well. These women suffer from the limited resources, inadequate health education and above all, they do not have an organized access to preventive and diagnostic procedures.
The importance of early diagnosis of breast cancer in reducing mortality has been demonstrated in many long-term studies of organized breast screening programs. Because approximately 1 in 10 women with a breast mass or abnormal mammography result will have breast cancer, a sequence of decisions must be taken to exclude or establish a diagnosis of breast cancer among these women. To establish a definite diagnosis, it is essential to refer patients for additional diagnostic services, including diagnostic mammography, ultrasonography, ultrasonography-guided biopsy, stereotactic biopsy and breast magnetic resonance imaging.
According to the global initiative awareness in Egypt, community profile findings in Alexandria, 2010, treatment expenses were not the sole barriers against Egyptian women in joining early detection programs. Misbelieves that treatment will work constituted 60.9% of restrictive barriers while 51.4% of women had ignorance of service location which means they do not know where or whom to go to if they discover symptoms of breast cancer.
Thus, it is quite obvious that the problem of breast cancer in developing countries is not only confined to the diverse barriers for participation in screening programs but is overwhelmed with the delay in the treatment of women with mammography signs suggestive of breast cancer. Delay in the treatment of breast cancer results in a considerable increase in the breast carcinoma death rate. Furthermore, it has long been apparent from many studies that such delay, and its lethal consequence, is also one of the most expensive malpractice category
In spite of the fact that the Egyptian National Screening Program, "The Women health Outreach program (WHOP)" offers completely free of charge post mammography diagnostic services for all Egyptian women joining the program, 65.6% of the ladies with suspicious mammography findings refused to join these services. On recall, they declared variable misconceptions and they had various adaptive and accessibility problems.
Thus, it has become essential to design special programs for underserved and under insured Egyptian women to eliminate delays in diagnostic resolution of abnormal screening mammograms, provide services for abnormalities noted during breast cancer screening, and to describe and assess post screening follow-up care.

What is the initiative about? (the solution)
It has been documented in many studies that compared with low- and medium-level resource countries whose health care systems typically lack core infrastructure elements, countries with well-funded health care systems have higher rates of breast cancer incidence, but also have better overall rates of breast cancer survival. The burden of high mortality rates from breast cancer in countries with low and middle income resources is equally halved between the lack of high quality diagnostic procedures and inaccessible dedicated post mammography services. It is impossible for women in these countries to receive appropriate care in a timely fashion, and thus most breast cancer cases are diagnosed at late stages of the disease. The “Women Health Outreach Program” (WHOP) is the first Government funded Egyptian National Breast Cancer Screening Program. Since the launching of the Program in 2008, it has been concerned with providing high quality and in the same time accessible free of charge diagnostic mammography services. Because most women joining the program are uninsured, underserviced and are of low socio economic standards, the program also offered free of charge post mammography diagnostic testing and different treatment options for women whose screening mammography outcome was abnormal. These women were referred to University teaching hospitals. Unfortunately, the provided services were structurally challenged to meet their intended goals. University teaching hospitals are overcrowded, inadequately organized and do not provide the optimum care for breast cancer cases. These services undermined and undervalued the anxiety and agony of these women. Many women with suspicious mammography findings refused to join the delivered services or escaped after their first visit. A phone conducted open format questionnaire was delivered to these women. "The post mammography services are tedious and time consuming" was one common complaint amongst these women. With a strong determination to enhance the delivery of post mammography services with improved quality through adequate coordination, the idea of the "Multidisciplinary Breast Cancer Clinic" was born. The breast clinic is a virtual unit based on the collaboration of various professionals. Up till now, the core staff members include breast cancer experts including radiologists and surgeons, technologists, nursing staff, data managers, clerks, IT engineers and in the near future breast pathologists all working under one roof to provide the best available breast cancer care in a time orderly fashion. It has been documented that the most efficient screening and the best treatment of patients are available at the breast centers that combine up to date diagnostic facilities, expertise and significant curative option experiences. Outcomes Analyses of the clinic's performance was important to monitor its efficiency and effectiveness. The Breast clinic has accepted 1533 ladies with suspicious mammography findings within Cairo Governorate. Proved malignant cases were referred for further surgical intervention. By providing accessible and high quality post mammography screening services for these ladies, access to health care is increased, and the costs and efforts on the part of the patient are minimized.

Who proposed the solution, who implemented it and who were the stakeholders?
The “Women health Outreach Program” is an outcome of a cooperation protocol signed between the Egyptian Ministry of Health and the Ministry of Communication and Information Technology. . In January 2010, the "Multidisciplinary Breast Cancer Clinic" was established, in "WHOP's Center of Excellence" located in Fum El Khalig, Cairo Governorate. All ladies with suspicious mammography findings within Cairo Governorate are referred to the clinic to complete their diagnostic assessment. Ever since then, not a single women with suspicious mammography findings was turned away from the clinic. The clinic was committed to provide a multidisciplinary assessment to plan individualized treatment plans for breast cancer patients. When a diagnosis of breast cancer is made, it is imperative that a thorough discussion occurs with a surgeon who will present all treatment options. Thus, the core staff members were extended to include two breast surgery teams from the Cairo University Teaching Hospital and from the National Cancer Institute. They offered a free of charge service to all re-invited women starting from a breast clinical examination up to various surgical intervention options performed in either institutes. Referral links with breast oncologists were also established in both institutes. The clinic was set in collaboration with GE (General Electric) who supplied the project with two ultrasound logic machines. An ultrasound examination was performed to all women joining the clinic, and ultrasound guided biopsy was performed for selected cases on the same day. A full field digital mammography unit coupled with Stereotactic core biopsy, supplied by GE Healthcare, was also fixed in the clinic. Stereotactic core biopsy would be incorporated into the diagnostic algorithm for the study of nonpalpable breast lesions and breast micro calcifications. Because the success of any breast screening program lies behind the ability to achieve an accurate clinical, radiologic and above all a cytohistopathologic studies, an up to date pathology lab is under construction by Hoffmann La Roche. Immediate examination of core biopsy specimens are expected to save time, money and efforts. In addition, New Technology Egypt works in collaboration with Paxeramed View Corp. They provide the clinic with the soft ware used in data entry, reporting and statistical analysis. The above described achievements are performed under the umbrella of the Ministry of Health &population which provides the overall coordination of policy formulation, national data collection, quality control, monitoring and evaluation of WHOP's performance.

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
Being service providers, WHOP staff members recognized that their main objective is to deliver accessible and high quality services. They realized that key strategy to improve the quality of provided post mammography services and in the same time achieve patient satisfaction lies behind setting a comparison between the "expectations" of the women joining the program with the actual "current performance". In an attempt to study the "patients' expectations" we had to develop and use feedback mechanisms. This was approached via two paths. Complaints received by the call centre were re-evaluated and in the same time an 'open format questionnaire' was delivered by an enthusiastic WHOP staff member to all women who refused to join the program in the past. The feedback of the questionnaire was analyzed and the following results were obtained: 65.1% of the ladies complained from the place of the delivered services, 32.4%complained from the bad coordination between the Center of Excellence, University Teaching Hospital and the Call Centre, 22.9% complained from the tedious and time consuming procedures and 2.13% did not join the program because they feared surgery. Unfortunately, 15 women had no access to any organized medical care, 6 of them died and 9 were in a bad general condition with late stage disease. The "current performance" of the project's post mammography services was assessed by the "SERVQUAL" multiple item scale for measuring consumer perception of service quality. The customer touch points, which are the key point of interaction between the women and delivered services, were identified. These included four points: the mobile mammography vans, the Centre of Excellence, the call centre and the University teaching Hospital. Each delivered service through these points was assessed individually for: tangibles, reliability, responsiveness, assurance and empathy. The main objective of these two strategies was to reduce the gap between the actual ongoing and the expected performance of the delivered services. This entailed the collaboration of the efforts of all WHOP staff medical and non medical members together with the project's quality control team.

b. What were the key development and implementation steps and the chronology? No more than 500 words
By mapping the women's pathway along the customer touch points, WHOP staff members realized how tedious and time consuming the delivered services were. After performing the mammogram ladies with suspicious mammography findings were invited by the call centre to continue their investigations. Those who accept the invitation passed through a serial of visits to the University Teaching Hospitals to perform a clinical examination, ultrasound examination, ultrasound guided biopsy and receipt of the pathology reports before being given an appointment to surgery which may be also postponed several times. The services delivered by the University Teaching Hospital being overcrowded and disorganized, required at least 5 individual visits with an intervening time interval of at least one weak. Fig 1: The original tedious and time consuming pathway of the delivered post mammography services. Accordingly, WHOP staff members had to work hard to identify and dismantle the barriers that deterred the women from making use of the current post mammography services. Putting the results of the delivered questionnaire in view, this complicated pathway was attacked at all levels. This attack was based on four principles: maintaining standards of care by retraining employees, establishing good patient communication, ensure access to the full range of post mammography services and therapies and involving the patient in decision making. According to a systematic decision making strategy, several solutions were postulated and evaluated. Mobile Van employees were retrained to shorten the waiting time before the mammogram performance and to ensure proper data entry which in turn ensures accessibility to demographic data. To establish good patient communication, the call centre was bypassed and the women were re-invited directly via the Centre of Excellence employees. This reduced patient anxiety and reduced waiting time between the detection and the diagnosis of mammography perceived abnormalities. After the inauguration of the Centre of Excellence Breast clinic, the patient is now asked to come for a single visit to receive all delivered services, including clinical examination, ultrasound and biopsy. A dedicated clinic, exclusively performing to serve these ladies was a much better alternative to the overcrowded clinics of the University teaching Hospital. Candidates for surgery are also given several place options to choose from for surgical intervention.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
Under the present socio economic and cultural conditions, it was not expected that by simply upgrading the delivered services we would anticipate better attendance to the breast clinic. In addition to the usual financial, cultural and socio economic constraints, health literacy and inability to make health decisions were the most difficult to tackle. No doubt health literacy, which is common among illiterate ladies living under poor socio economic conditions, has a major impact on breast cancer outcome including both morbidity and mortality rates. Most women are positively conditioned that if they feel a lump in their breasts they might have breast cancer, but most of them do not know that they do not have to feel this lump to have breast cancer. Adding to this, the breast cancer stigma, it was a real challenge to convince these women to rejoin the program. An enthusiastic, talented staff member took over this duty through phone calls to the women and in the same time she trained some younger staff members to do the same job. Although convincing others is a natural talent she believed that others could acquire this by training and time. Through, prolonged phone calls, she gave the women enough time to express their fears and concerns and in the same time she was empathic, understanding and had profound knowledge of their clinical condition. Because we are mostly dealing with enclosed communities, convincing one woman to come was usually expected to be followed by others. Of course, financial constraints could not be disregarded. Although WHOP is fully financed from the Egyptian MOHP, but there is no specific money allocation for WHOP and all of the expenses are included in the general budget of the MOH, so we had to find separate resources to maintain the unit. Several awareness and fund raising campaigns delivered mainly through radio and television as well as banners held at special sites (e.g. clubs and public places) and special occasions (e.g. run for cure) were also used to overcome financial and cultural challenges include reluctance, misconceptions that breast cancer is a rapidly fatal, non curable condition and self denial of the disease. We also faced the challenge of providing equity of care for women living in rural or remote locations. Although establishing the 'Centre of Excellence Breast Clinic' was an important turning point in improving the quality of delivered services, it should be admitted that it did not solve the problem of many women living in rural areas with geographical and transportation barriers standing against giving them equal chances. Mobile breast clinics, are under trial to overcome this challenge. New mobile vans with portable ultrasound units are intended to outreach ladies within their remote communities. This will provide them with a mobile one stop clinic.

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The Multidisciplinary Breast Cancer Clinic staff members consist of a multidisciplinary team which includes a medical group (mammography reading consultants, surgeons, pathologists and oncologists), a para medical group (nurses, technicians and co-technicians), administrative staff as well as technical support staff and in the near future breast pathologists. These members were recruited according to their professional qualifications each according to his/her specialty. Ongoing training and upgrading courses are delivered to these staff members. In addition, training to future expected staff takes place to go in line with the program objective and to keep pace with expected expanding future requirements. Financial resources are mainly supplied by Hoffman La Roche Ltd, Ministry of Health, Ministry of international Co-operation, USAID and New Technology Company. Fund raising celebrations and campaigns are held at special occasions. A bank account has been established to receive donations as well. Technical resources mainly include computers, workstations, DSL connections, mammography and ultrasound machines that are fixed in the multidisciplinary clinic and in the mobile vans which are mainly supplied by New Technology Company. The multidisciplinary breast clinic started by a demo mammography machine supplemented by two demo ultrasound units. Through communication with the different major supplying companies in Egypt we got a free mammography unit as well as 2 ultrasound machines which are now running the clinic supplied by GE General Electric. Digital Mammography Units and ultrasound Machines fixed in the mobile vans are supplied by Philips Electronics The Egyptian Foundation for Breast Cancer Elimination supports the follow up unit through buying disposable supplies needed to run the unit.

Is the initiative sustainable and transferable?
In fact, WHOP is the first program of its kind to implement the principle of the Multidisciplinary Clinic in Egypt. For women with breast cancer, there is evidence that multidisciplinary care has the potential to reduce mortality, improve quality of life and reduce healthcare costs. In previous studies, the treatment options recommended for breast cancer patients by a multidisciplinary panel differed from that recommended by the individual physicians and were more likely to accord with internationally accepted standards of “best practice”. By operating mobile units WHOP brought mammography clinics close to the target population, especially women living in rural areas. Using telecommunication technology ensured rapid expert diagnosis of screening results. The project improved the early detection of breast cancer in Egypt. Combining early detection with free treatment gives women the best chance of surviving the disease. Considering the inequity in the access of healthcare services between women living in rural and urban areas, the principle of the above mentioned mobile multidisciplinary breast clinic should be applied to outreach women within their local communities to overcome geographical and transportation barriers. Taking a global look, the unique experience of the multidisciplinary clinic could be replicated in other countries and should be applied to other cancers and chronic diseases as well according to each nation's requirements. We think that every country should endeavor to set up at least one Centre of Excellence multidisciplinary clinic for each major health problem equipped with up to date diagnostic technologies, medical and paramedical expertise in the fields of diagnosis and treatment to implement the delivery of high quality diagnostic and therapeutic services.

What are the impact of your initiative and the lessons learned?
The idea of the multidisciplinary one stop breast clinic has saved time, efforts and cost burden and in the same time fulfilled the satisfaction of women with suspicious mammography findings. To enhance the health seeking behavior of the screened females, it was proved that, the smaller the number of steps they should pass among different health care providers, the better will be her compliance/ capacity to complete the required screening steps. Now, ultrasound, surgical examination, and biopsy are all conducted in one place and on the same day. Another achievement of the clinic, is including the BIRADS 3 cases in the free of charge post mammography services. Before setting the clinic, these services were only legible for women with mammography findings categorized as BIRADS 4 and BIRADS 5 categories with high incidence of breast cancer (98-100%) according to the Breast Imaging Reporting and Data System (BIRADS). Most mammography breast lesions categorized as BIRADS 3 with a low incidence of breast cancer (<2%) could not be referred to the University teaching hospitals due to the formerly mentioned working conditions' obstacles. According to previous studies, BIRADS 3 category can become a 'holding tank' for problematic lesions which are so categorized without further diagnostic procedures. It is documented that diagnosis of these lesions could be supported using more additional imaging techniques than in a screening setting. At this moment, amazing improvement was noticed in the health seeking behavior of the females. Outcomes Analyses of the clinic's performance was important to monitor its efficiency and effectiveness. The Breast clinic has accepted 1533 women (1225 BIRADS 3 and 308 BIRADS4 &5 cases) for further investigation along the past 14 months; biopsy was performed for suspicious cases and confirmed malignant cases were referred for further surgical intervention. Most of the women have expressed their appreciation to the delivered services through the clinic and some have also volunteered to share in future awareness campaigns. The idea of the clinic will be implemented in other governorates as well.


Institution Name:		Ministry of Health
Institution Type:		Government Agency
Contact Person:		Rasha Kamal
Title:		Professor Doctor
Telephone/ Fax:		002.0122.7457992
Institution's / Project's Website:		http://www.whop.gov.eg/
E-mail:		rashaakamal@hotmail.com
Address:		1053 Fum el khaleg ,kornish el nile, Cairo
Postal Code:		25252
City:		Cairo
State/Province:		Cairo
Country:		Egypt

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information