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Mobile Mammography UNIT
National Association for Cancer Awareness
Oman

The Problem

The cultural taboos and perception of “cancer” are deeply imbedded in the society. The accepted perception in society was that cancer was death sentence, there was no hope of surviving and the acceptable option was to submit oneself to “the mercy of the Almighty”. To talk about cancer was not acceptable and in many sectors it was deemed bad luck and potentially contagious. This attitude resulted in many cancer patients being diagnosed with the disease at relatively advanced stages of the disease and hence the correlation of cancer with death. More so, the notion that a women would request or discuss a breast exam was something that was tragically closeted, especially given that the medical profession was dominated by male physicians, even though female nurses and physicians were available and in practice. Any worrisome lumps or anomalies were mainly discussed (if at all) among the closest of family members who would invariably –unless the enlightened few – advise application of a home remedy and balm. As the Ministry of Health expanded its facilities and programs, physician referrals for mammography and other cancer screening involved long waitlists which frustrated the patients and in some cases this has resulted patients ignoring to follow up with their appointments and more tragically the disease progressing to a stage that result unfavorable prognosis/survival.

Other major issues that needed to be addressed were the growing number of women who were being diagnosed with breast cancer; invariably these women were in the capital area and had access to both public and private sector diagnostic services. The MOH mammography units were generally oversubscribed and the waiting list was long. This mammography did not use the latest digital technology. Private sector offered mammography for a fee which was not affordable by all women, especially those in the interior or with limited income. Women, particularly those in the interior, had limited access to mammography facilities and private sector services or care. In order to address many of these issues it was clear that any comprehensive cancer screening service would have to be accessible to all sectors of the community especially those living and working in the interior. Furthermore the service should be state of the art, efficient and provide meaningful diagnostic results in timely manner. Along with the screening service there would be workshops and campaigns to promote awareness and encourage self examination and self advocacy.

As a result of the strong and effective campaigns of the national Association for Cancer Awareness through working closely with multiple governmental agencies and private sector service provides, there has been a very noticeable increase in the number of people having checkups and more so requesting mammograms and other cancer diagnostic test. NACA initiatives with public awareness campaigns, workshops and fund raising event are witnessing increasing attendance by all sectors of the community. This has been extremely encouraging in confirming the efficacy of NACA initiatives and impact on the community. As a result, NACA are able to confirm that their initiatives have and continue to have a very positive impact on all sectors of the community but more so on women, children and communities in the interior regions of Oman.

Solution and Key Benefits

 What is the initiative about? (the solution)
The National Cancer Awareness Association was officially registered as an NGO in April 2004.

NACA has rapidly established its credibility and presence as an NGO committed to serving the community. Working on concurrent activities of raising awareness and funds to establish its headquarters, NACA immediately embarked on its first major initiative which was to commission a mobile mammography unit that would be made accessible to the entire community through well planned campaigns to the various regions of Oman offering state of the art breast cancer screening to all the community at no charge. This was an unique initiative that had never been implemented before. In conjunction with NACAs other activities the Mobile Mammography Unit (MMU) initiative would provide the following benefits in line with NACA objectives:

(i) Reaching out to all sectors ( Omanis and expatriates) of the community to promote awareness
(ii) Provide digital mammography screening to a sector of the community that would otherwise not have (ready/local) access to these services at no charge
(iii) Demonstrate and encourage local involvement, advocacy and social entrepreneurship by employing Omani radiographers, auxiliary staff and technicians
(iv) Empowering Women to support other women
(v) Generating and contributing to the comprehensive cancer registry
(vi) Endorsing corporate and other sponsorship and donations by demonstrating a tangible benefit of donated funds.
(vii) Contributing to the potential sustainability of the initiative through positive utilization of funds for a civic community initiative (in keeping with CSR ethos).

The MMU initiative has clearly benefited all the women of the community which could be extrapolated to improving the quality of life (befitting) the entire community (male and female, Omani and expatriate) by providing potentially life saving care/services to women. The benefits the community has derived from this initiative are and have been measured both qualitatively and quantitatively. A qualitative measure of the tremendous benefit of the MMU to the community is confirmed through

( i) Extensive and continuous verbal feedback and appreciation by women from all sectors of the community during the MMU campaigns, calls to the NACA HQ, recorded ( video) interviews of women who have used the MMU facilities and response from regional interest groups who have heard about the NACAs MMU initiative and are interested to provide a similar service for their communities.
(ii) A more significant and tangible qualitative measure of the positive impact of the MMU initiative is the recent overwhelming fund raising response for NACA’s new initiative for “A home Away from home” – an initiative that provides a house and home comforts for parents and children who travel from the interior of Oman to come to The Royal Hospital Oncology Unit for their treatment. This is clearly a positive measure of the success and confidence that the community, especially the corporate community, maintains for NACA’s ability to implement and sustain community initiatives in keeping with its founding objectives.
(iii) A quantitative survey was and conducted to measure the community response to the MMU. An overwhelming majority (over 88%) of the respondents agreed that the MMU has significantly and positively changed their lives, perception of cancer and their desire to seek additional tests and or care.
NACA continues to design and refine their feedback/measure questionnaires and surveys.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
NACA primary objectives were directed towards a solution, rather than passive discussion. NACA’s successful launch and fund raising campaigns provided the platform and impetus for NACA to embark on its first ambitious initiative that would endorse its objective of awareness and early diagnosis of cancer. Recognizing that over 22% of all cancers reported in Oman ( Ministry of Health, 2005 ??) were breast cancer it was clear that NACA’s initiative should be to address this issue, targeting all women in the community and uniquely ensuring access to free, state of the art breast cancer screening and awareness campaigns to women in the interior regions Oman.

The NACA board carefully reviewed and agreed on a strategy which included organized several subcommittees to address the tasks identified in the strategy for realizing the commissioning of the first mobile mammography unit (MMU) to serve the community in Oman. These committees include:
(i) Technical committee which included the top medical specialists in Oman -tasked to review and asses the best available technology for mobile mammography units operating globally. This included the design, technology, infrastructure, technical support/staffing and costs (both capital and operational)
(ii) A fund raising committee –tasked with marketing and securing corporate sponsors and events that would raise funds for the procurement and operation and maintenance of the MMU
(iii) An outreach/social committee – tasked with developing campaigns in all the regions of Oman to promote awareness and review the feedback from the local communities on their response to an MMU
(iv) Legal committee –tasked to review all legal/institutional requirements related to NACA owning and operating a mobile “medical diagnostic facility” and legal requirements/liabilities that may be associated with clinical/medical reports that are generated from the mammography tests.

This initiative required exhaustive efforts from all the committee members and demanded skillful and patient lobbying with various agencies including, public, private and institutional. Public sector agencies that were recognized as key drivers to support this initiative included (but not limited to):

(i) Ministry of Social Development
(ii) Ministry of Health –including all regional clinics
(iii) Ministry of Information
(iv) Ministry of Interior
(v) Muscat Municipality –Diwan Royal Court
(vi) Royal Oman Police

Public institutions and other NGOs that contributed and supported this initiative included:

(i) Oman Women’s Association
(ii) American Women’s Group
(iii) Embassies
(iv) Regional and International Cancer agencies and organizations (e.g. GCC Cancer Society; Susan B. Corman; Avon; ICCPO; American cancer research; World child cancer; MD Anderson Cancer Research and others).
(v) Oman Association for the disabled
(vi) Schools, national and international

Private sector agencies and corporate houses made (and continue to make) significant contribution in support of this initiative. Apart from private/individual monetary contributions there are over 40 major corporate houses provided financial endorsement and sponsorship.

(a) Strategies

 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.
To ensure a successful implementation of the MMU initiative, the NACA board and its members recognized that they needed develop strong partnerships and sponsorship commitment from private sector entities. The capital cost of the MMU was estimated in the region of OR 300K with an annual O&M budget of around OR 45K. In addition to the financial requirements there was also the need to secure the technical services of radiographers, nursing assistants, heavy vehicle drivers etc. An additional feature that is unique to the NACA MMU initiative is that the entire unit, digital mammography, ancillary services and van were to be built in Oman, as compared to other MMU units which were procured readymade (turnkey). This decision was made early on after very detailed and careful review and assessment of existing mobile medical units operating in Oman and the need to customize the MMU to certain Oman specific criteria such as local weather, access and availability of power for the unit at various remote locations, long distance travel, technical support for any preventative and corrective maintenance, cultural norms etc. NACA also recognized that there would also be an opportunity to provide training to Omanis to operate the state of the art digital mammography unit and technology transfer for local suppliers and technicians. Crucial for the successful implementation of the MMU initiative was securing access to the extensive infrastructure and oncology knowledge base of MOH facilities and staff was extremely important for the success of the MMU. MOH certification of the MMU as a “Mobile clinic” was an exemplary endorsement for the MMU to ensure credibility and public comfort by and our corporate sponsors. A key partnership with the local supplier (Muscat Pharmacy for the digital mammography unit and Al Hashar, for the vehicle) technology provider, Siemens, was a key factor in ensuring that the all finite technical and mechanical aspects of the MMU were being addressed by experienced and seasoned professional committed to provide their support throughout the lifecycle of the project. The relentless support, time, knowledge and experience of one of the most senior medical consultant from MOH was certainly a valuable asset for NACA in realizing this initiative.

The strategies developed included a comprehensive corporate funding and sponsorship campaign aimed at the addressing the CSR (corporate Social responsible) ethos and focal points of all major corporations, banks and High net worth individuals who were known to practice philanthropy. Furthermore, lobbying and attaining the full endorsement and support of the ministry of health was very important for the MMU success.

Naturally, the primary objectives for the MMU initiative were to provide efficient state of the art breast cancer screening facilities. It was also important that these facilities were made available free of charge and the accessible to all stakeholders hence the need for mobility. Concurrent activities for the MMU were to promote cancer awareness and the need for self examination and follow up (if required) and develop a closer cooperative relationship with all the interior MOH clinics and services.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
In the fall of 2000 the initiation of the first “cancer survivors” group was the key to ignite the passion and commitment of the founder of NACA, Ms. Yuthar M. Al Rawahy, herself a three times cancer survivor. A small group of women, all of them cancer survivors announced their intent to cycle from Muscat to Salalah (over 900 km) with a primary aim of raising awareness in the community and they committed to dedicate all the proceeds of any sponsorship fund to the “Oman cancer group” to help them raise awareness throughout Oman. The event raised an impressive amount of around OR 10,000 and was well covered by media and carefully monitored by the various governmental agencies concerned with oversight of NGO registration and activities. The cancer group immediately seized this opportunity to formally announce their intent to launch and register the national Association for cancer Awareness. From that date, (around November 2000) volunteers and members of NACA would meet and work towards compliance with Ministry of Social development requirements for registering of NGOs. In April 2004 NACA was formally registered in full compliance of all requirements to establish an NGO in Oman. A board comprising primarily of founding members was convened and a ‘Strategic 5 year Plan” was drawn up. This was key to presenting credibility for NACA as they approached corporate houses and various other private sector organizations for fund raising. Later in 2004 NACA formally announced its plans to implement its first program/initiative which was to procure and offer mobile breast cancer screening services and make those available to all the communities free of charge. Over the next two years (2004-2006), NACA members worked diligently to organize fund raising campaigns, organize and participate in cancer awareness workshops, network with various local, regional and international NGOs and other nonprofit cancer groups and institutions. As the success and credibility of NACA and its fundraising campaigns gained momentum, initiatives were activated to visit operating mobile screening and medical units locally, regionally and internationally to gain firsthand experience and review of the technical, logistical and resources requirements for commissioning a state of the art digital mammography unit. The concept design and preferred technology for the MMU were also being developed by a dedicated team of NACA volunteers lead by senior medical officers and technicians. A viable partnership was developed between a local technology supplier and their Principals to provide the mammography unit and oversee its installation and commissioning, all negotiated at cost prices. Legal advice was acquired to ensure that operating guidelines and patient selection criteria were not ambiguous or contained any intent of discrimination or liabilities. After unanimous Board approval in mid 2007 the final steps and agreements were taken to procure, build and commission the MMU. The final delivery dates delivery erection program of the MMU was finalized between 2007-2008. For most of 2009, various components of the MMU and truck were being delivered and being assembled on site in Oman. Concurrently, the NACA board continued to lobby for MMU fund raising campaigns to secure funding for the procurement of all the MMU components, truck and the beginning of seed funds for its operation (staffing). In December 2009 the MMU was commissioned and began its mobile campaign. A detailed program was developed that included various regions of Oman; required staffs were secured in collaboration with MOH and other medical agencies in Oman. The MMU has and continues to operate successfully, representing a milestone achievement in Oman and the region. (High quality Video material is available to support and attest to this claim).

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
NACA confronted many challenges in their plight to establish and sustain an NGO that was addressing cancer and overcoming the taboos and fears that were entrenched in the minds of the local community. Furthermore, the ambitious initiative to procure and operate the first mobile breast cancer screening unit was literally scoffed at by many. The notion of philanthropy and social entrepreneurship was (and is to a certain level) very much in its infancy. The effort to attract and retain volunteers committed to giving up their time and put the effort required to realize the objectives of NACA was in itself a mammoth task, left to the few dedicated members who all worked tirelessly to achieve the milestones of NACA. Early campaigns involving the promoting “cancer awareness” went unsold and some of the public walking by the stalls would even cringe and “pray for protection” when they walked by, let alone even touch the T-shirts , believing that would transfer bad omens and they would contract cancer! These are not by far exaggerated anecdotes, NACA volunteers, supported by major retailers and outlets, the media and the few cancer survivors who were brave enough to talk openly about their disease providing credible testament to the erase the myth that cancer is a “death sentence”, were all effective in slowly changing the mindset of the community. Fund raising, at the corporate level was especially challenging given that many of the major corporate entities, local and international, had not embedded CSR ethos into their corporate mission and vision. At the public sector level. Government had established very explicit guidelines and rules governing “charitable donations” under a central government managed account in keeping with the cultural norm encouraging the public to rely on the “benevolence” of the government to meet their charitable needs. This was a particularly challenging obstacle, but thankfully, together with the growing number of NGOs in Oman, public sector policy adapted and supported the cause and plight of legitimate, professionally run NGOs like NACA. Within NACA, the fund raising committee worked aggressively to present detailed proposals requesting funds and endowments; this was a time consuming and exhaustive task at times. Carefully orchestrated presentations in various forums and conferences were found to effective tools to attract and secure sponsorship from private sector entities which were auditable and at times accountable to shareholders. NACA rapidly developed transparent financial systems that were auditable and provided real time data to review the financial status of various fund raising campaigns and donations. NACA found that membership in regional and international cancer organization and fraternities provided valuable credibility for NACA and were also a positive conduit for NACA to exchange ideas and learn from their experiences. NACA can attest to their ability to overcome all these obstacles by managing to procure commission and operate the first independent mobile digital mammography unit in the country. With over forty corporate sponsors and several private endowments NACA was able finance and maintain their organizations, campaigns, embark on new initiatives which they aim to launch in the very near future. NACA continues their efforts to lobby for finite funds in an ever competitive market.

(d) Use of Resources

 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
Naturally the most tangible resources utilized with this initiative are financial. The technology for digital mammography and peripheral add-ons in addition to the operating costs all require significant funds. The capital cost of the unit at commissioning was in the region of OR 350,000 and the operating and maintenance costs average at around OR 45,000. NACA has secured adequate funds to ensure the proper operation and maintenance of the MMU for at least 36 months.
The MMU design and assembly required state of the art technical resources. NACA negotiated an amicable partnership with a local supplier (Muscat Pharmacy) to include the provision of full time technology expert and consultant. The digital mammography unit was supplied by Siemens using their latest technology. Siemens technology experts travelled to Oman and worked closely with NACA technical experts, who comprised of senior consulting physicians, oncologist, radiologist and mechanical engineers. The Nissan truck supplier (Al Hashar Automotive) also provided their technical experts to assist in the layout, internal connections and ergonomic design of the unit.
By far the greatest resource utilized in this initiative was the human resources of NACA board, members, volunteers and the whole community who committed their time and energy to raise the funds and support every step of the initiative. Countless people, students, parents, and teachers, vendors who consistently provide their support whether in person or in kind at all the events – this was the greatest and most valuable resources that permitted the realizing of this initiative.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The MMU initiative is both sustainable and transferable. Sustainable form the financial perspective given the reservation of adequate O&M funds and transferrable from the technical and operational perspective given the number of efforts and emphasis that NACA has placed on technology transfer. NACA has trained operators, social workers, and technicians to a level that would allow them to confidently operate and manage all aspects of the MMU. The MOH has requested NACA to offer training programs for their social workers and some technicians. Omani support staff have acquired IT specialist IT skills related to data acquisition, transfer and storage specific to the application of digital mobile technology. Siemens has committed to support the MMU throughout its lifecycle with provisions for software updates, troubleshooting and corrective maintenance.
Socially and economically, the community has embraced the MMU services and continue to express their accolades and appreciation to NACA for provision of this service (Institutionally the MOH continues to express their support by working closely with NACA on the MMU initiative. Data generated from the MMU would be shared with MOH and joint collaboration on any referrals from the MMU to MOH for further investigation continues to develop. It is envisaged that a feasible timeline for eventual handover of the MMU to MOH could be developed over the next few years depending on how receptive the MOH may be to the notion.
Recent attendance at regional cancer advocacy conferences where NACA presented the MMU initiative has been well received. NACA has been approached by several representatives from different countries to request more information and details on how NACA developed the unit and their experience and knowledge of setting up a similar unit in the respective countries. NACA has been responsive to al enquires and expressed their total support in sharing their knowledge and experience of the MMU. NACA would envisage knowledge transfer for the MMU could be successful by organizing workshops and seminars to be attended by interested parties. Inviting representatives to visit Oman and view the MMU in operation, talk with the technology suppliers, operators and any other agency that NACA has interfaced with. NACA would emphasize sharing their advise and experience of the learning curve thy went through to any interested party for their benefit. Sharing fund raising material and templates would also be another area that NACA may facilities’ the transfer of the knowledge for the successful implementation of the MMU initiative by another organization.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
Without reservation it is clear that the key elements that have contributed to the success of NACA and their MMU initiative include:

(i) Working on public awareness campaigns together with cancer survivors as presenters and reaching out to all sectors of the community to overcome the traditional fear and enigma associated with cancer has certainly played a big role in gaining the support and participation of all stakeholders. More so by making a concerted effort to include and visit all interior regions and talk first hand to community leaders and citizens about the objectives and aims of NACA contributed greatly to changing the public view of cancer and encourage them to be proactive in going for examinations (mammograms) and follow ups. Furthermore NACA has been very successful in demonstrating their relentless commitment to support cancer patients whether coming to terms with a cancer diagnosis or coping and understanding how to manage their treatment and the disease.
(ii) Maintaining the motivation and being persistent in lobbying for funds and volunteers. Disseminating information about the activities and objectives of NACA though different media has proved to be an effective approach to ensure success of NACA initiatives. Using information technology to contact members and providing useful information through the NACA website has also been effective. NACA was recognized with the Gold Award for the best website by the Oman Website Awards in 2007.
(iii) Being responsive to collaborate with other NGOs has also served to promote the awareness campaigns of NACA together with initiating annual Cancer Awareness activities such as the Cancer Walk and organizing the human cancer ribbon (in 2008) are all positive activities that promote NACA and encourage the support of all stakeholders.
Above all, we at NACA have learned that being passionate and true to the cause and objective of NACA working with the community are the most important criteria to success of NACA and the MMU. Knowing that a few can make such a positive difference to the lives of many is by far the most rewarding outcome of the NACA initiative. Together we can work to make cancer history!

Contact Information

Institution Name:   National Association for Cancer Awareness
Institution Type:   Government Agency  
Contact Person:   Yuthar Al-Rawahy
Title:   Founder & President  
Telephone/ Fax:  
Institution's / Project's Website:  
E-mail:   ocancer@omantel.net.om  
Address:  
Postal Code:  
City:  
State/Province:  
Country:   Oman

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