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Women Health Outreach Program
Ministry of Health
Egypt

The Problem

Detection of breast cancer at early stages, when it is still confined to the breast provides the best treatment options for women with the disease. In addition, early detection increases survival rates with an improved quality of life. No doubt, the treatment of early breast cancer is also less resource-intensive and generally has superior outcomes.
Although the world has witnessed advances in breast cancer early detection and treatment strategies, morbidity and mortality rates have been steadily increasing throughout the world; the highest rates are recorded in underdeveloped and developing countries. The reason for this is that most of these countries face numerous challenges in designing and implementing effective breast cancer screening programs.

The National Cancer Institute in Cairo Registry reported breast cancer to represent 35.1% of female cancers in Egypt. Extensive disease was also reported at presentation with stages III and IV cancers representing 80-90% of detected cases. This means that many Egyptian women with breast cancer fail to seek medical attention until their cancer is advanced.
Breast cancer in Egyptian women also has a younger age distribution with the majority of cases occurring at a median age of 46 years; that signifies one decade younger than the corresponding age in Europe and North America.

Considering the above stated facts, breast cancer has placed itself on the top of the list of health problems in Egypt; yet, the stigma of breast cancer, particularly in women living in poor communities, still has a profound impact on treatment and survival rates. Efforts aimed at early detection can reduce the stage at diagnosis, and thus enabling simpler and more cost-effective treatment options. Nevertheless, poor people are not seeking help and do not have easy access to care. Treatment is unaffordable for many as there are difficulties in procuring the required diagnostic services. Adding to this, there are no nationwide statistics for the incidence of Breast cancer in Egypt which makes it even harder for healthcare organizations to plan for the required diagnostic and therapeutic services coverage. Against this background, many women deny their condition, believing that a painless lump is nothing to worry about. Likewise, most of the local general practitioners are unaware of the dangers of breast cancer, adding to the delay in early diagnosis and adequate treatment.

Solution and Key Benefits

 What is the initiative about? (the solution)
In Egypt, a partnership between the Ministry of Communications and Information Technology and the Ministry of Health is expanding healthcare provision to women nationwide, using information and communication technologies (ICT). This partnership aims at developing health services directed to women, especially in remote areas, through the effective utilization of e-health tools.
With this strong conviction, the launching of the first Egyptian National Screening Program; “Women Health Outreach Program” (WHOP), was announced in October 2007. This project is a Government funded program that offers free breast screening for all Egyptian women above the age of 45 years old. In addition to free mammograms, the program gives those women a chance to be screened for diabetes, hypertension and obesity as well. positively detected cases are also offered the option of completely free of charge treatment.
The fundamentals for breast cancer early detection are identified as: ensuring that women are supported in seeking health care services and that they have access to appropriate, affordable diagnostic tests and treatment facilities.
The project has a strong belief in the value of providing a supportive environment for women through outreaching them within their local communities. This is through allowing women to seek medical care on a regular check up basis or even with the appearance of early breast symptoms by supplying them with affordable and easily accessible diagnostic and therapeutic procedure. Breast health awareness and clinical care delivery at all levels from diagnosis; treatment and post treatment care are provided for women joining the project within their local communities.
The diagnostic process entails both initial diagnosis of cancer, and, when cancer is present, further staging is considered essential to choose the appropriate treatment option. The whole diagnostic process starting by additional mammography views and complementary ultrasound examination up to biopsy taking are all offered for women free of charge.
Knowing that success and effectiveness of screening program goes hand in hand with providing effective therapy, patients with suspicious mammography findings are subjected to a sequence of assessment procedures in predetermined well equipped Health Service Centers or University Hospitals for more advanced evaluation and treatment strategies. Again the whole operative and post operative procedures are performed free of charge.
By bringing screening services to each area, access to health care is increased, and the costs and efforts on the part of the patient are minimized. The only alternative for a woman resident in a rural area is to go to one of the radiology centers in the main cities, but that involves paying for the journey and obviously takes much more time. It is also questionable whether women without any symptoms would make that effort from the start.
Up till now, November 2010, 70,000 women have already been screened across 13 different Egyptian Governorates. 306 women with suspicious mammography findings have been completely cured after undergoing surgery at the state's expense. Another 307 women have been downgraded after performing a complementary ultrasound examination and/or biopsy which revealed benign or probably benign findings.

Actors and Stakeholders

 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 in 2004 between the Egyptian Ministry of Health and the Ministry of Communication and Information Technology.

The responsibility of the initial primary and preparatory procedures was fully given to the Cairo University Hospital “Women Imaging Unit” staff members. They took full charge of defining the policies and procedures of the whole program.

The Ministry of Health provides overall coordination of policy formulation, national data collection, quality control, monitoring and evaluation of WHOP.

The Ministry of Communication and Information Technology is responsible for road mapping the locations were the mobile vans set according to a predetermined time schedule.

The Ministry of International Co-operation is responsible to provide the necessary funds to implement, run and sustain the Program.

New technology Company Egypt provides the program with the mobile vans; necessary equipments including computers, workstations and a Centre of Excellence that is located in Cairo were mammograms are read. It is also responsible for continuous on site rehabilitation. It cooperates with TE Data, to communicate the mobile vans and static units were digital mammography screening is performed with the Centre of Excellence that is located in the Centre of Cairo were these mammograms are interpreted. This is achieved through Internet cables, lease lines and satellite systems

In addition, New Technology Egypt works in collaboration with Paxeramed View Corp. They provide the program with the soft ware used in data entry, reporting and statistical analysis.

Digital Mammography Units and ultrasound Machines fixed in the mobile vans and static units are supplied by Philips Electronics and General Electric companies

A contract has been also signed with Raya call centre to dedicate a subdivision for the program to answer patient inquiries and distribute out mammography reports.

Hofmann La Roche ltd company is the main fund raising and public awareness liaison The company also provided up to date devoted breast pathology labs which are currently under construction in the Ministry of Health central lab and in the Centre of Excellence.

Funding also takes place through the United States Agency for International Development USAID.

(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.
The program’s main objective is to reduce the mortality rate from breast cancer among Egyptian Women by raising awareness about the importance of early diagnosis and in the same time providing the necessary tools for early detection, namely, mammography screening.
The working team comprises a multidisciplinary group of trained, experienced and professional radiologists, radiographers, surgeons, oncologists, pathologists, nursing staff, data managers, engineers, and clerks, all working under one mission statement: “We are determined to reduce mortality from breast cancer in Egyptian women and provide an utmost quality of life for discovered cases. We believe our mothers, our sisters and our daughters deserve our utmost care’.
Raising public awareness is performed through three routes; in reach, outreach and public education programs. Inreach programs mainly address women who seek medical care and include staff member’s development and training which help to improve the provided services. Outreach programs are mainly accessed through religious organizations and working institutes with large numbers of staff members. Public education is implemented by television and radio advertisement campaigns as well as fund raising celebrations at special occasions.
The large-scale populated areas of Egypt has made it essential to design a suitable early detection program that can address and outreach women residing in out-reached governorates and high-density housing areas which are completely underserved having a fraction of essential health services available to them. A successful screening program is that which can reach low income, underserved, uninsured and hard to reach women
With this belief that a program with limited accessibility to the population will never reach its objectives, we have chosen to deliver our services mainly through mobile vans exclusively designed to fulfill the project requirement. These vans roam through different districts according to a pre-planned time schedule in order to minimize travelling time and distances to women. Breast cancer treatment incorporates an integrated, multidisciplinary approach using multiple resources in a focused, disease-oriented manner. Therefore, wherever the vans are set, our first priority is to provide place facilities for prompt clinical diagnosis and surgical treatment. In addition to the mobile vans; static units have also been organized in some Ministry of Health Hospitals.
Performed mammograms are automatically sent via the DSL connections or satellites systems to the Cairo Centre of Excellence, were they are interpreted by three different professional mammography readers. Women with suspicious mammograms are re-invited to join the program and are given the option of completely free of charge post mammography services.
Database development with ongoing improvement has been a priority of WHOP. We have implemented a self designed, co-apt structured reporting system were all patient data (demography, mammography and operative data) are recorded by clicking check boxes. This system allows easy data accessibility. Patients’ names and unique medical record numbers, dates, clinical findings, imaging findings, and results of surgical intervention are all documented in the system.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
The screening program consists of mobile and static mammography units placed in general hospitals connected to a center of Excellence via video SAT and ADSL so that images can be transmitted from the remote unit to the center for further diagnosis by senior radiology consultants. Based on the findings of their initial mammograms, patients will be directed to the nearest hospital to receive adequate treatment and follow up.

The work plan design of the program included 5 phases with a 1 year pilot phase that started in October 2007 and terminated in October 2008. Each implementation phase will address a number of governorates. The target is to expand over a 5-year implementation plan, to reach the entire Egyptian governorates.
This was preceded by a small scale 1 year project demonstration study which was carried out in ‘Women Imaging Unit”, in Kasr El Aini Hospital by screening women referred from a small village in Giza; ‘Rawdat Abou Ghaleb’. The demonstration Project aimed to show how the project could be applied on a small scale while the pilot study aimed to field test and validate the field plan of the project, test citizen’s response to the program and validate man power capabilities. Guided by this pilot study, the business plan was amended.

The pilot phase was very important as it highlighted the major problems encountered before starting the actual program implementation and allowed the concept of mobile services to be tested and its effectiveness demonstrated in a location within the country with a high population density.

A call center has been initiated to allow the general public to communicate and connect directly with the program. It started functioning at the start of June 2008. Trained medical personnel are working on the system to provide information and answer inquiries about the screening process. Results to women attending the program are also delivered through the call center.

In May, 2008 the WHOP launched its website www.whop.gov.eg as a one stop store for all information related to the program. The website includes the latest information about the program’s activities. A valuable application on the website is the online form allowing users to submit queries, the most popular of which are answered in the frequently asked questions section.

In 2008 the National Foundation for Breast Cancer Elimination has been established to oversee the overall implementation and performance of the program. Members of the board will be mainly responsible for all medical policy issues related to the delivery of clinical care in the framework of the program. The foundation also receives funds that help in financing some of the projects activities especially in continuous medical education for the radiologists and radiographers working in the field of mammography.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
Despite the various delivered mammography and post mammography services, we are still facing several community based challenges that hinder delivery. Cultural challenges include reluctance, misconceptions that breast cancer is a rapidly fatal, non curable condition. A further cultural challenge is the self denial of the disease. To defeat these social and cultural barriers we have arranged several awareness campaigns delivered mainly through radio and television as well banners held at special sites (e.g. clubs and public places) and special occasions (e.g. run for cure). Flyers and leaflets are distributed among inhabitants of predetermined van locations with useful information inviting them to attend the delivered screening services. These active moves have tremendously improved the public response to the mammography services but have raised another considerable challenge.
In spite of the fact that all post mammography services are free of charge, most of the ladies (65.7%) with suspicious mammography findings refused to re-join the program. Hence, we delivered an open format questionnaire through phone calls to all women who refused. Guided by this questionnaire, we were able to upgrade the delivered services starting by Cairo Governorate. We have constructed a ‘One stop Breast Clinic’ within the Centre of Excellence were women perform all services in one day; including clinical and ultrasound examinations, additional mammography views and biopsy for recommended cases. A similar clinic which will include a dedicated breast surgery theatre and Oncology centre is also under construction in Cairo University hospital. The breast clinic has tremendously improved the acceptance of the women to the delivered services. The percentage of women with suspicious mammography findings who refused to join the program has dropped from 65.7% down to 5% after the clinic construction considering the fact that most of these women have health insurance in Military and Health Insurance Hospitals. The clinic has received 1050 women along the last eleven months

To overcome the inequity of access to care between rural and urban populations we have also arranged special training courses for staff members serving urban localities. New vans that will soon come to function will be equipped with ultrasound units and will serve as a small model of a similar, yet mobile, van based ‘one stop clinic’.

Other challenges include financial constraints, and shortage of well trained personnel to deliver the provided services (including medical, paramedical and administrative staff members). Several fund raising campaigns were held and a special bank account was assigned for funds’ acceptance. At least bi-annual training courses are held for staff members at all levels and for in future expected ones.

To guarantee quality performance, a quality improvement team has been established to investigate and solve any foreseen quality conflict. It also monitors achievements; compares results against plans, continuously update information, and uses feedback to adjust plans, structures, and processes for future results. One of the main objectives of this team is to inspire the team members to perform better, and teach them how to identify their obstacles to service quality, initiate improvements, and serve their clients well.

(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
WHOP 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. 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 mobile vans, computers, workstations, DSL connections, mammography and ultrasound machines that are fixed in mobile vans and static units which are mainly supplied by New Technology Company.

The following table shows the overall expenditures that were spent to date since the program was launched in October, 2007. The listed figures clearly show that budget challenges will continue to occur in the future.

Table [1]: Project Financial Expenditures:

Item Description Costs in EGP / year Estimated Costs Required for the upcoming 5 Phases (i.e. 5 years) Notes
1. Capital Assets
1.1. Durable Assets 7,755,250 38,776,250 for 50 Mobile vans
1.2. Van 3,317,600 16,588,000 for 50 mobile Vans
1.3. Fixed Mammography Unit 2,197,500 59,332,500 27 Fixed Mammography unit
1.4. Radiology Information System 306,000 15,300,000 RIS installation in 50 Mobile units
1.5. Trailer 750,000 37,500,000 for 50 trailers
Generator 125,000 6,250,000 for 50 generators
Consumables 158,100 790,500 for 5 years
Human Resources 107,000 535,000 for 5 years
Operational Expenses 1,331,700 6,658,500 Operational Expenditures required for 5 years
Total 16,048,150 181,730,750

Sustainability and Transferability

  Is the initiative sustainable and transferable?
In fact, WHOP is the first program of its kind to implement Picture Archiving and Communication (PACs) and Tele-radiology system in the Egyptian Ministry of Health public hospitals. The implementation process has helped the Ministry understand the practical and operational issues essential to a successful PACS implementation and define strategies, for applying the system all over MOHP hospitals. This has also opened a new channel for training the radiologists at these hospitals on mammography film reading.

So far the project fleet consists of 4 mammography mobile clinics and ten fixed mammography unit located at Kasr El-Aini Hospital, Cairo University hospitals and in Ministry of Health Hospitals in different Governorates. By the end of this year 2010, additional 6 mammography mobile clinics are expected to be added to the project.

By operating mobile units to bring mammography clinics close to the target population, especially women living in rural areas, and using telecommunication technology to ensure rapid expert diagnosis of screening results, the project is improving the early detection of breast cancer in Egypt. Combining early detection with free treatment gives women the best chance of surviving the disease.

The project could be replicated in other countries, based on the experience gained in Egypt. We readily shared our experience with multiple neighbor countries (KSA, Jordan, Sudan,…). Consultants from the Program were invited to screening programs in these countries to transfer their knowledge and experience and to help them implement similar nation based screening programs.

Staff members of the project are members of The Global Initiative for Breast Cancer Awareness in Egypt and the Global Initiative to Improve Cancer Care in the Arab World. Through these initiatives, they can exchange their experience with other screening programs within the area.

The program is well under way and is starting to reach the target population. But screening is an on-going challenge. The program is aiming to strengthen its operational capacity through increasing the number of units as well as training more staff. Another overall goal is to find new partners that could support offering the service free of charge

Lessons Learned

 What are the impact of your initiative and the lessons learned?
Although women form a fundamental segment of the society, they are frequently faced with numerous socio-cultural barriers which hinder their accessibility to healthcare services. In addition to these impediments, Egyptian women place their families far before their needs.

As mentioned earlier, breast cancer has been placed at the top list of healthcare priorities in Egypt, thus it was essential to establish an early detection program which addresses this issue. Actually, strategies for breast cancer early detection in developed countries might not be suitable for developing and underdeveloped ones.

Considering the fact that resources are limited, it was crucial to design a program that could overcome specific healthcare problems in Egypt and in the same time ensure a rapid effective outcome. WHOP work plan design had made this dream come true. Combined fixed and mobile breast screening units had a major impact on overcoming constraints of health care service delivery in Egypt. Breast cancer early detection is now available to all Egyptian Women within their local communities. Up till now, 70,000 women have been screened along 13 different governorates.

The idea of the multidisciplinary one stop breast clinic that were constructed in response to the public’s request for high quality services has also saved time, efforts and cost burden to 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, sonar, surgical examination, and biopsy were all conducted in one place i.e. in the center of Excellence. At this moment, amazing improvement was noticed in the health seeking behavior of the females. The breast clinic has accepted about 1050 women for further investigation along the past 11 months. 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.

We now have a strong belief that raising general public awareness on the value of breast cancer early detection is a key strategy that ensures the success of any breast cancer early detection program. Establishing early detection programs should be coupled with dedicated education programs for all concerned personnel and should go hand in hand with community awareness campaigns that foster individuals to seek both diagnostic and treatment facilities

Early breast cancer detection should also be coupled with providing advanced diagnostic and treatment options. Actually, there is no need to diagnose if we cannot treat. Ensuring a closed circuit of multidisciplinary diagnostic and therapeutic medical team in any location where the vans are set is a cornerstone in successful service delivery.

Establishing a quality control team that monitors the delivered services at all levels is indispensible to ensure that Egyptian Women receive the best screening services. Ongoing efforts to upgrade delivered services, that meet customer’s requests, are indispensible.

Contact Information

Institution Name:   Ministry of Health
Institution Type:   Government Agency  
Contact Person:   Rasha Fouad
Title:   Professor  
Telephone/ Fax:   +2 0127457992
Institution's / Project's Website:   +2 02 23645813
E-mail:   rashaakamal@hotmail.com  
Address:   1053 Fum El-Khalig, Kornish El Nil
Postal Code:  
City:   Cairo
State/Province:   Cairo
Country:   Egypt

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