Cervical Cancer Vaccination Save Women and Balinese Culture
Health Offices of Badung District

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Cancer is the main leading cause of death in worldwide. In 2012, cancer causes the death of 8.2 million people. Based on data from International for Research on Cancer (IARC) there are 14,067,894 new cases of cancer and 8,201,575 deaths because of cancer in worldwide. According to Riskesdas in 2013 the prevalence of cancer patients in Indonesia amounted to 1.4%. In Indonesia, the incidence of cervical cancer around 0.9% with 45 – 54 years old as range of age. More than 70% cervical cancer cases diagnosed in advance stage so it is more difficult to treat, and every hour recorded one woman died of cervical cancer. In Bali, the incidence of cervical cancer around 0.89% and is assumed at 10% of the proportion of the incidence in Badung. Deaths of women in Bali, there were three people died in two days caused by cervical cancer in which patients come to the Sanglah Hospital, 85% of them already at an advance stage. In 2012 only about 1% of 107,591 women in fertile age who already received vaccine for cervical cancer in Badung. This is happen because of limited access to obtain information about this cancer, lack of public knowledge and high economic burden and also the expensive price of vaccine itself. Bali is a major tourist destination with total 2,5 million visits of foreign tourist and 500,000 domestic tourist each year with 75% of tourism accommodation is located in Badung district. Acculturation occurs that makes Badung carried away by the new lifestyle like cafes, night clubs, drug trafficking, prostitution, violence and thievery. Especially in the field of health, it is can be seen by detection of various types of disease. In fact, new emerging disease such as avian and swine flu, rabies, human immunodeficiency virus / acquired immunodeficiency syndromes (HIV/AIDS) and others infectious disease which is fatal. One of them is HPV infection with high risk oncogenic group as cervical cancer causes. HPV is an important infectious disease and mostly sexual transmitted. On the other hand, Balinese women have important role. In addition to the role of reproduction in general, they also have important and special role in the preservation of socio-cultural customs and traditions. In facts, Balinese women act as a person in charge for economic who work hard to support the family. In education, Balinese women are a family educator who is very reliable and responsible. Considering the strategic role of Balinese woman who highly susceptible to cervical cancer, Badung government launch “Vaccination Cervical Cancer, Save Women and Balinese Culture” program. This activity consisted of improving primary prevention in the form of education and vaccination for cervical cancer which is free of charge to the public, in addition to improve secondary prevention efforts such as early detection and improve services for cancer patients by given free all the costs borne by the patient. This is a direct manifestation of Badung government to prevent cervical cancer and also encourage gender responsiveness in providing services to the community.

B. Strategic Approach

 2. What was the solution?
The high incidence of cervical cancer in the society and still low coverage of cervical cancer early detection. Cervical cancer is the only cancer known cause and can be prevented. By providing vaccination free of charge to the public will be able to provide protection to woman and to reduce the economic burden on society.

 3. How did the initiative solve the problem and improve people’s lives?
In 2015, the Health Ministry declared commitment to prevent cancer in Indonesia. The Health Ministry appealed to the health authorities, communities and other stakeholder to support the strengthening commitment to prevent cancer in Indonesia by giving special attention to the improvement of promotive and preventive effort to raise public awareness about cancer, the development of early detection efforts in order to reduce cancer mortality and support all elements of society in the control of cancer in a comprehensive and sustainable. The emergence of innovation program “Vaccination Cervical Cancer, Save Women and Balinese Culture” launched by Badung goverment is inseparable from the idea of Badung Regent. The role of Regent highly synergistic with the vision and mission of Badung District Health Bureau and the hopes from Yayasan Kanker Indonesia (YKI), Badung in the fight against cancer. This synergy is able to address existing problems which is the high incidence of cervical cancer in Bali. In fact, cervical cancer is the only cancer that 90% caused by viral and can be prevented by immunization. Similarly, the WHO stated that one third of all cancer can be prevented. On third can be cured if found at an early stage. While the rest can be alleviated suffering. Therefore, cancer detection at early stage is an important matter. Cancer that can be detects early and given proper management have higher probability to be cured. The vaccine effectiveness which reaches 99% would be able to provide good protection to women and ensure a healthy life and also able to encourage prosperity in all ages according to the sustainable development agenda 2030/ Sustainable Development Goals (SDGs). Given some limitations and problem in the pap smear, the effort to prevent HPV infection through vaccination be the right answer. This is because the vaccine capable of providing protection from infection with HPV oncogenic high-risk groups, especially HPV 16 and 18 as well as phylogeny. Vaccine effectiveness against HPV type 16 and 18 is 72% and cross protection against phylogeny is 20% so the overall protection amounted to 92%. The earlier vaccination in women (aged 10-26 years old), immunoglobulinulin can be form two times higher than in the group above 26 years old. Along with the implementation of the cervical cancer vaccination program, Badung government since 2005 has been implementing the Program Penanggulangan Kanker Terpadu Paripurna (PKTP) or Integrated Cancer Prevention Program. This program targets children from elementary, junior high school, and also public. The emphasis of this program on primary prevention of cancer which include: health education, making posters, choir competition, simulation, traditional drama performance, herbal medicine and food which is free from preservatives, coloring, sweeteners and also flavoring that are prohibited by Food and Drug Administration. This program aim is to provide insight to students and the public about the importance of early cancer prevention. Other primary prevention is also done through improving Perilaku Hidup Bersih dan Sehat (PHBS) in five elements: household, healthcare facility, educational institutions, public and religious places. PHBS criteria used are eating varied nutritionally balanced according to the needs, personal and environmental hygiene, sleep at least 6-8 hours per day, not eating hazardous and dangerous substances, regular exercise and stress control. The purpose is to improve understanding PHBS community to prevent disease, to accelerate healing process and to suppress the disease progression. Secondary prevention by improving prevention early detection of cervical cancer by inspection using acetate acid and Pap smear. Tertiary prevention can be done by providing services to cancer patient to increase life expectancy and bear all the medical expenses.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Cervical cancer is a silent killer for women. Considering the effectiveness of vaccine is up to 99%, the development of qualified human resources as a main asset of country can be achieved through vaccination. Cervical cancer vaccination becomes more effective and efficient compared to a high-cost cancer treatment which also constitutes a social and economic burden. This becomes a creative primary prevention program, seeing that our target priorities are all students from elementary school, junior high school, and senior high school. Besides of students, Local government staffs were also vaccinated. Students in school age as target is a strategic approach to provide protection for women against cervical cancer. In addition, those who were vaccinated, hopefully would be able to give health promotions and informations to community about the danger of cervical cancer and its prevention efforts. Government's commitment to fully bear the prevention costs, include primary (vaccination), secondary and tertiary prevention, make this program being unique. So that Balinese women can be protected from cervical cancer, then they can live healthy, prosperously and productively at all ages and be able to preserve Balinese culture.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
This innovation is implemented by the Department of Health and his officials. The goal of this innovation is the entire girls from elementary schools, junior high schools, high schools and government employee in the Badung regency.the district government employee in the
 6. How was the strategy implemented and what resources were mobilized?
In Indonesia, cancer slowly began to overtake heart attack as the main cause of death. The increment of cancer as cause of death are due to high number of new cases which are coming at an advanced stage. Implementation strategy for cervical cancer prevention through vaccination is carried out with an action plan includes: 6.1 Study This activity begins with a data collection activities to determine the incidence rate of cervical cancer in the Badung regency which will be used as a frame of reference in the implementation of these activities. 6.2 Socialization Socialization includes giving information about the disease course, early detection, and prevention through vaccination as well as clean and healthy behavior. Socialization conducted to all targets includes female students, Badung government employees, and community. Socialization is carried out in collaboration with Indonesian Association of Obstetrics and Gynaecology. both directly through face to face counseling and indirectly by using electronic and print media. Total targets cumulatively from 2012 that have received socialization about cervical cancer are being Increased, as many as 18.140 people in Badung Regency had been informed about cervical cancer. 6.3 Vaccination Coverage of cervical cancer vaccination in Badung Regency was 1,502 people in 2012; 2,455 people in 2013; 2,150 people in 2014; 1977 people in 2015 and 7,217 people in 2016. In total, as many as 15,004 women in Badung have been vaccinated for cervical cancer. The number of women who get cervical cancer vaccination in Badung is increasing. It means there is an increasing in quantity related the readiness among women in Badung Regency to protect themselves from cervical cancer. Technically, cervical cancer vaccination is given three times with interval 0, 1 and 6 months. Things to consider before vaccination is those who are sexually active are required to undergo VIA examination or pap smear as secondary prevention. 6.4 Resource Research results showed that program input of cervical cancer vaccination in Badung Regency has been going well. Input could include funding, existing oranizations, potential cooperation partners, interpersonal or organizational networks, staff and volunteer, time, facility, equipment and supplies. It is including availability of personnel according to the requirement in order to ensure a highly efficient, effective and productive implementation. Infrastructure in this program are all potential used things such as brochures, vaccines, place and transportation which is very important to be prepared so the activity implementation could be well established. Regarding financial resources as a program input, entirely sourced from Badung district budget from 2012 to 2015 is 11,45 billion Rupiah ($ 880,770), where the total target as many as 6,647 people, as following: 1.,65 billion Rupiah ($ 126,924) in 2012, for the purchase of up to 3,000 vials of vaccines to target 1,517 people; in 2013 amounting to 5,665 billion Rupiah ($ 435,770), for the purchase of as many as 10,300 vials of vaccine targeting 2,892 people; in 2014 amounting to 4.125 billion Rupiah ($ 317,308), for the purchase of 7,500 vials of vaccine targeting 2,238; while in 2015 amounting to 4,708,169,500 Rupiah ($ 362,167), for the purchase of 7,500 vaccine vial with 2,070 targets; and in 2016 amounting to 15,529,248,800 Rupiah ($ 1,194,558) for the purchase of 24,807 vials of vaccine with 8,269 targets. The total budget is already budgeted by Badung Regency government and until 2016, it is amounting to 31,667,418,300 Rupiah ($ 2,435,956). This demonstrates the high commitment of the Badung regency government to prevent cervical cancer.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Many stakeholders are involved in implementation of this cervical cancer vaccination, with cross-sectoral involvement in accordance to their respective duties. The involvement and role of these stakeholders include: 1. Badung Regent Badung regent as head of region as well as local policy makers have a high commitment to cervical cancer vaccination program. 2. Education, Youth and Sports Office of Badung Regency Education, Youth and Sports Office as an agency in charge are responsible to mobilize vaccination target. 3. Health Department of Badung Regency Health Department along with Technical Executing Unit of Public Health Center are technically responsible, include in the provision of logistics and event implementers. 4. Badung General Hospital As a referral hospital, Badung General Hospital have a responsibility as a supervisor and implementer, also responsible for follow-up in case of adverse events following immunization. 5. POGI, IDI dan IBI As a professional organization, POGI, Indonesian Medical Association and Indonesian Midives Association has acted as a resource and supervisor in these vaccination activities. 6. Peers Peers have an important role in motivating and encouraging target so that the target proactively come to seek vaccination. 7. Family Family is the main motivator in supporting these young women to involve in vaccination program. 8. Female Adolescents As the main target, female adolescent are expected to be a major stakeholder in promoting and forwarding this activity to others. 9. Other Relevant Parties Many parties are involved as a supporting element for this vaccination implementation, is Badung Regional Secretariat, Women's Empowerment Office, Family Planning and Family Welfare Department, and other relevant parties.

 8. What were the most successful outputs and why was the initiative effective?
The output is a product of certain services are expected to be generated by an activity of the input provided to achieve program objectives. Output program is the result to be achieved from this program. In detail, the results of vaccination coverage of cervical cancer in the Badung regency year period 2012-2015 as follows: in 2012 by 99%, in 2013 84.9%, amounting to 96.1% in 2014 and 2015 amounted to 96%. This indicates that the active participation of young women in Badung very high to protect themselves from the threat of cervical cancer. Cervical cancer vaccinations that have been held by Badung Regency Administration have reached outputs as follow: 1. Increasing the knowledge of students and society how to prevent cervical cancer through vaccination. The high average number of vaccination participants who attend this program in every year indicate an enhancement of cervical cancer prevention. Several studies of cervical cancer vaccination program in Badung Regency imply similar results. 2. Providing spesific protection in women against HPV infection. Cervical cancer vaccination demonstrated a good effectiveness, hence this vaccination is expected to provide maximal protection against cervical cancer. Based on studies, protection of this cervical cancer vaccination is up to 10 years, means that women are protected in the course of 10 years. 3. Stimulating the society to be more concerned about cervical cancer. Vaccinations are given by the government to female students in public senior high school or public senior vocational high school as well as all public and private junior high school in Badung Regency. The goal of this program is to stimulate other society to do vaccination indepedently, therefore the scope of cervical cancer vaccination may be greater. People outside the target are expected to prevent herselves from cervical cancer. 4. Reducing the financial burden against the threat of cervical cancer. Government fully covers the financial burden of this vaccination. This is expected to reduce the burden of public health costs. 5. Enhancing the coverage of noncommunicable disease prevention program, especially prevention againts cervical cancer through vaccination. The increasing number of targets that have been vaccinated cumulatively indicate cervical cancer prevention program performance is also getting better.

 9. What were the main obstacles encountered and how were they overcome?
There are many challenges in the implementation of this cervical cancer vaccination programs. In developed countries, cervical cancer vaccine are received by young women, parents and the medical communities, while in Indonesia the cervical cancer vaccine is still under challenge in the form of contrary to the administration of the vaccine because this is considered to bring sexual freedom to children. Another question is who should be vaccinated. If the vaccine main function is to reduce the incidence of HPV infection, the reduction in the number of infected will appear if the vaccine is given to girls before they have sex. Administration of the vaccine to women who had sexual intercourse before, also can reduce the number of HPV infection although not as effective as those who have never been sexually. Until now vaccination program for cervical cancer in the Badung Regency is prioritized to public senior high school as well as public and private junior high schools. The extension of this to private senior high school schools will bring some difficultiues in financial side due to the high price of the vaccine. Other issues in the vaccination for cervical cancer include the reluctance of women to be examined because of shame, doubting the importance of the examination due to lack of knowledge, fear of the reality to be faced, fear of feeling pain at the time of vaccination, reluctance of being vaccinated by men paramedics and lack of family encouragement. The solution to solve the constraints are by convening socialization to all stakeholders of society, the medics, the religion and the ethics, by using all existing media. Such efforts are needed to explain the importance of cervical cancer prevention through vaccination as well as straighten out misunderstandings regarding the cervical cancer vaccine.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The benefit of “Cervical Cancer Vaccination, Save women and Balinesse Culture” program that has been launched by Badung government can be described as follow: 1. For Badung government Healthy status is one defining factor of increasing in Human Development Index (HDI). The succesful of prevention of cervical cancer program will elevate women health status level to be more productive, and for its portion can contribute to achieve HDI increasing. Badung government commiment to improve gender mainstreaming constantly increasing with the implementation of this program. 2. For Health Office of Badung regency This program suiteable with Health Office of Badung which is realization of independent society to live healthy according to increase efforts to prevent infectious diseases and non-communicable diseases, where one of the activities of non-communicable diseases program is cervical cancer vaccination program. With motto “keep healthy, future invesment” then cervical cancer vaccination is one of the women’s investation in future, hopefully, cervical cancer would not be frightening threat in society. 3. For Education Office of Badung Various forms of gender gaps that occur in various aspects of public life, representated also in the world of education. Even the process and an educational institution is deemed a major role in disseminating and preserving the values and worldview that underlies the emergence of gender inequality in society. Thus the cervical cancer vaccine is capable to providing a specific protection for its students who are in a period of free sex, as a warranty with 92% effectiveness protection from infection HVP. 4. For Primary Health Care Centres The benefit factor, primary health care have been able to perform its function as a service center for preventive and promotive activities to the public. Acces factor, primary health care be able to make the access closer to community for understanding cervical cancer prevention. From economic and socio-cultural resources, the health centers were able to instill an understanding of the importance of self-protection from free-sex and the threat of cervical cancer. 5. For adolescent girls This program give benefit for adolescent girl through the information about cervical cancer, risk factors, prevention by vaccination which is convince these adolescents to become low risk recipient of cervical cancer and persuade other peer groups. 6. For YKI Badung For YKI Badung, this program is one form of real synergy with the Badung department of health in the prevention of cancer. It is also in line with vision of YKI that cancer is not just a matter of individuals or their families affected by cancer, so that the mutual support and cooperation is an effort that needs to be fostered in the implementation of the cervical cancer. 7. For Society Vaccination is not only has huge impact on individual or society, but also contributed in socio-economy development, such as suppress medical expenses. Moreover vaccination is the most effective intervention in prevention and reduction of cervical cancer incidence. The other benefit, this program is a stimulant to society to be able to held vaccination independently.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Cervical cancer vaccination has been carried out by the Badung regency government on an ongoing basis. In 2013 in addition to targeting SMAN, also given to permanent employees, THL and PNS Gol. I and II of the Badung regency administration. 2014 also adds the target on SMKN class X and XI . Whereas in 2016 cervical cancer vaccination targets developed by targeting the entire SMP Public and Private Badung Regency. Approach to the vaccination program with the school track strategy as a vehicle for these vaccinations have regard to the provisions age, whereas the age of 10-26 years is a period of the most effective vaccination. This is because at that age the formation of antibodies in the body reaches maximum. In addition it is based also on the consideration of social aspects and the availability of funds in which junior high school student has entered the phase of adolescents with social which is vulnerable to negative things. The program is a pioneer in the Badung regency even at the national level so that the required selective in the use of funds but in its implementation should be right on target.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
a. Increased scope of immunity 1. Before the program Cervical cancer vaccination coverage is only about 0.2% of women of fertile age (10-26 years old) in Badung who received a vaccine for cervical cancer. 2. After the program The result of cervical cancer vaccination from 2012 to 2016 amounted to 15,004 people. Cervical cancer vaccination coverage in 2016 increased to 5%. b. Innovative Service Model 1. Before to the program At first, cervical cancer prevention in Badung stagnant following the national program reference only. 2. After the program The existence of cervical cancer vaccination program is an effort to give specific protection to women in the Badung regency through vaccination. c. Acomprehensive Cervical Cancer Prevention 1. Before the program Secondary prevention with pap smear turned out to have problems related to accuracy, retrieval techniques and inspection, human resources and geography. 2. After the program Badung government has committed to tackling the threat of cervical cancer. Not leaving the government prevention program through pap smear and VIA, now all the young women who are listed as SMP and SMA / SMK in Badung have been vaccinated against cervical cancer so that they can stand against the threat of cervical cancer.

Contact Information

Institution Name:   Health Offices of Badung District
Institution Type:   Local Government  
Contact Person:   Putra Suteja
Title:   High Officer  
Telephone/ Fax:   087761773355
Institution's / Project's Website:  
E-mail:   ptmbadung@yahoo.com  
Address:   PUSPEM BADUNG, Jalan Rayan Sempidi
Postal Code:   -
City:   Badung
State/Province:   Bali

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