Cervix Cancer Sanning - A Life Saving Initiative
Greater Chennai Municipal Corporation

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Chennai, one of the four major cities of India is home to nearly 5 million, making it one of the largest urban agglomerates of the world. There is an increasing recognition of the impact of non-communicable diseases on the lives of the community. The occurrence of non-communicable diseases among women have a direct effect on families, especially among the poor income families. Early diagnosis and prompt treatment can ensure an almost 100% cure. Cervical cancer is the fifth most common cancer in humans, the second most common cancer in women worldwide and the most common cancer cause of death in the developing countries. Sexually transmitted human papilloma virus (HPV) infection is the most important risk factor for cervical intraepithelial neoplasia and invasive cervical cancer. The incidence rises in 30–34 years of age and peaks at 55–65 years, with a median age of 38 years (age 21–67 years). Estimates suggest that more than 80% of the sexually active women acquire genital HPV by 50 years of age. The worldwide incidence of cervical cancer is approximately 510,000 new cases annually, with approximately 288.000 deaths worldwide. 80% of these deaths occur in developing countries. Of these, over half occur in Asia. Unlike many other cancers, cervical cancer occurs early and strikes at the productive period of a woman's life. Cervical cancer is ranked as the most frequent cancer in women in India. India has a population of approximately 365,71 million women above 15 years of age, who are at risk of developing cervical cancer. The current estimates indicate approximately 132.000 new cases diagnosed and 74.000 deaths annually in India, accounting to nearly 1/3 of the global cervical cancer deaths. Indian women face a 2,5% cumulative lifetime risk and 1,4% cumulative death risk from cervical cancer. At any given time, about 6,6% of women in the general population are estimated to harbor cervical HPV infection. HPV serotypes 16 and 18 account for nearly 76.7% of cervical cancer in India. In India, cervical cancer accounts for 20-50% of all cancers; its annual incidence is about 126.000. The incidence of cervical cancer is very high in Tamil Nadu. Madras Cancer Registry reported an incidence of 190.000 cases in 2002. Rural/poor population is at high risk due to low socio-economic status, poor genital hygiene, early marriage, multiparity and lack of knowledge about the disease and treatment. The women are “silent sufferers” and most likely to seek medical help in advanced rate. Hence, it is important to screen the asymptomatic vulnerable population and detect pre-cancerous lesions at the earliest. The early detection test –i.e PAP smear– is not only very expensive but also very resource intensive and time-consuming for replication over a large population.

B. Strategic Approach

 2. What was the solution?
Controlling cervix cancer requires systematic early detection. The existing detection technique was too resource-intensive to be implemented over the large population. Simpler techniques were generalized, allowing for early detection and control of the disease.

 3. How did the initiative solve the problem and improve people’s lives?
The only solution to the problem of high prevalent disease was regular screening. All women in reproductive age group of 18-40 have to be screened once every 5 years to rule out the disease before it becomes symptomatic. Due to prohibitive cost of screening with the earlier popular test – i.e., PAP Smear–, it was never taken up at large scale as a public health initiative. Even among the affluent section the test was rare and resulted in symptomatic screening instead of preventive screening. The existing test for screening the cancer is extremely expensive and required expensive laboratories and trained Gynaecologists. Apart from the financial and human resource constraints the test requires multiple visits to gynaecologists. Further women were not willing to visit screening health posts multiple times due to burden of other work. Covering the eligible population of women in reproductive age group of 18 to 40 was just impossible with this test. The test cost approximately US$200 in India for one screening. The population of Chennai city in 2008 was 5 million and covering 500.000 thousand women every 5 years was an impossible task and was not happening. This resulted that poor women never got screened and borne the brunt of the disease. Late detection is fatal with this cancer. An easy, cheap, simple and less time-consuming test that can make an accurate prediction of pre-cancerous lesions in the cervix was the solution. the city selected a cost-effective test for detection of pre-cancerous lesions in the cervix : the “Visual Inspection using Acetic acid (VIA)” and the “Visual Inspection with Lugol’s Iodine (VILI),” techniques. This test was available but was not used for screening either in Tamil Nadu or in any other state of India despite its effectiveness. The city undertook the largest trial of the test in perhaps the whole world. This test involves applying a swab of table top vinegar at the cervix and the visual inspection of colour changes of the tissue indicates the possibility of development of cancer. Material (i.e. table top vinegar) was readily available and reduced the cost of screening from US$ 200 to 0,02. The technique involves a visual inspection through a magnifier of the cervix to detect any offending lesions with the help of a magnification device (Magna-vision). If no apparent lesions are seen, the cervix is swabbed with mild acetic acid (common vinegar). This has been scientifically found to cause whitening of affected areas, allowing easy detection. A further test to ascertain the presence/absence of lesion is done by swabbing the cervix with Iodine that caused affected areas to turn mustard yellow. With this technique detection of this very slow developing cancer can be detected early – nearly 12 years before it can be considered life-threatening to a woman. The technique presents many advantages to the City of Chennai: the test can be performed by trained paramedical personnel (trained nurses or health workers and does not require gynaecologists), it can be done in a few minutes, it requires only one visit to the clinic, it provides almost instant results (helping planning further treatment in positive cases), the equipment is simple to handle and inexpensive to procure. Besides, the test done directly on the cervix, eliminates lab associated costs as seen with cellular testing. A WHO review confirms that the VIA technique is 98.4 % sensitive in detecting abnormalities. As the cost of the testing was very low it could be taken up as a mass screening programme as a city public health initiative. Thus preventive screening, early detection and treatment was made possible first time in INDIA.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The test was available in medical journals. A WHO review confirms that the VIA technique is 98.4 % sensitive in detecting abnormalities. Nevertheless, the test had never been used as major public health initiative anywhere in the World. Why should the city government spend US$200 of public money for screening when it can be done with less than US$1? It should be noted that the cost are not that low due to government subsidies but because the material cost is almost zero, and because it does not require experienced gynaecologists and can be undertaken by trained health worker. The innovation of the city lies in identification of the test, standardising testing methodologies, developing equipment and making available the preventive screening to the masses especially poor women.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The project was undertaken by the Government of Chennai City called Greater Chennai Corporation (GCC). More precisely, it was implemented by the GCC women’s health division, called population project division. It consists of around 500 multipurpose health workers, 200 doctors and another 100 Gynaecologists, covering the entire city through 93 health posts and primary referral centres. The division covers the group of women under reproductive age in the whole city. The multipurpose health worker visit each home and keep a detailed account of women and their anti-natal health. They carry out counselling, advocacy and awareness about health initiative of the city government In 2008, the Chennai city had a population of 5 million. Now it is 10 million. Part of the increase is due to annexing of additional areas within the city. Initial pilot projects were performed in 2 health outposts of the city covering a population of 100.000. Over a period of 2 years, the project was extended to all 93 health posts covering the entire city population of 5 million. The women in 18 to 45 covers approximately 35 % of women population. It comes to approximately 800.000.
 6. How was the strategy implemented and what resources were mobilized?
With a small investment all the family welfare clinics were equipped with this equipment. The 93 health posts in Chennai corporation were equipped with Magna Vision (the equipment) at a cost of Rs 350.000. All the multipurpose health workers were trained in conducting these tests. There are 484 multipurpose workers and 170 doctors. Initially all the lady doctors were trained and subsequently all the MPHWs were trained with the help of doctors. There were issues associated with this test. Stigma of cancer made women feel that the screening was unnecessary and feared taking the test. The strategy was to integrate this preventive screening with existing health programmes, renaming the screening as a “General well-woman check-up”. This strategy was effective to reach the high-risk target groups, it created awareness and facilitated rolling out of the scheme. The screening was included in regular check-up of visiting mothers for anti-natal and other health check-ups. It means that Multipurpose health worker were visiting each home for popularising the preventive screening. This was combined with existing educational and clinical components. The outreach workers in each of these health centres and health posts called the Multi-Purpose Health Workers with a combined field presence of nearly 45-50 health visitors in each zone. These women go into low income communities and encourage them to come in for the equivalent of a master health check-up for women in these low-income communities. They escort the vulnerable contacts made during the day back to the health centre where the women are given a pre-examination counselling and the screening takes place. As a part of health programme all mothers in the reproductive age group visit the health posts at least once in a year for various tests and other health checks. This screening takes only 15 minutes and was integrated with other annual check-ups at the out posts. This found greater favour amongst the women of economically weaker sections residing in slums. During the preventive camp, they were not only screened but also educated about the symptoms of the disease. They were counselled about other preventive self-examinations and on importance of good nutrition. There is a strong element of outreach care in the program After that, the health visitors are expected to make intensive follow up home visits for the next one year and more spaced out visits over the next three years. In most instances it just requires one visit to the centres. This ensures that many of these women do not lose any productive time. The women with pre-cancerous lesions were made to undergo Cryotherapy on the same day and advised a follow-up for the treatment in a month, followed by a second visit within the next six months and an annual check-up thereafter. The Cryo therapy serves to kill the pre-cancerous cells to eliminate them from the system. This single visit approach accomplishes both screening and treatment in a short time, using minimal resources and without alarming a vulnerable group of women.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The key stakeholders were paramedical staff, medical staff and gynaecologists. The stakeholders were involved not only in basic design of the project but making it simpler and in integrating with ongoing reproductive health projects. Some of the equipment like magna vision was improved with the help of the paramedical staff. There was initial resistance among the paramedical staff and medical professionals fearing an increase in workload. It was slowly overcome by implementing the project over a period of 2 years, providing extensive training and initiating an innovative reward programme, with the best staff members being were awareded by City Mayor. The success stories were published in leading news dailies to get the recognition to hard working staff.

 8. What were the most successful outputs and why was the initiative effective?
The cost of screening was brought down from US$200 to US$1. This allowed to generalize it. The key ingredient was table top vinegar costing absolutely nothing. Moreover, it was readily available. In the first year, 102.196 women were screened for cervical cancer. 1.083 women were found to have pre-cancerous lesions in the cervix, meaning that these women are in early stages of cervix cancer which, if not treated, can develop the full-blown cancer. Until today, 591.619 women in Chennai city have been screened and 4.994 have been found positive and treated. The program has now been extended all over the state: 11.556.830 women have been screened and 383.607 have been found positive and treated. The program has thus been successful in saving 4.994 lives in Chennai city and 383.607 lives across the state. Besides these outputs, the programme also achieved important qualitative results: • A huge awareness about screening among the targeted group (i.e.: women under reproductive age group) has been created. The program has changed phase from supply driven to a demand driven. • The capacity of health workers has been enhanced and these can be used as resource person across the world. • A data base of cases has been created which can be used for further research and follow up. This the highest known traceable cases of likely cancer which can be followed by medical professionals and researchers. • The program has brought in change in outlook and destigmatised the reproductive health care. • This has created awareness about breast cancer examination and early detection as both were packaged together. • The simplicity of technique has made it reach even the smallest villages and hamlets across the length and breadth of the state. • It has brought focus on women’s health in public health programmes. This proactive health policy is certain to bring down the burden of cervical cancer in Chennai and it can become a model of early detection for third world countries with high prevalence. This methodology has been tested at this scale only in Chennai and Tamil Nadu. This is a low cost method developed by us can be replicated in all the Primary Health Centres (PHC) in the state. Presently there are no facilities at PHC as the Pap Smear test requires advanced laboratory and trained Gynaecologists.

 9. What were the main obstacles encountered and how were they overcome?
There were issues associated with this test. Stigma of cancer made women feel that the screening was unnecessary and feared taking the test. We pursued the plan by renaming the screening as a “General well-woman check-up.” This found greater favour amongst the women of economically weaker sections residing in slums. The outreach workers in each of these health centres and health posts called the Multi-Purpose Health Workers with a combined field presence of nearly 45-50 health visitors in each zone. These women go into low income communities and encourage them to come in for the equivalent of a master health check-up for women in these low-income communities. They escort the vulnerable contacts made during the day back to the health centre where the women are given a pre-examination counselling and the screening takes place. After that the health visitors are expected to make intensive follow up home visits for the next one year and more spaced out visits over the next three years. In most instances, it just requires one visit to the centres. This ensures that many of these women do not lose any productive time. Apart from this the testing procedures and equipment had to be standardised. The paramedical staff, Medical officers and gynaecologists had to be trained and motivated. Their fear of increased work load was overcome by innovative reward and recognition schemes.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The major benefit for women was availability of an easy, low cost, instantaneous screening method. Though the technique was available in textbook it has not been implemented at this scale anywhere in the world yet. Applying this technique led to the detection and treatment of about 5.000 and 400.000 individuals in Chennai city and the state respectively. The spill over effect is that many private hospitals also have started offering this test for relatively affluent sections of the society who are not willing to avail medical facilities of the government.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
It is the responsibility of the government to provide affordable health care to all the citizens. This affordable technique allowed government to take on this responsibility. This led to save lives of women who can keep participating in the society and its political processes.

 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)
This was mainly designed for women in reproductive age group, among which cervix cancer is the most prevailing one. The existing screening methods were too expensive, leading this target group to be left behind. This affordable technique has provided a ray of hope for many women in low income category. Moreover, each dispensary was modified to provide a small test room with equipment and privacy for women to undergo test without any stigma. At each hospital an exclusive women’s area was carved out. The design of space provided for dignity and overcoming stigma associated with test. The space was so integrated that a casual visitor cannot distinguish the patient waiting for reproductive health check-up and cancer cervix screening.

Contact Information

Institution Name:   Greater Chennai Municipal Corporation
Institution Type:   Local Government  
Contact Person:   Rajesh Lakhani
Title:   Mr.  
Telephone/ Fax:   044-25670390, +919840433055
Institution's / Project's Website:  
E-mail:   rajesh.lakhani.office@gmail.com  
Address:   Chief Electoral Office, Fort St George
Postal Code:   600001
City:   Chennai
State/Province:   Tamil Nadu
Country:  

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