4. In which ways is the initiative creative and innovative?
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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.
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5. Who implemented the initiative and what is the size of the population affected by this initiative?
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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.
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6. How was the strategy implemented and what resources were mobilized?
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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.
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7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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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.
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8. What were the most successful outputs and why was the initiative effective?
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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.
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9. What were the main obstacles encountered and how were they overcome?
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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.
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