Breast and Cervical Cancer Screening Program
Commissionerate of Health, Gujarat

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Global burden of diseases is steadily shifting towards non communicable diseases; according to Global status report 2014 57% of morbidity is accounted for non communicable diseases. Rising burden of non communicable diseases is a consistent threat for social, economical and health capital of the nation. Cancer is one of the largest contributors for morbidity and mortality among four common non communicable diseases. According to Global status report 2014, 26.2% of Indian population of age group 30 years to 70 years is estimated to die from the four main non communicable diseases. Breast and Cervical cancer are the most prevalent type cancers in women in Gujarat, 26.3% and 16.4%, respectively (Cancer Atlas of India). Breast and Cervical cancer also have strategic links to health status, universal health coverage, occupational and social determinants of health, communicable diseases, maternal, child and adolescent health. Population based prevention strategies and proactive screening will reduce premature mortality and Quality Adjusted Life Years in non communicable diseases. The non communicable disease burden can be greatly reduced by implementing cost-effective preventive and curative actions, along with available public health strategies. Women represent almost fifty percent of the population, thus targeted approach to improve health awareness among female pertaining to modifiable risk factors of non communicable diseases will also affect family health and quality of life. •More than three forth of patients suffer from poor prognosis due to diagnosis in late stage of cancer. •The magnitude of prevalence of non communicable diseases and relative inadequacy of accessible qualitative resources is a major challenge to be addressed to achieve “Health for all”. •Despite of higher public health importance of breast and cervical cancer, there are only sporadic efforts in hospitals and research settings. •Availability of trained health workforce and evidenced based decision making for cancer is a major challenge to be concurred. Population screening that aims to detect the disease at the pre-cancer stage is amenable to assure reduction in out of pocket expenditure for cancer treatment. The Breast and Cervical Cancer Screening program aims to provide accessible health care service that will ensure early diagnosis and timely services, thus it will prove a key to achieve healthy life, longevity and well being of the family.

B. Strategic Approach

 2. What was the solution?
1.Continuous population based screening and diagnosis of breast and cervical cancer for all women irrespective of economical class, caste and age in Gujarat. 2.Capacity building of Health workforce. 3.Accessible and affordable treatment and management of Breast and Cervical Cancer.

 3. How did the initiative solve the problem and improve people’s lives?
The state has envisioned providing accessible qualitative health services especially for non communicable diseases. The state government has launched “Breast and Cervical Cancer Screening Program” on World Health day 2015. The program is aimed to provide early screening, diagnosis and timely treatment of breast and cervical cancer to all women irrespective of economical class, caste and age in Gujarat. The said program targets to screen all women of 30 years to 59 years of age group for primary symptoms of breast and cervical cancer, moreover, suspected cases of any age group (apart from 30 years to 59 years of age group) are also being screened for diagnosis and treatment. • Preventive oncology has a major and important role in early diagnosis and to mitigate avoidable financial burden. • The health personnel carries out “House to House survey” for various twenty diseases comprises of communicable, non communicable diseases and birth defects like Club Foot, cleft lip and cleft palate, along with generating community awareness for risk factors and special attention to primary symptoms of breast and cervical cancer through inter personal communication. • A unique community based platform to facilitate screening for breast and cervical cancer. • Ensuring early diagnosis and treatment for breast and cervical cancer decreases the Quality Adjusted Life years in female and also improves reproductive and maternal health status in the society. This population based screening has improved health seeking behavior in women, especially of outreached, difficult to reach areas. The program also aspires to provide free diagnostic and treatment services for breast and cervical cancer in all public health institutes across the state, thus it helps families to break poor to poorer trap. The community awareness for breast and cervical cancer also helped to ensure family support that triggers early decision making behavior to access health services and to continue the same.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The emphasis on health awareness and early detection of breast and cervical cancer will go long way to modify socio – economical inequality. Generating awareness for modifiable risk factors of breast and cervical cancer will also aid to reduce burden of other non communicable diseases. Breast and Cervical Cancer Screening Program includes large scaled population based screening of all women of 30 years to 59 years of age group across the state. The primary screening is carried out by female health personnel that also help to remove gender based hesitance to access health services for breast and cervical cancer. The mobile screening units equipped with necessary diagnostic equipments are also utilized to improve services in outreached and difficult to reached areas. This program ensures free diagnostic and treatment at all public health facilities and private health facilities empanelled under state specific schemes; viz: ‘Mukhyamantri Amrutam” and “Mukhyamantri Amrutam Vatslya”. The breast and cervical cancer screening program also intend to reduce out of pocket expenditure for health services, thus leading to a step closer for sustainable social – economical development and to attain “Health for All”.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The Health and Family Welfare department has launched “Breast and Cervical Cancer Screening Program” on April 2015. Improving community inclusion by generating awareness for modifiable risk factors and symptoms of breast and cervical cancer is an important aspect of this program. More than one crore women are being screened regularly for primary symptoms of breast and cervical cancer by trained female health personnel.
 6. How was the strategy implemented and what resources were mobilized?
The state is committed to provide qualitative health services, thus different level of health personnel have been trained in coordination of State Institute of Health and Family Welfare (SIHFW) and Gujarat Cancer Research Institute (GCRI) for screening, diagnosis and management of breast and cervical cancer. Basic (filed level) female health personnel are generating awareness for risk factors, primary symptoms and available investigation and referral services for breast and cervical cancer in Gujarat. Medical officers and staff nurses of Community Health centers and Primary Health centers are trained for clinical examination and primary investigations for the breast and cervical cancer, similarly skills of secondary and tertiary level health staff have been enhanced with various diagnostic procedures for breast and cervical cancer. • A three tier system for screening and diagnosis of breast and cervical cancer. • Women of 30 years to 59 years of age group are being oriented by Female Health Workers and Accredited Social Health Activists (ASHAs) through IPC and target group is also being screened by Female Health Workers for primary symptoms of breast and cervical cancer (primary screening). • The suspected cases identified from primary screening are referred to Primary Health Centers and Community Health Centers for clinical examination by Medical officers and Specialists (secondary screening). • The suspected cases of breast and cervical cancer are further referred to District Hospital or Medical College Hospital for further investigations if required. Emphasis is given to early detection of breast and cervical cancer by outreached camps and clinical services. Three mobile diagnostic vans – “Sanjivani Rath”, along with a unit of medical specialists – “Vijay Rath” are also being utilized to ensure qualitative screening and diagnostic services in outreached or difficult to reach areas. Regular cancer detection methods like self examination of breast, mammography, examination of cervical PAP smear, etc. are being implemented during this program. Cervical PAP smear test are made available free of cost under “Mukhyamantri Nidan Yojana” (MNY) at each Community Health centers, Sub District Hospitals, District Hospitals and Medical College Hospitals. The Breast and Cervical Cancer Screening program ensures free diagnostic and treatment at all public health facilities and private health facilities empanelled under ‘Mukhyamantri Amrutam” and “Mukhyamantri Amrutam Vatslya” schemes. Total amount of rs.03 crore is exclusively approved for breast and cervical cancer screening from state budget. Eligible patients are entitled to receive free of cost treatment of rs 02 lakh per patient per year for breast and cervical cancer at private health facilities empanelled under ‘Mukhyamantri Amrutam” and “Mukhyamantri Amrutam Vatslya” schemes. This has promoted narrowing of socio – economical inequality by decreasing out of pocket health expenditure for treatment of breast and cervical cancer.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
• The Breast and Cervical Cancer Screening program is planned and implemented by department Health of Gujarat after thorough consultation with experts of Gujarat Cancer Research Institute. • Additional Director Family Welfare is a state nodal officer and District Reproductive & Child Health officer is a district nodal officer for this program. • Monitoring and evaluation of the program is being carried out by Family Welfare division of the state Health department. All beneficiaries irrespective to class and cast are a principal target of this program. The wide spread population based screening is being implemented through a trained workforce of more than ten thousands female health personnel. Training of these health personnel including Specialists, Medical Officers, Staff Nurses, Female Health Workers, etc. is accomplished in coordination with State Institute of Health and Family Welfare (SIHFW), a state nodal training division of Gujarat. Generating awareness and community mobilization is ensured through effective IPC and IEC for breast and cervical cancer. IEC material is designed by Family Welfare division in coordination with Gujarat Cancer Research Institute. The pyramid of three tier programmatic structure is being run by health functionaries of the state to ensure early diagnosis and timely treatment by delivery of qualitative services across Gujarat.

 8. What were the most successful outputs and why was the initiative effective?
Broad spectrum campaign of health awareness for breast and cervical cancer has played a vital role for community mobilization that lead to improved health seeking behavior and healthy living. Social awareness for importance of regular screening and early diagnosis for breast and cervical cancer have also helped to modify community attitude towards non communicable disease in female. Qualitative servicers for screening of breast and cervical cancer across the state including outreached and difficult to reach areas is ensured through this program. • Primary screening of more than 127 lakh women (99% of target population) has been completed in first round and repeat screening of 2.48 lakh women have been accomplished by February 2017. The target (women) represents almost fifty percent of total population, thus targeted approach to improve health awareness for modifiable risk factors of breast and cervical cancer will also affect incidence of other non communicable diseases. The campaign aimed early diagnosis and timely treatment of breast and cervical cancer has also decreased unnecessary sufferings and altered Quality Adjusted Life Years in women. • Around 2400 patients are diagnosed with either breast or cervical cancer during this program, where 24% of patients are diagnosed in first stage of either breast or cervical cancer. Availability of free diagnosis and treatment at all public health institutes have reduced poverty trap and improved family well-being. In nutshell, this program accelerated the state government efforts to ensure accessible, affordable, equitable health services for non communicable diseases, so as to improve quality of life in women.

 9. What were the main obstacles encountered and how were they overcome?
The magnitude of prevalence of non communicable diseases in female and relative inadequacy of easily accessible qualitative resources is a major challenge to be addressed during this program. Key barriers for this program also include availability of trained health workforce and accessible evidenced based decision making services for breast and cervical cancer in outreached and difficult to reach areas. Training of more than ten thousands Female Health Workers and other health workforce that comprises of Staff Nurses, Medical Officers, Gynecologists, Pathologists, Microbiologists, etc. has been carried out across the state. Community orientation by Female Health Workers and Accredited Social Health Activists (ASHAs) through IPC and screening of all women by Female Health Workers for primary symptoms of breast and cervical cancer (primary screening) has enhanced health seeking behavior for asymptomatic conditions and motivated the society for regular screening for breast and cervical cancer. Effective political will to provide free diagnostic services and treatment at all public health facilities and through “Mukhyamantri Amrutam” and “Mukhyamantri Amrutam Vatslya” schemes have decreased out of pocket expenditure for breast and cervical cancer.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Broad spectrum campaign of health awareness and screening has played a vital role for social awareness for early diagnosis for breast and cervical cancer that has also decreased frightful attitude towards cancer. Women represent almost fifty percent of total population, thus this program has been proved crucial to modify cancer risk factors and improve health and wellbeing in community. 24% of total diagnosed patients under the Breast and Cervical Cancer Screening Program were diagnosed in first stage of either breast or cervical cancer. This has ensured qualitative family life and social capital. Accessible early diagnostic services reduced unnecessary sufferings in women and availability of free treatment at all public health institutes have lessened poverty trap. Utilization of mobile screening vans – “Sanjivani Rath and Vijay Rath” has significant role to reach to unreached and improved state government capacity to provide accessible qualitative diagnostic services for breast and cervical cancer. In nutshell, this program accelerated the state government efforts to ensure accessible, affordable, equitable health services for non communicable diseases, so as to improve quality of life in women.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The state government is dedicated to provide accessible qualitative and equitable health services to ensure healthy family life. Widespread population screening for breast and cervical cancer has been proved vital to modify risk factors for all non communicable diseases. This program is a distinctive step of the government to improve preventive public health services in the community especially for female. This program has increased participation in reaching to unreached population to provide preventive, screening and diagnostic services that will also reduce the burden of non communicable diseases and increase in trained health workforce. Total amount of rs.03 crore is exclusively approved for breast and cervical cancer screening from state budget. Eligible patients are entitled to receive free of cost treatment of rs 02 lakh per patient per year for breast and cervical cancer at private health facilities empanelled under ‘Mukhyamantri Amrutam” and “Mukhyamantri Amrutam Vatslya” schemes. This has supported narrowing of socio – economical inequality by decreasing out of pocket health expenditure for treatment of breast and cervical cancer. Above all, this program has initiated an inclusive drive to attain qualitative life through utilisation of accessible health services. Increasing political and policy involvement in breast and cervical cancer has also modified social perspective towards cases of breast and cervical cancer.

 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)
Breast and Cervical Cancer Screening Program includes large scaled population based screening of all women of 30 years to 59 years of age group across the state. The primary screening is carried out by female health personnel that also help to remove gender based hesitance to access health services for breast and cervical cancer. Emphasis is given to early detection of breast and cervical cancer by outreached camps and clinical services. Three mobile diagnostic vans – “Sanjivani Rath”, along with a unit of medical specialists – “Vijay Rath” are also being utilized to ensure qualitative screening and diagnostic services in outreached or difficult to reach areas. Early diagnosis of breast and cervical cancer has definite effect to reduce mortality and loss of qualitative life years in women. Availability of free diagnosis and treatment at all public health institutes have helped to break poverty trap. Eligible patients are entitled to receive free of cost treatment of rs 02 lakh per patient per year for breast and cervical cancer at private health facilities empanelled under ‘Mukhyamantri Amrutam” and “Mukhyamantri Amrutam Vatslya” schemes. This has promoted narrowing of socio – economical inequality by decreasing out of pocket health expenditure for treatment of breast and cervical cancer.

Contact Information

Institution Name:   Commissionerate of Health, Gujarat
Institution Type:   Government Department  
Contact Person:   Dr. Prakash Vaghela
Title:   Administrative  
Telephone/ Fax:   0917923253211
Institution's / Project's Website:  
E-mail:   addir.health.fw@gmail.com  
Address:   Block-5, Dr.Jivraj Mehta Bhavan, Gandhinagar
Postal Code:   382010
City:   Gandhinagar
State/Province:   Gujarat
Country:  

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