Questions/Answers

The burden of cervical cancer remains greatest in low- and middle-income countries. A major obstacle to treatment is inaccessibility to services. The only conventional screening test was Pap smear which required many processes, having to wait for a long period before results come; for abnormal results women have to be referred. Women with cervical cancer had to be transferred to more technologically advanced facilities far away. These factors can burden women and families with transportation and budgets. Many women cannot adhere to such many appointments. Inefficiency and low quality outcomes with poor control and prevention was inevitable. Since 1999 Roi Et Provincial Health Office (PHO) has collaborated with strategic partners includes the Royal Thai College of Obstetricians and Gynaecologists (RTCOG), the Jhpiego – an affiliation of the Johns Hopkins University, U.S.A., Chulalongkorn and Khon Kaen Universities and Department of Health, Ministry of Public Health of Thailand, to conduct a demonstration project using visual inspection with acetic acid (VIA) and cryotherapy for cervical cancer control among 4 districts. Women get their results within 1 minute. For abnormal results, cryotherapy can be provided immediately. This innovative method can markedly reduce unnecessarily steps and waiting time, links screening and treatment and reduces loss of follow up rate. This scheme also trains nurses to be providers which can solve staff shortages in rural and remote areas. After publication in the Lancet, Roi Et PHO has extended VIA & cryotherapy services to all districts as a component of comprehensive cervical cancer control (C4). The Service Development Plan has been written and guided mainly by the WHO Health Systems Framework using six building blocks model. Infrastructures such as cancer registry has been strengthened. Under a collaboration with Chulabhorn Hospital, Roi Et Hospital has been designated by the Ministry of Public Health as a general cancer center.

The objectives of this initiative comprehensive cervical cancer control plan are to save women’s lives, especially those living in rural and remote areas with the ‘No One Left Behind’ project. Enabling objectives include protect girls in 5th grade with human papillomavirus (HPV) vaccination, providing an organized population-based screening program for women aged 30-60 year with VIA and Pap smear to increase coverage and uptakes, and women with cervical cancer can more easily access to quality cancer care nearer their home and reduce unnecessary referrals. This C4 plan extends from HPV vaccination for girls 9-13 years of age, screen women aged 30-60 years with VIA or Pap smear to increase coverage, efficiency, quality and treatment outcomes. Abnormal screening results must be treated appropriately and in timely manner. Those with invasive cancers must receive high quality cancer care and those with advanced diseases must have choices for palliative and end-of-life care. C4 activities include planning, prevention, early detection, diagnosis and treatment, palliative and quality-of-life, and policy and advocacy. Focus on screening initiative, an innovative of single visit approach (SVA) using VIA and cryotherapy has been introduced as an important component of the plan and aims to increase access to screening services.

New integrated approach through application of SVA using VIA and cryotherapy has been introduced to provide increasing access to sustainable, high quality and affordable services for women especially those in rural and remote areas. With VIA & cryotherapy, women can obtain information and feedback about the results immediately and if eligible immediate treatment can be provided at the same visit and ensures complete management for the women, especially the poorest and most vulnerable. In particular, the initiative responds to specific discrimination faced by women and the burdens they face regarding care, mobility and access issues and security risks. Counselling session of VIA & cryotherapy also help women obtain information about the services and their own rights and entitlements, to initiate investigations after decision-making about informed consent. Organized screening program, mobile clinics, consultation social media groups and a scheduled visit appointment system for colposcopy services at referral hospitals are some transformations in administration for the benefits of women in Roi Et and many parts of Thailand after introduction of VIA & cryotherapy.

Roi Et C4 program, especially with VIA & cryotherapy scheme, has changed and transformed the delivery of public services as it uses an integrated approach called single-visit approach (SVA). Women can be tested by nurse providers and if abnormalities are found and eligible, they can be treated with cryotherapy at the same visit. With this organized screening program it can be made sure that the Sustainable Development Goal 3 (good health and well-being) can be achieved by preventing women from premature deaths and burden from cervical cancer. Roi Et PHO is committed to developing policies and plans for the prevention and control of cervical cancer, developing and implementing C4 plan with a focus on equity and access and makes sure to offer adequate resources and infrastructures to provide high-quality, resource-appropriate cancer prevention and control services for all. Screening services are provided free-of-charge. The cervical cancer risk has also been reduced by integrating reproductive health program and promoting access to human papillomavirus vaccination which began in 2017 for 5th grade girls. The establishment of a cancer center can help reduce out-referrals of cervical cancer cases. These can help lessen women’s anxiety, transportation and other socioeconomic burdens.

Roi Et C4 Plan has involved all stakeholders as parts of the program. Primary care providers along with village health volunteers work hand-in-hand to address and encourage women to access to screening services. SVA using VIA & cryotherapy scheme also ensures that women with identified abnormalities attend for diagnosis, management and follow-up. Innovative activities like cause of death data quality development and a hospital-based cancer registry have addressed accurate and precise public health priorities. Roi Et C4 Plan can also help address cancer survivors care. Palliative care can be delivered early in the disease trajectory and offers opportunities to improve not only physical symptom management but also enhances communication, psychosocial care and promotes quality of life.

Cytological screening had been the only modality being carried out in Thailand. There was no organized programs and the testing was often of poor quality and performed inadequately and inefficiently among the population. As a result, there has been a very limited impact on the incidence of cervical cancer, despite the large numbers of cytological smears taken. The growing cancer burden has especially harsh consequences for women due to gender discrimination, stigma, and cultural taboos, along with well-founded fears of abandonment or even violence. SVA using VIA & cryotherapy has been introduced as an innovative approach for comprehensive cervical cancer control by Roi Et PHO. The advantage of VIA is that women can be screened and treated at the same time. If abnormalities (precancerous lesions) are found on a woman’s cervix, they can be treated on the same day by freezing and destroying them with cryotherapy. Other innovative is integrated approach of the plan that fully covers planning, prevention, early detection, diagnosis and treatment, palliative and quality-of-life, and policy and advocacy.

An integrated approach of comprehensive cervical cancer control has introduced a new concept of cancer control and care. This innovative helps both people and providers get the most benefits from cancer control plan. From prevention to early detection to diagnosis and treatment to palliative and quality of life care; all activities can be planned, provided and monitored. Before 2000, cervical cancer screening in Thailand depended solely on cytology method using Pap smear testing. SVA using VIA & cryotherapy was then a brand new cervical cancer screening method introduced to Roi Et and Thailand. This modality was an innovative idea of ‘screening and treatment’ under ‘single visit approach – SVA’ and can ensure that women with cervical abnormalities can be treated appropriately and immediately at the same visit. Training nurses to perform this ‘SVA’ is a robust initiative for health workforce development as nurse providers can perform the services at all levels of healthcare system.

Roi Et C4 Plan is an adaptation of Cancer Control: Knowledge into Action – WHO guide for effective programmes and has been tailored to local contexts. The Chulabhorn Hospital Collaborating Center for Comprehensive Cancer Control at Roi Et Province has been established as another initiative to extend and increase quality of cancer care with one of the strategic partners. Focus on cervical cancer screening, Roi Et PHO has introduced VIA & cryotherapy as an innovative service and integrated into C4 Plan with pre-existing Pap smear testing. Infrastructure development and strengthening includes hospital-based cancer registries has also been established with contribution from the International Agency for Research on Cancer (IARC) – the specialized cancer agency of the World Health Organization for high quality cancer data and population-based cancer registry is developed with Thailand National Cancer Institute (NCI).

At the beginning, Roi Et C4 initiative had financial support from the Department of Health (DOH) Ministry of Public Health (MOPH) for SVA training courses for nurse providers. Between 2013 and 2015 there was reimbursement from the National Health Security Office (NHSO) to support cervical cancer screening. During the period, Roi Et PHO had been involved for development of new online data application named CxS2010 to monitor and report performance and results of the program (www.nci.go.th/cxscreening/). VIA & cryotherapy has been accepted as an alternative choice to conventional cytology screening test using Pap smear and received a subsidy from the NHSO. Since 2016, VIA & cryotherapy has been integrated into Prevention, Promotion & Protection Benefit Package under Universal Health Coverage (UC) scheme and be provided free-of-charge to women aged 30-45 years. Nurses from all levels of healthcare system in Roi Et were supported from their supervisors to participate in SVA training courses. Cryotherapy machines were initially supported by Jhpiego and then later by local hospitals themselves. Since 2017, Roi Et Hospital has been designated by MOPH as a general cancer center and can now provide treatment and palliative care for advanced cervical cancer such as surgery and radiotherapy.

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Roi Et PHO’s experiences with C4, especially on VIA & cryotherapy, has been shared and transferred to many provinces and countries. Up to 2017 there are as many 30 provinces across Thailand providing SVA using VIA & cryotherapy as component of provincial cervical cancer control programs. Roi Et has been referred to as a prototype province and has been the host of many international training courses. It also has been recommended as a destination site of study visits for international colleagues such as those from Ethiopia and Myanmar. Roi Et PHO staff have also been requested as international trainer to help organize VIA & cryotherapy training course in many countries such as Uganda, Vietnam, Papua New Guinea; as country consultant to the Lao People’s Democratic Republic; and as country expert to share experiences with India, the Philippines and Cambodia. VIA & cryotherapy training course has been used as model for development of training course of nurse sonographers for liver and bile duct cancer screening project in Roi Et too.

In consideration of financial stability, when external funding ended in 2004, Roi Et PHO has provided SVA using VIA & cryotherapy services by allocating its own fiscal budget supported by MOPH and NHSO under the Universal Health Coverage (UC) Scheme. Financial security for VIA & cryotherapy initiative has also been covered by Social Security Scheme (SSS) and Civil Servant Medical Benefit Scheme (CSMBS) and is provided free of charge to all target women. The Thailand Nursing and Midwifery Council has approved and endorsed that trained nurses are qualified for providing VIA and cryotherapy services. Roi Et C4 Plan has been accepted as one of the standard means for cervical cancer screening and is highly sustainable.

After 17 years of VIA & cryotherapy in Roi Et Province, the sustainability of C4 Plan has been proved. The successful transition from a demonstration project to a national program in Thailand was dependent on a strong commitment from government health bodies and health professionals. VIA & cryotherapy under a single-visit approach is demonstrably feasible and sustainable and can be considered as national investments to control cervical cancer. Roi Et C4 with VIA & cryotherapy initiative is also very well aligned with His Majesty King Bhumibol’s Philosophy of Sufficiency Economy on financial matters, using appropriate technology and using ‘the Middle Path’. Sufficiency economy is very easy to understand as it is based on three principles that can guide any economic transaction. These principles are: moderation, reasonableness, and self-immunity, with two accompanying conditions: appropriate knowledge and ethics & virtues.

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There was a study on ‘Cervical cancer screening using visual inspection with acetic acid: operational experiences from Ghana and Thailand’ published in Reproductive Health Matters 2008 and found that providers maintained a high level of competence and performance. C4 plan has a set of indicators to monitor and evaluate. First, primary prevention with HPV vaccination. Second, secondary prevention with coverage and uptakes of screening tests; and third, rates of out of province referrals. Ongoing activities have been monitored and reported using CxS2010 and be available at www.nci.go.th/cxscreening/. The official monitoring and evaluation of the program is available from the Thailand Ministry of Public Health website at https://hdcservice.moph.go.th/hdc/main/index_pk.php.

The outcomes by evaluation of this initiative reveal that, first, the HPV vaccination has been given to 6,434 from a total of 6,742 girls in 5th grade – 95.4% which is greater than the average rate (94.3%) of the 7th MOPH Health Region. Second, Roi Et has the highest uptake rates of cervical cancer screenings by VIA and Pap smear (52.6%) as compared to the other three provinces within the Region (Khon Kaen – 48.2%, Mahasarakham – 41.5%, and Kalasin – 34.7%). Third, identify more women with cervical cancer and provide timely treatment. Between 2012 and 2016 there were 54, 55, 49, 72 and 53 cervical cancer cases respectively. There were 88 women had been referred to Srinagarind Hospital at Khon Kaen Province in 2016 and 71 in 2017. During the first trimester of 2018, no woman has been referred out of Roi Et because radiotherapy treatment has been installed and started. There is no report of cervical cancer as cause of death during this first trimester, too.

Indicators used to monitor and evaluate C4 plan includes, first, coverage of HPV vaccination to 5th grade girls. Second, coverage and uptakes of VIA and Pap smear screening tests. Third, rate of out-of-province referrals. These indicators were selected in accordance with the Sustainable Development Goals which are: ensure healthy lives and promote well-being for all at all ages, target to reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being by 2030.

The Roi Et PHO C4 Plan has engaged and encourage active involvement of various stakeholders. Collaborations with colleague organizations are evident involving the RTCOG, Jhpiego, Chulalongkorn and Khon Kaen Universities and DOH-MOPH. VIA & cryotherapy, for example, has involved stakeholders right before the SVA training course begin through stakeholder orientation session, participant selection, and quality assurance supervision. Action planning was done with responsible persons from the PHO, District Health Office and primary healthcare workers from corresponding areas. Roi Et PHO staff work closely with village health volunteers (VHV) and Roi Et is among the provinces with a very strong and large network of VHV. Primary healthcare workers and VHVs normally have regular meeting on a monthly basis. Since 2017, District Health Board (DHB) has been proposed and approved as a mechanism to the Thailand Health Care Reform Agenda. The Board Committee includes District Governor, District Health Officers, other district institutions, community leaders, civil society, and the private sectors. Collaboration, engagement, coordination, partnerships, and inclusion have been emphasized to ensure achievement of the 2030 Development Agenda.

First, strong leadership and good governance are very importance in the providing of public services. ‘No one left behind’ has been the ultimatum for the development of C4 in Roi Et Province and has been shared clearly to all levels of healthcare facilities. Second, C4 should be provided by an integrated approach with women at the heart of the services, especially those in the most rural and remote areas with both facility-based and mobile services at a community level. Third, trans-disciplinary approach of the health workforces which includes village health volunteers, primary care workers and registered nurses empowerment to transform VIA & cryotherapy providers. Specialization and professionalism is very important for provision of quality health services as a referral unit. Quality assurance must be integrated into the ongoing program. Forth, a data and information system strengthening both hospital- and population-based cancer registries; and pre-cancer registration are very important, as well as data quality on cause of death. Precision public health needs precision data for monitoring, evaluation and guiding the program. Last but not least, consideration for sustainability – health economic assessment and evaluation. Start small and scale up smart should be kept in mind along with the expansion of the program.