Strengthening the link between VIA/Cryotherapy and referral services in Tanzania

Jhpiego/MOHSW collaboration

Mary Rose Giattas MD,MPH CECAP TA Jhpiego, Tanzania

Presentation Framework
Overview of the CECAP program in Tanzania Rationale for strengthening the link between VIA/Cryotherapy and referral services Experience on the referral strengthening in three Regions in Tanzania Lessons learnt Conclusion and recommendation

Rationale for Supporting CECAP Services in Tanzania Trend at Ocean Road Cancer Institute 2006 - 2011 Type of Cancer Cervical cancer Kaposi sarcoma Breast cancer Esophageal cancer Head and neck Lymphomas Leukemias Urinary bladder Skin cancer Eye cancers Others TOTAL 2006 955 295 244 2007 1006 404 245 2008 1288 418 275 2009 1374 447 322 2010 1510 681 386 2011 1881 814 526

181
155 201 46 46 40 46 598 2807

256
206 199 78 88 108 76 472 3138

282
244 226 87 87 111 80 382 3480

307
272 245 103 98 123 95 390 3776

380
289 186 142 109 129 84 299 4195

511
361 269 261 153 141 119 208 5224

National CECAP and Control Program

Reproductive and Child Health Section (RCHS) Ag; Director-RCHS Reproductive Health Cancer Unit Collaborate with Partners RHCa-Coordinator Regional Health Management Team [RRCHCO] Health Facilities > 120 CCS 11 LEEP RC 1 Cancer Centre

Council Health Management Team [DRCHCO]

Jhpiego/MOHSW CECAP Program

USAID funded Duration: 2010-2013 The project has been part of the grander MAISHA program (Mothers and Infants, Safe, Healthy and Alive) Geographic focus: four Regions

In collaboration with the Ministry of Health

Laying the ground work

National cervical cancer service delivery guidelines Training resource package IEC materials (in collaboration with IMA World/ICAP) HMIS tools- client registers, monthly summary forms and now discussion of introducing CECAP in the DHIS CECAP advocacy package Support partners (GFH,ICAP,EGPAF,MST,PSI,UMATI) in training/supervision (added > 70 sites & TOT) Technical input-National Strategic Plan (WHO/Merck)
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Service Delivery Model

VIA ,Cryo ,LEEP, Biopsy VIA, Cryo,Biopsy VIA, Cryo

Regional Hospital

District Hospital

Health Centre

1.Advocacy-buy in /ownership 2.Site Assessment 3.Equipments and supplies 4.Capacity building-providers/managers 5.Community outreach +education 6.Supportive supervision 7.Strengthen referrals / CECAP +CTC linkage 8.Monitoring System

Integration Breast Cancer Screening & PITC Facility & outreach

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VIA/Cryo service delivery and referrals

VIA (RCH,OPD,HIV Clinic,GYN OPD) 30-50 yrs & HIV Positive of any age (routine/designated days)

Negative

Positive

Suspect Cancer

Follow up 3 years (HIV-) Follow up 1 year ( HIV+)

Treat Immediately

Cryotherapy Repeat VIA after 1 year

Refer/Treat with LEEP

Refer

Program Coverage- 21 sites

April 2010 June 2013
4 Regions ; Morogoro (9) , Iringa (6), Njombe (5) &DSM (1)

21 sites-phased approach;
o April 2010- 3 sites o April 2011-7 sites o April 2012-5 sites + 2 LEEP referral sites o Mar-April 2013-6 sites (Include MNH) o August 2013 -1 LEEP referral site (MNH)

Morogoro
Iringa

DSM

Njombe

All sites offer VIA/Cryotherapy 3 Hospitals offer VIA, Cryo & LEEP services
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Highlight of screening results from 20 sites April 2010June 2013

Indicator Total N New clients screened VIA-positive Treated with cryo on the same day Referred for large lesions NC with suspect CC 21,615 1706 1409 212 445 % and remarks % Among all screened HIV+: 5818 (27%) VIA+rate: 8 % SVA R = 94 % 12.4% (of all VIA+) 2%

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When screening !!

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Rationale for strengthening the linkage

Implement -comprehensive care /close the loop High referrals of large lesion cases Linkage with HIV care services-increased number of referrals for large lesions High referrals of suspect cervical cancer cases from the district level facilities Women who were referred for LEEP/high level of care -difficult to ascertain their outcome Lack of skilled LEEP service providers
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What have we done to improve ?

Build Regional Capacity :
Site strengthening: provided- 3 LEEP machine/supplies Trained service providers in three regional health facilities to offer

LEEP services (AMO,MD & Specialists) o April 2012 (Two Facilities) o August 2013 (One Facility)

Trained national LEEP trainers to support the MOHSW in scaling up/supportive supervision Established a system for biopsy processing with Hfacility Support the cost of biopsy processing (LEEP/suspect cancer) Build monitoring system to track the referral cases & provide feedback (referral log form/ documentation/ reporting)
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LEEP Training and Site Monitoring

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What else did we do to strengthen the referral services ?

Provided cervical punch biopsies forceps to District/Regional level facilities On job training- how to take tissue biopsy from the cervix Provide airtime to service providers to assist tracking the referral cases Support transportation cost of women to the referral site Identified a focal person at Cancer Centre to support cervical cancer referral cases Ensure continuous availability of supplies Conduct regular review meetings to monitor progress Conduct quarterly supportive supervision
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Outcome of referral service strengthening

212 LL cases identified since 2010 June 2013 LEEP services started April, 2012

54% (n=115)

45% (n=96))

Treated with LEEP Deceased Lost to follow up

0.4% (n=1)

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Results of LEEP Service Delivery

INDICATOR REGION HEALTH FACILITY Morogoro RH Mafiga HC Iringa RH Muhimbili* TOTAL Morogoro RH Iringa RH TOTAL 40 4 52 Started Aug 13 96 29 38

Number of clients treated with LEEP April 2012- June 2013

Morogoro Iringa Dar

Number of HIV+ clients treated with Dar LEEP

Morogoro Iringa

Muhimbili* TOTAL

Started Aug 13
67 (70%)

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Before and after LEEP service initiation

2010
3 VIA/Cryo only sites Refer LL for LEEP-other Regions Lost to follow up/feedback + tracking

2012
Established LEEP services in two sites (Regional Level) No need of travelling to other Regions for LEEP services

2013
21 VIA/Cryo sites Established the third referral LEEP site >90% of women seen past 1 year diagnosed with LL were treated with LEEP

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Outcome of referral service strengthening

Improved referral system/ travel hours for patients Improve linkage with pathology services-biopsy results are received within two-three weeks Large Lesion referral cases receive treatment (from April 2012) Cervical cancer cases are referred to cancer center with confirmed diagnosis Increased number of cancer cases treated with radiotherapy Improved tracking and feedback mechanism
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Lessons Learnt

Where the specimen will be processed /pathologist

Strong monitoring system assist in tracking the referral cases

The cost of biopsy processing Budget ??

Collaboration/engaging the MOHSW partners

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Lessons Learnt

Linking VIA/Cryotherapy and referral services can be done ! Assess, Plan, Start small, Learn, Expand, Dont Despair !! Strong f/up skills and commitment - key to success !!
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Challenges
Distance-referring facility and receiving end Work overload for service providers in tracking the referral cases Tracking the referral cases- wrong mobile numbers/not reachable/shift to another village Cost: Biopsy processing LEEP service establishment Transportation referral cases Increase in early cacx cases ..treatment ?! Limited resource- implement based on existing circumstance
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Key Points and Recommendations

Education: community, providers, planners/policy makers Equipment, supplies Logistics Training- hands on skills ? Supervision Collaboration

Government Ownership Budget & Sustainability

Efficient M and E system

Follow-up/tracking

Strengthen linkage; Cancer Care Centre Pathology Lab

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