Cervical Cancer Prevention and Treatment Programme in Malawi: Taking services where they are needed most Authors: Godfrey Nkhoma, Amy Kleine, Marya Plotkin, Watson Moyonsana, Abigail Kyei Presented by: Amy Kleine, MPH MSW Cervical Cancer Prevention Program Manager Good afternoon. I am pleased to present the experience of JHPIEGO implementing a cervical cancer prevention program in Malawi. I am presenting today on behalf of Mr. Godfrey Nkhoma, who was unable to be here, as well as the other co-authors. JHPIEGO is an international non-profit organization affiliated with Johns Hopkins University that has been working to improve the health of women and families since 1973. We are based in Baltimore, Maryland and currently work in 50 countries.

Learning Objectives At the conclusion of this session, participants will be able to: Describe results achieved by the national cervical cancer prevention program in Malawi, Discuss the challenges lessons learned of introducing cervical cancer prevention and treatment services into low-resource settings, and Explain key elements of starting or expanding cervical cancer prevention and treatment programs in low-resource settings. Here are the main objectives of this session. I will describe a national cervical cancer prevention program implemented in Malawi. In doing so, I will highlight the successes and lessons learned as a result of this process, and explain the key elements needed to start or expand a similar program.

Malawi is a small country of 11 million people located in Southern Africa, bordered by Mozambique, Tanzania, and Zambia.

Background Cervical cancer: leading cause of cancer deaths among women, 30% of female cancers (Malawi National Cancer Register 2001 - 2003) Cervical cancer is preventable Single visit approach (SVA) using visual inspection with acetic acid (VIA) and cryotherapy - feasible, acceptable, and safe for low-resource settings Program implemented from 6/2004 – 9/2007 at request of Ministry of Health, with funds from USAID and BMGF As background, there are a few things to keep in mind. Cervical cancer is the leading cause of cancer and cancer deaths in women in Malawi, and is the second commonest female cancer globally. Cervical cancer is highly preventable. The single visit approach using the screening modality of visual inspection with acetic acid and the treatment modality of cryotherapy has been shown in studies to be feasible, acceptable, and safe for low-resource settings. The cervical cancer prevention program that I present here was implement from June 2004 through September 2007 in Malawi at the request of the Ministry of Health and with funds from USAID and the Bill and Melinda Gates Foundation.

Program Objectives To raise awareness of the problem of cervical cancer, To establish a sustainable system for providing cervical cancer prevention services, To increase accessibility and availability of cervical cancer prevention services in an integrated reproductive health program, and To provide quality cervical cancer prevention services. The program had four main objectives. To raise awareness of the magnitude and gravity of the problem of cervical cancer and to increase the availability of cervical cancer prevention services, To establish a sustainable system for providing cervical cancer prevention services at community health centers, and districts and provincial hospitals, 3. To increase accessibility and availability of cervical cancer prevention services in an integrated reproductive health program and 4. To provide quality cervical cancer prevention services, through adequate number of trained providers, strong supervision and referral systems, and functional monitoring system.

Methods Formulated national strategy and service delivery guidelines in 2005 Held numerous advocacy meetings with key stakeholders (Cervical Cancer Technical Advisory Group) Trained 84 VIA/cryotherapy providers Developed 10 local trainers in VIA/cryotherapy Conducted community awareness campaigns to increase program visibility - Radio, TV, Leaflets, Posters, Flipcharts To achieve the objectives, a number of activities were undertaken, including: - Formulating national strategy - Convening a Technical Advisory Group Training front-line service providers - Developing a cadre of local trainers and - Conducting community awareness campaigns. I’ll describe these in more detail.

Stakeholders at a Technical Advisory Group meeting in Lilongwe Advocacy Advocacy is one of the key components of the program. To ensure ongoing support of stakeholders, JHPIEGO convened a technical advisory group composed of physicians, educators, community mobilizers, and policy makers. This group met quarterly to discuss the successes and challenges and provide guidance to the program. The group advocated for screening to be included in the essential health package. As the program was coming to an end, the group advised the Ministry of Health on how to ensure sustainability of the services. Stakeholders at a Technical Advisory Group meeting in Lilongwe

Training Group education session during a VIA/cryotherapy training The next critical component to the program was in-service training. Since health providers do not currently graduate with the skills of performing VIA and cryotherapy, they had to be trained in 2-week courses. This course focuses on competency-based learning whereby participants practice skills on models as well as live patients. There were 6 clinical skills training courses conducted from Dec 2004 to Sept 2007. In total 84 providers were trained. These were nurses, clinical officers, and physicians that work in facilities run either by the Ministry of Health or the Christian Health Association of Malawi (mission hospitals). Of all of the providers trained, 95% were still active as of September 2007 meaning there was very little attrition or staff turnover. This picture shows a group education session that occurred during a training course, as part of the clinical skills practice component. Group education session during a VIA/cryotherapy training

Provider performing a pelvic exam Service Delivery After providers are trained, they are dispatched back to their home facilities to begin providing services. A service delivery model was established in Malawi whereby providers integrated screening into their other duties, mainly in the family planning and reproductive health clinics. Each site has 2-3 providers, mainly nurses, who work together to provide the service. They organize services on specific days of the week and inform women in the community about the availability of services. In many sites, there is a clinical officer or physician who is also trained to provide backup and supervision. Women with a positive VIA test may either be treated immediately with cryotherapy or referred for more advanced care to the nearest tertiary health facility. The equipment that is needed to provide the services is minimal, but even so the program had to supply sites with such items as a gyne bed, a lamp, specula, forceps, vinegar, a cryotherapy machine, and a gas tank. Consumables such as gloves and cotton were available on site. Provider performing a pelvic exam

Community Mobilization Once services were up and running, the program began to develop communication materials in order to inform women throughout the catchment communities about the services. In this photo, we see a group of men and women attending an educational session where the materials were pre-tested. The program developed 2 leaflets, 1 flip chart, 1 poster, and radio and TV messages. The materials are being printed currently by local printing companies in Malawi, with funds from Rotary international through Rotary Malawi. It is important to note that the Health Education Unit of the MoH lead the whole process of material development. Although this was a lengthy process and may have been achieved more rapidly through a communications firm, it built the capacity of MoH staff to develop messages about the topic of cervical cancer. Pre-testing communication materials with community members in Mzimba

Results Number of service sites established Number of women screened Number of women VIA-positive Percentage of women VIA-negative, VIA-positive, and suspect cancer Percentage of women treated with cryotherapy Number of women referred for suspect cancer I am now going to share some selected results with you, which are listed on this slide. The program used an electronic database to capture and track data. Paper logbooks were completed at the facilities, and then copies were sent into the central office. Each client has a record in this database.

Results: 24 Service Sites By the end of the program, services were available in 24 sites located in all 3 regions of the country.

Results: Number of Women Screened Total Number of VIA Tests Reported (All Sites, December 2004 - September 2007) Nearly 16,000 women were screened with VIA over a three year period. The number of sites increased over time, as did the number of women screened.

Results: VIA Results VIA Results, in percentages (All Sites, December 2004 – September 2007) Of the total clients screened, approximately 10% were VIA-positive. This is close to the expected VIA-positive rate of 10% for an unscreened population. There were 585, or 3%, of clients who were referred for lesions suspicious of cancer.

Results: Managing VIA+ women Clinical Management for VIA-positive clients, in percentages (All Sites, December 2004 – September 2007) For those clients who were VIA-positive, 24% were immediately referred because their lesions were too large to be managed by the nurses. 65% received cryotherapy, either in the same visit or at a follow up visit. 11% were lost to follow up. Considering the environment in which the program was implemented, this loss to follow up rate is acceptable. 11

Discussion Four Program Phases for National Cervical Cancer Prevention Programs: Country Readiness Capability Development Performance Support Expansion JHPIEGO’s approach to implementing national cervical cancer prevention programs using VIA/cryotherapy as a screening modality is organized into four phases. I will go through each of the four phases in the context of this program and present the challenges and lessons learned for each phase.

Country Readiness CHALLENGES LESSONS LEARNED There was some resistance to use of VIA from those who were used to Pap smear. CECAP was not part of the essential health package (EHP) LESSONS LEARNED With results and evidence it can be demonstrated that VIA and Pap smear are complementary. The Programme visibility could influence Policy Change – CECAP is in DIPs of 11 districts showing recognition of its importance. The country readiness phase involves advocacy to ensure that key stakeholders are on board. In Malawi, the challenges were: Some stakeholders were not in support of VIA because they were worried it was substituting Pap smear. They were also concerned about the false positive rates associated with VIA. CECAP is not on the essential health package. This meant that it is not an important issue, but with the coming of this Programme it has been shown how important CECAP is though still not in the EHP but strides have been made towards that, 11 districts have CECAP in their district implementation plans (DIPS.) We learned that results are important to demonstrate the strength of the program. In this case, we were able to show and VIA was a very useful complement to the Pap smear. We also learned that the visibility and success of the program led District Health Officers to include CECAP in their district implementation plans.

Capability Development CHALLENGES There is critical shortage of health workers in Malawi Multiple tasks must be conducted by the few available health workers LESSONS LEARNED In low resource settings, creativity is needed for maximum use of resources to achieve desired results The Capability Development focuses on training providers and trainers, to ensure there are sufficient human resources available to sustain a quality program. The major challenges were that there is a shortage of health personnel in Malawi, and that the same staff have multiple responsibilities. This means that staff are often overburdened with work, so introducing a new task creates more burden. We learned that staff can be trained in this setting, and that the program needed to be creative in order to maximize their limited human resources. For example, schedules were established to be sure that at least one nurse who could perform VIA was on duty at all times, and that VIA would be offered on 2-3 days of the week so that staff would have time for their other duties. Also, facility managers were asked not to transfer staff once they were trained, and this resulted in very few transfers. Working with Zoe models during training in Blantyre

Coaching is an important part of competency based training Performance Support CHALLENGES Performance standards had to be developed. Malawi did not have a team of supervisors in CECAP to monitor providers at project start. At project start, MOH did have any CECAP data to support assessment of performance over years or for future reference. LESSON LEARNED Monitoring and evaluation is an important part of program sustainability. Supervision alone can motivate providers; most providers are encouraged by a visit of supervisors to their sites In the Performance Support stage, the focus is on ensure that providers maintain competence, and that the program is properly monitored and evaluated. The challenges were: The program had to develop a set of performance standards that could be used to measure provider competence. The program had to develop a group of supervisors who could visit trained providers to coach them and reinforce what they had learned in their training courses. The program had to generate data that could be used to measure progress and successes. The team learned that monitoring and evaluation are critical to program sustainability because this allows the Ministry of Health and others to understand the program needed. Also, the team saw that supervision visits really motivated providers because they felt supported and encouraged. Coaching is an important part of competency based training

Providers and trainers work to expand services to new sites Expansion CHALLENGES Some equipment had to be ordered abroad: Cryotherapy Speculums Gyne beds Insufficient funding to roll out the service nationwide Limited resources for demand generation in the expansion phase LESSONS LEARNED Government commitment is crucial to expand services. District budgets must include funds for the program The final stage is Expansion, which is when the service delivery model is scaled up to new sites. Malawi is currently in the expansion phase. Some challenges to scaling up the screening program in Malawi are: Obtaining equipment, since some of it is not available locally Ensuring adequate funding Generating awareness and demand in the community We learned the government commitment, at all levels, is crucial to be able to scale up services and that districts must budget for this activity in order to be able to implement it in their areas. Providers and trainers work to expand services to new sites

Future Plans MoH to coordinate all CECAP activities under RHU-Desk officer is assigned Scale up to 125 sites nation wide – per MOH plans Strengthen pre-service education in CECAP Strengthen links between CECAP and HIV services Utilize the existing team of trainers to produce more providers and trainer as needed Decentralize CECAP planning from central planning to district level planning using Sector Wide Approach (SWAp) funds Now that funding for this program has ended, the team is handing resources and lessons learned over to the government. Some of the future plans are: Continue scaling up Train health professionals in VIA and cryotherapy during their preservice education Strengthen links between screening programs and HIV testing, care, and treatment Use existing trainers Ensure that district level plans include provisions for screening In closing, I would like to acknowledge the efforts and commitment of the Malawian Ministry of Health, members of the technical advisory group, and the local JHPIEGO/Malawi staff who make this program a success in the face of rather challenging circumstances.