Strengthening the link between VIA/Cryotherapy

and referral services in Tanzania

Mary Rose Giattas MD,MPH

CECAP TA Jhpiego, Tanzania

Jhpiego/MOHSW collaboration

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

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Rationale for Supporting CECAP Services in Tanzania

Trend at Ocean Road Cancer Institute 2006 - 2011

Type of Cancer 2006 2007 2008 2009 2010 2011

Cervical cancer 955 1006 1288 1374 1510 1881

Kaposi sarcoma 295 404 418 447 681 814

Breast cancer 244 245 275 322 386 526

Esophageal

cancer 181 256 282 307 380 511

Head and neck 155 206 244 272 289 361

Lymphomas 201 199 226 245 186 269

Leukemias 46 78 87 103 142 261

Urinary bladder 46 88 87 98 109 153

Skin cancer 40 108 111 123 129 141

Eye cancers 46 76 80 95 84 119

Others 598 472 382 390 299 208

TOTAL 2807 3138 3480 3776 4195 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]

Council Health Management Team

[DRCHCO]

Health

Facilities

> 120 CCS

11 LEEP

RC

1 Cancer

Centre

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

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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)

6

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• Integration

• Breast Cancer

Screening &

PITC

• Facility &

outreach

Health

Centre District

Hospital Regional

Hospital

VIA ,Cryo ,LEEP,

Biopsy VIA, Cryo,Biopsy

Service Delivery Model

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

VIA, Cryo

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

Follow up 3 years

(HIV-)

Follow up 1 year

( HIV+)

Treat Immediately

Cryotherapy

Refer/Treat

with LEEP

Repeat VIA after

1 year

Suspect

Cancer

Refer

Program Coverage- 21 sites April 2010 – June 2013

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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)

• All sites offer VIA/Cryotherapy

• 3 Hospitals offer VIA, Cryo &

LEEP services

Iringa

Morogoro

Njombe

DSM

Highlight of screening results from 20 sites

April 2010–June 2013

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Indicator Total % and remarks

N %

New clients screened 21,615 Among all screened

HIV+: 5818 (27%)

VIA-positive 1706 VIA+rate: 8 %

Treated with cryo on the

same day 1409 SVA R = 94 %

Referred for large lesions 212 12.4% (of all VIA+)

NC with suspect CC 445 2 %

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

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45% (n=96))

0.4% (n=1)

54% (n=115)

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

Treated with LEEP

Deceased

Lost to follow up

Results of LEEP Service Delivery

INDICATOR REGION HEALTH

FACILITY TOTAL

Number of clients

treated with LEEP

April 2012- June

2013

Morogoro Morogoro RH 40

Mafiga HC 4

Iringa Iringa RH 52

Dar Muhimbili* Started Aug 13

TOTAL

96

Number of HIV+

clients treated with

LEEP

Morogoro Morogoro RH 29

Iringa Iringa RH 38

Dar Muhimbili* Started Aug 13

TOTAL 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

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Where the specimen will

be processed /pathologist

The cost of biopsy

processing

Budget ??

Strong monitoring

system assist in

tracking the referral

cases

Collaboration/engaging

the MOHSW partners

Lessons Learnt

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Linking VIA/Cryotherapy and referral services can be done !

Assess, Plan, Start small, Learn, Expand, Don’t Despair !!

Strong f/up skills and commitment - key to success !!

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

Government Ownership

Budget & Sustainability

Efficient M and E system Follow-up/tracking

Training- hands

on skills ?

Supervision

Collaboration

Strengthen

linkage;

Cancer Care

Centre

Pathology Lab