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Developing a Sustainable Programme of
Cervical Cancer Screening
A Scotland-Nkhoma Partnership
With 3 years funding from Sc...
• In Malawi, cervical cancer is commonest cancer in women (45.4%)
• Malawi Minister of Health estimates that if nothing is...
Partnership
Scottish team:
- Co-leads: Prof Heather Cubie; Dr Christine Campbell
- Gynae team: Sr Hilary Brown; Dr Graeme ...
Aims of Project
To reduce the burden and mortality from cervical cancer by:
• Upskilling VIA in Nkhoma Hospital and its as...
Successes -1
Numbers!
Awareness/ sensitisation delivered to
• Hospital Clinics [VIA, ART and Family Planning] daily for 4 ...
Successes – 2
Numbers cont
• 75% of women with treatable lesions received it on same day
• Monthly increase- influenced by...
Successes – 3
Additional skills
• Treatment by cold coagulation rather
than cyrotherapy has been well
received by staff an...
Challenges
• For Partnership: Recognising
The magnitude of the problem e.g with population served by Nathenje (first
Gover...
Learning
Value of preliminary preparation- 6 months before the first woman was
screened
Need for continuing preparation fo...
Learning -2
Enthusiasm, ownership and pride of local team –
now see themselves as centre of excellence for cervical screen...
 International healthcare charity
 Founded in 1842
 Works in Malawi, India, Nepal, Scotland
 Turnover £1 million
 Hel...
PARTNER: EKWENDENI COLLEGE OF
HEATLH SCIENCES
RNM AND CLINICAL OFFICER TRAINING,
EKWENDENI COLLEGE OF HEALTH SCIENCES
 Funded by: Scottish Government (£75,162) and EMM...
By 2016, Ekwendeni College of Health
Sciences is running accredited 3-year
RNM Diplomas and then Degrees, and 3-
year Cli...
RENOVATIONS
EQUIPMENT
BOOKS FOR LIBRARY
CURRICULUM DEVELOPMENT
 Working in partnership with 2 other donor-partners, Kwacha
Foundation (Netherlands) and Medical Benevolence
Foundation (...
 Principal resigned right at project start! (Got a better job.)
 Replacement still not recruited.
 No deputy, but compe...
 How to develop a curriculum in Malawi
 1 year to develop each curriculum
 Medical Council of Malawi, Nurse and Midwife...
Externally audited accounts
If only the government would implement the
requirement for all organisations to submit their...
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Sharing Lessons in Partnership-SMP Health Links Forum June 2014

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NHS Lothian and EMMS International give an update on their partnership focusing on the strengths, challenges and learning gained.

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  • April had dropped to >600 and May further to >200
  • April had dropped to >600 and May further to >200
  • Demand for palliative care massive & burden increasing:
    In Africa (2009 estimates)
    22.5M people with HIV
    1.8M new infections annually
    700K new cancer diagnoses a year
    600K cancer deaths
    Cancer forecast to increase by 400% over next 50 years.
    Very limited PC coverage (40% of countries have no formal policy).
    In India
    34M need palliative care – only 1% have access
    1M new cancer cases a year (60% need PC)
    2.5M people with HIV
    Increasing smoker numbers – now 1 billion
    Huge burden stretching health systems & traditional models of care.
    However, FBO’s major part of the solution.
  • Transcript of "Sharing Lessons in Partnership-SMP Health Links Forum June 2014"

    1. 1. Developing a Sustainable Programme of Cervical Cancer Screening A Scotland-Nkhoma Partnership With 3 years funding from Scottish Government International Fund for Development in Malawi, 2013-2016
    2. 2. • In Malawi, cervical cancer is commonest cancer in women (45.4%) • Malawi Minister of Health estimates that if nothing is done, the number of cervical cancer cases will rise by 60% by 2025.
    3. 3. Partnership Scottish team: - Co-leads: Prof Heather Cubie; Dr Christine Campbell - Gynae team: Sr Hilary Brown; Dr Graeme Walker; Dr Miriam Deeny [Oct-Dec 2013] - Academic and Support: Dr Liz Grant; Dr Isabel Bruce Nkhoma Team: - Medical Director & Surgeon: Dr Reynier Ter Haar - Deputy Medical Director & Physician: Dr David Morton - Project co-ordinator: Mr Savel Kafwafwa - VIA: Belito Madetsa, Harriet Chirwa, Savel Kafwafwa - Laboratory- Edson Kawonga, Rose Nkhoma, Mike First planning meeting, May 2013 ‘VIA Clinic’, May 2013
    4. 4. Aims of Project To reduce the burden and mortality from cervical cancer by: • Upskilling VIA in Nkhoma Hospital and its associated Health Centres • Sensitisation of healthcare professionals and local population to value of cervical screening • Providing treatment by cold coagulation through Scottish professionals spending time in Nkhoma • Ensuring good follow-up of all non-negative VIA patients • Increasing awareness of data collection and analysis to establish a robust evidence base for appropriate cervical screening • Providing HPV testing for potential triage to VIA • Interacting with Colleges of Nursing through VSO nurse tutors to develop a curriculum module based on knowledge of cervical cancer screening and prevention
    5. 5. Successes -1 Numbers! Awareness/ sensitisation delivered to • Hospital Clinics [VIA, ART and Family Planning] daily for 4 months reaching 5,600 males and females • 2 Traditional Chiefs, 24 Group Village Heads, over 150 Village Heads within the 10 villages, reaching ~20,000 people Infrastructure • 3 clinic rooms equipped and 7 Nkhoma staff trained to deliver VIA, with clinics running daily Screening • In Feb 2013, 24 women presented for cervical examination while in Feb 2014, 341 were screened. • Overall, 2336 women seen in VIA clinics between October 2013 and March 2014 Roll-out • 7 Health Centre staff now trained • Clinics commenced in 2 Health centres, one Government and one CHAM , in May 2014
    6. 6. Successes – 2 Numbers cont • 75% of women with treatable lesions received it on same day • Monthly increase- influenced by rains and harvest • Word of mouth spread of regular service has led to women travelling from much further afield VIA CC Total First visits Neg (2) Pos (1) Suspect cancer (3) Advanced cancer (4) Other Done on day Postponed Tx (P1) Other October (from 16/10/13) 275 267 235 26 5 1 3 20 0 1 November 282 212 223 19 6 3 16 12 0 0 December 192 159 146 29 5 0 8 19 10 0 Total Q4 749 638 604 74 16 4 27 51 10 1 2014 January 157 130 108 21 9 1 15 19 5 1 February 341 318 290 27 7 2 11 20 7 0 March 1089 1047 988 53 14 5 18 42 6 0 Total Q1 1587 1495 1386 101 30 8 44 81 18 1 Half year total 2320 2109 1993 175 46 12 71 132 24 2
    7. 7. Successes – 3 Additional skills • Treatment by cold coagulation rather than cyrotherapy has been well received by staff and women, is cheaper, more transportable • Biopsies – can now be taken in clinic rather than in surgery, giving cost saving and greater accuracy • Expanded surgical skill set to radical hysterectomy due to expertise in Scottish team, providing better chance of survival for more women
    8. 8. Challenges • For Partnership: Recognising The magnitude of the problem e.g with population served by Nathenje (first Government Health Centre involved) it would take 8 years of daily clinics to reach all eligible women Success should not be measured mainly by numbers of women screened but by good clinical outcomes for women with abnormalities • For Scottish team: Understanding that there are capacity pressures when staff have many different duties of which VIA is one small part Data keeping is not a strong point and considerable input is required on on- going basis to ensure records are up to date • For Nkhoma team: Recognising the importance of follow-up - addressed by introduction of monthly biopsy review and weekly palliative care clinics service and skills must be maintained by consistent working practices and quality control, team work including sharing knowledge across different professional groups and by regular assessment of competence
    9. 9. Learning Value of preliminary preparation- 6 months before the first woman was screened Need for continuing preparation for roll-out – training, competence and capacity, practical issues (Sufficient instrumentation for every clinic, adequate sterilising facilities and instruments ready for every clinic; stock taking eg vinegar) Communication – monthly, minuted skype calls with actions in addition to frequent email traffic with all members of both teams and more frequent visits Flexibility- change from funding request for 9m each year of senior registrar level to shorter time from consultants Recognition of time commitment – project funds part of salary of 5 permanent staff in Nkhoma; Scottish team have also invested much more time than anticipated which have resulted in
    10. 10. Learning -2 Enthusiasm, ownership and pride of local team – now see themselves as centre of excellence for cervical screening (commitment to quality service) likely to become additional training centre for MoH now part of MoH Safe Motherhood Sub-Committee word has spread not only to other parts of Malawi but beyond
    11. 11.  International healthcare charity  Founded in 1842  Works in Malawi, India, Nepal, Scotland  Turnover £1 million  Helping 68,000 poor and vulnerable people/year  14 staff, all in Edinburgh  3 programmes:  Maternal and Child Health  Palliative Care  Disease and Disability EMMS International
    12. 12. PARTNER: EKWENDENI COLLEGE OF HEATLH SCIENCES
    13. 13. RNM AND CLINICAL OFFICER TRAINING, EKWENDENI COLLEGE OF HEALTH SCIENCES  Funded by: Scottish Government (£75,162) and EMMS International (£45,000)  July 2013 to March 2013  £120,162, of which:  £58,819 to partner to start courses  £45,000 to partner for students’ fees and maintenance  £13,343 for Edinburgh project management and 2 visits  £3,000 for final evaluation
    14. 14. By 2016, Ekwendeni College of Health Sciences is running accredited 3-year RNM Diplomas and then Degrees, and 3- year Clinical Officer training, sufficient to graduate > 20 COs/year and >200 RNM/year, with the first graduates in September 2016 (20 RNMs and 20 COs) bonded for 5 years to hospitals serving rural areas. OVERALL OBJECTIVE
    15. 15. RENOVATIONS
    16. 16. EQUIPMENT
    17. 17. BOOKS FOR LIBRARY
    18. 18. CURRICULUM DEVELOPMENT
    19. 19.  Working in partnership with 2 other donor-partners, Kwacha Foundation (Netherlands) and Medical Benevolence Foundation (USA)  Fortnightly Skype calls  Kwacha Foundation has mentored us  MBF has provided additional monitoring  Renovations of hostels and classrooms are complete.  Equipment and textbooks are nearly all purchased.  Curricula are developed and approved by relevant authorities.  RNM course starts this month (June 2014).  Clinical Officer course starts when Kwacha Foundation approves its quality. SUCCESSES WITH OUR PARTNERSHIP
    20. 20.  Principal resigned right at project start! (Got a better job.)  Replacement still not recruited.  No deputy, but competent Acting Principal started immediately.  Financial management turned out to be less good than expected.  We put 1-year finance training programme in place.  Assistant accountant is responding well to training.  RNM courses in Malawi turned into 4 years instead of 3  Took months for College to gain accreditation for 4th year from Mzuzu University.  Partner happy to start CO course with approvals from Malawian authorities, while we 3 donor-partners want better quality.  Potential for tempers to fray, but good relations with College chair help smooth things over.  Good relations among 3 donor-partners helps us stand firm. CHALLENGES WITH OUR PARTNERSHIP
    21. 21.  How to develop a curriculum in Malawi  1 year to develop each curriculum  Medical Council of Malawi, Nurse and Midwife Council of Malawi  Equipment, books, renovations  Costs of developing a course and fees and maintenance  Many students are prepared to self-fund  Partner wants to add in self-funding students in addition to those funded by Kwacha Foundation.  All partners need some sort of financial capacity-building  We contracted a Scottish accountant in Malawi to train.  Check which staff will take over if key staff leave.  Know at least one board member well.  Know deputies of key staff. LEARNING FROM OUR PARTNERSHIP
    22. 22. Externally audited accounts If only the government would implement the requirement for all organisations to submit their annual externally audited accounts – College and Synod. This would make a massive difference to Malawi. Remember that many students are prepared to self-fund. Education is valued. People need it to improve their lives. People at this level of education (completed high school) are prepared to find funding for it. HOW SCOTLAND MALAWI PARTNERSHIP CAN LEARN FROM OUR EXPERIENCES AND STRENGTHEN BILATERAL RELATIONSHIP
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