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.
Sharing Lessons in Partnership-SMP Health Links Forum June 2014
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
• 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.
- 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
- 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
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
• 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
Awareness/ sensitisation delivered to
• Hospital Clinics [VIA, ART and Family Planning] daily for 4 months reaching 5,600 males
• 2 Traditional Chiefs, 24 Group Village Heads, over 150 Village Heads within the 10
villages, reaching ~20,000 people
• 3 clinic rooms equipped and 7 Nkhoma staff trained to deliver VIA, with clinics running
• In Feb 2013, 24 women presented for cervical examination while in Feb 2014, 341 were
• Overall, 2336 women seen in VIA clinics between October 2013 and March 2014
• 7 Health Centre staff now trained
• Clinics commenced in 2 Health centres, one Government and one CHAM , in May 2014
Successes – 2
• 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
visits Neg (2) Pos (1)
cancer (4) Other
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
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
Successes – 3
• 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
• 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
Value of preliminary preparation- 6 months before the first woman was
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
Communication – monthly, minuted skype calls with actions in addition to
frequent email traffic with all members of both teams and more frequent
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
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
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
Maternal and Child Health
Disease and Disability
RNM AND CLINICAL OFFICER TRAINING,
EKWENDENI COLLEGE OF HEALTH SCIENCES
Funded by: Scottish Government (£75,162) and EMMS
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
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
> 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.
Working in partnership with 2 other donor-partners, Kwacha
Foundation (Netherlands) and Medical Benevolence
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
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
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
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
Externally audited accounts
If only the government would implement the
requirement for all organisations to submit their
annual externally audited accounts – College and
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