5/25/2010

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Dan Murokora MD, Ob/GynePresident:

Assoc. of Obstetricians & Gynecologists of Uganda

Putting Cervical Cancer on the Agenda in Uganda

Uniting Voices for Women’s Health Worldwide:

Integrating Advocacy as a Means to Improve Quality Care for Women

International Women’s Health Symposium June 2nd, 2010

SOGC’s 66th Annual Clinical Meeting

The Sheraton Centre, Montreal

Basic Facts Area: 236 Sq Km Population: 28.9m(2007) MMR: 435/100,000 Under 5 Mortality: 136/1000 IMR:90/1000 TFR: 6.7 children /woman HIV Prevalence 6.7%

Source: Human Development Report 2007

UBOS:www.ubos.org

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N. AMERICA

14,670

C-S. AMERICA

71,862

AFRICA

78,897

ASIA

265,884

EUROPE

59,931

Estimates of the number of cases and incidence of cervical cancer, 2002

Globocan 2002

< 87.3 < 16.2< 32.6 < 26.2 < 9.3 / 100,000

Uganda

Age Std Incidence: 45.6/100,000

Age Std Mortality: 25/100,000

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Kampala Cancer

Registry

Cervical cancer: 40%

Breast Cancer: 23%

Other cancers: 37%

13/07/2009

Prognosis is Poor at Diagnosis

Over 80% are stage III/IV

at diagnosis

Accounts for 70% of Gyne

Deaths

Gyne Oncology Bed

Occupancy 81%

Status of Prevention Services in Uganda - 2007

• Services for cervical cancer prevention are limited

– Opportunistic screening in majority of Hospitals <5%

– 5 labs have capability for cytology [2 private labs]

– Two radiotherapy units, only one functional

– 5 health units have capability for Cryotherapy

– LEEP can be possible in 2 health units

– Limited Knowledge and skills among Health Providers

– Basic equipment to perform a speculum exam available in

most hospitals

– No clearly defined referral mechanism

Formative research to introduce HPV vaccine in Uganda, 2007 by AOGU/CHDC/PATH-2007-unpublished

MoH Strategy & Response to Cervical Cancer

Strategy

Advocacy

Scale up plan

Technical advisory committee

Mobilization and awareness

Policy and guidelines

Primary prevention – HPV vaccines

Service delivery; screening and treatment & outreaches

Response

Prevention enshrined in Health policy

TAC appointed by MoH & meets regularly

Service Delivery Guidelines for cervical cancer screening updated 2006

HSSPII – emphasizes “see & treat”

Commitment from highest MoH office

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Advocacy At Various Levels

Parliamentary support for cervical cancer prevention Support health budget with inclusion of funds for cervical cancer Speaker’s office pledged to ensure cervical cancer is allocated funds Petition to GAVI for price reduction and making the vaccine available

First Lady’s office has actively lead sensitization and mobilization at new sites

Ministers of health commissioned all new sites

BBC filming of HPV vaccination and screening in Uganda to make available [aired 21st July, 09]

Advocacy Championed & Supported by 1st Lady, MoH & Parliament

Advocacy Activities Supported by Champions

Involvement of Women

Members of Parliament

Cervical cancer awareness walk

held

Media involvement – free

airtime

Live TV shows on cervical

cancer prevention

Live Radio shows

Print media published several

stories in local leading papers

GAVI Letter From Uganda’s Parliament

Community Mobilization & Awareness

Campaigns on cervical cancer Progress & Gains

Increased awareness - pushed up demand

A national 5 year Strategic plan – not funded yet

IEC materials developed –not translated

Mobilization at National level and in Districts implementing the HPV vaccine project

VIA Training Curriculum Completed

Organized “see and treat” screening being opened in a phased manner

Integration of cervical cancer prevention in other training curricular especially family planning has been done

5/25/2010

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CURRICULUM FOR SCREENING & TREATMENT OF CERVICAL

PRE-CANCER

Using a Screen & Treat

Approach

5 year Strategic plan

National Cervical Cancer Strategic Plan completed Focuses on phased

approach starting with regional referral hospitals

Expected to enlist support of several partners

Technical advisory committee guides the overall approach to cervical cancer prevention

Response by Directorate of Gynaecology at Mulago Hospital to Cervical Cancer

• Created an oncology division to address gyne cancers – particularly cervical

• Training of health providers• Visual Inspection with Acetic Acid

• Colposcopy

• LEEP

• Cryotherapy

• Train the trainers

• Opening up screening clinics

IN-SERVICE TRAINING ACTIVITIES

Participants conduct a role play during training

Trainee midwives receive certificates after completing the screening workshop

Health Facility Partner Date

Mulago Hospital Uganda Govt

Mbarara University Teaching Hospital PATH 2009

Masaka Regional Referral Hospital WHO 2006

Mbale Regional Referral Hospital Uganda Women’s Health Initiative 2009

Kawempe Health Centre IV Uganda Women’s Health Initiative 2006

Kampala City Council Clinics Uganda Women’s Health Initiative 2006

Mildmay Centre CDC 2009

Gulu Regional Referral Hospital To be supported by WHO -

Soroti Regional Referral Hospital PATH 2010

Ibanda Hospital PATH 2010

Itojo Hospital PATH 2010

Nakasongola Health Centre IV PATH 2010

Kisoro Hospital Albert Einstein College of Medicine 2008

Status of Prevention Services in Uganda – 2010Number of Screening Centres increasing

Health providers trained in VIA being passed out at Mbarara University

Teaching Hospital

5/25/2010

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Commissioning of a Screening Centre at Mbale Regional Referral

Hospital on 2nd June, 2009

Outreach Activities

• Uganda Women’s Health Initiative, SAWI, & PINCC done outreaches in which hundreds of women have been screened

• Fundraising for a mobile Clinic is ongoing

Challenges for CCP are linked to others in health care delivery

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•Competing health priorities-TB/Malaria/HIV•Funding constraints

13/07/2009 22

Human Resource Context

• WHO [2007] estimates of health workers in Uganda:– Doctors: 2209, – Nurses: 16221, – Midwives: 3104

Personal communication: Prof. Wabinga– Pathologists: 15– Cytotechnicians: 3

• Doctor Population ratio: 0.05/1000, • Nurse Population Ratio: 0.16 • Providers 0.77 /1000 population

– This is less than 30% minimum standard of 2.5/1,000 recommended by WHO

The task:

Approx. 6.6 million women

need to be screened.

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Challenges in Cervical Cancer Control

in Uganda

Demand for screening and treatment of pre-cancerous lesions

is far beyond available capacity for.

Capacity for treatment of precancerous lesions such as

Cryotherapy and LEEP is still limited.

Capacity for radiotherapy & other tertiary care is limited

Lack of infrastructure & personnel to run a good cytology

based program

Limited pool of trainers & skilled Health workers

Funding constraints – CCP not funded directly by Gov’t

Behavioral & Socio-cultural barriers

Way forward

• Phased approach to scale up

• Training of trainers

• Budget line for cervical cancer prevention in Ministry of health budget

• Discussions ongoing to address radiotherapy gaps and tertiary care