How to Create Comprehensive Care for Non-Communicable Diseases

by Deepti Mathur, Senior Specialist, Knowledge Management, PSI India

& George Philip, Technical Advisor, Systems Strengthening, PSI India

The government of Uttar Pradesh continues to be recognized throughout India as a leader in women’s health for its National Health Mission: Sampoorna (“comprehensive” in Hindi) clinics.  In addition to receiving honors for ‘Best Practice in Health Care Excellence’ from the Rajasthan Government and ‘Best Practice in Health Care’ from India’s national Ministry of Health and Family Welfare, for replication and scale in other Indian states, the Sampoorna Project received the SKOCH Gold Medal, one of the highest independent civilian honors in India, celebrating human excellence and agents of change spearheading positive socio-economic developments in society and governance.

PSI India’s Managing Director, Mr. Pritpal Marjara, congratulated Uttar Pradesh’s Mission Director Mr. Alok Kumar, a Senior Officer from the Indian Administrative Services on this success. The two had a candid discussion on healthcare service integration. The government has offered a comprehensive screening package for non-communicable diseases (NCDs) for women. They also discussed plans for the future of the program.

Check out their Q&A below.

Pritpal Marjara: What prompted you to the idea of Sampoorna–a comprehensive package of NCD screening services for women–and how did you think of layering on cervical cancer screening along with this?

Alok Kumar: NCDs are a major public health challenge, now causing more than 60% of global deaths. This includes India: every fifth woman suffering from cervical cancer in the world is Indian. The highest incidence of cervical cancer cases in India was reported in Uttar Pradesh, with a total 18,692 cases in 2012. These alarming numbers were always at the back of our minds.

Cervical cancer is caused by persistent infection of the human papilloma virus (HPV) . It takes 10 or more years for the virus to cause cancer. This gives ample time to screen and treat women at the precancerous stage. Thus, early detection is the most efficient method to prevent this disease. However, due to poor access to screening and treatment services, the majority of deaths occur in women living in lower-middle income groups in rural and urban areas of India.

PSI ran a model in the private sector where each woman visiting a private clinic was offered a screening for cervical cancer through a simple test known as “visual inspection with dilute acetic acid (VIA)”.  The women found positive were offered simple treatment by using cryotherapy method in suitable cases. It was in line with the ‘single visit screen and treat approach’ endorsed by the World Health Organization (WHO). We at the Mission Office looked at the potential for replicating this approach. Originally, NCD clinics were located in select District Male Hospitals in Uttar Pradesh. These clinics are rarely accessed by women and lacked the privacy to conduct screening tests for cervical cancer and breast cancer.

Our team worked with PSI to look at the learnings of the cervical cancer screening program in the private sector, and co-created a program design that was both scalable and cost-effective. We conceptualized the Sampoorna Clinics with a clear vision of providing comprehensive health care screenings, treatment and referral opportunities for cervical cancer and other NCDs such as diabetes, hypertension, cardiovascular diseases, and clinical examinations for breast cancer amongst women aged 30-60 years of age who visit district women’s hospitals and CHCs in Uttar Pradesh. These clinics were also meant to make women aware of lifestyle modifications and screening approaches, which are important for the prevention of NCDs, including cervical and breast cancers.

As a technical assistance partner, PSI was initially asked to demonstrate a ‘proof of concept’ in District Women Hospitals in five districts of UP. The results were promising: within six months, we had screened 10,094 women. At this stage, we transitioned implementation to the State Innovations in Family Planning Services Agency (SIFPSA). Standards for screening and treatment protocols were developed in line with both WHO and national guidelines, which was then reviewed by a Technical Advisory Group constituted by the government of Uttar Pradesh.

Pritpal Marjara: How do the Sampoorna clinics function?

Alok Kumar: At the facility level, these clinics are managed by a team of trained female health care providers and two screening assistants, who serve women with the utmost privacy. To ensure this, three stations have been organized. At the first two stations, the women undergo screening tests, including blood pressure measurement, height, weight, hemoglobin (to assess anemia), and random blood sugar, along with appropriate counselling. The first two stations are staffed by trained screening assistants. The female doctor is at the final, third station where she examines screening results and client history. She also carries out the VIA test for ruling out cervical cancer. If the VIA test comes back positive, the client is further counselled and, if consent is given, the cryotherapy is performed for treating the pre-cancerous lesion. For more serious cases, the client is immediately referred to higher-level technical facilities for further investigation and treatment. This systematic screening approach using multiple screening stations not only makes efficient use of resources, but also reduces patient waiting time, which is often a challenge in public sector hospitals.

Several local medical colleges have been identified as training centers for capacity building on screening techniques and the management of the diseases covered under the project.

Pritpal Marjara: What is the contribution of the Sampoorna program to Cervical Cancer prevention in India? Do you think it will change the scenario?

Alok Kumar: While there’s still a long way to go, we don’t want to undermine the budding contribution of this immensely promising project. Between September 2015 and January 2017, more than 45,628 women were provided NCD screening services at Sampoorna Clinics. Out of these, nearly 70% of the clients screened positive after Visual Inspection through Acetic Acid (VIA) were treated through cryotherapy.

Additionally, the annual allocation by the National Health Mission (NHM) for operational costs related to Sampoorna Clinics has now been made a regular budget line item and is likely to be scaled up to remaining districts in the state.

With these promising results and commitment from the government, the scenario is only going to get better for India.

Pritpal Marjara: Are there any further plans for its scale up? How are you preparing yourself for it?

Alok Kumar: Uttar Pradesh has about 28 million women aged 30-59 who require screening for cervical cancer and other common NCDs. On average, there are roughly 370,000 women per district, while with the current efficiency, a static Sampoorna clinic established at district women hospital will be able to screen about 53,00 women per year.

An average district women’s hospital receives about 250 to 500 women every day seeking various services, and an almost equal number of accompanying women visit the hospital every day. This gives a huge scope for providing opportunistic screenings for Cervical Cancer and other NCDs. However, we’ve only been able to reach 10% of these women for screening. So, in order to cater to this large number of women in need, we are looking to expand the Sampoorna Clinic Program to other geographies and additional facilities within the same geographies, wherein a dedicated team of professionals in the form of a ‘Sampoorna Cell’ consisting of 1-2 technical consultants nested within the NCD Department of NHM can ensure smooth operationalization of the program, including timely program monitoring, data managements, and quality assurance at the state level.

The recent Government of India guidelines on screening three common cancers at the primary health care level recommends task shifting of screening responsibility to paramedics after due training. The state would like to explore this possibility to reduce the current screening burden on doctors. We also plan to revisit the client flow to integrate compulsory referral of all clients to Sampoorna Clinics.

The initial investment in the ‘proof of concept’ model to test the feasibility and scalability of the Sampoorna Clinics came from a private philanthropist and founding member of the Maverick Collective at PSI. The Maverick Collective engages individual philanthropist members’ experience, time, talent, and resources to address priority health problems faced by women and girls. In each area, a Maverick Collective member dives into the core of the issue alongside PSI and partner experts to pilot new innovative approaches that can be scaled through leveraging institutional donor funding. To date, Maverick Collective programs have supported over 300,000 women and leveraged over $60m in additional program funding.