By Indrani Kashyap
The Provincial Health Office (PHO) of Roi Et, Thailand, received a 2018 United Nations Public Service Award this week for its comprehensive cervical cancer prevention and control program that uses a single visit, screen-and-treat approach pioneered by Jhpiego.
The rural province in northeastern Thailand has been at the forefront of efforts to reduce women’s deaths from cervical cancer since 2000. That was when Dr. Khunying Kobchitt “Kobbie” Limpaphayom—a former student of the late Dr. Theodore M. King at Johns Hopkins University and then president of the Royal Thai College of Obstetricians and Gynaecologists– led colleagues at the professional association and Chulalongkorn University in running a demonstration project in Roi Et to show the feasibility of the low-cost, single visit approach, which could be implemented by nurses.
The health office, honored for “promoting gender-responsive public services to achieve the Sustainable Development Goals,” was chosen out of more than 400 nominations from 79 countries to receive the prestigious UN award during ceremonies in Marrakech, Morocco, June 21–23.
Women have been at the heart of this program, says Limpaphayom, Professor Emeritus, Faculty of Medicine, Chulalongkorn University, who traveled to Morocco to receive the UN award. “The single visit approach helped in giving women easier access to care by bringing care closer to their homes,” she says.
Cervical cancer is the fourth most frequent cancer in women and, according to the World Health Organization, killed close to 270,000 women across the world in 2015. Ninety percent of these deaths were in low- and middle-income countries, like Thailand. Today, Roi Et PHO is a model for many countries. Countries like India, the Philippines and Cambodia have sought to learn from Thailand’s comprehensive cervical cancer control program.
But just two decades ago, Thailand, like many other low-income countries, struggled to find a way to address cervical cancer. For 30 years, it had tried the test-and-refer approach, which involved cytology screening using Pap smear and referrals. But this approach had not made a dent in the incidence of cervical cancer deaths in the country. Looking back, Limpaphayom believes the main reasons were the “lack of accessibility, lack of infrastructure and no organized screening program.” “The cervical cancer prevention program using Pap smear began in Thailand in 1956, even before I was a medical student,” she recalls.
The trajectory of the country’s efforts to establish a viable cervical cancer prevention and control program changed in 2000. Then, Jhpiego, in partnership with the government of Thailand, Roi Et PHO, and the Royal Thai College of Obstetricians and Gynaecologists, led by Limpaphayom, began the 7-month demonstration project. A proof of concept study, this project used acetic acid, the basic component of household vinegar, to inspect the cervix and detect precancerous lesions, which turned white from the acid. If such lesions were found, they could be treated then through cryotherapy, using cold carbon dioxide to freeze and kill those cells—all in a single visit. Unlike a cytology-based approach, this simple, low-cost method did not need electricity, sophisticated labs or equipment. It was provided by non-physicians, required women to come only once, and it could be made available even in hard-to-reach interiors of the country.
Limpaphayom recalls she had to convince authorities that the purpose behind this approach was not to replace the Pap test, but to increase screening and treatment coverage, especially to those women who could not access or afford a Pap test.
The project, known as the SAFE study, successfully tested the Safety, Acceptability, Feasibility and program implementation Effort (SAFE) of the single visit approach, combining visual inspection of the cervix with acetic acid (VIA) and cryotherapy. Twelve trained nurses provided services in village health centers and hospital-based sites in four districts of Roi Et province. Over 7 months, 5,999 women were screened with VIA. If a woman tested positive, after counseling about the benefits, potential risks and probable side effects, she was offered cryotherapy. Data measuring safety, acceptability, feasibility and effort to implement the program were gathered.
While the SAFE study can be called the bedrock of the success that followed, allowing nurses to conduct the VIA and cryotherapy was a major catalyst. As Limpaphayom states, “Doctors in my country at that time were about 1 for 60,000 population. A major part of the success of the program was due to the nurse who was doing the cryotherapy.”
Limpaphayom played a pivotal role in getting the required permission for nurses to perform cryotherapy, previously a doctor-led procedure. She also got the nurses training curriculum approved by the country’s nursing council. Starting with the 12 nurses trained during the study, Limpaphayom has since trained close to 1,600 nurses in VIA and cryotherapy.
The SAFE study was published in the Lancet in 2003 and, subsequently, informed the World Health Organization’s recommendations as a component of comprehensive cervical cancer control.
The momentum gathered by the SAFE study within Roi Et spread the single visit approach using VIA and cryotherapy fast across the province and the country at large, with 32 provinces now providing these free services to women. Other preventive measures, like providing HPV vaccines to young girls aged 10 to 13 years, were added to further bolster the country’s fight against cervical cancer.
Looking back, Limpaphayom feels multiple factors contributed to Roi Et PHO’s success story—leadership and teamwork being prime. The Royal Thai College of Obstetricians and Gynaecologists, the Thai Nursing Council and the Ministry of Public Health all played a part in ensuring the program’s success and sustainability. One person Limpaphayom points out by name is Dr. Wachara Eamratsameekool, her former student and aide who worked with her to push past roadblocks and guarantee the program’s success.
The UN award to Roi Et PHO is truly a celebration of a public health program—one that has allowed a low-cost, simple intervention provided by nurses to increase access to sustainable, high-quality, affordable and lifesaving services to women who might otherwise not had a chance at receiving care.