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STRENGTHENING HEALTH

SYSTEMS

Dr Nuriye Ortayli

UNFPA, Technical Division

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WHAT IS THE IMPACT

Efficacy of your intervention

Coverage Scale up to national level (Gradual, or Start Big)

Specifically target high risk, underserved groups

PAP

VIA

HPV test

Refer

Screen and treat

Single visit

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SELECT THE BEST

Screening method with highest

sensitivity and specificity

Treatment that is most effective,

involves the least risk

Cover everybody Go with the established?

Develop your own solution?

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CAN YOU DO IT?

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GETTING STARTED

Do the numbers!◦ How many women in the target age?

◦ How many facilities capable of screening?

◦ How many women/week/facility if all screened in first year?

How many if spread over 5 years? 10 years? What is

feasible?

◦ If ~15% are screen-positive, how many cryos/week?

Phase-in strategies◦ Gradual build up to steady state with re-screening at

desired intervals

◦ Campaign style with big push up front, then drop-off of

demand (and drop-off of skills)

Vıvıen Tsu, PATH

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SERVICE DELIVERY

Where should screening take place (as close to the

community as possible)

Where and when should treatment (of

precancerous lesions) take place (to minimise lost

to follow-up, balanced with resources)

◦ Screen and treat

◦ Tracking and management of referrals

Where and how should invasive cancer referred?

Balance between highest coverage

and ability to provide quality service

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HUMAN RESOURCES

What are the available human resources to ensure

highest coverage? (Numbers, geographic

distribution, workload, attrition, possibilities for task

shifting)

How much (time and resources) it will take to

furnish them with needed competencies?

What should be the mechanisms of training?

What should be the mechanisms for supervision?

What measures will be taken for sustainability?

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INFORMATION SYSTEMS

HOW EFFECTIVE IS OUR SYSTEM?

HOW EFFECTIVE IS OUR SYSTE

EFFECTIVE IS OUR

EFFECTIVE IS

EFFECTIVE IS

EFFECTIVESYSTEM?

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INFORMATION SYSTEM

Informing clients (tracking)

Informing health system (both

decision-makers and providers) Coverage (%) and who do we screen?

What do we find (how many positives)

How accurate we are (sensitivity, specificity)

What % we treat

How many cancers we prevent?

How many deaths we prevent?

Informing the public and politicians

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INFORMATION SYSTEMS

WHO recommends all countries to

establish/enhance cancer registries to

be able to evaluate impact of cervical

cancer prevention activities, including

vaccination and screening.

Information on service delivery should

be collected and used for decision

making.

No vertical system should be planned

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MEDICAL

PRODUCTS,TECHNOLOGY

Tests: Which one to use? Cost (initiation/continuation)

Infrastructure (both physical and human

resources)

Logistics and maintenance

Based on sensitivity and demands on health

systems, cytology based screening is not

recommendable when starting a programme.

A mixture of approaches can be used.

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FINANCING Who is going to pay for these?

Are they willing to pay for it?

Can they afford it?

What is the balance between increasing access

and being realistic?

WHO-UNICEF joint statement of Vaccine donation

is also applicable for donation of other equipment

and supplies,

◦ suitability,

◦ sustainability

◦ informed

◦ supply shelf life, functional

◦ licensed and adoptable 12

LEADERSHIP,

GOVERNANCE

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Simple elements, complex

integration

Good synchronization

Advance planning

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VACCINATION

Plan for introduction of HPV vaccine should be part of country

immunization comprehensive multi-year plan and

comprehensive cx ca prevention and control strategy

Introduction of vaccine can be integrated with delivery of other

essential services for adolescents.

Price is a big barrier. Negotiated price should be made public.

Competitive bidding or conjoint purchase mechanisms (PAHO,

GAVI etc) can be used. Financing of delivery should also be taken

into account.

Donations are only acceptable when in line with WHO-UNICEF

statement.

Different modalities of delivery are possible with their pros and cons.

(community based, school based, mobile clinic)

Monitoring for coverage, effectiveness, impact, usage and safety

should be planned.

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COMMUNITY

ENGAGEMENTServices that are not used are;

useless!

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NO VERTICAL SYSTEMS

No vertical systems.

◦ Screening part of PHC

◦ Treatment part of PHC/Secondary HC

◦ Information should be collected as part of HIS

◦ Training and supervision should be integrated.

◦ Vaccination should be part of comprehensive

programme of immunization

Beware of over-medicalization/over treatment/over

specialization

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AT the servıce of two generatıons

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