Setting out to improve and expand cervical screening and treatment for women screened in hospital and rural screening camps.

The partnership between Nottingham University Hospitals NHS Trust in the UK and Maternity Hospital Kathmandu in Nepal focused on training and capacity development for colposcopy and cervical pathology reporting. The project set out to improve and expand cervical screening and treatment for women screened in hospital and in rural screening camps.

The project continued a programme of work on cervical cancer prevention which was already underway thanks to two non-governmental organisations (NGOs). In 2002, PHASE Worldwide and the Nepal Network for Cancer Treatment and Research (NNCTR) began working together to introduce cervical screening, with the support of clinicians in Nepal and in the UK. The doctors involved were already working with the NGOs when the partnership funded by the Health Partnership Scheme began.

An issue that nobody owns

The World Health Organization (WHO) describes cervical cancer as “one of the world’s deadliest – but most easily preventable – forms of cancer for women” and WHO recommends screening and treatment of pre-cancerous lesions to prevent cervical cancer developing.

In Nepal, there was a national policy on cervical cancer screening, but it was not actively implemented. Early screening should be offered to women who have no symptoms – and with no symptoms and no understanding of preventive screening, women are unlikely to seek out health services. For the project to increase the number of women being screened, it was important to work in the community, increasing awareness, knowledge and accessibility of screening.

David Nunns, consultant gynaecologist at Nottingham University Hospitals NHS Trust, says that initial conversations about cervical screening in Nepal happened within NGOs. “Cervical screening didn’t actually naturally sit within a hospital setting. Effective cervical cancer prevention ideally requires a wide screening population, effective treatment and a clear operational link between screening and treatment. To enable this involves a variety of different interlinked stakeholders including public health, gynaecology, community and women’s groups. In Nepal there’s no coordinated set-up of these groups. It just so happened that people within the NGOs – myself and colleagues in Nepal – worked in hospitals to try and make some links.”

Surendra Bade, Director of NNCTR in Nepal, remembers the first NGO-led screening programme, set up in 2002. “It was a pioneering project, because before that nobody was talking about screening programmes. If a woman had cervical problems she would go to the doctor, but otherwise there was no plan to screen and detect the problem.”

NGOs can provide valuable project management support

David says that having an NGO such as the NNCTR providing effective project management support to the partnership was invaluable. The partnership work programme included temporary camps, where screening services were brought to a rural area, and many women were screened in a short period – as many as 1000 women in 5 days. It also included education and training workshops for pathologists in separate workshops.

The clinicians in the partnership had responsibility for teaching skills and providing training, but the NGOs managed the logistics of camps and training workshops, including raising awareness with community groups to ensure good attendance. These events required significant work to set up and networking to ensure that large numbers of women attend the camp.

David says, “The NGOs were the implementers really, in terms of the logistics of setting up workshops, travel, exams, paperwork. There’s no way we could have done the project without having the project management input from the NGOs. For me to try to do that, out of country, in an NHS hospital – it would just have logistically been very difficult.”

NGOs can extend a partnership’s reach

Surendra says that having the NGOs working with local communities was an important part of the success of the screening camps. They were able to lay the groundwork by approaching community leaders and local groups – particularly women’s co-operatives and mother’s groups – and explaining what the camps were about. By taking the time to explain the importance of screening, the objectives, and what would be involved, more women felt comfortable attending.

Unlike other types of health screening, such as blood pressure checks, having a cervical screen is something women may feel uncomfortable or embarrassed about. The background work was crucial in engaging people with the issue.

“When we were organising camps, local partners had much more information about how to get women for the camp,” says Surendra. “Previously it was more difficult, people weren’t coming ready for the screening. In Nepal, in many districts, there are women’s groups and their cooperation was very useful for us and for the people there.”

Making partnership information accessible

Although the relationships between the NGOs and the clinical leaders at Nottingham University Hospital and Maternity Hospital Kathmandu were already in place, they developed over the course of partnership. The grant and formal partnership agreement got the project off the ground and the partners agreed a clear work programme and outcomes.

As the lead partner in the UK, David had a good understanding of the partnership documentation, work programmes and monitoring and evaluation requirements. While it was important that all the partners, including the NGO staff, had an understanding of the aims of the partnership, his experience was that these documents needed to be considerably simplified.

“We worked with the THET reporting template and all the work programmes were laid out, but is that meaningful to somebody in Nepal, when English isn’t their first language? I personally found it difficult to translate what is a robust document into a language that everyone could understand. It was a challenge to make it very simple.”

Working on a simple version of the work programme, outcome data and objectives is something David recommends for anyone approaching a partner organisation or clinical lead. For a project like this, clinical leadership is important. And for NGOs looking to work with clinicians in this way, simplicity is key when looking for their buy-in. Many clinicians have little time to spare, and need to be able to quickly see a good reason for getting involved in a project.

For medical partnerships looking to work with NGOs, the same applies. David says, “We summarised a very complex pathway in one page. Everything you want to do should be on one sheet of paper – keep it really basic.”