Universal Health Coverage (UHC) means that all individuals and communities receive the full spectrum of essential, quality health services without suffering financial hardship. Chugai is supporting the Bhutan Cervical Cancer Eradication Project to contribute to the further advancement of UHC in Bhutan from 2021. Support mobilized from Chugai Pharmaceutical company, is used to complement the implementation of the National Flagship cancer screening program led by the Ministry of Health, Bhutan. 


Background
Worldwide, 15 million people die from non-communicable diseases (NCDs) before the age of 70 every year, with 86% of these premature deaths occurring in developing countries*1. Bhutan is no exception. In 2019, NCDs accounting for 71% of reported deaths, while cervical cancer remained as the most common cancer among Bhutanese women*2. According to Bhutan’s population-based cancer registry, Bhutan has high cervical cancer incidence with age-adjusted incidence rate (AAR) of 20.5 per 100,000 women, and a mortality rate of 5.3 per 100,000 women - one of the highest rates in Asia^*３. Given the rising trends in cervical cancer, Bhutan committed to eliminate cervical cancer.

• Increase the cervical cancer screening coverage using the high sensitive HPV test through outreach screening camps and HPV test integration as one of the screening tools in the health facilities
•  Enhance cervical cancer screening and follow up service quality and improve service uptake by women

The project support is carried out in three phases, spearheaded by the Reproductive, Maternal, and Child Health Program in collaboration with the National Flagship Cancer Screening Program, under the Ministry of Health. The first year of implementation (2021-22) was primarily focused on primary prevention, particularly on augmenting the screening coverage in selected districts with low coverage. This was achieved through outreach screening camps utilizing highly specific screening tests like HPV-DNA tests. This support was a component of the flagship program on nationwide screening, which successfully reached 90% of all eligible women with the HPV DNA test. This test detected 9.23% of women positive for HPV types 16 & 18, which are the most common causes of Cervical cancer. All women who tested positive for HPV underwent colposcopy to confirm the diagnosis. Of these, 23.8% were reported to have precancerous lesions, which can develop into invasive cancer within 5-10 years if left untreated.

Supporting the Project for Eliminating Cervical Cancer Toward the Promotion of UHC in Bhutan
～　Summary of outreach screening camp Report in 2021-2022　～


Programme for 2022-2023
During the 2022-23 phase, Chugai's support was directed towards continuing professional development via in-service programs, aimed at augmenting the capabilities of healthcare providers in cervical cancer screening and pre-cancer treatment. There was also an emphasis on bolstering laboratory capacity and quality, which involved enhancing the capabilities of pathology services at regional pathology centers. Furthermore, efforts were made to expand surgical capacity through targeted training programs.

Results for 2022-2023
Enhanced knowledge and capacity of service providers in diagnostics service quality, cervical cancer detection, treatment and  management

International Cervical Cancer Symposium on September 10 and 11, 2023 in Thimphu(Provided by UNFPA)

1. Through this assistance, 90% (26) of the cytotechnicians and pathologists from all three regional referral hospitals were trained in improving Liquid-Based Cytology (LBC) quality through hands-on training and real slide examination.
2. All 15 histotechnicians and laboratory assistants in Cervical Histopathological examination from three Regional Referral Hospitals underwent training to improve their skills in processing, embedding, sectioning, and staining cervical tissue samples. This training also included safety protocols, quality control measures, identifying abnormalities, applying staining techniques, and adhering to safety protocols to enhance the quality of diagnostic results. This capacity development also contributed to their Continuing Medical Education (CME).

3. To ensure the availability of specialized services for both cervical cancer diagnostics and treatment, a Gynecologic Oncologist and Obstetrician from the National Referral Hospital was supported to undergo an observer fellowship training in gynecological cancer surgeries. This fellowship training equipped the only in-service gynecologic oncologist with improved techniques for performing radical hysterectomy for cervical cancer and surgical staging laparotomy for ovarian and endometrial cancers, including both open and laparoscopic/robotic approaches. Additionally, a pathologist from the National Referral Hospital participated in an international conference for pathologists, providing a platform for the specialist to enhance their knowledge and establish professional linkages with external expertise and networks on cytological diagnosis of female reproductive systems and HPV testing in gynecological cytology.

Dr. Namkah Gynecologic Oncologist and Obstetrician, with Prof. Artem Stepanyan at the NAIRI Medical Center.


Reference

＊1 WHO Noncommunicable diseases
　　https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases
＊2 Annual Health Bulletin 2020, Ministry of Health, Bhutan.
　　https://www.moh.gov.bt/wp-content/uploads/ict-files/2017/06/health-bulletin-Website_Final.pdf
＊3 Cervical Cancer Elimination - UNFPA Asia-Pacific
　　https://asiapacific.unfpa.org/sites/default/files/pub-pdf/bhutan_final_16_12_21.pdf