Challenges facing cervical cancer control in India: An Overview

1. Challenges facing cervical cancer control in India: An Overview ASSOCHAM Summit, 7th November, 2013

2. India has a disproportionately high burden of cervical cancer… Disease burden …accounting for nearly one-third of global cervical cancer deaths Age-standardized Cancer Incidence & Mortality Rates in India (2008) Cervical Cancer Incidence & Mortality Worldwide (2008) • 3rd most common malignancy in women, and 7th most common cancer overall globally • As of 2008, five-year prevalence in India accounted for 22% of global prevalence and ~70% of total prevalence in South East Asia • Leading cause of cancer mortality in India, accounting for 12% of all cancer deaths • Mortality from cervical cancer estimated to increase from 72,825 deaths in 2008 to 101,362 deaths by 2020 (Thousands) (Thousands) Source: GLOBOCAN 2008 (IARC)

3. Overall Challenges This high burden is further exacerbated by multiple challenges facing our healthcare system (1/2) Awareness Affordability The 4A’s to Win Over Availability A nationwide study by IMS Health provided insights on four most critical challenges: accessibility, awareness, affordability, and availability Accessibility Affordability Distance travelled to physically access an IPD healthcare facility Source of payment for IP Treatment 37% 51% 53% 58% 67% 69% 70% 74% 74% 73% Accessibility 63% 6% 6% 6% 5% 49% 47% 6% 42% 27% 27% 25% 24% 22% 20% All India Urban Rural Affording Poor All India Urban Rural Affording Poor Own Sources Free Less than 5 Km Over 5 Km Partly free/Partly paid • Poor accessibility results in: • Loss of daily wages • Deferment of treatment at early stages of disease ~70% of in-patient care financed through out-of-pocket expenditure Even insurance schemes do not cover doctor fee, diagnostics and cost of medicines Source: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012 The quantitative study involved an extensive nationwide survey covering 14,746 households, across 12 states, equally distributed into progressive, middling, and lagging states

4. Overall Challenges This high burden is further exacerbated by multiple challenges facing our healthcare system (2/2) Awareness Availability The 4A’s to Win Over Affordability A nationwide study by IMS Health provided insights on four most critical challenges: accessibility, awareness, affordability, and availability Availability Channel diversion due to lack of availability of quality healthcare resources Accessibility • Non availability of doctors, facilities and adequate free medicines cause : • Patients to move from government to private facilities • One in three people either delayed or were never admitted for an IPD treatment Source: Household Healthcare Access Survey Conducted by IMS Consulting Group, 2012

5. The same issues afflict screening, prevention, diagnosis and treatment of cervical cancer Screening Awareness Affordability The 4A’s to Win Over Availability Lack of organized screening programs and poor awareness has resulted in low detection rate in the long pre-cancerous period • Lack of awareness in • General population • Providers related to screening techniques and guidelines • Pap Smear is unaffordable for • majority women • Near complete absence of • organized subsidized/free • screening programs Lack of infrastructure at PHC/CHC forces women to travel to district hospitals Unavailability of infrastructure and trained manpower for Pap Smear/VIA techniques at PHC/CHC level Accessibility A study in premier colleges of Kolkata showed that only 11% were aware of Pap smear as a screening modality and only 15-20% knew about the risk factors for cervical cancer* A study amongst nursing staff of a referral and teaching institute in rural India showed only half of respondents knew that a Pap smear can detect pre-cancerous lesions and only 34% knew about VIA as a screening technique *Source: A Saha, A Nag Chaudhury, P Bhowmik, R Chatterjee. Awareness of Cervical Cancer Among Female Students of Premier Colleges in Kolkata, India. 2010 VIA: Visual Inspection using acetic acid application

6. Low awareness about risk factors and role of HPV Vaccines, coupled with high cost of the vaccine pose key challenges… Prevention Awareness Affordability The 4A’s to Win Over Availability …to prevention of cervical cancer in India • Single cycle of HPV vaccine costs ~INR 3000, an unaffordable cost for the majority of Indian population • Lack of awareness about • Role and availability of HPV vaccines • Risk factors for cervical cancer Access to vaccine restricted to big cities and private hospitals or big government institutions HPV vaccines currently not included in public healthcare system Accessibility A study from a tertiary hospital showed that only 25% of nursing staff knew about HPV vaccines* This number dropped to 14% in a study evaluating knowledge of vaccines in the urban population ** *Source: ShashankShekhar, Chanderdeep Sharma, SitaThakur, Nidhi Raina. Cervical Cancer Screening: Knowledge, Attitude and Practices among Nursing Staff in a Tertiary Level Teaching Institution of Rural India ** HemaDivakar, Knowledge and Awareness about Preventive Health Seeking Behavior and Acceptability of Cervical Cancer Vaccine in Urban Women in Comparison with School Students, 2012

7. Since most cases get diagnosed at an advanced stage, high-end, expensive treatment modalities have to be deployed.. Diagnosis & Treatment Awareness Affordability The 4A’s to Win Over Availability …in place of cost-effective techniques such as LEEP* and Cryotherapy • Lack of awareness in • General population related to signs and symptoms • Providers related to early signs of disease • Cost of treatment is ~INR 1-2 Lakh in a private set-up and ~INR10,000−20,000 in a government set-up Diagnosis requires lab support and presence of a skilled pathologist and gynecologist which are available at district hospital level or above Paucity of trained medical professionals and technology Accessibility As per BARC, there are ~300 radiation therapy machines in India compared to the 1,000 that are required as per WHO guidelines *LEEP: Loop electrical excision procedure

8. Way forward In the face of these challenges, we believe that strengthening screening initiatives should be our foremost focus… ..in controlling cervical cancer in India Recommended priority level for Cervical Cancer Control in India • Promote VIA as the preferred screening technique, in line with the National Cervical Cancer Screening Guidelines • Engage local level panchayats for mass awareness programs Train ASHAs/ANMs and FHWs in VIA technique Provide facility for 'See and Treat' at CHC level ASHA: Accredited Social Healthcare Worker ANM: Auxiliary nurse and midwife FHW: Frontline health worker

9. About IMS Consulting Group IMS Consulting Group is present across 70 countries with over 500 consultants across the globe. We focus only on the healthcare and life-sciences sector. Consequently, our team of consultants bring a wide and in-depth skill set that is unmatched by any other firm in this sector. IMS Consulting Group works with clients to facilitate a wide range of mission critical business decisions. Our typical work includes strategies to grow in or enter into specific geographic/ business/ therapy/ product markets and operational excellence initiatives to cover sales force as well as internal operations.