Is India's public health care system prepared for cervical cancer screening?: Evaluating facility readiness from the fourth round of the District Level Household and Facility Survey (DLHS-4)

• Authors: Preet K. Dhillon, Public Health Foundation of India; Benjamin D. Hallowell, Centers for Disease Control and Prevention; Sutapa Agrawal, Public Health Foundation of India; Arpita Ghosh, Public Health Foundation of India; Awdhesh Yadav, Public Health Foundation of India; Elizabeth Van Dyne, Centers for Disease Control and Prevention; Virginia Senkomago, Centers for Disease Control and Prevention; Shivani Patel, Emory University; Deepika Saraf, Indian Council of Medical Research; Roopa Hariprasad, National Institute for Cancer Prevention and Research, India; Neha Dumka, National Health Systems Resource Center, New Delhi; Ravi Mehrotra, India Cancer Research Consortium, New Delhi; Mona Saraiya, Emory University
• Journal Title: Preventive Medicine
• Volume: Volume 138
• Publisher: Elsevier Inc. | 2020-09-01, Pages 106147-106147
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.ypmed.2020.106147
• Subjects: Health Sciences, Oncology; Health Sciences, Public Health; Health Sciences, Health Care Management; Health Sciences, Epidemiology
• Keywords: Science & Technology; Life Sciences & Biomedicine; Public, Environmental & Occupational Health; Medicine, General & Internal; General & Internal Medicine; Cervical Cancer; India; Screening; Prevention; Middle income; None

Abstract

India's cervical cancer screening program was launched in 2016. We evaluated baseline facility readiness using nationally representative data from the 2012–13 District Level Household and Facility Survey on 4 tiers of the public health care system - 18,367 sub-health centres (SHCs), 8540 primary health centres (PHCs), 4810 community health centres and 1540 district/sub-divisional hospitals. To evaluate facility readiness we used the Improving Data for Decision Making in Global Cervical Cancer Programmes toolkit on six domains - potential staffing, infrastructure, equipment and supplies, infection prevention, medicines and laboratory testing, and data management. Composite scores were created by summing responses within domains, standardizing scores across domains at each facility level, and averaging across districts/states. Overall, readiness scores were low for cervical cancer screening. At SHCs, the lowest scores were observed in ‘infrastructure’ (0.55) and ‘infection prevention’ (0.44), while PHCs had low ‘potential staffing’ scores (0.50) due to limited manpower to diagnose and treat (cryotherapy) potential cases. Scores were higher for tiers conducting diagnostic work-up and treatment/referral. The highest scores were in ‘potential staffing’ except for PHCs, while the lowest scores were in ‘infection & prevention’ and ‘medicines and laboratory’. Goa and Maharashtra were consistently among the top 5 ranking states for readiness. Substantial heterogeneity in facility readiness for cervical cancer screening spans states and tiers of India's public healthcare system. Infrastructure and staffing are large barriers to screening at PHCs, which are crucial for referral of high-risk patients. Our results suggest focus areas in cervical cancer screening at the district level for policy makers.