A three-day training on “Establishing a System of Audit and Implementation of Standard Treatment Guidelines for Oncology Procedures” was conducted for the Orissa State Health Assurance Society (SHAS) by ACCESS Health International and the Health Systems Transformation Platform. The training focused on developing STGs for breast cancer in the state. The training was part of a larger orientation program for the state health team, district teams and providers on standardized treatment guidelines, conducted from November 16 to 18, 2021.

ACCESS Health International and Health System Transformation Platform (HSTP) have been providing technical support to the SHAS which has been implementing the BSKY as ‘assurance trust mode’ scheme for the last two years. The focus has been on increasing the delivery base to include more beneficiary families, and on increasing the network of empaneled provider hospitals to facilitate medical care. In the last two months, more than 100 hospitals have been empaneled under the scheme and utilization has increased almost 100 per cent.  

Breast cancer is among the most common female cancers in the world, and its burden in India is growing exponentially. According to ICMR’s Consensus Document for Management of Breast Cancer, breast cancer is the most common female cancers in urban India, and while the age adjusted incidence rates of breast cancer in India is lower than the western countries, owing to our large population, the burden of the disease in India is high.

The state of Orissa in east India has also recorded similar trends in breast cancer, and studies on the incidence and disease burden in the state have confirmed this. Last year in an interview  Published Dr Saroj Kumar Das Majumdar, Medical Oncologist at All India Institute of Medical Sciences, Bhubaneswar, said that breast cancer incidence in Orissa has risen by almost 30 percent over the past 20 years. This worrying trend of the disease has been seen in women under 50 years of age, primarily due to lifestyle changes such as unhealthy diet, lack of physical activity, increasing incidence of smoking, and use of multiple hormonal drugs, he told the publication. 

While advanced diagnostic tools and treatment options are available, the prognosis is dampened by the fact that almost 70% of patients of breast cancer continue to be diagnosed in stages 3 and 4 when the disease has reached advanced stage, according to Dr Kumar. 

Cost of treatment of cancers can be high, and to ensure the diagnostic and treatment facilities reach every household in Orissa, irrespective of their ability to afford out-of-pocket medical expenses, breast cancer has been included in the packages of the state-run Biju Swasthya Kalyan Yojana (BSKY). The scheme covers 96.5 lakh families with an annual coverage of Rs. Five lakh per family and an additional Rs Five lakh for female beneficiaries. The scheme covers all kinds of secondary and tertiary care treatments ranging from simple fevers to complex medical procedures such as organ transplants. On an average 5-6% of total received claims under BSKY are related to oncology specialty annually. 

Growth of this network of provider hospitals also demands the establishment of quality systems and processes, and standardizing these across the network, to ensure control and assure quality of care managed and delivered under BSKY implementation. This will ensure that every beneficiary receives the care the scheme promises. 

To this end, the three-day training and orientation on establishing a system of audit and implementation of STGs, was designed to help SHAS in establishing medical audit systems and implementation of STGs for packages related to breast cancer (as a starter, to other oncology treatment packages). 

The STGs are based on the guidelines for cancer treatment planning, developed by the National Cancer Grid (NCG), and which has been adopted by the National Health Agency (NHA) under the Pradhan Mantri Jan Arogya Yojana (PM-JAY) a national scheme that provides health insurance and aims to provide universal health coverage to about 40 percent of the population. The NHA has finalized parameters for the PM-JAY framework of guidelines and treatment protocols for oncology.   

To ensure similar quality of healthcare and standardization of claims processes under BSKY, Orissa has preferred to adopt NHA’s STGs in its health benefit packages.  

Oncology Care in BSKY

The training was part of a larger cancer treatment planning of standard treatment guidelines, and Breast cancer was used as an example, to start implementation. It focused on the importance of STGs and National cancer grid (NCG) guidelines on Breast cancer, to orient the oncology empaneled network hospitals as well as other Providers and SHAS team on the STGs related to breast cancer. As a result, an expert committee has now been formed for utilisation of breast cancer packages within the BSKY. 

The orientation was conducted by the team of experts from HSTP and ACCESS Health International. Dr. Sudha Chandrashekar from HSTP and Dr Rajeev from Access health international led the training for the BSKY team focusing on the importance of STGs and quality assurance in implementation. The process of STGs prepared through consultations with clinical experts and providers was explained along with the structure of STGs published. NHA’s detailed guidelines on breast cancer include infrastructure requirements, clinical qualifications for oncologists, packages available, tumour board concept and its importance and National Cancer Grid guidelines on breast cancer.

AHI partnership and expertise

ACCESS Health International and HSTP teams supported the initiative by conducting orientation on medical and field level audits and an audit process has been set up at the state level. Dr. Dhananjaya Naidu led the discussions on audits supported by Dr. Prasad H S and Dr. Arun Tiwari. The STGs orientation was led by Dr. Rajeev A.G. The discussion related to data analysis was handled by Swapan Ghosh, (designation) of ACCESS Health International.

To ensure maximum coverage among the provider network, the orientation was conducted in both offline and online mode. Field teams from districts joined the discussions and training that were being conducted in Bhubaneshwar through an online platform. 

The program related to medical audits was attended by the SHAS team, claim processing doctors and field-level district coordinators of all the districts. The orientation and training on STGs was additionally attended by the network providers empaneled for oncology. 

Challenges and solutions

Representatives of network hospitals raised queries on tumor board implementation, especially due to scarcity of clinical professionals in medical oncology and radiation. The Providers felt it was difficult to get their opinion on treatment plans, especially in the network hospitals that perform only surgical treatments and refer the patient to higher centres for further treatment.  The training team explained the importance of comprehensive treatment planning in oncology case management, and suggested building tie-ups with the consultants related to medical and radiation oncology to overcome the issue of shortage of in-house experts.

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