Cacu, Detection & Health Care in Pando-Bolivia

The Plurinational State of Bolivia has four general characteristics that need to be known because they directly or indirectly influence the health sector:

1) "Andean Country", a concept that conditions the actions of the State and international cooperation to favor almost exclusively this area between the Andes mountain range called the Altiplano (35% of the national territory), where the two majority native peoples live: Quechua and Aymara. The remaining 34 peoples inhabit more than 65% of the territory, which are tropical and subtropical areas.

2) Bolivia is among the low- and middle-income countries, being the fourteenth largest economy in Latin America and number 97 by volume of GDP. Its public debt in 2022 was 35,707 million dollars, with a debt of 82.62% of GDP. Its per capita debt is $2,956 dollars per inhabitant; 30.8% of women with CACU have informal work and 25.2 work at home.

3) Health spending in 2018 was 92 US dollars per inhabitant; for every 10,000 inhabitants there are 8 doctors, 3.9 nurses and 1.5 dentists; there are 12,000 hospital beds (ratio of 1.1 beds per 1,000 inhabitants).

4) The COVID-19 Pandemic has revealed in general terms: i) the insufficient number and quality of trained health personnel ii) reduced capacities (physical structures, equipment, health materials); iii) Network of minimal and fragile diagnostic laboratories.

5) The CACU mortality rate is the highest in the Americas (26.3 per 100,000 women). The department of Pando is the furthest from the national capital; It is divided into 5 provinces and 15 municipalities; the road infrastructure is deficient and is enabled only in the dry period; Its population is dispersed, reaching 168,776 inhabitants this year, 77,724 (46%) are women and 91,052 (54%) are men, with a density of 1.7 inhab/km². Public health services are divided into three Network Managements and 14 first-level health centers (where there is a doctor) and 32 first-level health posts (there are only nurses or assistants), and a second-level hospital; its coverage is limited and underreporting is evident mainly in rural forest areas.

In this complex scenario and based on experience as a health team, we have been able to typify and define the barriers detected:

a) Barriers for service users: The population is unaware of the magnitude of each disease; there is geographical and cultural inaccessibility and; distrust in the health system.

b) Barriers from service providers: Insufficient campaigns for timely detection; precarious information and training systems; lack of trained and motivated professionals; precarious disorganized network of laboratories; slow process of the digital platform for Telehealth.

c) Structural barriers: Deficient organization of health services; stress dispersion; insufficient resources; lack of consensus on intervention strategies; Doubts about the applicability of Telehealth in CACU screening.

Initially we will review the innovative technological resources proposed for the care of various pathologies (malaria, dengue, HIV-AIDS) in addition to the situation of CACU in neighboring countries and other low-income countries, with emphasis on the situation at the national level " National Plan for the Prevention, Control and Monitoring of Cervical Cancer" followed by the Guides, Manuals, documents and departmental, regional and municipal reports, will allow us to consolidate and document the baseline from which we are starting.

It is necessary to consider the availability of "Telesalud para Bolivia", implemented since 2014, with four areas (Tele-management, tele-education, Telemedicine and Tele-epidemiology), which generated much expectation and enthusiasm. According to the Ministry of Health and Sports, this should guarantee access to the use of state-of-the-art medical devices in the 339 municipalities of the country with 340 technological equipment implemented in health establishments, with which they carry out the early detection of non-chronic diseases. communicable, disability, and diseases prevalent in endemic areas; That is why the medical personnel of the Telesalud project participate in health fairs for their respective socialization that are carried out in regions far from the national territory.

However, the results achieved show the need to improve the exchange of knowledge, maximize the experience according to their local availability, improve universal health education (train and implement the social marketing strategy and ICTs as support for women users through social marketing and ICTs), in addition to optimizing medical practice with the implementation of new digital and artificial intelligence tools based on research and their medical practice supported by scientific evidence.

We believe that it is essential that there should be a greater number of women assisted with their CACU detection tests, as well as guaranteeing a user-centered approach, working on the acceptability of women to this solution, with the protection of their data and confidentiality, through the initiation of the processes proposed in the project so that in the future they are transferred to the national Telehealth system.

Another important need concerns health workers, so that good health care practices are updated and practiced, accompanied by research that generates evidence and this is the basis for supporting the application of these services.

Developing cost-effective and equity-first local solutions that become regional solutions starting with a pilot health institution that offers effective multidisciplinary detection services will allow us to overcome existing barriers and continue the search for new and effective tools not only for the CACU, being able to extend to other endemics.

Considering some of the following indices presented by Bolivia:
• The highest mortality rate from cervical cancer (CACU) in America (26.3 per 100,000 women).
• The second incidence rate (56.55 per 100,000 women).
• It is the leading cause of death in women between 35 and 55 years of age.
• Women between 25 and 46 years old register the highest incidence rates (151.4 per 100,000).
• Mortality rate more alarming with 4.56 per day (WHO).
• The prevalence of HPV in women is 18.1.
• PAP coverage reached 16.6% of women in 2015.
• To double PAP coverage to 30% of women between 30 and 64 years of age, 192 pathologists must be trained and hired.

The solution will do:
• The better health of the female population of the department of Pando.
• The progressive reduction of CACU morbidity and mortality.
• Increased screening and improved health records
• Improve and ensure HPV vaccine application coverage in the school-age female population.
• Implement and develop social marketing strategies and ICTs, tending to improve training processes and screening methods for timely detection of CACU.
• Develop the prevention of CACU, committing the authorities of the Ministry of Health, Ministry of Education, SEDES, Foundations for the Fight Against Cancer, Pando Amazon University, Collegiate Bodies of Physicians, Biochemistry, Pharmacy, Nursing, the general population.
• Prevent lesions from progressing from a simple Squamous Intraepithelial Lesion (SIL) to becoming a high-grade invasive cancer.

The solutions to such a complex and multifactorial problem allow us to propose only the resolution of some barriers so that women have physical, mental and social well-being in all aspects related to the reproductive system.

La Paz Foundation is a non-profit organization with 28 years of experience, which promotes the design, execution and advice of promotion and social management programs and projects aimed at improving the standard of living of girls, boys, youth, women and population of vulnerable sectors. The Foundation has experience in the following works that can serve as a reference:

● Development of training projects in the use of ICT applied to education with financing from the Spider project of Stockholm University. Aimed at teachers from public educational units, through a strategy of face-to-face and virtual training workshops (from 2013 to 2021), more than 2,000 participants from 120 educational units were trained.
● TECNITIC educational technology training center (2022 onwards), equipped with computer rooms, broadband internet access, aimed at developing initiatives for the training of students, teachers and parents of Public Educational Units of the Municipality of La Paz through a wide range of practical training workshops for the use of ICT (applications and digital platforms).
● In 2023, we expanded our coverage to the health area, through the association with individual consultants who stand out in the area of Public Health, Epidemiology, Laboratory Medicine, Communicable diseases, Social Marketing and ICTs with more than 20 years of work in the field. technical-scientific area as well as community teaching, undergraduate and graduate.

Currently we intend to focus our knowledge and experience on the
development of the project through our multidisciplinary team.

It is estimated that there are 40,000 women of childbearing age in the department of Pando.

For years we have seen the start of different traditional control processes, investigation of the CACU, without achieving an evident change in the rates of this scourge of a disease that is for women, which is more evident in those who live in peripheral and rural areas of secondary populations of Bolivia, for which we consider the urgent need to have a partner with whom we can develop other more effective innovative processes for the prevention of CACU to curb its growing prevalence.

One of the main reasons is the insufficient State budget for the health sector, for which we ask our SOLVE partners to help us defeat this economic barrier and other structural barriers, for users and service providers by facilitating a successful implementation of the proposed technological solutions:
* Optimize Telehealth in the detection and care of CACU.
* To educate our population in health, through new social marketing tools and ICTs so that the population and particularly women acquire skills to access, understand and apply health information, as there are many taboos and social stigmas that harm prevention of the illness.
* Improve the updating of health human resources through e-training (remote access to information to improve their practice based on research and evidence).
* Transform first-level health care by improving access and coverage of CACU screening tests, improving cervical screening through the application of acetic acid (VIAA) and the use of portable colposcopes).
* Have an improved software that allows the documentation of each exam (photographs, videos) to be used by smartphones and desktop or laptop computers and allows filtering the cases that require more attention, repetition of the exams or direct participation of the specialist doctor .
* Optimize the transmission of images through the multimedia messaging service (MMS) to the operations center.
* Build real and timely epidemiological information on the CACU in Cobija, Pando.
* Finance the travel, support, and salary of our multidisciplinary team (three permanent researchers and two temporary ones) and front-line personnel (6 auxiliary nurses).

The health care circuit against Cervical Cancer (prevention, promotion, detection, diagnosis, treatment, surveillance), has worked for decades and is not reaching the objectives set by evidencing the persistence of unfavorable rates for the population and even the increase in morbidity and mortality in the most disadvantaged groups of women (indigenous women, women from low-income countries who live in rural areas or on the outskirts of cities, illiterate women or women with basic education, women with an early onset of their sexual life and adolescent pregnancies ), as is the case of Bolivia.

Our solution proposes to improve health care and particularly the detection of CACU thanks to existing 'apps' that allow comprehensive monitoring of the entire medical process to be implemented in the care of indigenous women in the Bolivian Amazon. Personalized digital counselling, monitoring and surveillance programs adapted to the idiosyncrasies of the population (age, ethnicity, degree of literacy, place of residence, parity, marital status, comorbidities, type of work).

We do not have the experts in Artificial Intelligence (AI) or in other informatic areas to improve our health care process and allow us to develop more efficient and economical tools for the care of our regional and national endemics, but we do have support inputs, experience and ideas for its creation.
    
Having a captive population with particular demographic, social, organizational, and health characteristics will allow us to develop our initiatives and field-test the innovative tools to be implemented with the support of our MIT-SOLVE partners, aiming to reduce morbidity and mortality. caused by CACU through simple training processes and use of innovative technology that in its implementation will have a low cost and can be scalable in case of success, being able to expand nationally and to other countries, or be adapted to other priority diseases worldwide.

The needs market is very broad and their needs are not resolved despite the efforts made.

By the end of the pilot period (first year), we would seek to improve technical response capacities to the CACU problem and increase the number of nurses trained and committed to assist in the problem of cervical cancer in health centers; friendly software and computer processes can be adequately used to carry out all the tests designed in response to the local requirements of the actors (female patients, frontline nurses, medical specialists, clinical pathologists) and adequately fill the information requirements of the state with regard to the National Health Information System (SNIS), in order to implement the required responses in a timely manner and with evidence.

In the first year of the project, we intend to provide CACU health care to a minimum of 50% of women of childbearing age in the municipality of Cobija; Every year, we will seek to increase the coverage of the health centers with which we work until reaching all the health centers in the city of Cobija to later extend it to the entire department and carry out pilot tests in other departments that demand the attention through strategic alliances.

We start from the data provided by the SNIS of the Ministry of Health and Sports, which can be summarized in the following table:

This general information will be broken down by health centers in which both, entry and exit statistics, will be carried out (for the first year), these will be worked on based on monthly information generated by the project in order to monitor the work, community acceptance, knowledge, demand and monitoring of cases by nurses.

Other ways to measure the impact will be carried out with meetings with natural leaders of women, community authorities and surveys with women that demand the service.

Telehealth implementation in the detection and care of cervical cancer was implemented by Owuor Jhon et al. (2016) in Rwanda, Kenya and Zambia, Stockholms universityt - SPIDER (www.spidercenter.org); organization with which Fundación La Paz implemented an ICT project in education.

Recalling the experience in Africa, we believe that the improvement of the complete and clear visual inspection of the cervix (cervical screening) through the application of acetic acid (VIA or cervigrams) and the use of Gynocular (portable colposcopes), with software that allows documentation of each exam through images to be used by smartphones and desktop or laptop computers and transmitting the images via multimedia messaging service (MMS) to the operations center and international experts. (electronic control and quality management of cervical cancer); It will allow in this first phase (first year) to improve the detection of CACU in women from the municipality of Cobija, Pando.
  
Weekly follow-up and surveillance circuits will also be carried out for the confidential delivery of results to patients via cell phone or at their care center, the explanation and interpretation of the same, as well as their follow-up in case of other treatments or exams, in addition to the taking samples from other women.

Consultations by Telehealth (WhatsApp or HIPAA software), will seek to improve the effectiveness of detection and especially in cases of positive results. The digital clinical history and cervigram images of each patient (Digital Data Bank) may be used to talk with the patient as part of their detection information and results session, or as a suspicion for women to be referred to hospital facilities. where there is a specialist with time and experience, guaranteeing evidence-based practice.

At the end of the first year of implementation of the Project, we will carry out its evaluation as well as the qualitative needs that are required by exploring the opinions of the participants.

The focus of our proposal is in harmony with the country's national health policy, which falls on care and management models of Family Community and Intercultural Health (SAFCI in Spanish), to eliminate all forms of social health exclusion, guaranteeing effective access to comprehensive health services, claim, strengthen and deepen social participation with decision-making with shared and effective management of health, considering the person, family and community, to improve the living conditions of the population. Within this framework, the problem of cervical cancer (CACU) develops its strategies based on the health policy principles of: Community Participation, Intersectoriality, Interculturality and Comprehensiveness, where communication for health is constituted in the application, planned and systematic. of social marketing and ICTs, for the achievement of behavior changes, focusing on thinking, the steps to follow about what you want to do, be clear about what, how, when, where with how much and with whom to do, correlated the compatibility of the demand for timely detection of the CACU, through the motivation that helps to achieve the commitments of the female population, also the orientation, providing pertinent information, the training of nursing assistants who must acquire skills in the use of colposcopes , the stimulation that helps to achieve continuity and its link between organizations related to the central purpose of the proposal.

The profile of women in Cobija has a work and family dynamic; A different story is told in each native woman, but her experiences, family, daily activities are the same: doing her job well, looking to help her partner, as long as they are still in a relationship, and obtaining a profit with which they maintain themselves and become the support of their family; The obstacles that are presented to them as women are several: mothers, heads of household, caregivers, helpers, etc. Her job is to help and take care of the health of her partner and her children, it is paramount, which is why we will prioritize her training in the "mothers' club".

The approach used has the following results:

-Confidence and security of women of reproductive age
-Get out of the stigma of early sexual initiation
-Ditto, avoiding multiple sexual partners.
-Know the presence of HPV in the STI
-Decrease multiparity
-Improve nutrition throughout the reproductive age
-Definitely exclude smoking and alcohol
-Improve the state of immuno-suppression
-Improved the attitude of women to perform the PAP

Due to stablished conditions in the municipality of Cobija, for the project we thought of a social economic model, aiming to save resources for the municipality and at the same time change a social situation, benefiting many women through the generation of value in Health Service. All this with the help of the implemented software. Changing the following situations:

• The tests will no longer have appointments in the busy schedule of gynecologists who perform other more complex specialty tasks, it will be enough for an auxiliary nurse to take the tests, this will reduce the cost of professional personnel with high human capital.
• Early diagnoses will avoid the costs of eventual surgeries assumed by health centers. Allowing them to invest their resources in other problems and thus generate a "snowball" effect on population health, improving current processes, reducing costs and making resources more efficient.
• The ease of taking samples will allow the service to be extended to people who live in peripheral and rural areas, currently in many areas only patients with a delicate state of health are received, so prevention is non-existent.

The main idea of sustainability over time is that, as the months go by, the Artificial Intelligence in the software automates the diagnostic processes in order to reduce the time and personnel required.

It is a reality in Bolivia that the Autonomous Governments will have fewer and fewer resources and international cooperation will diminish their collaboration; Therefore, if what has been committed is achieved, a problem of a social, cultural, economic and environmental nature will be fought. Only technology allows you to maximize the impact achieved with fewer resources.

As women only know the old health care system, we will start with health literacy, promoting the new service that we are implementing with the municipal authorities who will participate with their counterpart of physical structures, frontline nurses and access to digital connections. permanent. We will also guide the advantages and disadvantages of traditional services: traditional midwife, grandmother with knowledge and experience, natural medicine doctor, including outreach from Public Educational Units, reaching parents, teachers and students.

We seek to radiate a broad social impact with entrepreneurship for what we have done:

* For years studies to identify the options that allow generating an approach to solve the problem of the CACU in Cobija, carrying out an analysis of materiality and priorities that allow to have as a result a greater social value and indirectly an economic value in the families of the municipality.

* The social project that worked aims to generate services (solutions) that have economic benefits to eradicate the CACU problem in the municipality and then throughout the country.

* At the beginning we involve the community to correct and adapt our theoretical/practical planning, investigating visions and approaches to a more popular solution, and harmonizing our training objectives for women, enriching the process by offering training to women and later they are the ones manage the CACU care process.

The idea is to be able to have a greater impact with existing resources; that is to say, to make health expenses more efficient and achieve a large-scale impact thanks to the prevention of CACU, analyzing a large number of women in the municipality.

For this financing plan we have stages:

1) We mainly need initial capital for the implementation and operation of the "surveillance center", where there is a minimum of equipment for gynecological examinations, training, advice, counseling and carrying out eventual laboratory tests, but mainly the pilot center for management , control and development of the designated tasks of the project with the development of the software.

2) The Bolivian state has established a cost for all laboratory tests (SUMI Application Manual) that can be carried out at the national level; the rates of complementary benefits to gynecological medical care indicate a cost of 28 Bolivianos (approximately 4 US dollars), for the exam: PL71-Papanicolaou PAP stain, which in some way can guarantee a level of sustainability when large numbers of samples.

3) It will be put into consideration of the users and the authorities, that within the routine of gynecological health care, sampling, evaluation and performance of the VIA test. the diagnosis of sexually transmitted infections (STIs) can be expanded, with the costs financed by the SUMI, in order to increase income and provide more efficient health care.

4) Presuming success in health care, women from other municipalities will resort to the service, allowing a higher income for the costs assigned by SUMI to their municipalities.

5) Open spaces for new donations, research work with supplementary financing and others that are considered and help sustainability in the medium and long term.

The La Paz Foundation began its work as the San Gabriel Foundation in 1971. In the first years it had experience in health, reaching all the communities of La Paz with first-level mobile centers; with services that did not exist at the time. In the following years, she concentrated on education and the promotion of women's rights. Thanks to achievements implemented in laws such as the Law for Boys, Girls and Adolescents, the Law for Popular Participation and the Political Constitution of the State, Bolivia is already very advanced on the issue of respect for women. However, there are many deficiencies due to the Bolivian culture. Over the past 28 years, the foundation has made a big impact on cultural issues through education. Implementing issues such as gender violence in a transversal way in the Educational Units, is how it has had an impact on different generations. This aspect is taken advantage of much more in the times that we live in at the moment with the support of technology, being able to have access to knowledge that was not available before and using playful tools that facilitate the creation of knowledge and educating an entire community (teachers , students, mothers and fathers). Thus, Fundación La Paz has experience in generating impact through education and technology. It is also worth mentioning that the impact achieved by the Foundation was achieved thanks to the management of interns and the alliance with strategic public and private institutions (Ministry of Health, Mayor's Office of La Paz, Mayor's Office of Cobija, Ombudsman, Universidad Mayor of San Andres). The Foundation also received funding from the European Union, the Konrad Adenauer Foundation, Save the Children and the Bolivian Government.

With all this background, and due to the shortcomings that Bolivia has, the Foundation seeks to use its knowledge and alliances to have an impact in the health sector. This specific project will seek to coordinate with authorities from the Ministry of Health and Sports, the Sexual and Reproductive Health Program, to promote continuous economic support and training for the population. It will also seek to present the project to different instances such as the Vice Ministry of Public Investment and External Financing and obtain resources to ensure the continuity of activities.