Healthcare Innovations in ASEAN- Cancer Downstaging in Sarawak

How important is innovation in healthcare?

Despite us wanting healthcare to be ‘tried and tested’ and our doctors conservatively practicing only evidence-based medicine, innovation is healthcare is absolutely vital and arguably especially so in the management of the chronic diseases (Non-Communicable Diseases or NCDs in the technical jargon). This is because the NCDs present a different care paradigm, one where patients need to be much more proactive in their own health, one where to paraphrase Hilary Clinton, it takes a whole village. Can a doctor prescribe food choices and expect adherence? Not realistic unless the patient really wants to. Can a diabetic’s diet improve if the community offerings are caloric-laden, fatty and sugary foods? What if the cook in the family is totally unaware of the dietary modifications needed?

I used to joke with friends when I was practicing surgery that surgery appealed for two reasons: it was often almost immediately gratifying and secondly, no matter how much the patient did not want to, if the surgery was skillfully done and the post-operative care well-managed, he would get well! This was so unlike our internist counterpart who had to cajole, encourage, threaten patients into compliance…

Unfortunately for doctors and for society, modern diseases overwhelmingly fall into the latter category and so new skills, new ways of thinking are needed. How can the health professions work with patients, their families and the community to improve care for the individual patient in the context of the society he or she lives in?

This was the genesis of our work currently being undertaken in describing and analyzing innovations in NCD management across Southeast Asia. I have appended below a feature in TODAY vividly describing the cancer control efforts in Sarawak and also an abstract of a presentation I, on behalf of our group will be making next month in Manila at the 1st Regional Forum on NCDs organized by the Philippines Department of Health.

From TODAY 12 Sept 2013

Cancer control on a shoestring budget

Visit to Sarawak General Hospital to meet Drs. Beena and Tang

In 1993, a visibly agitated Beena Devi, Singaporean cancer specialist, looked in the mirror and asked herself: “Why are patients coming to the hospital so late? Don’t they know something is wrong? Maybe they believe nothing could be done?” As she explained: “I knew I wouldn’t be seeing many patients much longer.”

She decided that something had to be done. Fresh from Singapore and a newcomer to the Sarawak General Hospital’s Department of Radiotherapy, she found an able partner in Dr Tang Tieng Swee — a medical physicist with a PhD from London, who was a savvy local whose skilled organisational talents proved the perfect complement to Dr Beena’s passion and clinical expertise.

Working with a small team of like-minded clinicians and hospital managers, they patiently went about educating community nurses and medical assistants on early symptoms of cancer. They focused on breast, cervical and nasopharyngeal cancers, going deep into rural areas to ensure that they were reaching everyone.

Why not mammographic screening or Pap smears like what is done in advanced countries like Singapore? One word: Money.

Breast self-examination may not be as “accurate” as mammography but it is easy to teach, easy to perform — and, as the results amply demonstrate, can contribute to women seeking medical attention earlier. Best of all, it costs hardly anything for the women and the system.


Scrupulous data collection over two decades enabled the team to demonstrate that cancer stage at diagnosis had plummeted.

In 1991, 70 per cent of breast cancer patients came to the hospital with advanced disease; by 1999 this had dropped to under 40 per cent.

For cervical cancer, the rates of late diagnosis dropped from 70 per cent to under 30 per cent.

Education is not rocket science. Why did Dr Beena succeed when so many others had failed? A few crucial factors.

Firstly, Drs Beena and Tang had very astutely identified the point of maximum leverage.

As Dr Tang explained: “In rural clinics, the MAs (medical assistants are the male equivalent of nurses in Malaysia) and nurses are like resident doctors. Villagers see them for everything. But they lacked awareness and sometimes wouldn’t know how to handle what are actually symptoms of cancer. So us going into the field to improve their skill and knowledge made them happier and feel empowered.”

The MAs and nurses actually lived in the villages and knew the villagers well, he added. The greater sense of ownership, greater rapport and enthusiasm were critical.


Secondly, the hospital team mapped the entire “value chain” and systematically cleared roadblocks and rectified deficiencies. In particular, Drs Beena and Tang found early on that they would have to rectify the referral system in order for the programme to really work.

“You see, previously referrals could only be done by doctors. Even if we trained someone in a rural area, they still could not refer patients. So we got permission from the State Health Department for nurses and MAs to refer patients with cancer symptoms to the nearest hospital,” said Dr Tang.

What if there are doctors in the intervening district hospital fobbing off the nurses’ referrals? “No problem”, said Dr Beena. “The nurses and MAs could call me directly. After a while, everyone knew to take the nurses and MAs seriously.

“When your referrers are discouraged, they don’t bother any more and give up. The whole programme becomes a waste of effort. We needed to give them the assurance that we would also be there for them.”

The team also made sure waiting times for specialist attention were also kept short so that patients were reassured that being diagnosed early made a difference.

In fact, Sarawak has “one of the shortest waiting lists in the country — where new patients only need to wait about three to four weeks”, according to hospital director Abdul Rahim Abdullah.

Dr Beena explained: “The department had to work and continues to work really hard, but we have a great team. Very motivated; they can see it makes a difference.”




A third factor was the “localisation” of education materials and methods. Foregoing precise medical terminology which rural folk would not understand or connect with, the team instead produced materials customised to local norms.

Finally, the team went where the most vulnerable are. Not for the team were the comforts of a modern hospital, and getting rural paramedical staff to make the long journey to the hospital. Instead, heading out on fishing boats and crossing rickety bridges, they went to where the villagers were.

This was crucial for two reasons, Dr Tang said: “We showed the villagers we were serious and, just as importantly, we could teach the nurses and medical assistants by actually demonstrating how to do a breast self-examination or Pap smear.”

There is still much work to be done. Dr Beena remains troubled by a persistent 12 per cent of Stage IV breast cancers. “We are still not reaching every woman,” she said.

How much did all this cost? A mere US$9,250 (S$11,730) a year! (US$8,000 for staff training, mainly travel costs for hospital faculty; and another US$1,250 for printing of pamphlets and other educational materials).

Reporting their work in the Annals of Oncology, Drs Beena and Tang concluded: “Educating women empowers them to self-care and gives them the opportunity to seek treatment earlier. In countries with limited financial and manpower resources, down-staging of cancers is a cost-effective way of tackling the problem of cancer burden.”


Dr Jeremy Lim is a Founding Member of the ASEAN Non-Communicable Diseases (NCD) Network and Fatimah Z Alsagoff is with its Secretariat. The Network is an informal grouping of healthcare experts with a shared passion and commitment to improving care for NCDs in South-east Asia.

This is part of a series on healthcare innovations in ASEAN.



The healthcare burden of NCDs is well known: NCDs account for some 60% (35 million) of global deaths with the largest impact occurring in low and medium income countries. On the economic front, one of the most prominent warnings about the impact of NCDs came from the World Economic Forum 2011 study which highlighted that NCDs could cost the world US$47 trillion over the next 20 years. This represents approximately 4% of annual global GDP, leading Professor Klaus Schwab, Founder and Executive Chairman of the World Economic Forum to declare. “The need for immediate action is critical to the future of the global economy.”

At the same time, NCDs pose formidable challenges especially to developing countries already struggling with insufficient healthcare infrastructure and manpower. Many countries are already barely coping with the current burden of disease, what more addressing the expected 17% rise over the next decade?

Insanity has been described as “doing the same thing over and over again and expecting different results”. What can and should be done differently?

In January this year (2013), the ASEAN NCD Network, an informal grouping of policy thinkers, academics and clinicians banded together to study innovations in NCD management within ASEAN. These innovations could be at the system level, at the institution or even the department level. This presentation and discussion will showcase examples of innovative practices that have led to documented improvements in disease rates, risk factors or input factors such as increased intake of healthier foods, more exercise etc. Some examples: from Thailand, a hospital dedicated to promoting its patients’ food and lifestyle choices transformation and an innovative rural diabetic retinopathy screening program; from Malaysia, a cancer downstaging program which has won international acclaim; from Singapore, engineering food to increase fiber intake and establishing a tele-carers network to enable remote support of patients with NCD; from Indonesia, training of community health workers to manage NCD; from the Philippines, legislative advocacy to deter smoking through higher taxation, and many more.

More important than the individual examples, the presentation will analyze the cases collectively and identify common themes and success factors. It will offer a systems perspective framework that can assist policy makers and change-makers in understanding deeply the milieu which catalyzes innovation and what they can do to foster such environments.


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