What Sikkim Can Teach the Rest of India About Fighting Cervical Cancer

Cervical Cancer Awareness Month: More so, how did Sikkim convince parents of girls to take the HPV vaccine?

How did Sikkim get a head start in its fight against cervical cancer – and what lessons can the rest of the country learn from the 'Sikkim Model'?

The Centre – seemingly borrowing a leaf out of the tiny Indian state – declared in December 2022 that a nationwide HPV vaccination programme will be implemented by mid-2023.

However, in 2018, when cervical cancer hadn't started making the headlines, Sikkim started a timely implementation of free human papillomavirus (HPV) vaccine, vaccinating 97 percent of girls in the target age group.

So, when the rest of the country is catching up on awareness campaigns and vaccination, how did Sikkim move ahead?

How Sikkim Got a Head Start 

The answer lies in Sikkim's close association with the Cancer Foundation of India – which was actively campaigning to put a system in place since 2009 – almost 10 years before the inoculation programme was actually implemented.

India has the most number of cervical cancer patients in Asia and almost one-fifth of the global burden, according to the most recent Lancet study. Cervical cancer is also the second leading cancer among all cancer in women and accounts for approximately 10 percent of all cancer cases.

Sutapa Biswas, co-founder of the Cancer Foundation of India, told FIT, that the Sikkim government was convinced due to the following reasons:

• Compliance with cervical pap smear screening being almost negligent

• Patients coming to treatment facilities when they are in an advanced stage

• Absence of comprehensive cancer care facilities in the state

"The first step is always political will. We held several rounds of meeting with experts, until they were convinced at every level that what they were doing was right. They had to allocate their own funds, as it was not a central government-aided programme," Biswas said.

What Convinced the State Govt

But what convinced the state was also the fact that they had their own data to rely on.

"From 2009 to 2011, we had vaccinated 500 girls in India. So, in the seven-eight years that they got to observe, the Sikkim government realised that the girls are doing fine. They had grown up to be married, had their children, etc. They had data from their own backyard," Biswas said.

At this point, there was also a lot of literature from other countries like the UK and Australia, which had also begun making the HPV vaccine available for public. It made the government even more confident.

Once Sikkim decided to go ahead with the vaccination in 2017, they procured the required Gardasil – a US Food and Drug Administration approved HPV vaccine – through UNICEF at a subsidised price. This was crucial because India did not have an indigenous vaccine at that point.

"The vaccination strategy was a mixed one. It was offered both in government and private schools, as well as in healthcare centres for girls who are out of school. The round activities continued till August 2018. The second dose was administered April-May 2019," a senior government official told FIT.

But how did Sikkim convince parents of girls to take the vaccine?

How Did Govt Address Concerns of Parents?

"While there may have been scientific backing, there was absolutely no conversation about HPV vaccine or cervical cancer. There was no awareness. So, it was important to include healthcare workers in awareness campaigns," said Dr Shoma Rai, a practising gynaecologist at Gangtok.

"The major concern was whether the vaccine will affect the reproductive health of these girls, and these assurances can only be given general medicine practitioners and gynaecologists. This is what the government did. Specific awareness programmes were organised."

Dr Shoma Rai

Apart from these, specific training programmes were conducted for ASHA workers to boost the reach.

"ASHA and Anganwadi workers were involved in the process, specific training and workshops were conducted to help them not just understand why we are doing this, but also take it forward. Apart from this, awareness campaigns were conducted at schools and specific parent-teacher meetings (PTMs) was organised to address their concern," Rai told FIT.

But the size, and population of the state, the dependence on government infrastructure for healthcare, worked to the state's advantage.

"One must also remember that Sikkim is a smaller state with difficult-to-access areas. So, when you have a smaller population, and a system that is backing to deliver vaccine, it is easier to be done. Unlike Delhi and Mumbai, or any tier-one city, a majority of the population depend on the government for their healthcare. So, there is also an underlying trust," Biswas explained.

How This Can Be Replicated in Other States

1. Make Vaccines Affordable & Accessible

Dr Sabhyata Gupta, Chairperson, Gynaecology and Gynae Oncology, Medanta, Gurugram told FIT, affordability of the vaccine is the first roadblock to the nationwide implementation, manufactured by the Serum Institute of India's (SII) Ceravix.

According to reports, the vaccine is expected to be priced at Rs 400 per dose, almost 1/10th the price of what is available in the market right now – at Rs 3,500 per dose.

"When we talk of implementation, it should be available to people, it should be affordable, and people should be able to access it. The availability of the indigenous vaccine will eliminate the high price point which may dissuade people from opting for it."

2. Political Will

Before rolling out the programme, there should be complete political will to take it forward from the Centre's side.

"Punjab, for instance, piloted with two districts. As the programme advanced, the government could not continue and roll it out across the entire state. This would have involved money allocation, because once you vaccinate a set of girls, there will be a new set in the same age next year. This is a continuous process. It very important that you keep that commitment that you make to your people," Biswas said.

3. Correct Information Most Important

But the most important aspect to replicate the Sikkim Model is dissemination of the right information to the people.

"In order to make the programme effective, it's important to make the information available to the parents and the society at large. Although these persons are young, they are well aware. Even a Google search could lead them to get the wrong information. While we are hopeful that the nationwide programme is implemented, solid groundwork is needed like that in Sikkim," she said.