This document provides guidance on strengthening cervical cancer prevention programs through strengthening health systems. It discusses selecting the best screening and treatment methods based on effectiveness and feasibility of implementation at scale. Program planners must consider human and health system resources and phase strategies appropriately over time. Robust information systems are needed to monitor coverage, outcomes, and impact. Leadership and community engagement are also essential to ensure services are utilized and integrated within primary health care. Vertical programs should be avoided and vaccination should be part of comprehensive immunization strategies.

1. STRENGTHENING HEALTH
SYSTEMS
Dr Nuriye Ortayli
UNFPA, Technical Division
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2. WHAT IS THE IMPACT
 Efficacy of your intervention
PAP Refer
VIA Screen and treat
HPV test Single visit
 Coverage
 Scale up to national level (Gradual, or Start Big)
 Specifically target high risk, underserved groups
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3. SELECT THE BEST
 Screening method with highest
sensitivity and specificity
 Treatment that is most effective,
involves the least risk
 Cover everybody
 Go with the established?
 Develop your own solution?
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4. CAN YOU DO IT?
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5. GETTING STARTED
 Do the numbers!
◦ How many women in the target age?
◦ How many facilities capable of screening?
◦ How many women/week/facility if all screened in first year?
How many if spread over 5 years? 10 years? What is
feasible?
◦ If ~15% are screen-positive, how many cryos/week?
 Phase-in strategies
◦ Gradual build up to steady state with re-screening at
desired intervals
◦ Campaign style with big push up front, then drop-off of
demand (and drop-off of skills)
 Vıvıen Tsu, PATH
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6. SERVICE DELIVERY
 Where should screening take place (as close to the
community as possible)
 Where and when should treatment (of
precancerous lesions) take place (to minimise lost
to follow-up, balanced with resources)
◦ Screen and treat
◦ Tracking and management of referrals
 Where and how should invasive cancer referred?
Balance between highest coverage
and ability to provide quality service
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7. HUMAN RESOURCES
 What are the available human resources to ensure
highest coverage? (Numbers, geographic
distribution, workload, attrition, possibilities for task
shifting)
 How much (time and resources) it will take to
furnish them with needed competencies?
 What should be the mechanisms of training?
 What should be the mechanisms for supervision?
 What measures will be taken for sustainability?
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8. INFORMATION SYSTEMS
HOW EFFECTIVE IS OUR SYSTEM?
HOW EFFECTIVE IS OUR SYSTE
EFFECTIVE IS OUR
EFFECTIVE IS
EFFECTIVE IS
EFFECTIVE 8

9. INFORMATION SYSTEM
 Informing clients (tracking)
 Informing health system (both
decision-makers and providers)
 Coverage (%) and who do we screen?
 What do we find (how many positives)
 How accurate we are (sensitivity, specificity)
 What % we treat
 How many cancers we prevent?
 How many deaths we prevent?
 Informing the public and politicians
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10. INFORMATION SYSTEMS
WHO recommends all countries to
establish/enhance cancer registries to
be able to evaluate impact of cervical
cancer prevention activities, including
vaccination and screening.
Information on service delivery should
be collected and used for decision
making.
No vertical system should be planned
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11. MEDICAL
PRODUCTS,TECHNOLOGY
 Tests: Which one to use?
 Cost (initiation/continuation)
 Infrastructure (both physical and human
resources)
 Logistics and maintenance
Based on sensitivity and demands on health
systems, cytology based screening is not
recommendable when starting a programme.
A mixture of approaches can be used.
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12. FINANCING
 Who is going to pay for these?
 Are they willing to pay for it?
 Can they afford it?
 What is the balance between increasing access
and being realistic?
 WHO-UNICEF joint statement of Vaccine donation
is also applicable for donation of other equipment
and supplies,
◦ suitability,
◦ sustainability
◦ informed
◦ supply shelf life, functional
◦ licensed and adoptable 12

13. LEADERSHIP,
GOVERNANCE
Simple elements, complex
integration
Good synchronization
Advance planning
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14. VACCINATION
 Plan for introduction of HPV vaccine should be part of country
immunization comprehensive multi-year plan and
comprehensive cx ca prevention and control strategy
 Introduction of vaccine can be integrated with delivery of other
essential services for adolescents.
 Price is a big barrier. Negotiated price should be made public.
Competitive bidding or conjoint purchase mechanisms (PAHO,
GAVI etc) can be used. Financing of delivery should also be taken
into account.
 Donations are only acceptable when in line with WHO-UNICEF
statement.
 Different modalities of delivery are possible with their pros and cons.
(community based, school based, mobile clinic)
 Monitoring for coverage, effectiveness, impact, usage and safety
should be planned.
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15. COMMUNITY
ENGAGEMENT
Services that are not used are;
useless!
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16. NO VERTICAL SYSTEMS
 No vertical systems.
◦ Screening part of PHC
◦ Treatment part of PHC/Secondary HC
◦ Information should be collected as part of HIS
◦ Training and supervision should be integrated.
◦ Vaccination should be part of comprehensive
programme of immunization
 Beware of over-medicalization/over treatment/over
specialization
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17. AT the servıce of two
generatıons

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