CERVICAL CANCER SECONDARY PREVENTION SCALE-UP IN GLOBAL FINANCING FACILITY PARTNER COUNTRIES: A HEALTH SYSTEMS ANALYSIS OF INTEGRATION BARRIERS, ENABLERS, AND COUNTRY READINESS

Abstract

Background: Cervical cancer is a main cause of female cancer death worldwide; however,cervical squamous cell carcinoma (CSCC) is vaccine-preventable and curable if detected early. The fact that 348,000 women died from the disease, with 94% of deaths occurring in low- and middle-income countries (LMICs) in 2022, reflects the urgent need to integrate the multi-step continuum of care required for secondary prevention to increase coverage. Screening coverage across LMICs remains low, despite widespread national policies making cervical cancer screening a priority. Methods: This study used an explanatory mixed-methods design combining a quantitative survey phase (Phase 1) with a qualitative, multi-country interview phase (Phase 2) to explore how cervical cancer screening and treatment services are integrated into health systems in GFF partner countries. Results: Phase 1 demonstrated that screening coverage varies from 1% to 26% across GFF countries, with over 75% below 15%. A structural imbalance emerged: countries with the highest HPV vaccination rates had the lowest screening coverage. A tiered country classification was designed to group partner countries into three tiers based on policy commitment, funding availability, and disease burden to guide tailored program support. Phase 2 qualitative analysis explained the mechanisms underlying the quantitative results, focusing on participants’ experiences during the implementation of HPV DNA testing. Participants described that HPV DNA testing requires women to interact with the health system multiple times, increasing the risk of an incomplete healthcare cascade. A causal loop diagram synthesized from both phases makes this structural logic clear and highlights where governance and financing investments are needed to break the cycle. Conclusion: These findings reveal a gap between national commitments and operational realities, indicating that health systems are not yet structured to support the multi-step care pathway required by HPV DNA testing. Scaling up screening is not a technical challenge but requires a system level intervention. For those countries, this means tailoring support to each health system's readiness level, prioritizing government ownership and domestic co-financing, and viewing cervical cancer secondary prevention as an opportunity to strengthen the health system.