Building Capacities to Establish Cervical Cancer Prevention Programmes in Eastern Europe & Central Asia

The ECCA works with the United Nations Population Fund (UNFPA) Eastern Europe & Central Asia Regional Office as well as the UNFPA national offices, ministries of health and other organisations throughout this region to provide assistance for the establishment of cervical cancer prevention programmes.

The Eastern Europe and Central Asia (EECA) region is a challenging environment for the development of health services because while all the countries have common characteristics due to their shared heritage, they also have many differences in the structures of their health systems, their objectives for health system development and in their economic progress over the past 20 years.

One common characteristic is the economic crisis that followed the breakup of the Soviet Union led to drastic cuts in health budgets in all countries with the administrative and organisational elements of their health systems being severely cut [1-3]. This created many problems for all health services in the region but a key problem was a greatly reduced ability to plan or coordinate actions at the level of the health system. This is of particular relevance to cancer prevention because these programmes require the efficient interaction of multiple health services so their implementation can only be achieved if it is organised at the level of the health system [4-7].

Since 1991, there have been many projects to improve cancer prevention or treatment in the EECA region. However, most of these projects focused on improving a specific clinical service. This approach can be of benefit in countries where it allows the targeted service to operate more effectively within an otherwise efficient health system. However, it did little to improve cancer prevention in the EECA region because many other problems remained unresolved and still prevented the health system from working effectively, as evidenced by cancer incidence and mortality rates which have remained stable or increased [8,9].

Fortunately, the health sector in many EECA countries has improved over the past decade with increases in both clinical and administrative capacities. In addition, the UN Declaration on Non-Communicable Diseases has increased political interest in cancer prevention. As a result, a number of countries are now in a much better position to move forward with cancer prevention programmes. However, while capacities have developed in some health services, most countries in the EECA region still have unresolved gaps with the result being that each country has a unique mixture of service capacities and gaps.

In recognition of this, the ECCA has encouraged the use of a structured approach to the implementation of cervical cancer prevention programmes as summarised in Figure 1 [10-12]. This is the best way to ensure that all relevant capacity gaps are addressed and the cancer prevention programmes are effectively integrated into the existing health system so both sustainability and the benefits that will be derived by other parts of the health system are maximised.

One aspect of this process that is particularly important is the involvement of all relevant stakeholders. While most countries in the post-Soviet region require the improvement, expansion or implementation of some of the services required to deliver a cervical cancer prevention programme, they also all have:

  1. Areas where there is substantial knowledge and expertise,
  2. Existing formal and informal networks both within and between the health services,
  3. Senior clinicians having good contacts with politicians or who have become politicians themselves and who can work to increase political will for the implementation of these programmes.

The process must therefore start by identifying and recruiting all relevant stakeholders so they can be involved in the entire planning and implementation process, with international experts brought in to complement national expertise, but not replace it. Ultimately, the programme will be operated by these stakeholders so it is essential they are involved in its design and implementation so the realities of service provision are accounted for. Further, international experts will not know about the informal networks, communication channels or relationships that always play an important role in health service delivery so national experts must be relied upon to provide this information.

A second important aspect of this process is the assessment of the existing capacities of all the required health services. As these data form the foundation of the planning process, they need to be as complete and accurate as possible.

References:

  1. Gotsadze G, Chikovani I, Goguadze K, et al. Reforming sanitary-epidemiological service in Central and Eastern Europe and the former Soviet Union: an exploratory study. BMC Public Health 2010;10:440
  2. Davidow SL. Observations on health care issues in the former Soviet Union. J Community Health 1996;21(1):51-60
  3. Balabanova D, McKee M, Pomerleau J, et al. Health service utilisation in the Former Soviet Union: evidence from eight countries. Health Services Research 2004;39(6,II);1927-1949
  4. IARC. Breast Cancer Screening. IARC Handbooks of Cancer Prevention. Vol. 7. Lyon: IARC Press, 2003
  5. IARC. Cervix Cancer Screening. IARC Handbooks of Cancer Prevention. Vol. 10. Lyon: IARC Press, 2005
  6. European Commission. European Guidelines for Quality Assurance in Breast Cancer Screening (Fourth Edition) Perry N, Broeders M, de Wolf C, Tornberg S, Holland R, von Karsa L (eds). Office for Official Publications of the European Communities, Luxembourg (2004)
  7. European Commission. European Guidelines for Quality Assurance in Cervical Cancer Screening (Second Edition). Arbyn M, Anttila A, Jordan J, Ronco G, Schenck U, Segnan N, Wiener HG, Herbert A, Daniel J, von Karsa L (eds). Office for Official Publications of the European Communities, Luxembourg (2008)
  8. Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM. GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer; 2010. Available from: http://globocan.iarc.fr
  9. Arbyn M, Antoine J, Magi M, et al. Trends in cervical cancer incidence and mortality in the Baltic countries, Bulgaria and Romania. Int J Cancer 2011;128:1899–1907
  10. Alliance for Cervical Cancer Prevention (ACCP). Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers. Seattle: ACCP; 2004.
  11. UNFPA. Comprehensive Cervical Cancer Prevention and Control, Programme Guidance for Countries: UNFPA; February 2011
  12. PATH. Building Effective, Sustainable Systems for Procuring Essential Reproductive Health Supplies. Seattle, Washington: PATH; 2010