A global blueprint for
cervical cancer elimination:
learnings from Sweden

Supported byA global blueprint for cervical cancer elimination: learnings from Sweden

2

Contents

3

About this report

4

Executive summary

7

Background9

Prioritising the elimination of cervical cancer

10

Primary prevention of cervical cancer through HPV-vaccination

11

Secondary prevention of cervical cancer through screening

13

Treatment of cervical cancer

14

Progress towards elimination of cervical cancer and the WHO targets

17

The first country on the verge of eliminating cervical cancer: Sweden

26

Implementing a national HPV immunisation programme in a low-income
country: Rwanda

28

Improving access to high quality cancer treatment: Australia

29

Population-based cervical screening using hr-HPV testing and catch-up
vaccination programmes: Portugal

31

Implementing a successful cervical cancer elimination strategy

36

Conclusion

37

References©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

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About this report
A global blueprint for cervical cancer
elimination: learnings from Sweden is an
Economist Impact report, supported by MSD.
It examines the extent to which countries aremeeting, and in some instances exceeding, theWorld Health Organization’s (WHO) 90-70-90
goals for cervical cancer elimination within thiscentury. The report describes the exemplary
performance of Sweden, which could comeclose to eliminating cervical cancer before
2030. It also looks at other select countries,
across a range of income levels, population
health needs and budget constraints, thathave prioritised cervical cancer as a key healthpriority and are now reaping the benefits of
their commitment. The report is based ondesk research, an in-depth literature review,
and insightful interviews with a range ofglobal and national-level experts in the field,
including those involved in both upstream
and downstream levels of policy, strategy andimplementation. Through the synthesis of thesesuccess stories, it concludes with a 10-point
plan as a baseline of recommendations forother countries to consider in their pursuit ofeliminating cervical cancer.
We could not have developed this report
without the critical input and support of thefollowing experts (in alphabetical order):Dr Nino Berdzuli, Director of the Division ofCountry Health Programmes, WHO, Regional
Office for Europe, Switzerland
Professor Joakim Dillner, Head of Unit at
the Karolinska University Hospital, Center for

Cervical Cancer Elimination and Director of
Research & Development (FoU-chef) at the
Medical Diagnostics Karolinska, Sweden
Dr Marc Hagenimana, Ag. Director of Cancer
Diseases Unit, Rwanda Biomedical Centre,
Ministry of Health, Rwanda
Ulrika Årehed Kågström, Secretary General,
Cancerfonden (Swedish Cancer Society), Sweden
Professor Daniel Kelly OBE, Co-Chair,
European Cancer Organisation HPV Action
Network, UK
Professor Rui Medeiros, Professor of Virology
and Molecular Oncology, Head of Molecular
Oncology and Viral Pathology GRP; IPO Porto
Board Director of NRN-LPCC-Portuguese
League Against Cancer President of Associationof European Cancer Leagues; Co-Chair of theEuropean Cancer Organisation HPV Action
Network, Portugal
Barbro Sjölander, Chair, Network Against
Gynaecological Cancer, Sweden
Dr Karin Sundström, Principal Researcher andepidemiologist, Karolinska Institute and the
Karolinska University Hospital, Sweden
Economist Impact bears sole responsibility forthe content of this report. The findings andviews expressed do not necessarily reflect theviews of the sponsor.
The research was led by Emily Tiemann. The
report was authored by Ingrid Torjesen andedited by Shaileen Atwal. Rob Cook oversaw the
research programme.

©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

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Executive summary

Cervical cancer is a significant global healthchallenge, affecting over 604,127 womenand leading to 342,000 preventable deaths
worldwide.1 In Europe alone, there were30,447 new cases and 13,437 deaths as aresult of cervical cancer.2 Unless contained,

and eventually eliminated, the impact of
cervical cancer has the potential to destabilise
economies and societies, particularly those oflow- and middle-income countries (LMICs),
where inadequate resourcing remains a key
public health challenge that leads to a steadyrise in the number of new cases and deaths
from cervical cancer.3 Without swift andsubstantive action, the global cost of cervicalcancer is expected to increase to US$682bn
between 2020 and 2050; therefore, thecondition does not simply present a publichealth problem but a sizeable economic one.4
As a result of the remarkable advancements inscience and technology, the goal of eliminating
cervical cancer is now more viable than ever.
This optimistic sentiment has been propagatedand amplified through the concerted messaging
efforts of multiple stakeholders, including
policymakers, patients and patient advocates,
bio-pharmaceutical organisations, researchers,
and healthcare professionals. However, concreteplans to achieve this ambitious goal are still
nascent. Building on from the World HealthOrganization’s (WHO) global strategy forcervical cancer elimination, adopted by theWorld Health Assembly in August 2020,5 many
countries have begun developing national andregional strategies in pursuit of this lofty goal. For
instance, Europe’s Beating Cancer Plan (EBCP),
launched by the European Commission in 2021,
includes, among its many goals, the eliminationof cervical cancer, as well as other cancers causedby human papillomaviruses (HPV).6©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

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WHO’s 90-70-90 targets to achieving cervical cancer elimination:

90%

70%

90%

of girls fully vaccinatedwith HPV-vaccination by
15 years of ageof women are screened using
a high-performance test by 35
years of age and again by 45
years of ageof women identified withcervical disease receive
treatment

EBCP targets for cervical cancer elimination:

90%

90%

90%

of the European Union’s (EU) target
population of girls fully vaccinated with
HPV-vaccination and the vaccination ofboys significantly increased by 2030of the EU target population
offered cervical cancer
screening by 2025

of eligible patients have access toComprehensive Cancer Centres
for treatment by 2030

The WHO estimates that investing ininterventions to meet the 90-70-90 targets
would add $28 billion to the world’s economy
and avert 300 000 cervical cancer deaths before
2030, over 14 million by 2070, and over 62
million by 2120.8 Progress towards achieving theWHO’s 90-70-90 targets is highly variable both
between and within countries. Several countries– particularly (but not exclusively) high-income
countries (HICs) – are close to meeting, or evensurpassing, the targets by 2030. Such countries
include Sweden, Australia, Portugal and Rwanda,
the last being the exception in the list as the
only low-income country. These countries have
many lessons to offer the rest of the world,
particularly Sweden, which is an exemplar of
success, as demonstrated by its developmentof world-renowned registries, organised healthprogrammes, evidence-based decision-making,strategies to improve vaccination coverage forboth males and females, increasing screening
coverage, and most importantly, throughhigh-levels of political commitment within the
country. As a result of these organised efforts,
Sweden is likely to be the first country toeliminate cervical cancer by 2030.
Based on the insights of experts interviewed,
published evidence and learning from countries
leading the way towards cervical cancer
elimination, Economist Impact recommends a
10-point plan as a baseline for policymakers toconsider when developing national strategies
aimed at eliminating cervical cancer.

©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

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The 10-point plan for
cervical cancer elimination
Point 1
Build political commitment and momentum

Point 2
Ensure multi-stakeholder collaboration

Point 3
Prioritise HPV within national cancer policies and vaccination schedules

Point 4Generate data through the development of robust registries

Point 5
Include screening and vaccination under universal health coverage

Point 6
Understand the target population and design the roll-out of organised andaccessible immunisation programmes

Point 7
Ensure equitable vaccination and screening access to the entire population

Point 8Address the barriers of vaccination hesitancy and misinformation

Point 9Ensure equitable access to high-quality treatment and optimal care pathways

Point 10
Learn lessons from the Covid-19 pandemic to build system resilience andscale screening and vaccination coverage©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

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BackgroundThe global burden of cervical cancer
Cervical cancer is a defining global healthchallenge. It is the fourth most common cancer
in the world and accounted for 6.5% of all
new cancers diagnosed in women in 2020.1
According to the latest GLOBOCAN (Global
Cancer Incidence, Mortality and Prevalence) datafrom 2020, 604,127 women were diagnosed
with cervical cancer worldwide and 342,000
women died from the disease.1 In Europe alone,
there were 30,447 new cases and 13,437 deaths
as a result of cervical cancer.2 The vast majorityof the global prevalence and mortality is in subSaharan Africa, South America and South-East
Asia (Figure 1).1

Figure 1: Global age-standardised incidence and mortality rates (per 100,000 women-years) of cervical cancer in 20207
Age-standardised incidence(per 100000 women-years)≥33-8
22-0 to <33-8
17-7 to <22-0
14-8 to <17-7
11-2 to <14-8
8-0 to <11-2
5-6 to <8-0
<5-60
No data
Not applicableAge-standardised mortality(per 100000 women-years)≥20-8
14-3 to <20-8
10-5 to <14-3
7-4 to <10-5
5-4 to <7-4
3-4 to <5-4
2-0 to <3-4
<2-0
0
No data
Not applicable©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

The global toll of cervical cancer continues to growsubstantially over time. An analysis of the Global
Burden of Disease (GBD) data showed that overthe past two decades (between 1990 and 2019),
the incidence of cervical cancer increased by
68.5%, cervical cancer-related deaths rose by 52%,
and the number of disability-adjusted life years(DALYs) also grew by 44.99%.3
These numbers are particularly concerning,
considering that cervical cancer is in fact
highly preventable with the development of a
vaccination against human papillomaviruses(HPV). An HPV-infection is the leading cause of
cervical cancer; exposure to 14 high-risk HPV
subtypes cause more than 95% of cervical cancers,
and two of the subtypes (HPV16 and HPV18)
alone are responsible for 70% of cases.8,9 It should
be noted that HPV-related cancers are not limited
to the cervix, but also manifest in other areasof the body including the oropharynx (throat),and the male and female genitalia, thereby
compounding the burden of HPV-related cancers.9
Many countries, across income levels, havemade remarkable strides in limiting the growthof cervical cancer cases. This containment has
not been achieved through vaccination against
HPV alone, but has involved the deployment ofseveral effective and coordinated prevention
measures, such as improved health coverage,
screening of women, and vaccination ofboth boys and girls, as well as young women.
However, more needs to be done and many
countries need to place cervical cancer
elimination strategies on the top of their healthagendas; without significant intervention, theglobal incidence of cervical cancer is expected
to grow by 700,000 in 2030, potentially resulting
in 400,000 preventable deaths.10 These estimate
suggest a 16% rise over the 604,127 cases
recorded in 2020, and a 17% rise in deaths
relative to the 342,000 deaths in 2020 based on
GLOBOCAN data.1,10
The growing burden of cervical cancer
profoundly impacts women (primarily thosein their early-to-mid-30s), their families andsocieties, imposing both human and economic
costs. Economic modelling estimates that the
global cost of cervical cancer is set to increasesignificantly between 2020 and 2050, amounting
to US$682bn, with the highest costs expected8

to occur in several low- and middle-income
countries (LMICs), predominantly located in
Africa and South America.4 Conversely, in highincome countries (HICs), the cost of cervicalcancer is lower when compared to the cost ofother cancers, possibly because more progresshas been made in the prevention, monitoringand early diagnosis of cancers caused by HPVinfections.4 Although beyond the scope of
this report, it is worth noting that the overall
cost of cervical cancer in the United States in2020 was estimated at a staggering US$2.3bn,
representing 1% of all cancer-related costs.
Per patient, annual costs were highest in the
end-of-life phase (US$97,000), followed byinitial care (US$58,700) and continuing care
(US$4,000), highlighting the urgent need forrobust prevention efforts.105
In Europe, there are vast disparities in
the prevalence of cervical cancer and its
socioeconomic consequences. For instance,
the economic burden of cervical cancer issignificantly higher in Bulgaria as compared toother European Union (EU) Member States.
The direct annual costs of cervical cancer
to the Bulgarian health system amounts to€17.68m, mainly driven by drug acquisition,
administration costs and inpatient treatment.106
Investments in cervical cancer prevention,
including timely screening, early diagnosis,
and higher HPV-vaccination coverage rates,
could avert such costs that are relatively high in
Bulgaria, as well as in other Eastern European
countries, which have the highest share of thecervical cancer burden in Europe. In Sweden,
cervical precancerous and cancerous lesions are
responsible for most of the economic burden
posed by HPV-related cancers. A prevalencebased cost-of-illness study estimated thatthe total annual direct costs for cervicalcancer was €17.8m in 2006, in addition to€7.3m for precancerous cervical lesions.
Cervical precancerous and cancerous lesions
accounted for 67% of HPV-related outpatientcare (n=17,867) and 68% of HPV-related
inpatient care (n=1,948). Cervical cancer had
the highest indirect costs of all HPV-related
cancers, estimated at €40.6m, mainly due
to lost productivity, thus driving the Swedish
government to take concerted action towards
its elimination.107©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

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Prioritising the eliminationof cervical cancer
In 2020, the World Health Assembly adopted theglobal strategy for cervical cancer elimination,
which sets out a vision to meet key targets by
2030 in the pursuit of achieving cervical cancer
elimination within the century.5 The strategy,
developed by the World Health Organization(WHO), is the first of its kind because it declaredcervical cancer a public health problem andaddressed the health inequities between
different countries and within the dimension ofgender as the condition only affects women.
The WHO’s elimination goal is underpinnedby three targets (the “90-70-90” targets) to beachieved by 2030, in order to reduce the global
incidence of cervical cancer by 2% by 2030, by
42% by 2045, and eventually by 97% by 2120
when the cancer would be eliminated.8 Meeting
the goal of elimination would require countries
to reach and maintain an incidence rate of lessthan 4 per 100,000 women.

In August 2022, the WHO further publisheda roadmap to accelerate the elimination of
cervical cancer as a public health problem in theEuropean Region between 2022-2030, whichis specific to the opportunities and challenges
faced in this region.12 Political action in Europe
has demonstrated ambitions to accelerate
cervical cancer elimination even beyond the 9070-90 targets. In February 2021, the European
Commission published Europe’s Beating Cancer
Plan (EBCP), which includes goals and actions
to not only eliminate cervical cancer, but also
other cancers caused by HPV, through concerted
and coordinated efforts across the EU. The plan
was developed as a guide for EU Member States
to reach the United Nations’ (UN) Sustainable
Development Goals (SDGs) and the WHO’s
targets on non-communicable diseases. The
EBCP sets a goal of ensuring that cervicalscreening is offered to 90% of eligible womenacross Member States by 2025; it currently
varies from 25% to 80% between countries.
Furthermore, it recommends gender-neutral
vaccination, setting a target of at least 90% ofgirls vaccinated by 2030, while simultaneously
increasing vaccination amongst boys.13 The plan
includes the development of new guidelines
and quality assurance schemes for screening,
diagnosis, treatment, as well as follow-up andpalliative care for cervical cancer, including
accreditation and certification programmes.13
Investments are prioritised under multiple
structures, including the EU4Health programmeand other funding initiatives, to support Member
States’ efforts to broaden the implementation ofroutine vaccination.13©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

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Primary preventionof cervical cancer
through HPV-vaccination
Cervical cancer is highly preventable, as HPV
causes more than 95% of cervical cancer cases.
The virus, transmitted through sexual contact,
was first detected in biopsies of cervical cancers
in 1983 and became a therapeutic target.14
HPV-vaccination was first licensed by the US
Food and Drug Administration (FDA) in 2006,15
and clinical trials have showed that vaccination
is effective in preventing >90% of infections,precancerous lesions and precancers caused by
the HPV subtypes targeted.16,17,18
More recently, the roll-out of school-based
vaccination programmes has proved to be aneffective approach to achieving high coverage
rates. One such school-based HPV-vaccination
programme was rolled out in Sweden in2012, and an evaluation of the programmefound that it substantially reduced the riskof invasive cervical cancer at the populationlevel in the country, lowering the incidence ofthe disease by half among vaccinated females
in comparison to unvaccinated females.19
Similarly, another study in the United Kingdom
found that the cervical cancer risk was reducedby 87% among vaccinated females.20 These
trends were also seen in other HICs such as
Australia, which first launched its school-based

HPV-vaccination programme for girls in 2007,19
in tandem with a catch-up programme for older
girls and young women.15

WHO recommendations for
HPV-vaccination
The WHO recommends HPV-vaccination
targeted at girls aged 9-14 years, before they
become sexually active.21 HPV-infection in boys
is concomitantly reduced when coverage levels
for girls reach 80%.21
Vaccination of older girls, as well as young
women and boys, is recommended by the WHO
only “if this is feasible and affordable, and does
not divert resources from vaccination of the
primary target population or effective cervicalcancer screening programmes”.21
WHO’s roadmap for cervical cancer eliminationin Europe points out that routine vaccination ofboys will provide indirect protection to girls andwomen, contribute to lowering transmission,and prevent other HPV-related cancers inmen. Furthermore, it adds that gender-neutral
vaccination programmes may facilitate increased
acceptance of HPV-vaccination.12©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

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Secondary preventionof cervical cancer
through screening
For decades, screening using the Pap smear,
which involves a speculum examination of
the cervix along with the collection of cells forcytological examination to identify precancerous
lesions so they can be treated, has been themainstream approach against cervical cancer.

Pap smear-based screening programmes have
reduced cervical cancer mortality almost fivefold since the 1930s,22 but have their drawbacks– the testing is difficult to implement uniformly,
needs to be conducted by trained staff withlaboratory support, requires specialised©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Swedeninterventions for abnormal results, and only
picks up around half of abnormalities (ie, havea sensitivity of 50%).23 As a consequence, Pap
smear-based programmes have been difficult toimplement in LMICs, and where they have been,
coverage is generally low.8
Visual Inspection under Acetic acid (VIA)
screening programmes have been implemented
as an alternative in some LMICs. This uses 3%
to 5% dilute acetic acid to stain the cervix soabnormalities appear as white areas that canbe treated immediately using cryotherapy orthermal ablation. Two studies in India showedthat VIA was associated with a 30% to 35%
decrease in cervical cancer mortality. However,its sensitivity is modest, ranging between 16%
and 82%; it also has a high false positive rate
(low specificity) and is less effective in postmenopausal women.24
As 14 high-risk HPV subtypes are responsible
for almost all cervical cancer cases,8 HPV testing
using a nucleic acid amplification test (NAAT)(DNA or mRNA) on a cervical or vaginal sample
can be used to detect women who have or are
at risk of precancerous lesions.21 HPV testing ismore sensitive than cytology, meaning fewercases are likely to be missed, but has lower
specificity so more women without these lesions
will test positive. However, the use of a triage
test such as HPV genotyping for subtypes 16/18,
or cervical cytology for women who test positivefor HPV, improves specificity.25
Screening through HPV testing has beenshown to be better at reducing the incidenceof cervical cancer than conventional cytology.
Comparative trials in Europe suggest that HPV
testing gives 60-70% greater protection against
invasive cancer than cytology.26 In particular,
the effectiveness of cytology in detecting CIN2
lesions falls after HPV-vaccination whereas HPV

12testing is more accurate.27 Use of HPV testingfor screening has also been shown to better
reduce mortality due to cervical cancer thancytology or VIA.28
In November 2022, the Council of European
Union Testing recommended HPV testing using
clinically validated assays every five years or soas the preferred screening method for women
aged 30 to 65 years in Member States, with ages
and intervals adapted to individual risk. It also
recommended that Member States consider
offering self-sampling kits to non-responders toscreening invitations.29

WHO recommendations forscreening
The WHO recommends HPV testing using
validated HPV DNA NAAT as the preferred
method for cervical cancer screening. The HPVscreening test may be used with or without
triage (a second test such as genotyping,cytology, colposcopy or VIA) before proceeding
to treatment in HIV-negative patients. However,triage is recommended routinely before
treatment in HIV-positive patients.
Testing may be based on cervical samples
collected by health providers or vaginal samples
collected by women themselves;21 providing
women with the option of self-sampling
improves acceptability and access to services.8
Women aged 30-49 years should be prioritisedfor screening, which should be performed every
5-10 years; women aged 50-65 years should also
be prioritised if they have never been screened
before and if resources allow.30 Screening
should start earlier, at age 25 years, and be
performed more frequently (every 3-5 years)
for women with HIV or those who are otherwise
immunocompromised.30©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

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Treatmentof cervical cancer

There is no treatment for HPV infection, but
precancerous lesions, identified via screening,can be treated with thermal ablation or
cryotherapy to destroy the abnormal tissue.
Where these methods are inappropriate,
precancerous lesions can be surgically excised
to prevent progression to invasive carcinoma.
Without screening, women are unaware of suchlesions due to a lack of symptoms.
A diagnosis of invasive cancer must be
confirmed by cervical visualisation using
colposcopy and a biopsy. Clinical features, plus
pathological findings and/or imaging, such as,computed (axial) tomography (CT), magnetic
resonance imaging (MRI), positron emission

tomography (PET), may also be used, where
resources allow, to provide information on
tumour size, status and spread.31
Early-stage disease is treated with surgery orradiotherapy, and fertility preserving surgery
may be offered to some patients, with hormone
replacement therapy (HRT) considered for
women aged under 50 years who have lost
ovarian function. Locally advanced disease
is treated with combined chemotherapy andradiation, while advanced disease that has
spread beyond the cervix is typically treated witheither combined chemotherapy and radiation or
chemotherapy alone. Where there is extensive
local or distant metastatic disease, patientsshould be offered palliative therapy, with the best
supportive care and symptom control.

WHO recommendations
for treatment
Until HPV-vaccination programmes are
implemented universally, and all women havethe opportunity to benefit from vaccination,some women previously infected with HPV willcontinue to be at risk of cervical cancer. As aresult, WHO emphasises that improving accessto vaccination, screening and the treatmentof precancerous lesions must remain a toppriority of the global strategy to eliminate
cervical cancer.8©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

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Progress towards
elimination of cervicalcancer and the WHO targets
Global vaccination coverage remains extremely
low with only 13% of eligible girls vaccinatedworldwide, far below the WHO’s target of 90%.
As of July 2022, 117 countries, home to onethird of the world’s population of girls aged 9-14
years, have HPV-vaccination programmes.112
However, there are wide disparities in thevaccination coverage. The proportion of HPVattributable cancers is highest in LMICs andthese countries are the least likely to have
implemented HPV-vaccination programmes.34
While 85% of HICs had included HPV in theirnational immunisation schedule as of 2020,
less than 25% of low-income, less than 30%
of lower middle-income, and less than 60%
of upper middle-income countries had these

programmes.8 As of June 2020, the Americas andEurope were the regions where most countries
had introduced HPV-vaccination – 85% and 77%
respectively.35 At that point, GAVI (the Global
Alliance for Vaccines and Immunization) support
for vaccination had been extended to 19 LMICs(35% of LMICs).35
By 2019, 88% of HICs had introduced HPVvaccination for girls with half of them (44%)
having a gender-neutral vaccination programme.
In contrast, only 40% of LMICs had introduced
HPV-vaccination for girls and only 5% had
gender-neutral vaccination programmes.35
Overall, only 42 countries offer vaccination toboys as of July 2022.33

Figure 2: A comparison of HPV-vaccination programmes in HICs and LMICs
HPV vaccination programs in HICs in 2019

HPV vaccination programs in LMICs in 2019

12%

44%

No vaccination program

5%

44%

Girls only vaccination program

35%

60%

Gender neutral vaccination program©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

To this point, Daniel Kelly, Co-Chair of European
Cancer Organisation HPV Action Network, saysthat “There’s been a lot of pushback on boys
because of the cost issue, but also some people
are not persuaded that the boys are at risk.
However, unvaccinated boys put themselves andothers at risk of a range of cancers. To me it justmakes sense to vaccinate both groups. When
you consider the human costs of this disease,and [the fact] that it can be prevented, it stillamazes me that governments are still not doingit [vaccinating both girls and boys].”
In 2019, the majority of programmes (59%)
delivered HPV-vaccination through schools
alone or in a combination of school andfacility-based delivery, and in LMICs almost all
programmes were school-based or mixed (90%).
School-based delivery strategies have beenshown to achieve higher coverage than facilitybased programmes.35
Organised programmes that take the vaccination
directly to the target population, such as
programmes delivered through schools, areable to achieve higher coverage levels due tobetter access, in comparison to those that relyon opportunistic delivery mechanisms. Publicly
funded school-based programmes are the most15

effective because they take away cost barriers.36
Parents often report cost as a barrier to providing
their child with HPV-vaccination, along withinsufficient information and safety concerns.37
In addition to expanding access to vaccination,
publicly funded programmes also increasevaccination uptake indirectly by signalling
government and health system endorsement.36
On the other hand, opportunistic HPVvaccination can help boost coverage among girls
who missed or did not complete vaccination
through the school programme. It can also be
used as a way of reaching older groups who were
not offered HPV-vaccination at school because it
was not available.38
Coverage for HPV-vaccination fell during theCovid-19 pandemic, particularly in LMICs,
but also in some European countries,39 due
to school closures, delayed vaccination anddifficulties securing vaccination doses. Between
2019 and 2021, the number of girls globally
who received a first dose of HPV-vaccination
dropped from 20% to 15% – which means 3.5m
more girls missed out.33,40 The number of girls
who did not receive any doses increased in mostregions of the world over that period, apartfrom the EU.33

Figure 3: global HPV-vaccination coverage33
HPV vaccination coverage, first dose, females
HPV vaccination coverage, first dose, males

HPV vaccination coverage, last dose, females
HPV vaccination coverage, last dose, males

25%

Coverage

20%

15%

15%

12%

10%

Female

6%

5%

4%

Male
0%
2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

An analysis of the progress towards the WHO’s
target for 70% cervical screening coverageby 2030, based on data collected for 202
countries until February 2021, identified
recommendations for screening in 139
countries, covering 88% of HICs and 60% of
LMICs.41 Among these 139 countries, a majority,
109 countries (78%), recommended cytologybased screening, while 48 (35%) recommended
primary HPV testing for screening. VIA screening
was the most recommended test in resourcelimited settings. At least 21 of the 48 countries
recommending HPV testing were transitioning
from cytology to the HPV test.41
The 5-year coverage rate for screening of
women between 35 and 49 years of age was lessthan the WHO target of 70% in 32% of HICs,
72% of upper middle-income countries, 94%
of LMICs and 100% of low-income countries.41
Globally, two-thirds of women aged between
20 and 70 years – a total of 1.6bn women – areestimated to have never been screened for
cervical cancer.41
Concurrent chemoradiotherapy followed bybrachytherapy (internal radiotherapy) is thetreatment recommended for locally advanced
cervical cancer, but provision is variable both

16

across HICs and LMICs. Studies show thatup to 50% of patients in HICs such as France,
Australia and Japan did not receive treatmentthat conformed to guidelines for locally advanced
cervical cancer, and about 25% did not receive
brachytherapy. The presence of significant
comorbidities was the main reason cited for
non-adherence to treatment guidelines. In
addition, under-utilisation of brachytherapy
is attributed to inadequate training, time,and logistical challenges, as well as limitations
in reimbursement.41 There is an imminent
need to improve access to radiotherapy andbrachytherapy, increase the number of trained
radiation oncologists to administer treatment,
develop guidelines for management of the elderlywith comorbidities, and have quality control
measures in place to meet the WHO treatment
targets for treatment of cervical cancer.
Progress towards meeting WHO’s 90-70-90
targets varies markedly between countries.
The next section examines how four countries,
Sweden, Portugal, Rwanda and Australia,
despite their distinct differences (eg, intheir population, resources, health systems),
are paving the way towards cervical cancer
elimination, and provides lessons for othercountries who are in pursuit of the same goal.

©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

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The first country on theverge of eliminating cervicalcancer: Sweden
For most of the world, reaching WHO’s 90-7090 targets by 2030 will be a stretch, but Sweden
has surpassed expectations and is striving tobecome the first country to eliminate cervicalcancer before 2030.42“We’ve advocated for Sweden to become thefirst country to eliminate cervical cancer,” says
Ulrika Årehed Kågström, Secretary General ofCancerfonden (Swedish Cancer Society). “We’ve
worked with our politicians and said that what
we really need to do is catch-up vaccination for
women who missed out because they were too
old for the school-based programme, and help
ensure high participation in screening,” explainsMs Kågström.
With regards to the WHO’s 90-70-90 targets, thecountry is well on track. As of 2021, 90% of girls
had received a single dose of HPV-vaccination
by age 15, and 84% the full two doses.43,44
Nationally, cervical screening is above 70%,
with an estimated 78.5% coverage for women
aged 23-70 years, in 2021. Like many othercountries, Sweden also faces the challenge ofregional inequities, which has led to disparitiesin screening coverage. The highest screening
coverage is seen in Värmland (88.2%) in the
Uppsala-Örebro region, whereas the lowest
screening coverage rates were seen in Gotland(68.8%), and Stockholm (70.2%), both of which
are in the Stockholm region.45 Furthermore, for
2,212 women diagnosed with cervical cancer,
a population-based study, conducted between
2011 and 2015, found that only 6% of patients
did not receive treatment.46

As a result of Sweden’s efforts towards
elimination, the incidence of cervical cancer in
Sweden decreased from 24 per 100,000 womenin 1965 to 8 per 100,000 women in 2011. While
a 20% increase in incidence was noted between
2014 and 2015, the rise was mainly seen inyoung women who had attended screening andpresented with early-stage disease.47
The latest data (2021) indicates the incidence
rate is at 10.4 per 100,000 women, which isinching close to the 4 per 100,000 women
elimination target.48 In 2021, 533 new casesof cervical cancer were diagnosed in Sweden,
accounting for a mere 1.8% of all cancers; in thesame year, there were 149 deaths from cervicalcancer, representing 1.3% of all cancer deaths
in women.49 The number of women living withcervical cancer between 2015 and 2020 was
estimated at 2,081.50
Modelling studies have concluded that primaryprevention of cervical cancer through HPVvaccination for girls or with gender-neutral
programmes, based on 80% uptake and withappropriate funding mechanisms in place, iscost-effective in Sweden.51“We usually tend to talk about the humanitarianconsequences of cancer,” says Ms Kågström, “butthere is also productivity loss, especially since
this is a type of cancer that often affects womenwhen they are most productive, in their prime.
Costs for society are very expensive treatments
and loss of productivity compared to the very,
very small costs for a vaccination programme.”©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

18“We usually tend to talk about the humanitarianconsequences of cancer,” says Ms Kågström, “but there
is also productivity loss, especially since this is a typeof cancer that often affects women when they are mostproductive, in their prime. Costs for society are very
expensive treatments and loss of productivity comparedto the very, very small costs for a vaccination programme.”
Ulrika Årehed Kågström, Secretary General, Cancerfonden (Swedish Cancer Society), Sweden

Timeline of vaccination and screening initiatives Sweden
A school-based HPV-vaccination programme
introduced for girls aged 10-12

VACCINATION19

HPV-vaccination based on a three-doseschedule was approved for use• 2006• 2007

A free catch-up HPV-vaccination programme
launched for girls and women aged 13-18
years with the vaccination available fromprimary care

• 2012• 2015

HPV-vaccination subsidised
for girls aged 13-17 years

SCREENING52,53,54,55

Organised cytology-based
screening available nationwide• 1967• 1973Sweden introduces cytology-based
screening, and the roll-out ofnational programme begins• 2015

Boys in the fifth grade offered HPV-vaccination
for free via school health services• 2020

A two-dose vaccination schedule isintroduced to girls aged 9-14 years

Sweden implements new
guidelines recommending primary
HPV testing for women aged 30
years and older at 3-year intervals,
with extension to 7-year intervals
for women aged 50-64 years.
Screening is also made free

• 2017

Sweden recommends transition
from cytology to HPV testing• 2020• 2022Catch-up campaign to provide
HPV-vaccination for free towomen aged 23-29 years

Self-sampling kits for HPV testing sent to all
women eligible for screening in the Stockholm
region, including those aged 23-29 years• 2021• 2022

Cervical screening halted due to
Covid-19 pandemic

Self sampling offered to all womenin Sweden

Government allows self-samplingfor cervical screening as an
emergency measure

Screening recommended every 5
years for women aged 23-49 years,
and every 7 years for women aged
50-70 years©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

From Sweden’s late start to its
accelerated path to cervical cancer
elimination
Despite the country’s significant public healthchallenges of growing demand for healthcare
and finite health budgets, Sweden’s unswerving
commitment to eliminating cervical cancer has
been pivotal to its success. This success does
not stem solely from its long-standing national
cervical cancer screening programme or its earlyroll-out of the HPV school-based vaccination
programme; many countries were ahead of
Sweden to this respect, but a concerted national
effort on multiple fronts has ultimately pushed
Sweden to the front of the race to elimination.
“I think that we may have been a little bit latein starting the basic vaccination programmes
targeting girls and boys in school, and the catchup programme for girls to 18,” says Professor
Joakim Dillner, Head of Unit at the Karolinska
University Hospital, Center for Cervical
Cancer Elimination and director of Research& Development (FoU-chef) at the Medical
Diagnostics Karolinska. “Many other countries
were faster in implementing those. However,when we actually started, population uptake
was quite high. Uptake of the vaccination in girls
in Sweden is 90%, which is among the highest
globally – not the highest – and the uptakeof vaccination among the boys is over 85%.”
Although Sweden’s “tradition of organisationand equity and focus on prevention” has helped
achieve these high uptake levels, he says, when
there is an effective vaccination to prevent
cancer, “it’s very easy to explain to people why
they should take it – it’s obvious.”
1. Organised vaccination and screening
programmes
While Sweden was later than many to begin
tackling cervical cancer, it has since madeup for lost time through its use of “organised
interventions”. Prof Dillner says, “I think this iswhat we call ‘organisation’. The concept is very
well described regarding screening. Organised
screening means that one starts by identifying
the population to be screened, and then invites

19

everyone to screening at a given time and place.
It is well documented that this approach ismore effective than trying to have mass media
campaigns asking people to book a time becausesome people will see this information and somewill not, and some people will understand theinformation and some will not. But if everyone
is invited, it tends to be that a much larger
population comes.”
The Nordic countries pioneered this systemof “organised interventions” in the 1960s, andit has gradually spread to other countries. In
2021, Sweden surpassed Iceland as the country
with the highest cervical cancer screening
attendance. Overall, screening attendance isaround 85% in Sweden, and, more notably, as
high as 92% in women aged 23 to 26 years.
Sweden also offers HPV-vaccination to school
children starting as early as the fifth grade, freeof charge through the school health services(although parental consent is required).56“The vaccination programme is also ‘organised’,
which means all girls are offered a vaccination,”says Prof Dillner. “Of course, they can say no, butthere shouldn’t be any girl in the country who is
not offered a vaccination when we have on-site
vaccination at schools.”
Sweden also pioneered a catch-up campaign
in 2012 to ensure that girls aged 12 to 18 years
who were too old to be eligible for the massvaccination programmes offered throughschools were not missed out of the HPVvaccination drive. This catch-up campaign
achieved roughly two-thirds of the coverageof the “organised” school campaign – just shyof 60% – because girls had to seek vaccination
within primary care. Vaccination was reimbursed
for females up to 26 years of age.113
2. Advocacy and political buy-in
Sweden may be at the forefront of eliminating
cervical cancer now, but the country has had to
overcome several hurdles to get here, including,for example, the fact that for many years cervicalscreening was not free for all women.57 After a2012 EU survey of countries’ policies on cervical©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

screening highlighted that Sweden was only
one of four countries in Europe charging for
cervical screening, some politicians were upset
and started work to change that, Dillner says.
In 2012, about 5% of women in Sweden were
estimated to have never attended a Pap smearbased screening test.58 The Swedish parliament
finally made cervical screening free for all
eligible women in 2017.
A number of patient advocacy groups have
had an important role in raising awarenessof cervical cancer and its elimination with
policymakers and pushing the government
to implement changes, such as the Network
Against Gynaecological Cancer. Its Chair,
Barbro Sjölander, has been vocal about thispublic health issue and driving cervical cancer
campaigns for almost 10 years. “I had a friend
who died of cervical cancer, I didn’t know muchabout it so that is why I became interested
in it,” she explains. The Network Against
Gynaecological Cancer has been actively
working for HPV-vaccination of girls since2007, and has also advocated for free cervicalscreening and the vaccination of boys, and most20

recently collaborated with Prof Dillner to push
politicians for a catch-up vaccination campaign
to accelerate the elimination of cervicalcancer. “Over the years, we [have] built a very
good reputation. We are well known among
politicians and we are well known amongpeople providing care,” says Ms. Sjölander.
Other patient organisations involved in increasingawareness and working to eliminate cervicalcancer include GCF Viola, which supports womenwith gynaecological cancers and their families,
as well as acts as an advocacy group to raiseawareness of the disease among policymakers.59
3. A long track record of evidence-based
decision-making
When Pap smear-based screening wasintroduced in Sweden beginning in the
1960s, for a number of years there was abelief that it could not really fail, explains Dr
Karin Sundström, Principal Researcher andepidemiologist at the Karolinska Institutet and
Karolinska University Hospital. “But in the 1970s,
the community started noticing that there may
be some issues with false negatives….and that’s©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

the start of Swedish cervical cancer screening
research. People started publishing on this andtrying to systematically see what could be done
to improve it.”Sweden has several attributes that enablerobust population-based studies – a publiclyfunded health system accessible to the entire
population including the vulnerable and hard-toreach populations, as well as a comprehensive
repository of population healthcare data ina variety of registries. “We have population
acceptance for traceability through national
registers,” says Dr Sundström. “The founding
idea is that if as a citizen you use publicly-funded
healthcare, you should also contribute backto its improvement with your data. During the
1980s, clinicians and researchers realised that
our national cancer registry, which was originallyprimarily built for cancer monitoring, could also
be used for active research.”
The principle upon which these cancer
registries are built means that researchers
conducting population-based studies do notnecessarily have to ask for permission to usepatient data. “We have what we would term
‘broad population acceptance’ for this typeof research, and we can use something called‘broad informed consent’ whereby a woman canconsent to several studies. If the research canbe demonstrated to be for the common good,
we can use a principle called ‘opt out’.” explains
Dr Sundström. “‘Opt out’ means that when awoman gets invited to cervical screening, she
is informed that unless she actively expresses
her wish for them not to, her data and samples
might be used for research if approved by the
Ethical Review Authority.” Dr Sundström adds
that it is rare for women to opt out and soresults from such studies typically carry very
high validity.
Researchers in Sweden have used population
studies based on data from the registries toprovide evidence to policymakers for the
introduction of specific interventions, as well as toanalyse the impact of these policies. “One of my21

favourite sayings is that if there is controversial
debate or uncertainty, the data is not clear
enough,” says Prof Dillner. “If the data is reallyclear then it’s obvious what to do. I find it much
more useful to try to obtain better data than toengage in lobbying or something like that.”
4. Comprehensive data in registries
Comprehensive registries are a major advantage
in Sweden, other Nordic states, the Netherlands,
and the UK, enabling them to conduct widescale population studies and ‘organised’ followup care for their populations.
Sweden has registries for HPV-vaccination,screening and cancer. A recent study ranked
Sweden’s electronic vaccination registry fifthamongst the EU Member States and the UK,
based on a number of factors including its
level of development, extent and timelinessof information, and integration with otherregistries and the national health system.60
The National Screening Registry captures
100% of the cervical cancer screening data. All
screening invitations and laboratory results arelinked to this registry using the unique personal
ID that is assigned to an individual at birth/
naturalisation. Data from the registry is collated
at the regional level, and is made available
to policymakers to act swiftly and improvescreening efforts.61“We started building the National Screening
Registry in approximately 1995, and it took
almost 10 years because there were a lot of
issues, such as counties using different IT systems
and coding results being different because there
was no standardised system,” says Prof Dillner.
“We got it to work for the whole country in
2005, and it is immensely useful.”63 It is therefore
possible to examine outcomes and other data
for all women in Sweden, rather than just a small
subset or random sample.
Prof Dillner is expanding the registry to also
include biospecimens. This enables obtaining
data for both current and candidate screening©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

tests to quantify how many deaths or otheradverse outcomes could have been prevented
if the screening test under assessment had
been available.
Healthcare professionals are also required toreport cases of cancers, suspect cases of cancer,
and certain reportable benign and precancerous
conditions to the Cancer Register at the
National Board of Health and Welfare, which
is a record of the incidence of new cancers andtrends over time.62
Sweden also has a national care programme
for cervical cancer prevention that provides
recommendations and guidelines forinvestigation, diagnosis, treatment, nursing
support, rehabilitation, and palliative carefor patients, and data for a number of quality
indicators are collected.64,55 The National Quality
Registry for Gynaecological Oncology collects
data on the care pathway for specific cancers,
including waiting times for management,
whether a central assessment is performed, andthe outcomes of treatment.65,55
5. Self-sampling for HPV testing – aninnovative outcome of the pandemic
In 2020, as a result of the Covid-19 pandemic,
Sweden’s pursuit of cervical cancer elimination
came to a halt; similar to the rest of theworld, the country had to divert all its healthresources towards containing the pandemic.
HPV-vaccination and cervical cancer screening
programmes, which normally took place
on-site and in-person ceased. However, thecountry implemented the innovative solutionof using self-sampling HPV test kits to continue
screening, thereby adapting to the pandemic.
Self-sampling had been recommended in
Sweden as a mechanism for reaching nonattenders – those too far away, or too busy toattend a clinic - for almost ten years, but had
not been used as a primary screening tool, says
Prof Dillner. In 2021 self-sampling HPV kits weresent to all women including those between 23

22

and 29 years of age who had previously beenoffered a Pap smear. An assessment of cervicalcancer screening in the Stockholm region, where
330,000 kits were sent out, showed coverageincreased by 5.3% within one year. “Attendance
was identical for women who regularly attended
screening appointments, but was much higher
among those who did not attend regularly,” says
Prof Dillner, “so the net result was a big increase.”
Other studies have also shown that selfsampling HPV tests have comparable efficacy
to clinician sampling and better acceptability
among patients.67,68
Based on the positive evaluation of selfsampling in Stockholm, the Swedish government
introduced regulations in 2022 to allow for selfsampling to be routinely used in the screening ofcervical cancer in non-emergency situations. The
decision followed a study which found that HPV
self-sampling tests achieved more screening
coverage (34.1%) than pap smear-based
screening; the study included a random sample
of 10,614 women who had not undergone Pap
smear-based cervical screening for at least six
years, who received a phone call from a midwife
offering the option of a Pap smear or HPV selfsampling test.69
Sweden’s concerted efforts to find the mosteffective approach to eliminating cervical cancer
are continually evolving based on the evidence.
Another population-based study is currently
underway in the country to evaluate whether
concurrent HPV-vaccination and cervicalscreening can result in the speedy elimination of
cervical cancer.70 Such studies have the potential
to not only identify the best and fastest courseof action, but also help to generate support,
through action and investment, among thepolitical class.
6. Catch-up for young women
The cervical cancer community, which includes
patients and patient advocates, researchers,
bio-pharmaceutical companies, and healthcare
professionals, has been pivotal to generating©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

23“If you are going to have an effect on the spread of infection,very high population coverage is needed and I don’t think thatcan be accomplished without an organised programme thatprovides free vaccination.”
Professor Joakim Dillner, Head of Unit at the Karolinska University Hospital, Center for Cervical Cancer Elimination and Directorof Research & Development (FoU-chef) at Medical Diagnostics Karolinska, Sweden

political momentum for the extended organised
efforts that ensure high HPV-vaccination
coverage across the eligible population, and in
driving the government to invest in catch-up
campaigns for young females who missed out
on the “organised” school-based vaccination
programme. “We wanted them to take advantageof the pandemic and offer HPV-vaccination to
women in that [eligible] age group when they got
their Covid-19 vaccination,” says Ms Kågström;
Stockholm and Gotland began offering thesecatch-up vaccination programmes first “Wethought it was a really positive initiative, andwe tried to encourage other counties to do thesame, but then the pandemic faded out [so wewere unable to adopt this approach].”Despite Sweden having a decentralised
healthcare system across its 21 counties, theapproach to eliminating cervical cancer required
coordinated, high-level decision-making at
the national level. “We calculated that the costof a national catch-up vaccination campaign
wouldn’t be that big, but it’s really challenging totake a decision like that on a national-level since
the counties are autonomous, but in the end,
parliament took that decision,” says Ms Kågström.
As part of that unusual decision, the Swedish
government allocated SKr 25m (or €2.1m) per
year for six years for a catch-up campaign toprovide HPV-vaccination and concomitant HPVscreening for free to women aged 23 to 29 years(born between 1994 and 1999), says Prof Dillner.
Around 85% of this allocation will be used to buy
the vaccination, as previously women in this group
could only access the vaccination if they paid forit themselves. “If you are going to have an effecton the spread of infection, very high population
coverage is needed and I don’t think that can beaccomplished without an organised programmethat provides free vaccination,” he says.
Sweden’s national vaccination programme is run
on the promise of generating vast amounts ofreal-world data. In exchange for free vaccinationsand HPV tests, counties provide healthcare staff
to administer the vaccinations, and have agreed tofollow the same standards and processes that will
enable the outcomes to be evaluated nationally.
All girls given vaccination through the programme
will also be tested to assess the prevalence of
HPV16 and HPV18 in this age group.
Cancerfonden is helping to communicate theimportance of vaccination to young womenin the target group using influencers on social
media, particularly Snapchat and Instagram,says Ms Kågström. “The regions aren’t goodat communicating with this age group (young
women), and it’s really complicated since they
are not all implementing it at the same time. It’sdifficult trying to reach this target group. Even
if they are informed, they are not ill, they havebusy lives, and they have plenty of things to do,so it’s really not on their radar.”©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

7. Understanding barriers to vaccinationand screening
To address the barriers to vaccination andscreening in the country, Sweden has dedicatedresearch to identifying and understanding
these hurdles. A 2022 survey of 2,000 Swedish
women found that one-third reported negative
attitudes towards HPV-vaccination expressing
some degree of vaccination hesitancy. Hesitancy
was correlated with low education, low income,lack of access to reliable information on
vaccination, and a general lack of confidence inhealthcare institutions.71
Another nationwide registry-based study
conducted between 2013 and 2020, mapped
the prevalence of HPV non-vaccination against
several variables, including parental placeof birth, education level, income, and placeof residence (urban/rural). Non-vaccination
was more common among people with low
education, low income, or of migrant status.72
Socioeconomic factors, including educationlevels, employment status, location of residence
and immigrant status have also been linked toother disparities.73
When it comes to screening, there are four main
determinants of non-attendance, according
to Prof Dillner, with the most important being
the region where people live (each region has adifferent screening programme). “We have notfound out exactly what the important differenceis between the regional programmes, but weknow that some screening programmes are very
actively communicating with the population,and have a lot of convenient times to attend.”
Other factors are rural domicile, ethnicity andhousehold income.

Looking ahead to a cervicalcancer-free Sweden
While Sweden has made impressive strides
towards the swift and robust eliminationof cervical cancer, there are still some
improvements that can be made in the areas ofcervical cancer prevention and treatment.
A population-based study of 2,212 patients with24

a cervical cancer diagnosis between 2011 and2015 found that only around 6% of patients
miss out on treatment;46 however, the study also
showed that, despite the exclusion of rarer andmore aggressive cancer subtypes, the estimated
5-year relative survival for patients studied
was lower than expected at 71%. While there
was fairly high adherence to evidence-based
treatment guidelines and excellent outcomesfor early-stage patients treated with surgery, the5-year survival for advanced disease was poorer
than expected, suggesting that there is scope to
improve cervical cancer treatment in Sweden.46
The study also revealed that 14% of patientswith early-stage disease received postoperative
adjuvant radiation, which is known to increasemorbidity. The researchers concluded thatuse of postoperative radiation in early-stage
disease needed to be reduced and treatment foradvanced disease improved.46
Lack of adequate infrastructure and healthcare
staff shortages may explain the poorer
outcomes for those with advanced disease. For
instance, the use of radiotherapy in Sweden
lags behind other Nordic countries, with thecountry facing significant shortages of bothradiation oncologists and trained nurses.
One study identified four clinics in Sweden
where at least one radiotherapy machine waseither partly or fully closed due to the lackof an operator; furthermore, less equipment
is available for radiotherapy in Sweden ascompared to other Nordic countries with newtechnologies spreading at a slower rate. The
governments of Denmark and Norway are also
more involved in financing radiotherapy than
the government of Sweden.74
Importantly, overall, not all women in Sweden
with cervical abnormalities detected during
screening obtain treatment. “It’s not a systemic
issue, because [although] in some regions we havezero women with a screening abnormality not
being treated, if you look at the WHO goal that atleast 90% of the women who have abnormalities
should be treated, we are [still] far above that at
95 or 96% [nationally]” says Prof Dillner.

©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

While survival rates for cancer were very highand patients were generally satisfied withtreatment in Sweden as compared to several
countries, it was generally recognised that
the Swedish health care system could reduce
waiting times and improve care coordination.
In 2015, the Swedish government, therefore,
initiated a national reform programme
to standardise the patient care pathway
and expedite the treatment of cancer. A
Standardised Care Pathway (SCP) is a timebound clinical guideline covering the patient’s
journey from presentation through diagnosis
and referral to treatment.75,76 The Swedish
National Board of Health and Welfare (NBHW)
monitors and evaluates the SCPs and submit
annual reports to the Ministry of Health.75
The programme has demonstrably improved
waiting times and patient satisfaction, but otherchallenges remain, such as General Practitioners(GPs) misdiagnosing cancer patients who
present with multiple comorbidities andnonspecific symptoms, and ethical concerns
about side-lining other patients.77

Addressing inequities in screening
and vaccination coverage
The road to cervical cancer elimination is more
viable when the entire eligible population is
included within the national efforts. Parents who
do not return the consent form for their children
to receive HPV-vaccination at school should, if
possible, be followed up, says Dr Sundström. “Ifthey say no, they have made an active decision,
which is of course to be respected, but there
are some parents who perhaps don’t fill out
the form; and for reasons of equity, ideally theyshould be contacted in order for this cancer
prevention opportunity not to be missed.”Engaging women not attending screening isharder because they have to be found. Womenare sent an invitation emphasising that screening
is free and offered, in some places, as a selfsampling kit for HPV, and in others, as a midwifebased appointment, explains Dr Sundström.
“We say we’ve reserved a time for you, you don’t
need to cancel if you don’t come, but this iswhen you should come if you want to come. We
think it makes it easy for the woman if she knows

25

that if she comes at that time, she will definitely
receive an examination.” This is especially key
for women who have been identified as beingat higher risk for cervical cancer to ensure thatthey are actively traced and followed up with for
examinations, as well as treatment, if necessary.
In 2020, 93,000 appointments for screening
were cancelled because of the pandemic,
says Prof Dillner. The switch to self-sampling
provided screening to all of these womenand also increased participation among nonattending women – for example those fromlow socioeconomic groups, or with disabilities,
mental health issues, busy work lives or previous
poor experience of screening.
The screening organisation that Dr Sundström
works with checks with the tax registry
regularly to identify newly registered immigrant
women in order to not overlook any recent
new inhabitants. They are sent the same letteras that sent to all Swedish women in the agegroup eligible for screening, which emphasises
the benefits of screening and the fact that it
is free. These letters are issued in Swedish but
information on screening is available online andin print in several languages.
A new initiative by Cancerfonden (the Swedish
Cancer Society) is now also providing new
immigrants learning Swedish with informationon the Swedish health services, says MsKågström. Immigrant students, for example,
are given information about HPV-vaccination,
cervical screening and other services likemammography so that they understandwhat the invitations are for, the benefits ofparticipating and that the services are free. In
addition, doulas that have the same cultural
background and mother tongue as foreign-born
women have been engaged to spread awarenessof screening, and this has been shown to
improve participation.78
Overall, Sweden has made tremendous
progress in its goal to become the first country
to eliminate cervical cancer, and its experience
may help other countries to emulate its efforts
to improve the delivery and uptake of HPVvaccination, cervical cancer screening, andcancer treatment.
©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

26

Implementing a national HPV
immunisation programme
in a low-income country: Rwanda
Rwanda, defined as a low-income country,
became the first African country to implement anational HPV immunisation programme for girls
in 2011. On the path to becoming one of thefirst countries to eliminate cervical cancer, thecountry is an admirable example of what can beachieved with strong political will and multisectoral partnerships, even in an environment
with limited resources.
Despite the country’s remarkable progress
towards cervical cancer elimination, Rwanda
has faced its share of challenges. According
to Dr Marc Hagenimana, Ag. Director ofCancer Diseases Unit, Rwanda Biomedical
Centre, Ministry of Health, “the first challenge
is limited funding to scale up the programme
especially including capacity building of healthcare providers to deliver those services”.
Dr Hagenimana explains how there is lack ofawareness and skills to manage cervical cancer
in the Rwandan health workforce and thisincludes insufficient gynae-oncologist specilaist.
However, Rwanda has been quick to address
such challenges through the introduction of a

Gynae-oncologist fellowship programme in the
country to strengthen the overall managementof cervical cancer.
The vaccination programme was initially
supported by a donation from a vaccination
manufacturer, and since 2015, vaccination
have been procured with support from GAVI,
the Vaccine Alliance.79 Girls in the sixth grade,rather than a particular age group, are targetedbecause some girls in rural settings do notknow their age.80 Rwanda has a high rate ofschool enrolment, which has allowed a large
proportion of girls to be reached at school withthe vaccination delivered on school premises
on dedicated “Health Days” that occur threetimes a year. Girls not enrolled in schools, orabsent on vaccination days, are traced by ateam of community workers so that they canbe vaccinated at local health centres.80 Two“catch-up” vaccination rounds in the third yearof secondary school were held in 2011 to ensurethat all girls younger than 15 years were offered
the vaccination.80©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden“Awareness and education campaigns havebeen integrated into the package of community
health workers; they [community health workers]
have been trained to provide education in thecommunity about cervical cancer prevention
and advise them [eligible females] to go to healthfacilities to receive those services”, explains
Dr Hagenimana. Other approaches to bolster
awareness has been through the provision ofawareness and education campaigns provided
via mass media outlets including community
radio, articles, social media and mobile network
operators, says Dr Hagenimana.
Between 2011 and 2018, 1,156,863 girls
received at least their first vaccination,
representing 98% of the target population.81
As schools were closed during the Covid-19
pandemic, some girls missed their first
vaccination and coverage decreased from
97% in 2019 to 89% in 2020,82 so a catch-up
campaign was implemented in 2022 to lift
coverage above 90% once again.83

27

Before the roll-out of the vaccination, theRwandan ministry of health assembled
a technical working group comprising
healthcare professionals, representatives fromdevelopment agencies, private industry, andthe community to plan the process. Microplanning committees were set up to manage
specific aspects of the roll-out, including supply
chain, logistics and data management. Thiswas followed by broader education of thecommunity through the media, collaboration
with religious institutions, and speeches
by local and national leaders. Frontline
healthcare professionals and teachers also
received education and training regarding thevaccination process, benefits and risks.84
The success of the vaccination programme has
been the direct result of partnerships between
the public, the private sector and civil society
to organise and deliver the school-based
programme,81 rigorous monitoring of vaccination
coverage, and awareness campaigns led bycommunity influencers.

©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

28

Improving access to high quality
cancer treatment: Australia
Australia launched one of the world’s first
fully funded, school-based HPV-vaccination
programmes for girls in 2007, has an organised
cervical cancer screening programme, has madehuge financial investments in tackling cervicalcancer, and supported the development of a
National Cervical Cancer Elimination Strategy.
It is therefore also well-placed to achieve theelimination of the disease in the near future.85
In 2013, the organised vaccination programme
for girls aged 12 to 13 years old was expanded
to include boys, and by 2020, 87% of girls and
85% of boys younger than 15 years had received
their first vaccination; high rates of vaccination
coverage, including gender-neutral vaccination,
will only improve Australia’s efforts directed at
cervical cancer elimination.86
Since 2017, Australia’s organised cervicalcancer screening programme uses primary
HPV testing every five years for women aged
25 to 69 years, with a final test for women aged
70 to 74 years. However, between 2018 and
2021, only 62% of women aged 25 to 74 years
underwent HPV testing. Self-sampling for HPV
testing has been provided as an option for all
women since July 2022, and is expected to help
improve screening rates, particularly among
hard-to-reach populations, such as indigenous
women and women who belong to ethnic
minorities, have experienced sexual violence,are post-menopausal, identify as LGBTQ+,
have a disability, or have previously had poor
experiences of cervical screening.87
In addition to gaps in screening, referrals
for colposcopy and biopsy will need to be
streamlined to achieve the WHO targets.88
Australia has been steadily improving access totherapeutics for cervical cancer, and there havebeen corresponding improvements in survival
rates. In 2020, 60.9% of patients diagnosed
with a high-grade cervical lesion were treatedwithin eight weeks and 85.8% within six months.
National level data is not available for treatment
of invasive disease, but data from Queensland
between 2010 and 2015 shows a 95% treatment
rate in metropolitan areas and 90% in remoteand rural areas.89
Government policy and regulatory efforts havehelped push the treatment of cervical cancer andthe elimination agenda forward. Cancer Australia,
a government agency established in 2006 to
improve cancer care, is developing an optimalcare pathway for cervical cancer; it is intended asa quick reference guide for physicians to ensurethat appropriate multidisciplinary care is provided
to patients.90 National Cancer Control Indicators
are currently being published by Cancer Australia,
covering various domains such as prevention,screening, diagnosis, treatment, psychosocial
care, research, and outcomes.91
Australia also has a national population-based
cancer registry, and cancer is a notifiabledisease in Australia so all cancers, except forbasal and squamous cell carcinoma of the skin,have had to be registered in the Australian
Cancer Database since 1 January 1982.92 The
health system in Australia is jointly run bydifferent levels of government – federal, state
and territory, and local. Some states haveindividual cancer control plans,93 and the firstnationwide Australian Cancer Plan to develop
the country’s future approach to cancer care isin development. A public consultation on thedraft closed in April 2023, and publication of the
final plan is imminent.94©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

29

Population-based cervicalscreening using hr-HPV testing
and catch-up vaccination
programmes: Portugal
Cervical cancer is a rare disease in Portugal.
In 2020, 865 new cases and 379 deaths due
to cervical cancer were recorded; the agestandardised incidence rate in the same year
was estimated to 10.7 per 100,000 and theage-standardised death rate was 3.7 per
100,000 women.1
Portugal is a very interesting example of acountry that is doing well with respect to the
WHO targets for cervical cancer elimination
because it’s not considered a rich country,
says Rui Medeiros, Professor of Virology
and Molecular Oncology, Head of Molecular
Oncology and Viral Pathology GRP, IPO Porto
Board Director of NRN-LPCC-Portuguese
League Against Cancer President of ECL,
Association of European Cancer Leagues, CoChair of the European Cancer Organisation’s
HPV Action Network. “We were rolling out
HPV-vaccination before the WHO strategy. Our

national vaccination plan is considered one of
the best in the world. Now we have vaccination
coverage of over 90% and screening at over
70% in most regions.”
The country has a strong history of supporting
vaccination, having introduced vaccination
against smallpox in the early 19th century
and an organised national vaccination system
in 1965. “Vaccination is not obligatory,” Prof
Medeiros adds, “but everyone believes it’snecessary and natural to be vaccinated. We have
low rates of [vaccination] hesitancy, and thoselower rates are due to our culture of accepting
public health strategies.”
HPV-vaccination was introduced in the national
vaccination programme for girls in 2008, and in
October 2020, it was expanded to include boys
aged 10 years.95 By 2021, 96% of girls in thetarget age group had received at least one doseof HPV-vaccination.44“Vaccination is not obligatory, but everyone believes it’snecessary and natural to be vaccinated. We have low rates of[vaccination] hesitancy, and those lower rates are due to ourculture of accepting public health strategies.”
Professor Rui Medeiros, Professor of Virology and Molecular Oncology, Head of Molecular Oncology and Viral
Pathology GRP; IPO Porto Board Director of NRN-LPCC-Portuguese League Against Cancer President of Associationof European Cancer Leagues; Co-Chair of the European Cancer Organisation HPV Action Network, Portugal©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

Cervical cancer screening has been offered
opportunistically in Portugal since 1978 andstarted to become organised after 1990.
The organised screening programme, which
originally included cytology followed by reflex
HPV testing, was progressively implemented indifferent regions of the country.108 In 2017, thePortuguese Gynaecology Society changed theirrecommendations for cervical cancer screening
in 25- to 60-year-olds to be performed using“hr-HPV testing”, followed by cytology inpositive cases. However, the adoption of HPV
DNA testing for cervical cancer screening has
been slow.109“We have been arguing for 15 years that weshould go on the molecular test and only use a
Pap smear or biopsy afterwards to confirm thediagnosis,” says Prof Medeiros. “We reviewed
what was best for our population, and thedecision was that we should have a molecular
test that could give us more epidemiological
data to evaluate.” HPV DNA-based cervicalcancer screening was first implemented in thenorth of the country where the health system

30

struggles to cope with the 150,000 [women] whoare eligible for a Pap smear every year, he adds.
The geographic coverage has been expanding
and in 2022, 342,223 women were invited forscreening and 321,888 took part – a 32% riseover the number screened in 2021. However, atthe population-level, this number represents onlyaround 61% of eligible women. Typically, family
doctors are responsible for inviting women for
cervical cancer screening, but invitation rates are
low suggesting that awareness needs to be raisedamong frontline physicians.110
The National Cancer Control plan of Portugal(2021-2030) confirms continued support for
the national HPV-vaccination program andsets a goal of 95% population-level coverageby 2030 for cervical cancer screening. This is
expected to be achieved by developing anddisseminating guidelines for cervical cancer
screening, standardising screening procedures,
creating indicators for monitoring screening
programs, and by assessing the satisfactionof users of the screening program. Improving
access to radiotherapy to achieve at least 90%
coverage among referred patients and ensuringhigh-quality therapy conforming to the criteria
set by the International Atomic Energy Agency
are other objectives of the plan.111
Furthermore, after Portugal launched thenational immunisation programme in October
2008 for girls aged 13 years,95 it quickly ran auniversal catch-up vaccination campaign from2009 to 2011 for girls aged 17 years and older,
who were born between 1992 and 1994. Girls
aged 10-13 years were covered from 2014 to
2016, and since 2017 only girls aged 10-years
were receiving the vaccination. Since 2020,
the country has opted for gender-neutral
vaccination programmes in which the HPVvaccination is offered to all 10-year-old children
regardless of sex.

©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

31

Implementing a successful cervicalcancer elimination strategy
Implementing a successful cervical cancer
elimination strategy essentially involves atleast two key pillars. “HPV-vaccination is thefirst pillar in the cervical cancer elimination
strategy and the most effective tool forprimary prevention of cervical cancer,” says
Dr Nino Berdzuli, Director of the Division ofCountry Health Programmes, WHO Regional
Office for Europe. “When we can prevent thecancer from happening, and have vaccination
with an excellent safety and effectivenessprofile that can prevent it, it’s unjust actually
not to use this vaccination.”“The WHO recommendation is that the
HPV DNA test be the preferred method for
cervical cancer screening because of its costeffectiveness and higher sensitivity, and also
because it offers women the option of selfsampling – a convenience factor that we needto consider, particularly in terms of hard-toreach women, [and] women who don’t feel
comfortable enough or have the time for thevarious reasons to come to the health system.
Despite this evidence for its use, HPV-based
screening adoption has been limited outside of
HICs” says Dr Berdzuli.

The WHO European region comprises 53
Member States, of which 45 have introduced
HPV-vaccination in routine schedules;
the middle-income countries are lagging
behind. Some countries have reached highHPV-vaccination coverage, moving steadily
towards the 2030 target of 90%, but many facechallenges with HPV-vaccination uptake orstalled progress. Globally, 126 countries haveintroduced HPV-vaccination, but 65 are yet tocommit. “There is glaring inequity in terms of
the access to and uptake of HPV-vaccination,”
Dr Berdzuli explains. “This inequity exists
between and within countries – within countries,
disparities are prominent among vulnerable
groups, such as with low socioeconomic
refugees and migrants,” she adds.

“Coverage also varies and the biggest problem
many countries have in reaching the 70%
cervical screening target is a lack of organised,well-functioning and quality assured screening
programmes. A population-based cancer
screening programme followed by adequate
diagnosis and management of positive results[are] very important for effective cervicalcancer control. If we only have opportunistic
cancer screening, it’s going to be very hard toreach the elimination target.”

The second pillar in elimination strategies isscreening, and while most countries in Europe
offer cervical cytology screening with an HPV
test or Pap smear-based test, some countries in
Eastern Europe still use an outdated tool from theSoviet era – Romanowsky-Giemsa staining.96

Across the European region, there is significant
disparity in terms of cervical cancer outcomes,
Dr Berdzuli says. While mortality rates havesignificantly decreased in Western Europe,
they are three times higher, and rising, in
Eastern and Central Europe, the Baltic states,
and Central Asian countries.97,98 “The disparity
is due to the capacity of the health system tobe able to diagnose cervical cancer early, andthen to treat it properly. The cancer may bediagnosed early, but if the health system does
not encompass the full spectrum of cancer©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

care, the outcomes will not be the same. It’s
about offering high quality, comprehensive
cancer care – surgery, chemotherapy, radiation
therapy and palliative care – through a wellfunctioning cancer care pathway. Cancer is acomplex disease and treating cancer requires
a well-functioning and coordinated healthsystem, as well as highly trained and qualified
healthcare providers.”
While in many cases, coverage for vaccination,screening and treatment is higher in Europe,
as compared to other countries, the barriers
to uptake and the mechanisms for addressing
them are generally the same. It is important tounderstand why there are gaps in vaccinationand screening coverage by using behaviouraland cultural research to understand why certain
population groups are not coming forward
and what drives a late diagnosis. This may
be due to cultural factors or health literacy,
misinformation and disinformation damaging
trust in vaccination efforts, or lower confidence
in healthcare institutions; it is therefore vitalto tailor efforts to specifically target thevarious populations and sub-populations thatexperience these myriad reasons for neglecting
screening and vaccination, explains Dr Berdzuli.
“Unless we understand the specifics of these
populations, and find the reasons, the factorsthat contribute to these equity gaps, our policies
and strategies for cervical cancer elimination

32

won’t be effective. A blanket approach is noteffective. It is very important for policymakers
to listen to target groups, healthcare workers,
parents, girls, and women, to gain insights.
Challenges can be local and they require tailoredsolutions and intervention plans and this is acontinuous process,” she adds.
Based on published evidence, insights from theexperts interviewed, and lessons from countries
leading the way towards cervical cancer
elimination, Economist Impact recommends a
10-point baseline plan for policymakers acrossthe world to consider when developing national
strategies to eliminate cervical cancer.
1. Build political commitment andmomentum
All the countries discussed in this paper, who areleading the way forward in the pursuit of cervicalcancer elimination, have at least one thing incommon: a high degree of political commitment.
Guidelines and policies from global and regionalorganisations, such as WHO, have helped focus
global attention on cervical cancer, and havehelped build political will to implement nationlevel policies. Furthermore, political commitment
to the elimination of cervical cancer has been
fostered through strategies such as the EBCP,
which goes a step farther than the WHO targets,by setting benchmarks for EU Member States toachieve by 2030 (as opposed to the end of the“Unless we understand the specifics of these populations, andfind the reasons, the factors that contribute to these equity gaps,
our policies and strategies for cervical cancer elimination won’t
be effective. A blanket approach is not effective.”
Dr Nino Berdzuli, Director of the Division of Country Health Programmes, WHO Regional Office for Europe©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

century). Benchmarks of the plan include a 90%
vaccination rate among the target populationof girls, while simultaneously supporting theincreased vaccination of boys, as well as offering
screening to 90% of the qualifying population by2025, and widening access to effective treatment
modalities across borders in the EU to reduce thepersistent health inequities within and between
countries.6 It also brings forward the goal of
ensuring that cervical screening is offered to
90% of women eligible within EU Member Statesby 2025. The plan also supports these goals
with funding to help EU Members establish theinfrastructure and public health interventions
necessary to achieve them.13 Setting global
and regional benchmarks and targets can alsobuild political accountability and ensure that
implementation is followed through.
Advocating for stronger, long-term andsustained political commitment, and ensuringthat policy guidance exists for cervical cancer,
can greatly improve the rates of screening andtreatment. Therefore, having a supportive policy
environment is critical to the elimination of
cervical cancer.
2. Ensure multi-stakeholder collaboration
Building collaboration between multiple
stakeholders, including patients and patientorganisations, researchers, healthcare
professionals, and bio-pharmaceuticalorganisations, is one way to encourage politicalcommitment, and has the added benefitof helping scale effective strategies for the
management of the condition.
Having targets such as those described above
help create a sense of accountability for all
stakeholders who are invested in tacklingcervical cancer. For instance, the European
Cancer Organisation (ECO), established in 2019,set out to influence the EBCP so that every
country would incorporate HPV prevention in
their national cancer plan – not just for cervicalcancer but also other HPV-preventable cancers,
says Prof Kelly.

33

Additionally, healthcare professionals should be
consulted in policies aimed at increasing HPVvaccination and cervical screening coverage togenerate awareness and to build trust among
the public. Developing innovative collaborations
and ensuring multi-stakeholder approaches
could help scale and sustain cervical cancer
elimination efforts globally.
3. Prioritise HPV within national cancer
policies and vaccination schedules
Once political will has been established toeliminate cervical cancer, countries mustformalise their commitment within a national
cancer plan, if there is one, or establish anothersimilar policy with goals, strategies and funding
mechanisms. Including HPV-vaccination in
the standard vaccination schedule is also
important because it “normalises it” and builds
trust in vaccination.
In some countries, the low uptake of HPVvaccination may be due to it not being mandatedby law, unlike other childhood vaccinations.
This can create distrust due to contradictorymessages from health professionals,
governments, and the media, says Prof Medeiros.
He adds, “I think it is key to implement HPVvaccination as a normal vaccination as with theother childhood vaccinations.”
4. Generate data through the developmentof robust registries
Population-level disease registries provide
an accurate picture of the size of the target
population and the state of women’s vaccinationand screening status to enable policymakers
to monitor progress on HPV-vaccination,screening and treatment goals, while serving
many other practical and research functions.
Registries provide a mechanism for identifying
and inviting girls and women for vaccination andscreening and following up with them if they do
not attend; they also ensure that women withabnormal screening results are followed up andmonitored, while enabling researchers to analyse©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden“It’s really important that you don’t
have to pay for it – you need to makeit free, otherwise – you will widen
inequity gaps.”
Ulrika Årehed Kågström, Secretary General, Cancerfonden(Swedish Cancer Society), Sweden

trends and outcomes and assess new diagnostics
and interventions that could improve care forwomen now and in the future.
5. Include screening and vaccination under
universal health coverage
Vaccination and screening programmes achieve
higher coverage when they are free because
payments exclude women from the lowest
socioeconomic groups and deter women
who would otherwise participate. “It’s really
important that you don’t have to pay for it – youneed to make it free, otherwise – you will widen
inequity gaps,” cautions Ms Kågström.
6. Understand the target populationand design the roll-out of organised andaccessible programmes
The WHO’s primary objective is to eliminate
cervical cancer as a public health problem
globally, so the primary target population for
HPV-vaccination is girls aged 9-14 years. The
WHO European Roadmap for Cervical Cancer
acknowledges the benefits of vaccinating
boys, but cervical cancer, which comprises
84% of all HPV-related cancers, should remain
the priority for a cervical cancer elimination
roadmap. Gender-neutral vaccination should be
implemented, where feasible, at the discretionof each member state. Though supporting
gender equity and protection of girls and boys
through herd immunity would have positive
impacts, as Dr Berdzuli emphasises, “Genderneutral vaccination should not direct resourcesfrom the primary targets of the elimination of
cervical cancer.”

34

Once the target population has been identified,an organised programme needs to be developedthat takes HPV-vaccination to them. A schoolbased programme is generally the preferred andmost effective delivery mechanism for HPVvaccination because it reaches all young children
in attendance, and is convenient for families.
For the healthcare service such vaccination
programmes are straightforward, easy toorganise and cost-effective. Other strategies
may be required in countries where attendanceof girls in the target age group is low.
“Sometimes it is said that it is a matter of money
to achieve high attendance, but a number ofcountries that have very low-income levels
have managed to achieve very high attendance
rates by organising it well by community after
community,” says Prof Dillner. “So I think that is
an interesting message – that it’s not really about
the money but about being well organised.”
7. Ensure equitable access to vaccinations
and screening for the entire population
Eliminating cervical cancer means that theentire population must be vaccinated, and thisincludes marginalised women who often havegreat barriers to accessing healthcare services.
These include women who are caregivers, livein rural areas, come from ethnic minorities,
or victims of domestic abuse. Therefore,
innovative methods such as self-sampling
screening kits could be used as an alternative
approach to increasing coverage.
Cervical cancer elimination can be accelerated
by widening population coverage throughcatch-up campaigns. These campaigns cantake vaccinations to the girls and young
women who were too old to receive when it
was introduced, as well as to those who did
not receive vaccination at school because
they were absent, their parents would notconsent or schools were closed due to the
Covid-19 pandemic. Additionally, schools
should proactively follow up with children who
miss out on vaccination because of hesitant©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

35

parents, and such parental concerns should be
discussed and addressed with the appropriate
resources to increase awareness.

of health authorities to prevent or manage
any potential confidence crisis; we work withcountries to build these capacities.”

Linking delivery of HPV-vaccination to other
health interventions such as another vaccinationor screening can provide additional opportunities
for reaching unvaccinated populations who
do not come forward when invited for HPVvaccination alone. Health services/healthprofessionals should follow up with women who
miss out on cervical screening to ensure that they
are fully aware of the benefits of vaccination.
Any concerns women may have about theprocedure can then be addressed.

9. Ensure equitable access to high quality
treatment and an optimal care pathway

8. Address the barriers of vaccination
hesitancy and misinformation
Attitudes, culture, beliefs and behaviour vary
both between and within countries and it
is important to really understand a specificpopulation in order to design effective strategies
to boost uptake of vaccination and screening.
Research on the drivers of vaccination
inequity in Europe highlight poor access andlow trust, particularly among those with low
socioeconomic states, as key problem areas, andthere are many case studies of interventions
that have been successful in boosting coveragein some countries which could be implemented
and/or adapted to have successful results
elsewhere.99 Resources have also beendeveloped to help the public tackle myths andmisinformation.100,101 In 2022, many social media
platforms also signed up to a strengthened Codeof Practice on Disinformation.102
It is important to tackle misinformation anddisinformation to prevent “mushrooming”, says
Dr Berdzuli. “The only way we can counter this is
to increase the trust in the healthcare system andhave confident healthcare professionals. This canbe achieved by equipping healthcare providers
with evidence and facts and by improving theirconfidence in HPV-vaccination’ effectiveness andsafety, and importantly by boosting the capacity

To help provide equitable treatment for
women diagnosed with cervical cancer, it isimportant that the care pathway is standardised
throughout the patient journey, from diagnosis
to referral to treatment. Health systems shouldhave adequate infrastructure and healthcare
staff to reduce waiting times, as well as
efficient navigation procedures to expedite thetreatment of cancer.
10. Learn lessons from the Covid-19
pandemic to build system resilience andscale screening and vaccination coverage
The Covid-19 pandemic demonstrated that theworld is able to design a vaccination and deliver
it to populations quickly and at scale. There ismuch that can be learned from this experiencein terms of strengthening supply chains andsystems capacity for both vaccination andscreening. The pandemic provided opportunities
for more efficient, and less wasteful, prevention
efforts, such as prioritising women by risk,
extended HPV testing using self-collected
samples, and by discouraging inefficient policies,
such as screening with two tests.103
Innovative Covid-19 vaccination delivery
methods such as the “vaccine bus” and “drivethrough clinics” could increase coverage, andare reportedly favourable amongst young
people. A survey of 1,200 young people,
between the ages of 16 and 35, in three
European countries, France, Germany, and Italy,
found that 75.5% of respondents wanted to see
the continuation of vaccine buses and drivethrough clinics for other vaccinations in the
future.104 Additionally, 55% of respondents werein favour of e-vaccination cards for vaccinations
beyond Covid-19 ( including HPV) to help keep
their health records up to date.

©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

36

Conclusion

Cervical cancer is a growing public health concern, which threatens
the lives of women, their families and societies. The cost of cervicalcancer threatens the global economy because early morbidity meansthat diagnosed women are unable to participate fully at work and earlymortality means that they are missing entirely from the labour force.
While the political commitment to eliminating cervical cancer within the
century has been harboured at the global level through policy reforms
such the WHO’s 90-70-90 elimination strategy, the alignment of multistakeholder collaboration, including patient advocates, healthcare
professionals, researchers, to name a few, has increased political
momentum towards the development of regional and national plans.
Increased HPV-vaccination and screening coverage are the foundationalpillars for eliminating cervical cancer, but these efforts require asense of organisation to ensure that coverage is truly “universal”.
Therefore, an increase in funding – while welcome – is not the only
solution to eliminating cervical cancer; instead, a step-wise approach is
required on multiple fronts to ensure accountability and the effective
implementation of measures.
Positively, many countries have made significant gains in their efforts
to eliminate cervical cancer, with Sweden set to be the first country toachieve this before 2030, followed by Australia by 2035. But all countries
studied in this report have demonstrated that political commitment
is the essential foundation for achieving this ambitious goal. This
political commitment is often built on evidence-based decision
making, which requires actors from the health and science community
to take accountability for the generation of data to understand andcommunicate the true needs of their unique populations. The 10-point
plan forms the baseline of actions each country should consider whendeveloping national strategies and implementing measures aimed at
the elimination of cervical cancer. The recommendations in this baseline
plan will not only alleviate fiscal pressures, but also ensure that womenare protected from this highly preventable cancer.

©Economist Impact 2023

A global blueprint for cervical cancer elimination: learnings from Sweden

37

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