Reaching 90-70-90 cervical cancer elimination targets: How context shapes implementation

• The World Health Organization's (WHO) 90-70-90 cervical cancer targets define a shared destination, but disease burden, health-system capacity, and access barriers make the implementation pathway country-specific
• Coverage data shows how many women were screened for cervical cancer, not whether women received results, or when needed, completed follow-up and treatment
• Where the barrier is transport, cost, or trust rather than the test itself, changing the screening technology alone will not close the gap

Turning cervical cancer elimination from ambition into sustained impact is not about finding a perfect model and replicating it everywhere. It is about building an effective system that works in context, works for women, learns from implementation, and becomes part of what the health system routinely does.

Since the WHO launched the global strategy to eliminate cervical cancer in 2020, country experience has given us a clearer picture of what implementation takes. The 90-70-90 targets give countries a common destination and a clear framework for measuring progress.¹ But countries are not starting from the same place. Disease burden, health-system capacity, infrastructure, resources, and barriers to access vary significantly. The destination is shared; the starting points and pathways are not.

Recent WHO implementation guidance recognizes that implementation strategies need to work across health systems, providers, and women, and be adapted to the country context.² Indonesia’s national elimination plan, for example, sets phased milestones alongside the service delivery, workforce, governance, financing, and monitoring capabilities needed to achieve them, including the transition toward human papillomavirus (HPV) DNA testing.³ Other countries are solving the same implementation challenge differently. Nigeria’s National Taskforce on Cervical Cancer Elimination provides a mechanism for coordinating national action; Zambia has built cervical screening into existing human immunodeficiency virus (HIV) services; and Vanuatu’s island geography has shaped an outreach model that brings screening and treatment closer together.⁴

The mechanisms are different, but the underlying challenge is the same: What does this health system need to make the pathway work?

Addressing context does not stop at the national level. Women living within the same country can experience the same screening program very differently. We often talk about bringing care closer to women, but what does “closer” mean, and which parts of the pathway need to be closer?

In Colombia, physical access was a greater barrier for rural women, while low-income urban women were more affected by wait times and concerns about their experience in health facilities.⁵ That matters because no single technology or delivery model makes a program woman-centered. The starting point is understanding the barrier women actually experience. Self-collection, for example, is important not simply because women can collect their own sample, but because it creates new possibilities for where and how they enter the screening pathway. In Peru, Project HOPE has combined self-sampling with community education and clinical follow-up in peri-urban communities.⁶ In a recent study evaluating Project HOPE, of 2,078 women who self-sampled with an HPV kit, two-thirds reported never having had a Pap smear.⁷

The same thinking applies to where testing happens. Centralized high-throughput testing can offer scale and quality; Point of Care approaches may be particularly valuable where returning for results is difficult. The question is not which model is best. It is which configuration can deliver quality, access, and continuity for the population it needs to serve.⁸

A program cannot respond to barriers it cannot see. Coverage tells us how many women have been screened, but we also need to understand who is being reached and what happens afterward. Did women receive and understand their results? Following a positive result, did they move into care? Are some populations benefiting less from national progress than others?

Australia shows why this matters. Although the country is progressing toward elimination nationally, Aboriginal and Torres Strait Islander women were projected to achieve cervical cancer elimination in 2047, 21 years later than for Australian women overall.⁹ National progress matters, but so does understanding how that progress is distributed across the population.⁹

By increasing screening uptake, on-time attendance, and follow-up tests to match national rates, models project elimination in Aboriginal and Torres Strait Islander women to move up four years to 2043. Models also show that a screening initiative with sustained follow-up could achieve elimination for this population by 2036.⁹

Disaggregated data tell programs where to look; they do not tell them why. That requires listening to women and communities and understanding what sits behind the numbers. In Aotearoa New Zealand, lower screening participation among Māori women was understood alongside financial and other access barriers, contributing to responses including fully funded screening for Māori and Pacific women and other priority groups.¹⁰

In western Kenya, the Boda Girls initiative uses female motorcycle riders as community health advocates and navigators, helping rural women overcome transport, cost, and safety barriers to reaching health services. If transport is the barrier, changing the test alone will not solve it.^11,12 Nor does getting a woman screened mean the pathway has worked. The goal is not simply to make screening easier to access; it is to make the pathway easier to complete. Women need to receive and understand their results and, where necessary, move into follow-up and treatment without being expected to navigate a fragmented system themselves. Expanding cervical cancer screening without preparing for what comes next may just move the bottleneck further along the pathway rather than resolve it.

This is where implementation becomes more than delivery; it becomes a source of evidence. Programs can learn who is being missed, where women are being lost, what capacity is failing to keep pace, and what needs strengthening next. Some constraints can and should be anticipated, while others will emerge only as programs scale. Progress may reveal the next constraint. Strong implementation responds to and anticipates emerging constraints.⁴

Taken together, several practical lessons emerge:

• Know your starting point and the population you need to reach

• Build the capabilities that connect prevention, screening, and care

• Anticipate what you can

• Learn from what you could not

• Strengthen over time

• Make those capabilities part of routine health-system delivery

Country experience is giving us a clearer understanding of what it takes to reach the destination we already share. The destination remains 90-70-90; context shapes the implementation pathway.¹