Primary prevention: HPV vaccination

The implementation of HPV vaccination within PHC systems offers substantial health and economic benefits. The WHO EMRO economic model16 estimates that in the lifetime of a cohort of girls born in 2020, HPV vaccination is expected to prevent around 42 000 cases and nearly 24 000 deaths, resulting in a highly cost-effective intervention with costs of US$3422 per case prevented and US$ 6109 per death prevented.

A return-on-investment (ROI) analysis indicates that HPV vaccination yields positive ROIs, ranging from US$2.2 to US$6.2 for each dollar invested, in high-income, middle-income and low-income EMR countries, respectively (figure 2). This entails that governments may expect a return two to six times higher than their initial investment in population-wide HPV vaccination programmes by preventing cervical cancer, as a result of decreased healthcare expenditures, decreased premature mortality and morbidity, thus increased productivity in the labour market.

At the time of the data collection for the situation analysis16—April to November 2023—seven EMR countries (Bahrain, Kuwait, Libya, Morocco, Qatar, Saudi Arabia and UAE) have successfully established nationwide HPV vaccination programmes. For example, the UAE has implemented a systematic HPV vaccination programme that achieved 87% coverage by using school-based vaccination initiatives. Additionally, cervical cancer screening is incorporated into the periodic screening programme ‘Itmi’nan.’ Morocco has adopted an opportunistic HPV vaccination strategy and integrated early detection services into PHC, achieving a 21% one-dose coverage rate in its first year.17 Table 1 summarises the key features of these programmes.

Early detection

Early detection is the cornerstone to effective cancer control programmes, encompassing two complementary approaches: cancer early diagnosis, and screening. Screening focuses on testing all individuals within a defined target group, regardless of whether they show symptoms, while early diagnosis aims to identify cancer in individuals who already exhibit symptoms suggestive of the disease. Early diagnosis approach improves cancer outcomes by providing care at the earliest possible stage, similarly to screening, but is logistically simpler to implement than screening and is therefore an important public health strategy in all settings.18

The WHO EMRO economic model16 estimates that the ROI for cancer screening was below 1 across different country groups (0.4–0.8), which may be attributed to the reported low incidence of cervical cancer in most of the EMR countries. Based on this, policy-making should consider different dimensions of the issue, including the projected socioeconomic burden of cervical cancer and likely changes in risk factor prevalence due to changing cultures, migration and increased tourism affecting reproductive practices. While early diagnosis, coupled with timely management of cervical cancer, is cost-effective and thus recommended in all settings, full-fledged country-level screening programmes should be considered in light of national cancer burden and current capacities.19

In addition, screening high-risk groups such as short-term and long-term migrants from high-incidence countries, victims of sexual and gender-based violence, HIV-positive women and those with substance addiction may generate higher ROI and guide towards better resource allocation. Such high-risk groups have higher incidences for developing cervical cancer. Identifying and targeting these high-risk groups with more intensive screening or prioritising them for vaccination could be beneficial, while ensuring they are not subjected to stigma and stereotyping. In addition, strengthening referral pathways and treatment options, including palliative care, should be prioritised.20

In the EMR, some countries have integrated cervical cancer early detection into their PHC systems, although the extent and effectiveness of this integration vary. For instance, Morocco and Oman have embedded cervical cancer early detection, including Pap smears and HPV testing, within their PHC networks, especially in the reproductive health services.21 In contrast, other countries face challenges in fully integrating these services. In Lebanon, while some cervical cancer early detection services are offered through PHC, coverage remains inconsistent and is not systematically monitored. In Saudi Arabia, cervical cancer screening is primarily conducted by gynaecologists rather than being integrated into PHC, which may limit accessibility, particularly in rural and underserved areas.22

Cervical cancer resources and infrastructure

Funding for health services in the EMR is complex, with fragmented services and provided by multiple sectors, including public (Ministry of Health), parastatal, military, private sector and civil society organisations. This complexity can pose challenges in ensuring consistent and equitable access to cancer services across the region.

In countries where HPV vaccination is available, it is free at the point of delivery in Qatar, Saudi Arabia, Morocco and for citizens in the UAE. Cervical cancer early detection is also free in countries such as Sudan, Egypt, Iraq, Syria, Bahrain, Qatar, Saudi Arabia and for citizens in the UAE. These initiatives are crucial in promoting access to preventive services and reducing the financial burden on individuals. Bahrain and Kuwait have extended school-based vaccination programmes to include boys. This approach helps normalise HPV vaccination, thus reducing stigma and decreasing HPV prevalence in the broader community,27 contributing to a more comprehensive public health strategy. Table 2 presents the cancer services included in national essential health benefit packages.

Sociocultural barriers

Sociocultural barriers significantly hinder the uptake of preventive services and screening. Stigma associated with HPV—due to its sexual transmission—and fear of discrimination following a cancer diagnosis discourage women from seeking care. The conservative nature of society poses challenges for school immunisation as families may resist vaccination due to concerns that it could be perceived as giving tacit approval for sexual activity. Additionally, low awareness and a perceived low risk of cervical cancer among populations further contribute to inadequate utilisation of available services.28 A survey conducted in the EMR in 2022 highlighted that vaccine hesitancy, either due to (low) perception of HPV infection or to safety concerns, was a barrier to establishing a national HPV vaccination programme for 65% and 60% of respondents, respectively. The perception of insufficient cervical cancer burden was cited as a barrier to introducing screening programmes with HPV testing by 55% of respondents.29

Policy-related

Policy-related challenges further obstruct advancements in cervical cancer prevention efforts. Policy-makers in some countries question the cost-effectiveness of screening or nationwide HPV vaccination programmes, citing financial constraints and safety concerns.29 According to the WHO EMRO situation analysis on women’s cancers, cost of programme, HPV vaccine supply, lack of demand for HPV vaccination and lack of political will were barriers for HPV vaccination for 55%, 45%, 40% and 25% of respondents, respectively. Similarly, lack of existing screening programme infrastructure, costs, lack of understanding of need for screening by women, and lack of political will were barriers to CC screening for 70%, 65%, 60% and 35% of respondents, respectively.29

In addition to financial and logistical barriers, slow integration of cervical cancer services into PHC also reflects limited political prioritisation and broader governance challenges. In many EMR countries, cervical cancer competes with other pressing health issues—such as communicable diseases and maternal health—resulting in limited visibility and investment. Fragmented service delivery and weak intersectoral coordination further hinder coherent national strategies for prevention and early detection, especially where regulatory oversight and accountability mechanisms are lacking.

Consequently, both screening and HPV vaccination coverage remain low, undermining efforts to prevent and detect cervical cancer at its earliest stages.

Healthcare system and workforce

Utilisation rates for private health services in some low-income and middle-income EMR countries reached as high as 77% in 2021.30 However, private sector services often lack accreditation and national standards for quality monitoring. Private providers tend to concentrate in urban areas and are generally reluctant to invest in preventive care, limiting access for rural and underserved populations. Furthermore, referral systems linking PHC centres to specialised care are frequently underdeveloped, often relying on fragmented, paper-based processes prone to delays.31

Severe shortage and uneven distribution of healthcare workers across the region are critical challenges. New and protracted crises exacerbate the outflux of health workers, disrupting previously successful preventive and screening programmes. Projections indicate that by 2030, the EMR will face a shortfall of 2.1 million health workers, accounting for over 20% of the estimated global deficit of 10 million health workers.32 This is especially concerning given that EMR countries constitute approximately 10% of the global population.33 Addressing these shortages will require significant investments in training, retention and equitable distribution of health professionals.

Unavailability of the needed infrastructure is a critical barrier to the successful implementation of cervical cancer programmes. Many PHC centres lack the necessary equipment such as Pap smears or HPV testing.34 Delays between Pap screening and its results—as mentioned in some countries—might lead to delayed diagnosis and loss of follow-up from the women’s side.35

Economic analysis and policy formulation

National health authorities in the EMR should further analyse the findings of the economic analysis of the WHO EMRO women’s cancer investment case and conduct similar economic evaluations at the national level. This will help prioritise the most cost-effective cervical cancer interventions and inform evidence-based policy formulation as relevant to each country context.36

Infrastructure and human resource development

It is essential to address infrastructure and human resource gaps in PHC, particularly in rural and underserved areas, and to streamline referral systems to ensure timely diagnosis and treatment of cervical cancer. Training and retraining, especially in cultural competencies and early cancer detection, helps reduce loss of specialised staff. Adaptation to the resource-limited situation and lower incidence of cervical cancer leads to recommendations of single-dose regimens of HPV vaccination, as well as HPV DNA testing every 5–10 years for women aged 30–50 with prior negative results.

Stepwise approach to screening

Adopting a stepwise approach, starting with early diagnosis and timely referral—cost-effective in all settings as happened in Pakistan and Greece37—may be more appropriate for countries with constrained resources or low cervical cancer incidence, while the integration of cervical cancer prevention programmes can be achieved through regional funding mechanisms and international support. This can be achieved with the international collaboration within the EMR, particularly through the establishment of pooled procurement mechanisms for medical commodities and supplies, including HPV vaccines and screening kits. Pooled procurement mechanisms have been implemented for paediatric chemotherapy medication in Jordan and Lebanon.38 This would significantly reduce costs and enhance affordability across countries.

Innovative screening methods

The use of HPV-DNA testing is clearly evidenced in several countries.39 In low-risk settings, such as Oman, the use of HPV-DNA testing as a primary screening tool allowed only the women who tested positive for HPV to undergo cytological examinations, reducing the number of such examinations and allowing centralised analysis by experienced pathologists, thereby improving cytology performance.39 Self-collection of samples, particularly in resource-constrained or culturally conservative communities, can increase uptake and accessibility.

Likewise, in resource-limited settings, identifying and targeting high-burden areas, policy-makers can implement phased rollouts. This approach can maximise impact, improve equity and accelerate progress. Thus, interventions must be prioritised based on data-driven insights.

Addressing sociocultural barriers

School immunisation programmes that are culturally sensitive have proven effective in achieving high HPV vaccination coverage in several LMICs, including countries with religious and cultural contexts similar to those in the EMR—such as Indonesia, Malaysia, the Maldives and Uzbekistan.40 However, one should not assume that the delivery approach alone was critical in overcoming cultural barriers.

Complementary strategies such as community engagement, sensitisation campaigns and strong political commitment are pivotal to ensure programme success.41 42 PHC community outreach plays a vital role in educating populations about cervical cancer prevention and overcoming stigma, especially where low awareness hinders the use of HPV vaccination and screening.43 As the most accessible level of healthcare, PHC is crucial for delivering essential health services, minimising costs, and overcoming geographic and socioeconomic barriers, particularly in rural and low-resource settings. To sustain public confidence and prevent service backlogs, these demand-generation efforts must proceed in tandem with adequate workforce capacity, infrastructure and availability of treatment services.

Leveraging public–private and cross-sector partnerships

Public–private partnerships are one of the key solutions that have been adopted by many countries. For example, South Africa developed a national strategy to regulate and harness the private sector towards the achievement of public health goals, including HPV vaccination and early detection programmes. These policies have a positive influence on enhancing vaccination and early detection programmes. This success has been achieved and strengthened through established public–private partnerships that can expand access to preventive services, especially in areas where public health infrastructure may be limited.44

Expanding school health programmes to deliver HPV vaccinations can increase coverage while significantly reducing operational costs. Expanding maternal and child health frameworks to include cervical cancer care could serve as a platform for holistic women’s health strategies, including mother and daughter programmes as well as integrating vaccination with other routine immunisations, which could optimise outreach and efficiency. Tailored awareness campaigns that resonate with local values, coupled with male and community engagement, including religious leaders, can be transformative. Enhanced data collection and monitoring activities are necessary to track progress and inform policy adaptations.