A task shifting strategy for elimination of cervical cancer by 2030

Dear Editor,

With great interest, we read the article “Cervical cancer awareness, knowledge, behavioural patterns, and practice of screening and vaccination in females of hilly regions of North India – A hospital-based observational study” by Yadav et al. (2024).[1] The study was well written, and we like to contribute additional insights to the article. Cervical cancer was the second leading cause of cancer-related fatalities among females in India, despite being one of the most preventable and curable forms of cancer when detected early and managed effectively. The census of India (2011) shows 833 million (68.84%) live in rural and remote areas with a sex ratio of 949 females per 1000 males.[2] The majority of women living in these areas are illiterate and ignorant about the hazards of cervical cancer. The current estimation shows that every year 123907 women are diagnosed with cervical cancer and 77348 die from the disease.[3] Alarmingly, 80% of women with cervical cancer were diagnosed in advanced stages, because the majority of them were never screened for the disease.

To make healthcare more accessible to all including women living in rural and remote areas, the government of India implemented various schemes and initiatives. Among them, the Comprehensive Primary Health Care (CPHC) through Ayushman Arogya Mandirs (AB-AAMs) (formally known as Ayushman Bharat-Health and Wellness Centres) was established. The mid-level healthcare providers (MLPHs) posted in these centres deliver an expanded of services, ranging from the management of simple acute illnesses to the early identification of complicated cases and referring them to higher centres if needed. The cases referred to higher centres are then followed up by the MLHPs to ensure a complete continuum of care.[4] A global shortage of 18 million healthcare workers is anticipated by 2030, mostly in low- and lower-middle-income countries, so the World Health Organization (WHO) recommends the task shifting strategy to improve access and to deliver healthcare services in remote areas. In 2020, WHO launched a global comprehensive strategy with three pillars including preventing, detecting and treating cervical cancer. It aims to achieve 90-70-90 targets by 2030, the target includes vaccinating 90% of girls, screening 70% of women, treat 90% of cervical disease for the elimination of cervical cancer.[5]

The AB-AAMs are responsible for the promotion of healthy lifestyles and awareness campaigns in the community, with a particular focus on vulnerable groups that are often overlooked. The critical health issues identified over time are brought to the forefront during Gram-sabhas, where key community members like Mahila Arogya Samitis, MLHPs and, community health workers discuss and raise awareness about these often-neglected aspects of women’s health. The government of India has unveiled plans (2024–25) to incorporate the vaccine against human papillomavirus into its National Immunization Schedule. The vaccine will be administered to all girls aged between 9 and 14 years. Over the next three years, the vaccines will be made available in schools or nearby government primary health centres. In AB-AAMs, it is mandated to regularly conduct population-based screening for non-communicable diseases.[4] The National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD) provides a framework for MLHPs to detect cervical cancer using Visual Inspection with Acetic Acid (VIA) along with mass-screening of other NCDs including hypertension and diabetes. This large-scale screening has proven to be a cost-effective method for cervical cancer screening. If the VIA screening result is positive, the patient is counselled and referred to a higher centre for confirmation.

The secondary and tertiary level centres need to be well-equipped to manage these diagnosed cases of cervical cancer. However, higher centres often grapple with a dual challenge: they are typically located at a considerable distance and are frequently operating beyond their capacity due to understaffing.[6] As the mass screening program at the AB-AAMs becomes more efficient, the onus shifts to these higher centres to accommodate an increasing number of patients for advanced treatments including chemotherapy and radiotherapy. This influx of patients underscores the need for these centres to upgrade their infrastructure, equipment and drug supplies, and to invest in skilled human resources. In essence, the success of the mass screening program at the AB-AAMs is intrinsically linked to the capacity and readiness of these higher centres to manage the subsequent patient load. This calls for a holistic approach that addresses not only early detection but also the effective treatment of cervical cancer.

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Conflicts of interest

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