Cervical Cancer in Sub-Saharan Africa: A Narrative Public Health Policy Synthesis and Integrated Framework to Support WHO Elimination Targets

2.1. Literature Sources

The search primarily focused on literature and policy documents published between 2020 and 2025. However, foundational publications on systems thinking, One Health, and laboratory quality management systems published before 2020 were retained to provide conceptual and methodological context. The interpretation of complex systems and laboratory-strengthening techniques was supported by foundational efforts by Meadows, de Savigny and Adam, and Yao et al. [9-11]. Special attention was paid to:

• The WHO Global Strategy for Cervical Cancer Elimination [4].
• Regional reports on vaccination, screening, and treatment coverage from the WHO African Region [5].
• The African elimination roadmap and policy briefs [6].
• Peer-reviewed studies on HPV vaccination, screening technologies, and diagnostic systems in African settings [2, 3, 12-14].
• Publications outlining systems thinking and One Health approaches in global health [8-10].

2.2. Analytical Framework

Two frameworks guided our synthesis:

1. One Health: One Health highlights how human, animal, and environmental health are intertwined, although it has historically been used to address zoonotic and antibiotic resistance issues. This study extended the concept to cervical cancer, presenting the disease as a consequence of interactions between environmental and social determinants (e.g., sanitation, inequities, stigma), biological risk factors (e.g., HPV infection, HIV co-infection), and systemic health system limitations [13, 16-18].
2. Systems thinking: Analysis of intricate, non-linear relationships between disease causes is made possible by systems thinking. It emphasizes how high burdens are maintained by reinforcing feedback loops (e.g., late diagnosis → strain on the health system → reduced public trust → decreased screening uptake). This approach also facilitates the identification of leverage points at which interventions may generate system-wide effects [9, 10].

2.3. Synthesis and Mapping

The data were summarized narratively and categorized into the following domains: prevention, detection, therapy, and systemic/social drivers. To show how various domains are interdependent, a conceptual systems map was created. Opportunities for integration are highlighted by this mapping, such as integrating HPV vaccination into community and school health initiatives or integrating Laboratory Quality Management Systems (LQMS) together across the environmental, animal, and human sectors.

3.1. HPV Vaccination: Progress, Gaps, and One Health Opportunities

The cornerstone of cervical cancer prevention is HPV vaccination. Precancerous lesions, genital warts, and HPV prevalence have all significantly decreased in high-income nations as a result of universal vaccination [7]. However, progress has been uneven across Africa. Only 28 of the 47 nations in the WHO African Region had implemented HPV vaccination by 2022, and the mean coverage among girls between the ages of 9 and 15 was 33% [5]. Although more recent estimates indicate a slight improvement to about 40% in 2023, this is still significantly below the global target of 90% [6, 12].

Scaling up vaccination is hampered by a number of factors, including a lack of funding, reliance on Gavi and other external funding sources, community-level vaccine hesitancy, and fragile cold-chain infrastructure in remote areas [2, 12, 19]. Some nations have limited the impact of vaccination by implementing it only in pilot districts rather than across the entire country [5].

Clinical investigations have shown that the single-dose HPV vaccination regimen offers long-lasting protection on par with traditional multidose schedules [8, 20]. This is a significant advancement. From a One Health perspective, integrating HPV vaccination with community outreach programs, school health initiatives, and reproductive health services could improve coverage and efficiency [21]. In rural places, existing veterinary and public health logistics networks may offer chances for infrastructure sharing. However, when implementing cross-sectoral cold-chain initiatives, disparities in governance structures, vaccine handling requirements, legal frameworks, and public perception pose significant hurdles that should be taken into account [13, 22].

3.2. Screening and Diagnosis Challenges

Screening is crucial for women who are currently at risk, while vaccination provides protection against future disease. However, less than 10% of women in the majority of African nations have ever had screening, whereas over 60% in many high-income environments have undergone screening [5, 23]. Visual Inspection with Acetic Acid (VIA), a low-cost but low-sensitivity technique, is commonly used for screening. HPV DNA testing (the gold standard), which provides greater sensitivity than VIA, remains largely confined to research settings or urban centres in many countries [15].

The infrastructure for diagnostics is also limited. Inadequate laboratory quality systems, a shortage of pathologists and cytotechnologists, and limited capacity for histopathology lead to delayed or erroneous diagnoses [12]. Diagnostic algorithms and risk stratification may benefit from locally generated knowledge on the biology of cervical neoplasia (e.g., VDR signaling across lesion grades) [24]. To enhance risk stratification and facilitate diagnostic procedures, digital pathology and AI-based methods are increasingly being investigated [25]. However, widespread adoption in many African contexts is still hampered by the high cost of scanners, poor internet access, erratic power supplies, and a lack of workers and training opportunities. Therefore, a more practical route to achieving enhanced diagnostic capability prior to 2030 would be a phased deployment through regional referral centers and telepathology networks [12, 25].

Systems thinking illustrates the interaction among these limitations: a negative feedback loop is created when the proportion of advanced disease rises due to delayed diagnosis, overwhelming already precarious oncology services, decreasing survival, and undermining public trust in health institutions. Integration with current One Health laboratory networks for the surveillance of antibiotic resistance and zoonotic diseases offers an opportunity to improve diagnostic capabilities and standardize quality control across industries [16, 17].

3.3. Environmental and Social Determinants

Environmental and socioeconomic factors also influence the burden of cervical cancer. HIV-positive women are up to six times more likely to develop cervical cancer, and the HIV epidemic in Africa makes HPV persistence and progression worse [17, 18]. Furthermore, chronic cervical inflammation brought on by parasite diseases such as Schistosoma haematobium may make a person more vulnerable to HPV infection [18, 26].

Women's access to immunization and screening is further limited by social barriers, such as poverty, living in a remote area, transportation difficulties, and exorbitant out-of-pocket expenses [27, 28]. The use of preventive interventions is also hampered by stigma, gender disparities, and low health literacy [28]. Evidence regarding the frequency, causes, and features of precancerous cervical lesions in Africa provides additional support for the development and execution of successful cervical cancer screening programmes [29]. Through chronic inflammation, oxidative stress, immune dysregulation, and impaired clearance of persistent high-risk HPV infection, environmental exposures such as poor sanitation, contaminated water, indoor air pollution, and occupational chemical exposures may indirectly contribute to cervical carcinogenesis [18, 26, 30]. Women with HIV infection and parasitic illnesses such as schistosomiasis, which are quite common in some regions of sub-Saharan Africa, may be more susceptible to these consequences [17, 18, 26]. These linkages reinforce the broader One Health idea that environmental factors influence susceptibility to and progression of illness, even though the specific biological pathways are still not fully understood [30].

3.4. Health Systems, Governance, and Policy Integration

One major obstacle to eradication is a weak health system. Inadequate budget, heavy reliance on donor funding, fragmented national policy, and a significant shortage of oncology and pathology personnel are among the difficulties [5, 12]. Inadequate laboratory quality systems and limited implementation of Laboratory Quality Management Systems (LQMS) undermine the timeliness, comparability, and dependability of diagnostic services [11, 18]. Underinvestment in laboratories and staff development, from a systems-thinking perspective, leads to poor outcomes and delayed diagnoses, which in turn diminish political prioritization and prolong the cycle of neglect [9, 10]. Cervical cancer elimination programs can be supported, and diagnostic capacity increased, by strengthening laboratory quality systems through integration with current One Health laboratory networks [11, 16, 18].

Adopting a One Health lens highlights opportunities for integration:

• Integrating HPV vaccination into school-based and routine immunization programs.
• Including screening for cervical cancer in HIV and reproductive health programs.
• Connecting One Health laboratory quality initiatives with cervical cancer laboratory strengthening.
• To improve outreach and equity, cross-sector relation-ships are being developed in the fields of education, the environment, and community organizations.

Such integration aligns with broader regional and community-engaged approaches to accelerating the elimination of cervical cancer [22, 29, 31].

5.1. Strengthen HPV Vaccination Coverage

• To reach the WHO 90% objective by 2030, national HPV vaccination programmes need to be expanded.
• Implement and scale up the single-dose HPV vaccine, which lowers expenses and logistical complexity [8, 20].
• Use community-based platforms to reach adolescents who are not enrolled in school and integrate immunization delivery into school health programs [21].
• As part of a One Health strategy, make use of current cold-chain networks, such as those utilized in veterinary programs, to enhance vaccine distribution [13].

5.2. Enhance Screening and Diagnostic Capacity

• Switch from VIA to HPV DNA testing, giving point-of-care, reasonably priced molecular tests priority [15, 23].
• Make investments in cytology and pathology workforce training, bolstered by AI-assisted diagnostics and digital pathology [12, 25].
• To guarantee quality and comparability, link One Health laboratory systems with Laboratory Quality Management Systems (LQMS) across national laboratory networks [11, 17].

5.3. Address Social and Environmental Determinants

• Considering the significant co-burden in Africa, combine HIV care with cervical cancer prevention [17].
• To combat stigma, enhance health literacy, and boost screening participation, promote community involvement and education initiatives [27, 28, 31].
• Encourage more studies on environmental exposures, pollution, inadequate sanitation, occupational hazards, and parasite co-infections, as these factors may affect HPV persistence and cervical carcinogenesis through intricate biological and ecological interactions [17, 18, 30].

5.4. Strengthen Governance and Financing

• Create multi-sectoral policies that connect initiatives for HIV prevention, education, environmental health, and reproductive health to the elimination of cervical cancer [22, 29, 31].
• To reduce reliance on donor funding, raise domestic funding for vaccine acquisition, screening, and treatment [2, 6].
• Use integrated health information systems to track and assess progress toward the 90-70-90 eradication targets.

Through integrated One Health initiatives, African nations can enhance health systems, increase efficiency, and hasten the elimination of cervical cancer by utilizing synergies across the environmental, animal, and human health sectors [9, 10, 29].

5.5. Future Research Directions

Future studies should validate the proposed One Health systems-thinking framework in specific sub-Saharan African countries and evaluate its applicability across different health systems. Implementation science studies are needed to determine how HPV vaccination, screening, laboratory strengthening, and community engagement can be effectively integrated into existing healthcare systems [6, 22, 29, 31]. Further research should evaluate the feasibility and cost-effectiveness of point-of-care HPV testing, digital pathology, and AI-assisted diagnostics in settings with limited resources [12, 15, 25]. Additionally, research on the biological impacts of environmental exposures and the function of current One Health laboratory networks in aiding the diagnosis of cervical cancer is necessary [11, 16-18, 30]. Country-specific implementation studies and comparative evaluations across African settings will be particularly valuable for identifying scalable models that can accelerate progress towards the WHO 90-70-90 targets.