Building demand for cervical cancer elimination services in Malawi

Key Messages

• Women in Malawi want to be screened and take protective steps against cervical cancer
• The key coordination role of health centres must be consolidated and built up to improve the availability of and access to screening and treatment services for all women in Malawi.

In Malawi, a woman can invest a lot of time and expenses in visiting a health facility. Civil society organisations and service providers should work together to improve the ability of more women to access health services and ensure all women are informed and have regular screening for cervical cancer.

Our two groups – Women Living with HIV and AIDS (COWLHA) and Women Coalition Against Cancer (WOCACA) – share the same goal of a more holistic approach to providing women with Sexual and Reproductive Health Services. We see tremendous potential in working together more closely. Our support groups for women living with HIV and cancer can link up immediately in the regions where we already overlap (Nkhatabay in the North and Mangochi in the south) but all our groups can work together, expanding our reach and impact in Malawi. By joining forces, we hope that our rights-based approach can further mobilise community engagement and inspire our policymakers to embrace cervical cancer elimination ambitions and make the early upfront investments needed to scale up services in our country. 

Our challenges

At the outset with respect to cervical cancer screening, we experienced push back from traditional leaders and particularly men in the community. They did not like the idea of their women having this type of intimate health examination, particularly if there was a chance that it would be conducted by a male health worker. But our work with community leaders and in supporting health workers has addressed these initial concerns.

Now the challenges are in the provision of routine services. For example, while there may be trained staff at a health facility, the requirement for rotation of staff, often at short notice, means that women cannot be sure the services will be available when they arrive at the clinic – even if there are scheduled days for screening each week.

Women that COWLHA supports further report frustrations with the lack of key equipment, which also means screening services are cancelled. WOCACA has addressed these issues by bringing consumables like acetic acid or even hand sanitiser to the health facilities and ensuring they remain stocked. We also train community-level health workers so that knowledge stays in that location, but we often encounter screening teams that do not have treatment options for the precancers found, so referral is yet another hurdle for women. Here lies a true opportunity to scale up services countrywide by building the capacity of community health workers to ensure they can offer “screen and treat” options, ideally in one visit.

Finally, we hear of women being turned away after expressing interest in screening because they do not have their health passport with them. WHO’s call to action on cervical cancer elimination is an opportunity to generate a more positive attitude among staff, energise the system and really engage health workers to be supportive of women. Only when every woman was counted did we see progress in maternal health – we want this for cervical health too. 

Our progress

Women in Malawi want to be screened and take that protective step against cervical cancer. What we are finding is that once we have done our foundational work to build awareness in the community – working with village chiefs, engaging community health workers and importantly explaining to men – rural women are able to take that step for their own cervical health and adopt healthy behaviours. 

At WOCACA, we also wonder whether we should not also be focusing on women in urban settings. In cities, the stigma associated with cervical cancer is much higher than for other cancers. Our COWHLA support groups are also less visible. It is perhaps harder to know where to go in cities. With no clear path to a health centre that provides services, women are busy and the uncertainty makes it easy to just put off this simple prevention step.

In Malawi, we have conducted national campaigns to support HPV vaccination. These are successful, so we should also be doing public awareness campaigns about cervical health and screening. Women who have been through the screening experience and have had a good outcome – in other words, have been given the all-clear or have completed successful treatment of precancers – are critical to lowering the barrier for a first-time screen and normalising this exam. They can help make this one of the routine things that all women do to protect themselves. And by continuing to encourage women to speak out about cervical health, we can address simple fears about what cervical screening entails and break down commonly held misconceptions.

Finally, Malawi has started implementing self-sampling and HPV testing. We are really excited about the potential for these innovations to expand choices for women and the reach of services to all communities. We see real value in their potential in reducing some of the barriers in accessing care, including fears of a speculum exam, especially for that first-time screen.

Elimination campaigns with a focus on screening and treatment should be instigated to empower women, inspire health workers and drive national-scale services.