Closing the gaps between policy, plans and implementation for cervical cancer prevention in Indonesia

The possibility of eliminating cervical cancer as a public health problem by the year 2030, relies on population-dense countries such as Indonesia having the required political commitment, clear policy and implementation plans, and most critically, health systems that can support widespread and rapid scale-up of primary and secondary prevention technologies.

Collaborative research between the Nossal Institute and our partners at the Centre for Reproductive Health at Gadjah Mada University have been at the forefront of assessing health system readiness for upscaling both cervical screening and human-papilloma virus (HPV) vaccination in Indonesia. Findings from our most recent investigation across thirteen districts and three provinces found significant differences in readiness to upscale cervical screening by region and by facility.

By identifying these gaps, we aim to provide guidance on the specific resources and processes required to bring the health system to the point of readiness needed to support scale-up across the diverse contexts of Indonesia’s thirty-eight provinces. A fully up-to-date National Plan for Cervical Cancer Elimination was launched in November 2023, and in 2024 the Indonesian Ministry of Health released its new National Cancer Control Strategy signalling that Indonesia is now at a critical juncture where the requisite political will and strategic framework exist, but the challenge of implementation remains.

Our findings from a mixed methods study conducted in late 2024 and early 2025 identify three key areas where readiness for cervical screening scale up is yet to be achieved, these are: facility readiness, health worker readiness, and health promotion readiness. Key gaps in health facility readiness include: lack of uninterrupted medical supplies, lack of cryotherapy devices or working cryotherapy devices, lack of gas required to operate cryotherapy devices and in some instances lack of access to functional autoclaving equipment to ensure efficient sterilisation of speculums. Relevant health worker gaps include an insufficient number of trained health workers to offer screening on a continuous basis. Although health workers who have been trained asserted that they had adequate knowledge of HPV and cervical cancer, many felt unprepared to communicate this knowledge to clients and were unprepared to discuss positive test results. The demand for culturally appropriate and accessible health promotion materials was extremely high among the health workers interviewed. Additionally, a range of focus groups were conducted with a variety of community members, revealing high demand for accessible information about HPV and cervical cancer, significant false information within communities, and low-risk perception. The need for improved health promotion efforts was asserted from both the demand and supply sides of the equation.

In a nut shell, the study confirms that the current system has significant gaps in readiness, and that these need to be addressed via: ensuring facility capacity, promoting health worker competence by including communications and counselling skills in health worker training on HPV and cervical cancer, ensuring all eligible health workers receive the relevant training, the development of suitable health information materials, and widespread locally appropriate health promotion within communities. In the longer term the redesignation of tasks, including making cervical screening a designated competency for nurses and not just doctors and midwives, and making cryotherapy a designated competency for midwives and not only doctors, would dramatically increase health worker availability for the screen and treat approach. Finally, the allocation of dedicated budgets at central, provincial and district levels for cervical cancer prevention will be critical for achieving the success of Indonesia’s scale-up.

Professor Linda Bennett, Nossal Institute's Head of Education & Learning, is a global leader in research on sexual and reproductive health and rights (SRHR), in Indonesia . She is a medical anthropologist who focuses on reproductive and sexual health and rights, gender based violence, and gendered health inequities..

Professor Siswanto Agus is a Professor of Population Health and the Director of the Center for Reproductive Health (CRH), Faculty of Medicine, Public Health and Nursing at Universitas Gadjah Mada (UGM), Yogyakarta Indonesia.