Integration of Cervical Cancer Screening Into Primary Healthcare: A Multi-Country Analysis of Vertical and Horizontal Approaches
Leshia Hansen, Prajakta AdsulPURPOSE
To understand how cervical cancer screening interventions are integrated into primary healthcare settings, with attention to vertical and horizontal integration approaches, using Valentijn’s integrated care framework and WHO people-centered health services model.
METHODS
We conducted a secondary thematic analysis of 32 semi-structured interviews collected between June and October 2022 with stakeholders involved in cervical cancer screening programs. Participants represented 25 countries across all WHO regions and multiple World Bank income classifications, and included health ministry officials, program managers, clinicians, and epidemiologists. Transcripts were coded deductively using Valentijn’s framework (clinical, professional, organizational, and system integration; functional and normative enablers) and WHO integrated care components. Analysis examined how integration strategies were operationalized across the cascade of care, staff roles, colocation of services, readiness for integration, self-collection, and point-of-care testing.
RESULTS
Integration approaches spanned a continuum from vertical, program-specific delivery to horizontally embedded primary care models, with most countries using hybrid approaches. Vertical integration was most evident at system and organizational levels through national programs, dedicated funding, and centralized laboratory networks along with structured referral pathways. Horizontal integration was most prominent at clinical and professional levels, including embedding screening into routine primary care, task-sharing among providers, and colocation within maternal and reproductive health services. Functional integration, particularly data systems, patient tracking, and referral coordination, served as a critical bridge between vertical and horizontal approaches and is likely to be associated with reduced losses along the cascade of care. Normative integration supported provider engagement but was inconsistently institutionalized. WHO-aligned strategies, including self-collection and point-of-care HPV testing, facilitated decentralization and showed the potential to strengthen primary care delivery. Persistent challenges included misalignment between programs and primary care, workforce constraints, and fragmented follow-up systems.
CONCLUSION
Cervical cancer screening programs operate along a spectrum of vertical and horizontal integration, with effective models leveraging strengths of both. Strengthening functional integration and alignment with primary healthcare systems is critical to support sustainable scale-up. This study reflects collaboration with partners across multiple countries including LMICs, the Principal Investigator maintains established professional relationships with in-country collaborators to support equitable research partnerships.