Challenges in implementing a cervical screening program in South Africa

Background: The Cervical Health Implementation Project was initiated with the aim of developing and evaluating health system interventions for improving public sector cervical screening services. The project was conducted between January 2001 and May 2003 in three districts in South Africa. This paper describes the districts, interventions and their evaluation, and discusses the implications of these findings for the roll out of a national cervical screening program. Methods: A pretest/post-test study design was employed. The following interventions were developed and implemented: health worker training workshops, health system tools and protocols and a community awareness program. Pre- and post-intervention facility audits, key informant interviews, staff knowledge, attitude and practice (KAP) surveys and client KAP surveys were conducted. Clinic records and cytology laboratory data were reviewed. Results: Service organization, availability of screening equipment and education and communication materials improved. The proportion of staff who knew the screening policy increased from 43% to 82%; and 68% of staff agreed with the screening policy after, as opposed to 23% before the intervention. In two of the districts, cytology turnaround times continued to be long. Only 50% of women with a high-grade squamous intraepithelial lesion had a colposcopy and biopsy within 6 months of a Pap smear. Although the number of new smears performed in the three districts increased from 1544 in 2001 to 2801 in 2002, overall the coverage remained less than 4%. Conclusion: This project highlights the considerable challenges that need to be addressed to effectively implement the national screening policy.