Cervical cancer remains a pressing public health concern in Namibia, with significant barriers to prevention, particularly in rural areas.
This study explored health system’s challenges and their impact on cervical cancer prevention efforts.
This study was conducted in the Ohangwena and Kavango West regions of Namibia.
A qualitative exploratory design was employed, focusing on healthcare workers directly involved in cervical cancer prevention. In-depth interviews were utilised to collect data from 11 participants from four district hospitals. Thematic analysis, guided by the World Health Organisation’s six health system framework pillars, was used.
Key service gaps were identified across critical areas of cervical cancer prevention, including a lack of awareness, a lack of human papillomavirus vaccines and referral screening equipment that limited local outreach services. Other significant findings included the shortage of trained personnel and the manual data systems, which resulted in deficiencies in decision-making. Financial constraints, including reliance on non-governmental organisation funding and weak community engagement, exacerbated by cultural stigma, presented leadership challenges.
Investing in human resources for health, decentralising budget trends and enhancing data systems are critical for cervical cancer prevention in rural Namibia. Equally important is the active involvement of the community in these efforts.
This study highlights key health system constraints in the Ohangwena and Kavango West regions.
Cervical cancer continues to be a significant public health concern, with a pronounced variation in its incidence and mortality rates globally.
Over the years, healthcare systems in Africa have suffered from numerous challenges that have cut across institutional, financial, human resources, technical and political development.
Namibia faces challenges in the healthcare delivery sector that have influenced the high prevalence and incidence of cervical cancer. These challenges include a lack of awareness, a lack of HPV vaccines in the public health sector, which is the primary prevention method for cervical cancer; and a limited healthcare service delivery infrastructure.
Several studies have documented that cervical cancer prevention (CECAP) programmes are present in the healthcare systems of most developing nations.
There is a paucity of studies on CECAP, screening and treatment in Namibia. Though multiple studies have addressed prostate cancer
The study employed an exploratory qualitative design to explore the health system challenges in CECAP. The study was conducted in the Ohangwena and Kavango West regions, two predominantly rural regions located in northern Namibia. Ohangwena is a densely populated region bordering Angola, with a population of 261 691 people. Approximately, 94% of this population resides in rural areas.
The target population was healthcare workers (nurses, doctors and community health extension workers) involved in CECAP. This study employed a purposive sampling method to identify healthcare workers with firsthand experience of CECAP across the Ohangwena and Kavango West regions. Eleven participants were recruited from all the district hospitals in both regions. In addition, participants were approached through formal invitations sent through the office of their regional health directors. Healthcare workers from the two regions with at least a year of working experience in CECAP services were included in the study. This ensured insights from experienced individuals directly involved in cervical cancer management. Staff with less than one year in their role, those not directly involved in CECAP and those from outside the targeted health districts were excluded from the study.
An in-depth interview guide was used to conduct face-to-face interviews in English from June to August 2024. The guide’s themes were guided by the pillars of the WHO health system frameworks.
The socio-demographic data were analysed descriptively in Microsoft Excel and presented in a frequency table. The interviews were transcribed verbatim 24 h after each interview. An inductive thematic analysis approach was conducted, guided by the Braun and Clarke Framework.
Ethical clearance to conduct this study was obtained from the Research Ethics Committee of the Faculty of Health, Natural Resources and Applied Sciences at the Namibia University of Science and Technology (NUST) (No. FHNRAS:58/2023) and the Ministry of Health and Social Services Ethics Committee (No. 22/3/1/2). Permission to conduct the study in the selected settings was granted by the health regional directors for each region. Following the complete presentation of the study’s objectives and the expectations surrounding their participation, all participants gave their written consent. Participation was entirely voluntary, and transcripts were anonymised at reporting to protect the participants’ privacy. The data were stored and password protected on the personal computer of the corresponding author without access to any third parties to ensure confidentiality.
Eleven participants agreed to participate in the study; seven were females, and four were males. The demographic characteristics of the participants are outlined in
Socio-demographic characteristics of participants (
| Variables | Categories | % | |
|---|---|---|---|
| Age (years) | 18–29 | 1 | 9.0 |
| 30–35 | 4 | 36.4 | |
| > 35 | 6 | 54.6 | |
| Gender | Female | 7 | 63.6 |
| Male | 4 | 36.4 | |
| Education level | Diploma | 2 | 18.2 |
| Bachelor’s degree | 7 | 63.6 | |
| Master’s degree | 2 | 18.2 | |
| Occupation | Doctors | 4 | 36.4 |
| Nurses | 6 | 54.5 | |
| Health extension worker | 1 | 9.0 | |
| Working experience (years) | 1–5 | 4 | 36.3 |
| 6–10 | 3 | 27.3 | |
| > 10 | 4 | 36.4 | |
| Region | Kavango West | 6 | 54.6 |
| Ohangwena | 5 | 45.4 | |
| Employer | Government | 6 | 54.5 |
| NGO | 5 | 45.5 |
NGO, non-governmental organisation.
The findings are structured into six main themes: service delivery, health workforce, health information, health financing, essential medical products and technology and leadership and governance. The outline of themes, sub-themes and key findings is presented in
Outline of themes, sub-themes and key findings.
| Theme | Sub-theme | Key findings |
|---|---|---|
| 1. Service delivery | 1.1. Cervical cancer screening services | Clinics offer VIA and Pap smear screenings, but service interruptions occur because of shortages and logistical constraints, particularly in rural areas. |
| 1.2. HPV vaccine accessibility | HPV vaccines are primarily available in the private sector, with limited access to public health facilities. | |
| 1.3. Community outreach services | Outreach efforts are mainly clinic based, with occasional campaigns coordinated with community leaders. Resource and transportation challenges affect coverage. | |
| 2. Health workforce | 2.1. Staff shortages and retention | High turnover rates among healthcare workers, especially young professionals. Rural postings and lack of incentives contribute to retention challenges. Heavy reliance on NGO-funded positions raises sustainability concerns. |
| 2.2. Training and specialisation | Few healthcare workers receive specialised training in cervical cancer screening. There is a shortage of gynaecologists and oncologists. | |
| 3. Health information | 3.1. Data collection and management | Data collection is mostly manual, with limited use of electronic systems. Some districts have basic digital systems, but connectivity and equipment limitations pose challenges. |
| 4. Health financing | 4.1. Budget constraints | No dedicated government budget for cervical cancer prevention. Services rely heavily on NGO funding, raising concerns about long-term sustainability. |
| 5. Access to essential medicines | 5.1. Supplies for screening services | Frequent shortages of VIA and Pap smear kits disrupt service delivery. HPV vaccines are largely unavailable in public facilities. |
| 5.2. Equipment and infrastructure | Screening equipment is outdated, and storage facilities are inadequate. Basic infrastructure, such as examination beds, needs improvement to meet patient needs. | |
| 6. Leadership and governance | 6.1. Prevention policy | Leadership oversight is present, but strategic support is insufficient. Governance relies heavily on NGO funding because of the lack of a dedicated cervical cancer policy. |
| 6.2. Community involvement | Collaboration with community leaders is inconsistent. There is a lack of local advocates for cervical cancer awareness, and cultural stigma remains a barrier to screening. |
VIA, visual inspection with acetic acid; HPV, human papillomavirus; NGO, non-governmental organization.
High-quality service delivery ensures that personal and non-personal health interventions are safe, effective and accessible to those in need at the right time and place.
Cervical cancer screening services, including Visual Inspection with Acetic acid (VIA) and Pap smear tests, are available in all the district hospitals and some clinics. However, these services often face interruptions because of transport challenges and shortages of staff. A participant noted:
‘There are times we have to cancel trips to clinics because there is no car, even if the booking was made way earlier.’ (P1, female, 28 years old)
‘I am the only CECAP nurse here, and if I go on leave, then there is no one to screen, so patients should wait for me to come back.’ (P4, female, 48 years old)
This shortage hinders continuous access to cervical cancer screening services. While coverage was generally positive, consistency was affected by some challenges. Resource constraints occasionally slowed service provisions at the clinic, as noted by one participant:
‘It’s supposed to be in all clinics, but sometimes, due to staff and equipment shortage, you find some of the clinics stopped somewhere.’ (P6, female, 32 years old)
About 80% of the participants identified the availability of HPV vaccines as a critical issue, as these vaccines are primarily accessible through private-sector services only. The Namibian public health facilities have not introduced the HPV vaccine to date, and the participants were not even aware of any rollout, leaving lower-income populations underserved. One respondent stated:
‘Unfortunately, we cannot offer HPV to everyone who needs it, especially the patients who use public health services. It does not exist, but if you have medical aid, I am not sure, but I think you can get it in private.’ (P3, male, 51 years old)
Participants discussed varying views on outreach services, with some acknowledging the community sensitisation efforts through health talks on the community radio channel and the involvement of traditional leaders and Community Health workers. However, these efforts were often obstructed by logistical challenges. For instance, one participant indicated that:
‘Community campaigns are coordinated with traditional leaders, but screening primarily occurs in clinic settings, not really in the community, due to bad roads and long distances. Every clinic is given a specific date for when we are coming.’ (P1, female, 28 years old)
A responsive, fair and efficient health workforce works to achieve the best possible health outcomes, optimising available resources and adapting to prevailing circumstances.
Approximately 90% of the participants cited that the availability of trained healthcare staff was a prominent challenge, with many clinics served by only one or two CECAP-trained nurses and doctors, which limits service continuity and outreach capacity. Staff turnover was an ongoing issue, particularly in remote areas, where retention was almost impossible. One participant shared:
‘They come here to get into the system, then they want to leave. Housing and bush allowances are provided, but many nurses still transfer out to cities.’ (P3, male, 51 years old)
‘It’s hard to keep young professionals in these rural postings; they leave for better opportunities elsewhere.’ (P9, male, 40 years old)
Some participants also discussed the reliance on non-government organization (NGO)-funded positions, which further raises concerns about the sustainability of staffing:
‘All of us are conducting this service under NGO support. One day, when the NGO pulls out, there will be a huge challenge.’ (P7, female, 39 years old)
Most participants stressed the lack of specialised staff in CECAP and treatment, including trained gynaecologists and oncologists. Ohangwena region had one gynaecologist and Kavango west region had none. Most healthcare workers have minimal training in cervical cancer screening techniques, affecting the quality and reach of services. A respondent remarked:
‘We don’t have enough staff with specialised training, which limits the services we can provide.’ (P5, male, 37 years old)
‘If the patient comes in with an advanced stage of cervical cancer, we refer them to the Intermediate Hospital Oshakati (IHO). There is no capacity here.’ (P8, female, 36 years old)
A strong health information system allows the production, analysis, dissemination and use of accurate and timely data on health determinants, health system performance and population health status.
Participants from both regions reported that data collection largely relies on manual processes, with only a few districts employing basic digital systems. However, Internet connectivity issues and basic equipment shortages, such as computers, hamper digital data collection and management efforts. Some staff members noted:
‘Our data collection is still mostly manual, and without proper connectivity, digital options are hard to implement.’ (P1, female, 28 years old)
‘We don’t have enough computers because you would want them at each point of the care. The CDC should have, but most departments do not have.’ (P2, female, 35 years old)
One participant appreciated the quarterly data reviews that allowed clinics to assess and adjust service delivery:
‘Data is essential for planning and improving services. If I was here last quarter and I’m here now, it means I need to do more on this.’ (P11, male, 34 years old)
However, staff shortages occasionally disrupted data review meetings, reducing opportunities for thorough record analysis and feedback:
‘The data review meeting used to be conducted, but due to a lack of staff, we don’t attend all the meetings anymore.’ (P7, female, 39 years old)
A sound health financing system secures adequate funding to ensure that individuals can access necessary health services without risking financial hardship or poverty because of medical expenses.
The Namibian government has implemented Universal Health Care, and all health services in public facilities are free of charge. However, there is no dedicated funding for cervical cancer alone. Thus, the CECAP programme relies heavily on NGO financial support and primarily focuses on HIV-positive patients. While this dependence elevated sustainability concerns, participants appreciated the resources NGOs provided, which allowed facilities to maintain continuous services. One participant expressed appreciation for this partnership:
‘NGOs are collaborating with the government, giving us the necessary stock and supporting us.’ (P6, female, 32 years old)
Another participant noted the benefit of this funding, particularly for reaching remote communities:
‘With the support of NGO, we have been able to keep services running and reach out to more women, especially those that live in the inland.’ (P7, female, 39 years old)
However, participants expressed concerns about the absence of a district-specific budget, which made consistent outreach difficult and often drove health workers to resort to informal funding mechanisms such as the use of personal funds and other sales to meet agent needs. One participant emphasised this point:
‘We do not have a budget at the district level, only at the region, and the competition is high. Basically, first come, first serve. So, when there is no money, and we want to buy, for instance, curtains, staff members contribute money. Sometimes, we sell the empty containers from the pharmacy to generate more [
A functional health system ensures fair access to high-quality, safe, effective and cost-efficient medical products, vaccines and technologies supported by scientifically sound practices.
Essential screening supplies were generally available in many clinics, allowing for continued VIA and Pap smear services. However, for early-stage screenings and treatment for positive cases, participants reported adequate resources, although there were no HPV screening services. One participant noted:
‘When a patient presents with precancerous cells, for stage one and two treatments, we manage [
However, all participants from one district hospital reported facing recurring shortages of supplies for cervical cancer screening, requiring rescheduling of patients. A participant noted the need for consistent supply management, saying:
‘Pap smear testing kits usually run out of stock, then we rebook the patients, especially those who are above 60 years, and give them a date to come back, but sometimes most of them do not come back and only come back when they are sick.’ (P11, male, 34 years old)
A shortage of educational materials was also highlighted, which hindered awareness efforts, as one participant mentioned:
‘The ministry does not provide pamphlets anymore. Giving health information from the mouth without giving pamphlets is ineffective.’ (P7, female, 39 years old)
Health facilities require improved infrastructure, including updated equipment and sufficient storage, which facilitates the delivery of quality care. Basic amenities such as examination beds often need to be improved, impacting patient comfort and care quality. A participant remarked:
‘We don’t even have examination beds like this one I am using belongs to casualty, and they can come to get it anytime. Sometimes even this lamp you see here is not working; it’s challenging to provide quality care with such limited resources.’ (P4, female, 48 years old)
Challenges in governance and leadership reflect a lack of cohesive policies and insufficient community engagement in cervical cancer awareness and prevention.
While leadership oversight was evident, strategic support was limited; participants felt that logistical and policy support for CECAP required strengthening. One staff member commented:
‘The absence of a dedicated policy makes it hard to establish structured, long-term programmes for cervical cancer.’ (P5, male, 37 years old)
‘We don’t have a specific policy for cervical cancer here; it’s all managed under general health.’ (P3, male, 51 years old)
Although there is some collaboration with community leaders, it remains occasional, with limited advocacy for cervical cancer awareness, as most initiatives are focused on other diseases such as HIV/AIDS, TB and malaria. Furthermore, cultural stigma discourages many women from participating in screenings, as reproductive health discussions are deemed taboo in the setting. A participant explained:
‘Cultural beliefs and misinformation that your womb will be removed, and many others, discourage many people from seeking screening; we need more local champions to advocate for awareness.’ (P2, female, 35 years old)
Despite these limitations, the involvement of community leaders in health campaigns from one district was appreciated, as it helped build trust and engage the community. Another participant highlighted:
‘Community leaders are involved, and we hold meetings with them here and there to discuss health issues, including cervical cancer.’ (P4, female, 48 years old)
This study found that while CECAP services are available and actively implemented in both regions, issues related to staffing, funding and essential resources present significant barriers to achieving comprehensive service delivery. CECAP services delivery in these regions is structured into primary and secondary levels yet lacks consistency in coverage and effectiveness. Primary prevention efforts, such as awareness education and vaccination against HPV, are hindered by availability, with vaccines predominantly offered only in private facilities at a cost that is not affordable to many. As noted in studies by Al-Amro et al.
The study highlighted a lack of adequately trained health professionals, particularly in specialised areas such as gynaecology and oncology. Studies by Legasu et al. and Habila et al.
Staff retention issues, particularly among young nurses who relocate to urban areas seeking better living and working conditions, further complicated service continuity. For instance, it was identified that only one or two CECAP-trained nurses were available per district, often requiring rotational service to multiple clinics. These findings align with those of Mugassa and Frumence,
Moreover, the study revealed that data management was largely manual, limiting the potential for effective data collection, storage and analysis. Although some electronic tools were in place in some facilities, equipment shortages and Internet connectivity issues were reported to hamper their effectiveness. The study further found that even though manual data collection was consistent, users often perceived the process as ineffective because of its inability to be integrated into strategic planning. The limited use of collected data for actionable decisions in these regions could indicate a more significant trend seen in other studies, where data collection in low-resource settings tends to be administrative rather than strategic.
Additionally, funding was noted to be a critical barrier, highlighting that NGOs primarily funded CECAP services. This is consistent with previous findings highlighting that cervical cancer services in SSA are often donor dependent, with NGO funding accounting for a substantial share of resources.
Additionally, this study found that although some screening equipment is generally available at district hospitals, clinics and outreach points, it often lacks portable screening equipment, such as foldable beds and privacy tents. The need for portable screening equipment is emphasised in similar studies, where limited resources for mobile units directly affect the accessibility of cancer screenings in rural areas.
Finally, leadership and governance challenges, especially the double roles of healthcare managers, affect the coordination and delivery of healthcare services, including CECAP. Health managers struggle to balance administrative duties with direct patient care responsibilities and may face time constraints that hinder their involvement in operational oversight. This challenge echoes the findings by Obol et al.,
The results are contextual and cannot necessarily be extrapolated to other areas, particularly urbanised regions of either Namibia or other nations. Additionally, this is a qualitative study based on the perceptions of participants, which may lead to response bias. However, triangulating the new findings with some quantitative data would allow for a comprehensive description of the challenges of CECAP.
The cross-cutting challenges to CECAP observed in this study highlight systemic barriers that will need many solutions. Improving access to CECAP services is vital to tackle service delivery issues, workforce shortages and retention issues, health information challenges, financial constraints and pervasive governance gaps. This study adds to the literature by identifying region-specific barriers and potential evidence-based solutions in policy, such as district-specific budgets, improved workforce training and increased access to mobile service screening. These recommendations, if implemented, will enhance the CECAP framework within Namibia and could be a model for other low-resource settings.
Recommendations to policy and practice:
The Ministry of Health and Social Services (MoHSS) needs to allocate district-specific budgets to support regionally tailored CECAP efforts.
MoHSS is encouraged to improve training and retention of healthcare workers who are involved in cervical cancer screening and health education services.
The MoHSS needs to support and expand access to mobile screening services to reach remote and underserved populations.
Strengthening health information systems is critical to improve tracking, monitoring and reporting of cervical cancer services.
The MoHSS needs to incorporate community engagement strategies to address cultural norms and improve cervical cancer screening uptake.
Recommendations for future research:
Evaluate the cost-effectiveness of mobile cervical cancer screening in rural areas.
Explore culturally sensitive interventions aimed at enhancing community awareness towards cervical cancer screening.
Investigate the role of digital health technologies in improving health information management and follow-up care in cervical cancer screening programmes.
The authors would like to acknowledge the participants who took time off their busy schedules to participate in this study. This article is partially based on the author E.K.N.’s ongoing PhD titled The development of a community based prevention model for cervical cancer management in Ohangwena and Kavango West region in Namibia towards the degree of Doctor of Philosophy in Health Sciences in the Department of Preventative Health Sciences, at the Namibia University of Science and Technology, Namibia with supervisors Dr Mahalie and Dr Hailonga-Van Dijk.
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
E.K.N. was responsible for the entire study process through conceptualisation, methodology design, the conduct of the research, data analysis and validation. R.M. and P.H.-v.D. were the overall study supervisors and contributed to the article’s idea, method design, validation and critical review. All authors, E.K.N., R.M. and P.H.-v.D., discussed the results and contributed to the manuscript.
The data that support the findings of this study are available from the corresponding author, E.K.N., upon reasonable request.
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.