Global determinants of cervical cancer outcomes: a health systems analysis

Objective: Significant global health disparities persist in cervical cancer, with over 85% of cases and deaths occurring in low- and middle-income countries (LMICs). In many settings, access to screening, vaccination and treatment is limited. Despite cervical cancer being largely preventable through human papillomavirus (HPV) vaccination and early detection, many women around the world face inadequate healthcare infrastructure, lack of awareness, cultural stigma and gender barriers to seeking care. Therefore, we evaluated global health system metrics that may inform efforts to improve equity in access to cervical cancer care globally. Methods and analysis We derived estimates of age- standardised mortality-to- incidence ratios (MIRs) for female patients with cervical cancer of all ages from the Global Cancer Observatory (GLOBOCAN 2022 database), with complete data available for 121 of 185 countries in the database. We selected the following health system metrics: health spending as a per cent of gross domestic product (GDP), physicians/1000 population, nurses and midwives/1000 population, surgical workforce/1000 population, GDP per capita, Universal Health Coverage Service Coverage Index (UHC index), availability of pathology services, Human Development Index (HDI), Gender Inequality Index (GII) (a combined metric of health, empowerment and economic agency), radiotherapy centres/1000 population, out-of- pocket expenditure as percentage of current health expenditure, availability of cervical cancer screening, and HPV coverage. We evaluated the association between MIR and each metric using univariable linear regressions. To account for multiple comparisons, a Bonferroni correction using a p<0.0045 was applied. Metrics meeting this threshold were included in multivariable models. Variation inflation factor (VIF) allowed exclusion of variables with significant multicollinearity. R2 defined goodness of fit. Subgroup analysis was done by country income level using 2025 World Bank classifications. Separate regression models were then done for high-income and low-middle- income countries. Results On univariable analysis, 12 of the 13 metrics were significantly associated with MIR of cancer (p<0.001 for all). HPV coverage was not significantly associated with MIR (β=–0.0007, p=0.290). After including metrics that were significant on univariable analysis, HDI demonstrated significant collinearity (VIF=19). Therefore, after correcting for multicollinearity, the final multivariable model with 11 variables had R2 of 0.81. On multivariable analysis, the following variables were independently associated with lower (improved) MIR for cancer: (1) nurses/midwives per 1000 population (β=–0.0072, p=0.029) and (2) UHC index (β=–0.0022, p=0.026). In addition, greater gender inequality was associated with greater (worse) MIR (β=0.30, p=0.003). Further subgroup analysis by income classification showed that GII remained significantly associated with lower MIRs among HICs (β=–0.526, p=0.033), and only UHC index was significantly associated among LMICs (β=–0.0023, p=0.047) Conclusion: This comprehensive and global analysis of health system metrics suggests promoting progress towards UHC and strengthening the nursing/midwifery workforce may be independently associated with improved cervical cancer MIR. Furthermore, greater gender inequality was associated with worse MIR. These findings may inform efforts to improve global cervical cancer care and underscore the importance of reducing gender inequality to improve global cervical cancer outcomes.