Few diseases reflect inequity as starkly as cervical cancer. It is the fourth most common cancer among women worldwide, despite being one of the most preventable. Where a woman lives largely determines her chances of developing this disease, with more than 90% of cases and deaths occurring in low- and middle-income countries (LMICs).¹

In the Indo-Pacific, the incidence and mortality rates are up to ten-fold higher than in Australia. For example, in Timor-Leste, just over a one-hour flight from Darwin, the incidence of cervical cancer is estimated to be as high as 14.8 cases per 100,000 women, with mortality rates of 7.9 per 100,000.² These disparities reflect a long-term lack of access to, and confidence in, quality preventive health services, and in particular, cervical screening.

Through the Elimination Partnership in Cervical Cancer (EPICC) program,^3,4 we have been privileged to support Ministries of Health in multiple countries across the region to develop and implement their cervical cancer elimination initiatives. One of these is Timor-Leste, a young post-conflict nation undergoing rapid health system development, where we have been working in partnership with the Ministry of Health since 2023.

Globally, every two minutes, a woman dies from cervical cancer.
– Dr. Tedros Adhanom Ghebreyesus, Director-General of the WHO

Cervical Cancer Elimination Initiative – A Global Strategy for Coordinated Action

In 2020, the World Health Organization (WHO) launched its global strategy to eliminate cervical cancer as a public health problem.⁵ This strategy builds on decades of scientific progress, including the understanding that almost all cervical cancers are caused by persistent infection with oncogenic human papillomavirus (HPV) types. To eliminate cervical cancer, all countries must reach and maintain an incidence rate below four per 100,000 women. Achieving this goal relies on three fundamental pillars of elimination and their corresponding targets (Figure 1).

Implementing this three-pronged approach across the pillars of HPV vaccination, HPV screening, and treatment of pre-invasive and invasive disease will accelerate progress towards elimination and maximise the number of lives saved.

Fig. 1. WHO Cervical Cancer Elimination strategic pillars and corresponding targets, based on the Global Strategy to Eliminate Cervical Cancer as a Public Health Problem.⁶

Across the globe, and particularly in the Indo-Pacific region, many countries are committed to eliminating cervical cancer. However, this is an ambitious goal for many and will require sustained and collective effort by governments, health systems, communities, and partners across multiple sectors.

Australia has been at the forefront of global cervical cancer control and is positioned to be the first country to achieve elimination as early as 2035,⁴ which is why it is imperative for us to share our experiences and expertise to support our neighbouring countries.

Funded by the Australian Government and the Minderoo Foundation, EPICC is a multi-partner regional initiative working across nine countries in the region (Fiji, Papua New Guinea, Vanuatu, Solomon Islands, Nauru, Tuvalu, Timor-Leste, Malaysia, and Indonesia), bringing together country leaders and Australian and international partners (see the declaration below for more details).

EPICC takes an end-to-end approach, providing tailored support across the cervical cancer control continuum. This includes strengthening HPV vaccination delivery, implementing HPV-based screening supported by digital registries, as well as laboratory strengthening for molecular testing and histopathology, surgical treatment capacity building through our partner the International Gynaecologic Cancer Society (IGCS), and palliative care. Alongside these activities, EPICC is working with governments and communities to support policy and planning, training, and capacity-building, as well as health promotion and advocacy.

The EPICC model takes a tiered approach with some countries, including Vanuatu and Tuvalu, working towards national scale-up to meet the WHO “90-70-90” targets, while others such as Malaysia and Papua New Guinea are expanding their previous successful programs. Countries including Timor-Leste and the Solomon Islands, which are at an earlier stage of their elimination journey, are now piloting new models of care while strengthening policy and planning foundations. This flexible approach supports countries to progress at their own pace while contributing to the shared regional goal of eliminating cervical cancer.

Cervical Cancer Elimination in Timor-Leste: Addressing Inequities and Advancing Sustainability

Timor-Leste, also known as East Timor, is a small LMIC country in Southeast Asia that occupies the eastern half of the island of Timor. Its geography is predominantly mountainous, with limited transport infrastructure and many rural, hard-to-reach communities, which shapes access to health services and contributes to persistent inequities.

Timor-Leste is a post-conflict nation that restored its independence in 2002 following prolonged occupation and violence surrounding the 1999 Timorese crisis. The legacy of conflict continues to influence institutional capacity, health system development, and human resources. Despite substantial progress in rebuilding national systems, service delivery remains constrained by workforce shortages, geographic barriers, and reliance on external support.

The population is approximately 1.4 million, with a youthful age structure and a high proportion living in rural areas. Subsistence agriculture is a primary livelihood, and poverty remains widespread, particularly outside urban centres. Social organisation is strongly shaped by kinship networks, and family is a central unit of support, decision-making, and care.

Culturally, Timorese society places a high value on community cohesion, respect for tradition, and intergenerational relationships. Women play a critical role within households and communities, particularly in caregiving, childrearing, and managing family wellbeing. However, gender norms can limit women’s autonomy in health decision-making, access to education, and economic participation, especially in rural settings. While national policies increasingly promote gender equality and women’s participation in public life, disparities persist between formal commitments and lived realities.

These contextual factors – post-conflict recovery, geographic constraints, demographic pressures, and gender dynamics – are central to understanding both the challenges and opportunities for advancing equitable and sustainable health initiatives, including efforts toward cervical cancer elimination.⁷

A blind woman from the Disability Association in Timor-Leste holding a self-collection swab for HPV testing during a photo shoot for a cervical screening awareness campaign.

Cervical cancer in Timor-Leste is a profound equity issue, disproportionately affecting women and people with a cervix who face barriers related to disability, geography, stigma, and socioeconomic disadvantage. Nearly everyone we meet in Timor-Leste has been affected in some way by this devastating disease. Stories of mothers, sisters, or daughters who have tragically died of cervical cancer are all too common and testify to the lasting mark it leaves across families, communities, and generations.

In response, the Ministry of Health has made significant progress to control it, including through the successful launch of the national school-based HPV vaccination program in mid-2024, the establishment of two HPV screen-and-treat clinics using self-collection and point-of-care testing at the Vera Cruz and Formosa Community Health Centres in Dili in 2025, and with plans underway to strengthen histopathology and treatment services at the National Hospital Guido Valadares (HNGV) with support from EPICC. However, there is growing recognition that these and future services must be accessible, inclusive, and equitable.

Dr. Dimenia explaining the self-collection process for HPV testing to a screening participant at Formosa CHC in Dili, Timor-Leste.

To better understand these challenges, a Gender Equality, Disability and Social Inclusion (GEDSI) Workshop was held in Dili in late 2025, hosted by the Ministry of Health, the State Secretariat for Equality and Social Inclusion, and the EPICC Timor-Leste team. The aim was to listen to communities about access to cervical cancer preventive services, identify barriers, and co-design solutions that reflect lived experiences. Twenty-seven representatives from government, civil society, health services, UN agencies, and community groups joined the workshop, including people whose voices are usually underrepresented in health system design. For example, people with disabilities, sexual and gender-diverse people, rural women, and survivors of gender-based violence.

Press conference following the opening session of the GEDSI Workshop in Dili, with Sra. Elvina de Sousa Carvalho, State Secretary for Equity and Social Inclusion, being interviewed. In the background, from left to right: Ms. Deidre Ballinger (First Secretary for Health with the Australian Embassy in Timor-Leste), Dr Santina Gomes (National Director for Hospital Support Services the Ministry of Health of Timor-Leste), Prof. Deborah Bateson (EPICC Deputy Lead, University of Sydney), and Sra. Madalena F.S. Gomes (National Director of Maternal and Child Health and lead of the Cervical Screening Program in Timor-Leste).

The ten priority recommendations which focused on embedding equity and inclusion through accessible communications, community engagement, clinical training, and improving data systems to monitor equitable access and outcomes are tabled for endorsement by the National Steering Committee for Cervical Cancer Elimination.

As one participant reflected:

Cervical cancer is not only a health problem, but also about access, respect, and inclusion. I now feel confident to bring this knowledge back to my community.

To address another key priority for Timor-Leste, the EPICC team, supported by the Australian Government, convened a four-day “co-design sustainability workshop” at the University of Sydney in early 2026, with senior leaders from the Ministry of Health. It was a wonderful few days where we jointly considered what was needed to sustain the program beyond the initial implementation phase through building systems that are resilient, integrated, and locally-led.

Ultimately, eliminating cervical cancer in an equitable and sustainable way requires strong leadership and political will, as well as trusted partnerships, evidence-informed policies, effective implementation, and meaningful community engagement. With these in place, elimination becomes not just a global ambition, but a reality for every woman and person with a cervix, regardless of where they live, how they live, or where they come from. We are both honoured and delighted to be part of this journey with our colleagues (now our firm friends) in Timor-Leste and across the region.

Delegates from the Ministry of Health of Timor-Leste attending the Cervical Cancer Sustainability Workshop at University of Sydney. The workshop was organised through the EPICC program, led by Prof. Karen Canfell (fourth from the right) and Prof. Deborah Bateson (fifth from the right), with support from the Australian Government and the Minderoo Foundation. Also pictured are members of the EPICC team based in Dili, Timor-Leste: Dr Merita Monteiro, Dr Jose Antonio Guterres, and Dr Andriano Pereira; and in Sydney, Australia: Dr Telma Costa, Dr Carol Naidu, Mr Timothy Balshaw, Prof Kristine McCartney, Dr Ai Ling Tan, and Ms Kirsten Ridley, Ms Julia Da Costa, with Australian Government Representatives Ms Deidre Ballinger and Ms Julia Magno.

Declaration

EPICC is funded by the Australian Government and the Minderoo Foundation, and delivered by the EPICC consortium, led by the University of Sydney and including the Australian Centre for the Prevention of Cervical Cancer (ACPCC), the Kirby Institute at UNSW Sydney, Family Planning Australia, the National Centre for Immunisation Research and Surveillance (NCIRS), and Unitaid. The consortium collaborates with ministries of health and leading local and global organisations such as the Union for International Cancer Control (UICC), the International Gynaecologic Cancer Society (IGCS), The Women’s Health and Empowerment Network (WHEN), MD Anderson Cancer Center, and the Penn Center for Global Oncology (CGO) to advance cervical cancer elimination.

Combined funding commitments from the Australian Government and Minderoo Foundation in EPICC, and the foundational ECCWP program, exceed $42 million.