In Kampala's Mulago Hospital, Dr. Sarah Nakabugo sees roughly 15 women each week who test positive for precancerous cervical lesions using visual inspection with acetic acid (VIA). The test itself is simple and cheap—a cotton swab, a bottle of vinegar, a bright light. But the next step, treatment, often stalls. “I tell them to come back for cryotherapy, but half never do,” she says. The machines meant to freeze away those lesions sit unused in storage rooms across the country, victims of a broken supply chain and a procurement system that favors consumables over equipment.

A Preventable Cancer’s Slow Death

Cervical cancer kills roughly 3,500 Ugandan women each year, making it the leading cause of cancer death among women in the country. Almost all cases are caused by persistent infection with high-risk human papillomavirus (HPV). The disease is highly preventable through vaccination and screening, yet Uganda’s HPV vaccination coverage remains below 15%, far short of the 90% target set by the World Health Organization (WHO). Screening access is even worse: only about 5% of eligible women have ever been screened.

The WHO recommends that all women aged 30–49 be screened at least once, and preferably every 5 years. In Uganda, the government has adopted VIA as the primary screening method because it is inexpensive—around US$0.50 per test—and can be performed by nurses after a short training. But screening alone does not save lives. The evidence is clear: treatment of screen-positive women is what reduces mortality. And that is where the system breaks down.

A 2023 study in the Journal of Global Oncology estimated that only about 10% of Ugandan women who screen positive for cervical precancer actually receive treatment within the recommended timeframe. The rest are lost to follow-up, often because they cannot return for a second visit, cannot afford transport, or simply do not understand why treatment matters. The result is that thousands of women each year progress from treatable precancer to invasive cancer that is far harder and more expensive to manage.

To put that number in perspective, consider the experience of a single district. In Mityana, a rural area about 70 kilometers west of Kampala, a 2022 pilot program screened 1,800 women over six months. Of the 210 who tested VIA-positive, fewer than 30 received cryotherapy within three months. The rest were told to come back later, but most never did. By the time the program ended, at least five women had already developed symptoms of invasive cancer—pelvic pain, abnormal bleeding—that required referral to a regional hospital for biopsy and, if confirmed, radiation or surgery. Those treatments cost the health system roughly ten times what same-visit ablation would have, and the women faced far worse outcomes.

VIA’s Limits Without a Follow-Up Step

VIA is a visual test: the clinician applies dilute acetic acid to the cervix and looks for white patches that indicate abnormal cells. Its sensitivity in field studies hovers around 70%, meaning it misses roughly 30% of true precancers. But when it does detect a lesion, the WHO guidelines are unambiguous: treat immediately, ideally during the same visit. The recommended treatments for VIA-positive lesions are cryotherapy (freezing) or thermal ablation (heat-based destruction). Both are effective, with cure rates above 85% for appropriately sized lesions.

Yet in practice, same-visit treatment is rare in Uganda. A 2022 survey of 120 health facilities across 10 districts found that cryotherapy machines were present in about 60% of clinics but were functional in fewer than 40%. The most common reasons for non-functionality were lack of refrigerant gas (nitrous oxide or carbon dioxide), broken regulators, and absence of trained staff. At Kawempe Referral Hospital, a nurse who asked not to be named described the cryotherapy machine as “a decoration. It hasn’t worked in a year because we can’t get the gas.”

The consequences are stark. When a woman tests VIA-positive but cannot be treated on the spot, her chances of ever receiving treatment drop sharply. A 2019 systematic review found that loss to follow-up after a positive screening test ranges from 30% to 80% in low-income settings. In Uganda, a pilot program that introduced same-visit thermal ablation reduced pretreatment dropout from 65% to 12%, according to a 2021 Ministry of Health report. That is a difference of hundreds of lives per year, per clinic.

But even when treatment is available, not all women are good candidates. Cryotherapy and thermal ablation are only recommended for lesions that are small (less than 75% of the cervix), fully visible, and confined to the transformation zone. For larger or suspicious lesions, a biopsy and excisional procedure like loop electrosurgical excision procedure (LEEP) is needed. LEEP requires electricity, a generator, and more advanced training, which are even scarcer in rural Uganda. So the treatment gap is not just about machines—it is also about the absence of a full spectrum of treatment options. For the roughly 10–15% of VIA-positive women who have large or irregular lesions, there is often no treatment at all within the public system.

Why Machines Gather Dust in Kampala Warehouses

The disconnect between VIA kit availability and cryotherapy functionality is not accidental. It is the product of a procurement and supply chain system that systematically favors cheap consumables over durable equipment. VIA kits cost roughly US$0.50 each and are easy to order, ship, and store. Cryotherapy machines cost about US$2,000 each and require a steady supply of medical-grade gas, which is expensive and logistically challenging to distribute to rural clinics.

Gas supply chains in Uganda are fragile. Nitrous oxide, the most commonly used refrigerant, is produced at a single plant in Kampala and distributed through a network of private distributors that often prioritize hospitals in the capital. Rural clinics may wait weeks or months for a refill. Some have resorted to using carbon dioxide from fire extinguishers, which is not sterile and can cause infections. Others simply stop offering cryotherapy altogether.

Training gaps compound the problem. The national cervical cancer prevention program has trained roughly 1,200 nurses in VIA screening, but only about 300 have been certified to perform cryotherapy. The training for cryotherapy requires hands-on practice with the machine and a working gas supply—both of which are often unavailable. “We train nurses on a machine that doesn’t work,” says Dr. Nakabugo. “They learn the theory, but they never get to treat a real patient.”

This training bottleneck has a cascading effect. Even when a clinic has a functional cryotherapy machine, if the one trained nurse is on leave or transferred, the machine sits idle. At a health center in Jinja, a cryotherapy machine donated in 2021 was used for exactly three months before the trained nurse was promoted to a district role. No replacement was trained, and the machine has been in storage ever since. The district health officer said he requested training for two new nurses, but the Ministry of Health’s training team had no budget for travel to Jinja that year.

The Evidence for Same-Visit Ablation

Thermal ablation offers a way around many of these barriers. The devices are portable, battery-powered, and cost around US$800 each—less than half the price of a cryotherapy machine. They do not require gas; instead, they heat a small probe to around 100°C and apply it to the lesion for 20–40 seconds. The procedure is well-tolerated, can be performed by nurses after a 2-day training, and has a cure rate comparable to cryotherapy.

Multiple studies have demonstrated the feasibility of thermal ablation in low-resource settings. In Kenya, a pilot program introduced thermal ablation at 15 public health facilities and achieved a treatment completion rate of 88% among VIA-positive women, compared with 35% in facilities relying on cryotherapy with delayed treatment. The Kenyan Ministry of Health has since adopted thermal ablation as the preferred treatment method for cervical precancer and is scaling it up nationwide.

Uganda has its own pilot data. A 2022 study in the International Journal of Gynecology & Obstetrics reported on a Ministry of Health program that introduced thermal ablation at 20 clinics in central Uganda. Over 18 months, 2,400 women were screened, 340 tested VIA-positive, and 306 (90%) received same-visit thermal ablation. Loss to follow-up was under 5%. The study concluded that thermal ablation was “highly acceptable to both providers and patients” and recommended national scale-up.

Yet the Ugandan Ministry of Health has been slow to act. As of late 2024, only about 50 thermal ablation devices were in use across the country, most of them donated by international partners. The national cancer control plan for 2023–2027 mentions VIA 14 times but refers to “ablation” only twice, and does not specify thermal ablation as a priority procurement item.

Why the hesitation? One reason is that thermal ablation is still relatively new to the global health community, and some policymakers worry about the durability of the devices in tropical conditions. Batteries can degrade in heat, and the probes may need replacement more often than manufacturer claims suggest. A 2023 evaluation in Malawi found that after 12 months of use, about 15% of thermal ablation devices had minor malfunctions—usually a loose battery connection or a cracked probe tip. While these are easily fixed with spare parts, the supply chain for spare parts is not yet established in Uganda. Critics argue that the same gas supply chain problems that plague cryotherapy could simply be replaced by battery supply chain problems.

But proponents counter that batteries are far easier to distribute than heavy gas cylinders. A thermal ablation device can run on rechargeable lithium-ion batteries that last for about 50 treatments per charge, and a solar charger can keep them running even in clinics without grid electricity. In a pilot in rural Gulu, a solar-powered thermal ablation device treated 120 women over three months without a single power outage. The same clinic had previously been unable to offer cryotherapy because the gas distributor refused to deliver to the area due to poor roads.

Donor Dollars and Procurement Distortions

The preference for VIA over treatment is not just a local problem; it is shaped by global funding streams. PEPFAR and the Global Fund, two of the largest donors for cervical cancer programs in sub-Saharan Africa, have historically allocated their budgets toward screening and prevention rather than treatment equipment. VIA kits and HPV tests fall under “commodities” categories that are easy to approve and track. Cryotherapy machines and thermal ablation devices are classified as “equipment,” which requires separate justification, longer approval timelines, and often a higher level of bureaucratic oversight.

Uganda’s 2023–27 national cancer control plan illustrates the imbalance. The plan budgets US$1.2 million for cervical cancer screening commodities over five years, but only US$200,000 for treatment equipment—a ratio of 6:1. At the same time, the plan estimates that 80,000 women will screen VIA-positive during the period. Treating them with cryotherapy or thermal ablation would require roughly 400 devices (assuming one device per 200 women treated per year) and a steady supply of gas or batteries. The current budget covers about 50 devices.

Donor procurement cycles also create perverse incentives. Many donors require that equipment be purchased from approved vendors, often in the United States or Europe, at prices that are 2–3 times higher than locally available alternatives. A thermal ablation device that costs US$800 from a Kenyan distributor might cost US$1,500 from a US-based supplier. The extra cost is not matched by better quality; it is simply a function of procurement rules designed to favor manufacturers in donor countries.

This distortion extends to the choice of technology itself. Some donors have historically preferred cryotherapy because it has a longer track record and is listed in WHO guidelines as a “recommended” treatment. Thermal ablation, while also recommended, is still categorized as an “alternative” in some older WHO documents, which makes some procurement officers reluctant to approve it. A 2024 analysis by the Clinton Health Access Initiative found that switching from cryotherapy to thermal ablation could reduce per-treatment costs by roughly 40% in Uganda, but the savings are not captured by donor budgeting systems that separate equipment from consumables.

Clinicians on the Frontline Speak Out

Dr. Nakabugo is one of many clinicians who have grown frustrated with the gap between policy and practice. At Mulago, she says, the cryotherapy machine has been broken for six months. “We have a repair contract with a company in Kampala, but they take weeks to respond. Meanwhile, I have women coming from upcountry who have traveled for hours. I can’t tell them to come back.” She has started referring VIA-positive patients to a private clinic that offers thermal ablation for a fee of about US$10—unaffordable for most of her patients.

At Kawempe Referral Hospital, the situation is similar. The nurse there showed me a stock card that listed 200 VIA kits in the storeroom but zero cryotherapy gas canisters. “We used to do cryotherapy twice a week,” she said. “Now we just screen and refer. Most of the women we refer never show up at the regional hospital.” The regional hospital, 30 kilometers away, has a functional cryotherapy machine but only operates it one day per week due to gas shortages.

The problem is not limited to Kampala. A 2023 assessment of 45 health facilities in five districts found that only 12 had a functional cryotherapy machine, and only 6 had a trained provider available on the day of the visit. In the same facilities, VIA kits were in stock 95% of the time. “We are good at finding the disease,” says Dr. Nakabugo. “We are terrible at treating it.”

Another clinician, a midwife at a health center in Hoima, described her own workaround. She had been trained in thermal ablation during a short course run by a non-governmental organization, but her clinic did not have a device. So she borrowed one from a nearby mission hospital whenever she had a VIA-positive patient. The arrangement was informal and unreliable—sometimes the device was already in use, sometimes the battery was dead. Over six months, she managed to treat 18 women this way, but she estimates that at least 40 others were lost to follow-up because she could not offer same-day treatment.

What a Shift to Ablation Would Require

Scaling up thermal ablation in Uganda would require a rethinking of the supply chain, training, and budget priorities. The devices themselves are relatively cheap, but they need rechargeable batteries and spare parts. A single device can treat about 200 women before the probe needs replacement, which costs about US$50. The batteries last about 2–3 years. Compared with the recurring cost of gas cylinders for cryotherapy, thermal ablation may actually be cheaper over the long term.

Training midwives and nurses to perform thermal ablation is straightforward. A 2-day course covers lesion assessment, probe placement, and safety protocols. Several African countries, including Kenya, Zambia, and Malawi, have already integrated thermal ablation into their national training curricula. Uganda could adopt the same model. The cost per woman treated with thermal ablation is estimated at US$15–20, compared with US$8–12 for VIA-only screening. The difference is small but covers the cost of saving a life.

Uganda’s 2025 national budget allocated US$1.2 million for cervical cancer control, about half of which was spent on screening. Reallocating just 10% of that screening budget to thermal ablation devices and training could cover roughly 50,000 same-visit treatments per year—enough to treat every woman who screens VIA-positive in the country. The Ministry of Health has expressed interest in thermal ablation, but as of mid-2026, no concrete procurement plan has been announced.

The barriers are not insurmountable. A similar shift happened with HIV treatment in the early 2000s, when donors moved from funding cheap but ineffective prevention-only approaches to financing antiretroviral therapy. The lesson was that screening without treatment is a waste of resources and trust. Cervical cancer is no different. Until Uganda and its donors close the treatment gap, thousands of women will continue to receive a positive VIA result that leads nowhere.

Some critics, however, argue that thermal ablation is not a panacea. They point out that same-visit treatment requires the woman to be ready for a procedure immediately after screening, which may not always be feasible—she may have come with a child, or she may be menstruating, or she may simply need time to decide. A 2023 qualitative study in Uganda found that about 20% of women who were offered same-visit thermal ablation declined, citing pain concerns or the need to consult their husbands. For these women, a delayed treatment option is still necessary, and that means cryotherapy or thermal ablation must be available at a later date. But without a functioning machine, even delayed treatment is impossible.

Another counter-argument is that the focus on treatment equipment distracts from the need to improve the screening test itself. VIA is subjective and operator-dependent; a nurse in a busy clinic may miss lesions or over-diagnose. HPV DNA testing, which is more accurate and can be done on self-collected samples, is becoming cheaper and is now recommended by WHO as the primary screening method. But HPV tests cost US$5–10 each, require laboratory infrastructure, and take hours to return results—making same-visit treatment harder. Uganda is piloting HPV testing in a few districts, but the equipment and training costs are higher. The trade-off between accuracy and accessibility is real, and it complicates the argument for any single technology.

Ultimately, the solution is not just about buying thermal ablation devices. It is about building a system that can deliver the full cascade of care—screening, diagnosis, treatment, and follow-up—in a way that reaches the women who need it most. That means investing in supply chains for consumables and spare parts, training and retaining a skilled workforce, and aligning donor incentives with patient outcomes. It is a difficult task, but the alternative—letting women die from a preventable disease because of a broken gas cylinder or a missing battery—is far worse.

This article is for informational purposes only and does not constitute medical advice. Readers should consult qualified healthcare providers for personal health decisions.