education, awareness rising and behaviour change for prevention of the infection and risk factors are evident (ECDC 2008). While the integrated cervical cancer early detection activities in Macedonia follow the traditional model of primary-secondary-tertiary level health care, with defined roles and responsibilities of the stakeholders, the creation of the vertical program for screening, as well as the HPV vaccination program are new developments in the field. The tendency for inclusion of the stakeholders, especially the civil sector, in the design and implementation of the programs and processes related to cervical cancer in the country is evident and should be strongly supported. However, having revealed that other groups of stakeholders, as for example the primary and secondary gynecologists, are to an extent marginalised in the processes related to these new developments, rethinking of the participatory approach should be considered, the possible obstacles identified and removed, especially having in mind that although vertical in their design, these programs use the existing human and technical health care resources. This is particularly important having in mind that two complex and demanding population-based programs – organized screening and HPV vaccination, are being announced to commence in 2009. The effective dealing with a problem which involves young adolescents, but in the same time is related to the sexual and reproductive health of the women and which outcome might be fatal, demands gaining insight in the views, standpoints and the culture of the direct beneficiaries, especially the women. Performing baseline surveys could help in revealing cultural and socio-economic specificities of the different target groups (for example the reasons for the low screening coverage, the attitudes towards a vaccine against an STI, etc.), which in turn could help in dimensioning, focusing and rationalising the envisaged activities. This sort of research could also help in identification and understanding of the obstacles, as well as the hidden opportunities, useful for improving the current and design of future programs. In order for Macedonia, as a country with much lower income level than most of the other EU countries, to be able to justify the investment and prioritising the HPV vaccination, as a novel but expensive technology, the decision makers and the scientific and professional community need to perform a sound economic assessment, tailored to the circumstances in the country: the epidemiologic status of the population, the relevant local economic and market developments, the parallel cervical cancer screening program and its effectiveness etc. However, to determine the most suitable approach for the delivery of the vaccine to the citizens, the cultural perceptions of the beneficiaries, as well as the postmarketing assessments of the vaccine itself, should also be carefully considered. The elements which are given attention to in all screening evidence based guidelines are: defining of the target population and frequency of screening; effective recruitment strategies to achieve high coverage (promotion, counseling, training, financial aspects); the capacities of the health care system both for prevention, as well as follow-up – diagnosis and treatment; health information
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