Healthcare workers’ perspectives on institutional and health system barriers to cervical cancer screening in Greater Hoima, Uganda

Cervical cancer remains a major cause of cancer-related morbidity and mortality among women in Sub-Saharan Africa, including Uganda. While demand-side barriers to screening are frequently examined, health system and institutional constraints that limit service provision remain underexplored. In Uganda, where fewer than 10% of women have been screened in the last five years and an estimated 10% have ever been screened, understanding these supply-side barriers is critical for improving coverage. This study aimed to explore the institutional and health system barriers to cervical cancer screening in Greater Hoima, Uganda, from the perspectives of frontline healthcare workers. A qualitative exploratory design was employed. Key informant interviews were conducted with 45 healthcare workers - nurses, midwives, clinical officers, and general doctors - from 20 public and private-not-for-profit health facilities across Greater Hoima. Facilities and participants were selected using purposive sampling. Data were analyzed using inductive thematic analysis, with coding conducted independently by two researchers and themes finalized through iterative consensus. Four major themes emerged: (1) extreme centralization and scarcity of screening services, with reliable service provision limited to one regional referral hospital; (2) a critical shortage of trained and skilled personnel, particularly in Visual Inspection with Acetic Acid (VIA); (3) inadequate equipment, supplies, and infrastructure, including absence of specula and acetic acid at lower-level facilities; and (4) weak health system support and referral pathways. These barriers were cross-cutting across all facility levels. Institutional and health system barriers substantially constrain cervical cancer screening coverage in Greater Hoima. Demand-stimulation strategies are unlikely to yield sustained improvements unless underlying supply-side deficiencies are addressed through decentralization of services, systematic healthcare worker training in both VIA and HPV-based screening, reliable supply of essential equipment, and strengthened referral pathways.