Cervical cancer screening policies and implementation in Uganda - a qualitative study on policymakers', cervical cancer experts' and gynecologists' perspectives.

BACKGROUND: Cervical cancer remains the leading cause of cancer-related mortality among women in Uganda, despite national strategies to expand screening. Visual inspection with acetic acid is the predominant method used, while human papillomavirus testing, including self-sampling, is endorsed as a more effective alternative. However, screening uptake remains critically low. This study explores the current state of cervical cancer screening in Uganda, examining barriers and facilitators to implementation, and assessing stakeholder perspectives on community-based self-sampling as a potential strategy to expand coverage. METHODS: A qualitative cross-sectional study was conducted between March 2022 and March 2023 in Kampala, Mukono, and Wakiso districts. Semi-structured interviews were carried out with 12 key informants, including policymakers, cervical cancer experts, and gynecologists. Participants were purposively selected based on their involvement in cervical cancer screening. Thematic analysis was performed using deductive and inductive coding, guided by the World Health Organization's health system building blocks framework. RESULTS: Participants identified multiple barriers to screening, including low awareness, fear, limited accessibility, workforce shortages, and logistical constraints that compromise service quality and continuity. Services were concentrated in higher-level facilities, and efforts were perceived to focus mainly on women living with human immunodeficiency virus. Despite policy support, implementation gaps persist, and the health system remains heavily reliant on international implementing partners for funding, training, and service provision. Community-based self-sampling was perceived as highly acceptable, with potential to overcome demand- and supply-side barriers through privacy and outreach. Concerns included logistical feasibility, quality control, and sustainability. CONCLUSIONS: Uganda faces growing pressure to expand cervical cancer prevention as more unvaccinated women reach middle age. The health system is not yet prepared to meet this demand, and sustainable national investment will be essential to reduce donor dependence. The roll-out of HPV-based screening, complemented by community-based self-sampling and strong health education, offers a feasible pathway to expand access and accelerate progress toward WHO's cervical cancer elimination targets.