Barriers and Facilitators Influencing National Scaleup of a Women's Cancer Early Detection Program in Rwanda: Perspectives of Policymakers, Program Leaders, and Clinicians.

PURPOSE: Late-stage diagnoses drive high rates of cervical and breast cancer mortality in low- and middle-income countries (LMICs) where early detection efforts are typically small-scale. Rwanda's government-funded Women's Cancer Early Detection Program (WCEDP) integrates breast cancer early detection and cervical cancer screening and is being scaled nationally. We aimed to understand barriers and facilitators of WCEDP scale-up to inform program optimization and provide lessons for other LMICs. METHODS: We conducted 23 in-depth interviews with clinicians, health facility leaders, nongovernmental organization (NGO) staff, and policymakers. A codebook was collaboratively developed using a combined inductive and deductive approach; all transcripts were dual-coded. The Exploration, Preparation, Implementation, and Sustainment (EPIS) framework served as a guiding theoretical framework. RESULTS: Outer context: WCEDP facilitators include strong government engagement, national cancer control plans, and community acceptance. Barriers include low community awareness and insufficient resources dedicated to the program. Inner context: Rwanda's decentralized health care system and community health workers facilitated WCEDP scale-up. Nonetheless, workforce shortages, limited health facility leadership engagement and accountability, and clinicians' unfamiliarity with electronic health records (EHRs) were challenges. Innovation factors: The WCEDP-specific EHR was considered a strength. However, participants identified the need for training, technical assistance, ongoing quality monitoring, and adaptation to effectively use the EHR to improve care delivery and link patients to follow-up. Bridging factors: NGOs play a key role in WCEDP implementation. However, participants reported a need for improved coordination of different stakeholders. Phases of implementation: Identified facilitators and barriers provided lessons relevant to all EPIS phases (Exploration, Preparation, Implementation, and Sustainment). CONCLUSION: This study contributes to the limited literature examining scale-up of cancer programs in resource-constrained settings and informs strategies to optimize women's cancer early detection at scale in Rwanda and other LMICs.