Background: Hepatocellular carcinoma (HCC) is the leading cause of cancer-related mortality in Mongolia and the country has the highest incidence rate of HCC globally. Over 75% of cases are diagnosed at advanced stages, when curative treatment options are limited. This disproportionate burden reflects a unique epidemiologic context marked by historically high prevalence of chronic viral hepatitis and an emerging shift toward metabolic dysfunction–associated steatotic liver disease. Despite this evolving risk profile, Mongolia currently lacks an organized HCC surveillance system. Understanding barriers and facilitators to early detection across patient, provider, and health system levels is critical to informing contextually appropriate surveillance and care strategies.

Objective: To identify multilevel barriers and facilitators to HCC surveillance and care in Mongolia using a socioecological framework.

Methods: We conducted a qualitative study guided by a socioecological model to explore multilevel determinants of access to HCC surveillance and care. Between August and October 2025, semi-structured interviews were conducted with purposively sampled participants across multiple geographic regions of Mongolia, including urban, peri-urban, and rural provinces. Participants included patients with HCC or at high risk for HCC, healthcare workers involved in liver disease care (primary care physicians, specialists), and public-sector health leaders. Interviews were conducted in Mongolian, audio-recorded, and transcribed verbatim. Data were analyzed using reflexive thematic analysis supported by Dedoose software. Coding followed an iterative, team-based process combining inductive and deductive approaches, with themes mapped to individual, interpersonal, organizational, and policy-level domains. Analytic rigor was enhanced through reflexivity, audit trails, consensus coding, and ongoing engagement with local collaborators.

Results: Across 41 participants, we identified intersecting barriers and facilitators to early HCC detection and care. At the individual level, limited risk perception, normalization of chronic hepatitis, stigma associated with cancer diagnoses, and competing economic priorities delayed care-seeking. Patients often disengaged from follow-up in the absence of symptoms, particularly after initial hepatitis treatment. Interpersonally, fragmented communication between patients, families, and providers impeded continuity of care, while family encouragement and trusted provider relationships emerged as key facilitators. At the health system level, participants described inconsistent surveillance practices, lack of standardized recall systems, workforce constraints, limited diagnostic capacity outside the capital, and financial barriers related to insurance gaps and out-of-pocket costs. Primary care providers reported insufficient time and structural support to deliver longitudinal preventive care. At the policy level, the absence of a coordinated national surveillance framework and limited integration of metabolic risk factors into existing hepatitis-focused programs were repeatedly highlighted. Importantly, participants also identified actionable facilitators, including strong primary care infrastructure, high public engagement with health messaging, emerging digital health tools, and broad consensus on the need for organized surveillance.

Conclusion: In a country with the world’s highest HCC incidence and predominantly late-stage diagnosis, the absence of an organized surveillance system represents a critical gap in cancer control. This first nationwide, multi-stakeholder qualitative study identifies key barriers and facilitators to HCC surveillance implementation and provides actionable evidence to inform the design of equitable, context-appropriate surveillance strategies in Mongolia and similar low- and middle-income settings.