Background
Cancer-related mortality is high in low and middle-income countries, where health systems face challenges in delivering timely and continuous cancer care. Regional cancer centres play a key role in service delivery, yet evidence on system-level factors influencing care within these settings remains limited.
Aim
To identify system-level barriers and enablers affecting cancer care delivery in a regional cancer centre in a low- and middle-income country.
Methods
We conducted a formative qualitative case study at one of the regional cancer centres in India, as part of a project funded by the Indian Council for Medical Research. We performed in-depth examination of organisational practices, care pathways, and coordination mechanisms.
We employed multiple qualitative methods, including a review of existing studies from the same regional cancer centre, key informant interviews with healthcare providers, patient shadowing, and participatory observation within clinical and administrative settings. Interviews focused on diagnostic processes, treatment pathways, service organisation, coordination, communication, and patient navigation. We did patient shadowing and participatory observation to examine real-time care pathways, workflows, interactions, and system-level bottlenecks influencing cancer care delivery.
All interviews were audio-recorded, transcribed verbatim, and analysed thematically. Data from interviews, observations, shadowing, and document review were triangulated during analysis to strengthen analytic validity. Ethical approval was obtained before the study, and written informed consent was obtained from all participants.
Results
Several system-level barriers influenced cancer care delivery across departments at the regional cancer centre. Key challenges identified included delays in diagnostic and treatment pathways, treatment abandonment and loss to follow-up, communication barriers, and financial constraints. Limited availability of imaging services, operating theatres, intensive care facilities, and radiation machines, combined with high patient load and capacity constraints, led to delays in diagnosis and treatment in the care pathway. These delays were evident at multiple points along the care pathway.
Difficulties in navigating hospital services, resulting in missed appointments and repeated visits, were linked to treatment abandonment and interruptions. Although cancer treatment was provided without direct user fees, patients incurred substantial indirect costs related to travel, food, accommodation, and wage loss, and delays in scheme-related processes further contributed to financial constraints. Existing evidence from the setting indicates that 92.7% of patients experienced financial hardship during treatment, confirming persistent financial toxicity even within publicly funded care models.
Communication barriers, particularly language differences and limited consultation time, constrained patient understanding of diagnosis and treatment pathways and contributed to disengagement from care. Despite these barriers, several enabling practices were identified. Coordination across oncology departments supported treatment planning, healthcare providers prioritised critically ill patients to mitigate delays, patient navigation and communication supported by the nursing staff, and follow-up reminder calls contributed to continuity of care within the health system.
Conclusion
System-level barriers in regional cancer centres affect timely and uninterrupted cancer care. Strengthening service capacity, coordination, communication, and patient navigation may improve care delivery and cancer outcomes in low- and middle-income country settings.