Coordinating under constraint: a qualitative study of communication and teamwork along Ethiopia’s cervical cancer care continuum
As Ethiopia expands cervical cancer screening services, it urgently needs information to develop appropriate post-screening diagnostic and treatment services for women with abnormal results. Quality cancer care requires extensive coordination among multidisciplinary provider teams. This study explores experiences coordinating care among providers at multiple levels of the cancer-care continuum in Ethiopia. From February 2020 to January 2022, we conducted four focus group discussions (FGDs) and ten key-informant interviews with 34 purposively selected healthcare providers: health extension workers (HEWs) in communities; midwives and nurses at health centers; obstetrician-gynecologists at regional hospitals, and oncology nurses, oncologists, and pathologists at tertiary hospitals. FGDs and interviews were conducted in Amharic and audio-recorded. Audio transcripts were then simultaneously transcribed and translated into English for analysis. Investigators performed thematic analysis using inductive and deductive codes. We found four themes: resource scarcity, care centralization, lack of formal coordination mechanisms, and recommendations. Themes were dynamically connected by eight sub-themes. Providers valued teamwork and coordination. However, severe shortages of cancer specialists and high patient loads left little time for communication and hampered the formation of stable care teams. Facilities lacked formal coordination systems, such as patient navigators and case managers. The relative centralization of cancer care specialists and equipment in the capital exacerbated coordination problems. It impeded pre- and post-treatment care communication between tertiary and secondary facilities and caused secondary facilities to unnecessarily refer patients because they lacked the resources to treat them locally. Referral communication was unidirectional, with lower-level providers communicating regularly to higher-level facilities but rarely receiving feedback. The exception was regular, structured feedback from primary facilities to HEWs. Lower-level providers wanted to learn whether their referrals were appropriate or completed, and many used informal channels to gain this information. Respondents recommend decentralizing cancer care services, significantly increasing staff and equipment investments, and adding liaison staff at secondary hospitals to track and communicate patient progress and counsel patients for referral. Our findings underscore the need to rapidly increase cancer specialist staff and regional cancer centers in Ethiopia and highlight the importance of developing robust coordination and feedback mechanisms at secondary and tertiary facilities.