Capacity to care: Provider agency and socio-structural constraints in breast cancer care across public secondary and tertiary hospitals in Soweto.

Abstract

Timely breast cancer care remains challenging in South Africa, where both health-system and patient-level barriers contribute to delayed diagnosis and treatment. This study explored healthcare providers' experiences and perspectives on breast cancer care at Chris Hani Baragwanath Academic Hospital in Soweto and its two referring secondary hospitals in Johannesburg. Using a cross-sectional qualitative design informed by phenomenology, we conducted in-depth interviews with 30 providers involved in breast cancer care. Thematic analysis identified intersecting structural and individual barriers, together with provider-led strategies to improve care delivery. System-level constraints included high patient volumes, staff shortages, limited diagnostic capacity, referral delays, inconsistent treatment supplies, and the absence of radiation oncology services at CHBAH, necessitating referral to an affiliated hospital 25 km away. Providers also described patient-related contributors to delay, including fear, denial, symptom misinterpretation, socioeconomic hardship, and limited self-efficacy, often exacerbated by poor communication. Suggested priorities included community and primary care education, provider training, high-risk screening in primary care, and expanded diagnostic and treatment infrastructure, particularly radiation oncology services at CHBAH. Furthermore, providers described pragmatic mitigation strategies, including expedited diagnostic workup, multidisciplinary coordination, electronic records, NGO-supported patient navigation, and temporary disability grants to offset transport costs. In conclusion, these findings provide a foundation for a coordinated response to strengthen oncology care in resource-constrained settings.