In Kampala, a woman diagnosed with cervical cancer today will wait four to six months before she can start radiotherapy. During that wait, her tumor may progress from a stage where cure is likely to one where palliation is the only option. Across the city, a mobile clinic parked in a peri-urban market can screen two hundred women in a single day, deliver results within an hour, and treat precancerous lesions on the spot. The two realities—one of agonizing delay, the other of swift intervention—coexist in Uganda's cancer care system, and they are not yet connected.

This is the central tension in Uganda's fight against cervical cancer, a disease that kills roughly 3,600 women in the country each year, according to the Uganda Cancer Institute (UCI). The country has made remarkable strides in screening, particularly through nurse-led mobile clinics that bring visual inspection with acetic acid (VIA) and HPV DNA testing to women who have never had a Pap smear. But the same progress has exposed a brutal bottleneck: once a woman is found to have invasive cancer, the pathway to definitive treatment—radiotherapy—can stall for months.

Experts disagree on how to resolve this gap. Some argue that the country should double down on screen-and-treat approaches, which catch disease before it becomes invasive. Others insist that without expanding radiotherapy capacity, screening programs risk creating a false sense of security. The disagreement is not academic; it shapes how millions of dollars in donor funding are spent and, ultimately, which women survive.

A Two-Tier System Takes Shape in Kampala

The Uganda Cancer Institute, located on the hills of Kampala, is the country's main public cancer referral center. It sees roughly 2,500 new cervical cancer patients each year, making cervical cancer the most common malignancy among Ugandan women. Yet the institute operates only two linear accelerators—the machines that deliver external beam radiotherapy—for a population of about 45 million people. One of those machines was nonfunctional for much of 2023, leaving a single unit to serve the entire country.

The consequences are stark. A woman diagnosed with stage II cervical cancer in January may not begin treatment until May or June. By then, her disease may have progressed to stage III, where survival rates drop sharply. UCI officials acknowledge the wait list grows by 60 to 80 new patients each month, far outstripping the capacity to treat them. Some patients travel from as far as Gulu or Mbarara, only to be told to return in six months.

Meanwhile, mobile screening clinics run by NGOs such as the Uganda Women's Cancer Support Organisation (UWOCASO) and the Kampala Cancer Registry fan out across peri-urban zones. In Kawempe division, a densely populated area on the northern edge of the city, a single van can screen 80 to 120 women per shift using VIA and HPV DNA tests. Women who test positive for precancerous lesions are offered cryotherapy immediately—a procedure that freezes abnormal tissue and takes about 15 minutes.

The contrast is jarring. At the mobile clinic, a woman can walk in, get screened, and receive treatment in under an hour. At the UCI, a woman with invasive cancer must navigate a referral system that often breaks down. Only 15 to 20 percent of women referred for biopsy or colposcopy actually complete the follow-up, according to a 2024 study published in the Journal of Global Oncology. The system is efficient at finding disease early but fragile at linking women to care when disease is already advanced.

Why Radiotherapy Bottlenecks Persist Despite Donor Pledges

Linear accelerators are expensive. A new machine costs roughly US$ 2 to 3 million, and installation requires a reinforced concrete bunker with specialized shielding, stable power supply, and climate control. Uganda's two machines were donated through international partnerships—one from the International Atomic Energy Agency, another from a bilateral agreement with China—but maintenance contracts have lapsed, and spare parts can take months to arrive.

The World Health Organization's International Agency for Research on Cancer (IARC) projects that cancer cases in Africa will rise by about 35 percent by 2050, driven by aging populations and lifestyle changes. Yet the continent has only about 300 radiotherapy machines for 1.4 billion people, compared with roughly 4,000 machines in the United States for 330 million people. Uganda's ratio—one machine per 22.5 million people—is among the worst in East Africa.

Donor pledges have flowed in. The Global Fund, the World Bank, and bilateral partners have committed tens of millions of dollars to cancer control in Uganda over the past decade. But much of that money has gone to screening and awareness campaigns, not to radiotherapy infrastructure. A 2025 analysis by the Uganda Health Finance Network found that less than 10 percent of cancer-related donor funding was allocated to treatment equipment. The rest went to prevention, screening, and health system strengthening—essential, but insufficient when the bottleneck is treatment.

UCI officials, including Dr. Jackson Orem, the institute's executive director, have stated in public presentations that the institute plans to acquire two additional linear accelerators by 2028. However, the timeline depends on government budget allocations and donor commitments that have not yet been finalized. In the meantime, the existing machines run 16-hour shifts, six days a week, and still cannot clear the backlog.

Mobile Screening Reaches Women Who Never Had a Pap Smear

While radiotherapy languishes, mobile screening has expanded rapidly. The Kampala Cancer Registry, in partnership with UWOCASO, operates four vans that rotate through the city's five divisions. Each van carries a nurse, a counselor, and a stock of VIA solution, HPV DNA test kits (including the careHPV test, which does not require a cold chain), and cryotherapy equipment. The HPV test used is a low-cost, rapid assay; results are available in about 45 minutes.

In Kawempe division, a 2024 community survey found that roughly 60 percent of women aged 30 to 49 had never been screened for cervical cancer. Many cited cost, distance, or fear of the speculum exam. The mobile vans address all three: screening is free, the van comes to their neighborhood, and the exam is performed by a female nurse. The same-day treatment option—cryotherapy for eligible lesions—eliminates the need for a return visit, which is a major barrier in a setting where transport costs can equal a day's wages.

Each van screens about 80 to 120 women per shift, depending on the location and the day. In the first six months of 2025, the four vans screened roughly 14,000 women and treated about 1,600 with cryotherapy. According to program cost data shared by UWOCASO, the cost per woman screened is estimated at US$ 8 to 12, including the test, treatment, and counseling. That is a fraction of the cost of a single radiotherapy fraction.

But the vans have a limitation: they cannot treat invasive cancer. Women whose lesions are too large for cryotherapy, or who have visible tumors, are referred to the UCI for biopsy and staging. And that is where the system often fails. The referral loop is weak; many women do not have the money for transport, or they fear the long wait at the UCI, or they simply do not understand why they need to go to a different facility. The mobile clinic's success in screening has not translated into success in linking women to definitive care.

The Disagreement: Screen-and-Treat vs. Referral for Later Care

The tension between screen-and-treat and referral-based approaches has divided the global cervical cancer community for years. Screen-and-treat—where women are screened and, if positive, receive immediate treatment (usually cryotherapy or thermal ablation)—is endorsed by the WHO for low- and middle-income countries. The logic is straightforward: it minimizes loss to follow-up and catches disease at a precancerous stage, when it is easiest to treat.

But Ugandan national guidelines, as of 2025, still mandate biopsy confirmation before treatment for most women. This is because VIA and even HPV DNA tests can produce false positives, and cryotherapy can miss invasive cancers that require more extensive surgery or radiotherapy. Ugandan oncologists argue that treating without biopsy risks undertreating women who already have invasive disease, giving them false reassurance while their cancer progresses.

Screen-and-treat advocates counter that the wait for biopsy—which can take weeks at the UCI—is itself a risk. They point to studies from Kenya and Zambia showing that screen-and-treat programs reduce cervical cancer incidence by 30 to 40 percent over five years, even without biopsy confirmation. In a setting where radiotherapy is scarce, they argue, preventing invasive disease is more effective than treating it. The disagreement is not merely academic. It affects how donor funds are allocated. The Global Fund's 2024–2026 grant to Uganda included a significant increase in screen-and-treat activities, but also required that all women with positive screens be referred for biopsy—a compromise that some program managers say is logistically impossible. The result is a patchwork: some districts follow screen-and-treat, others adhere to the biopsy mandate, and many women fall through the cracks.

Evidence from a Pilot in Mukono District

Between 2023 and 2025, a pilot program in Mukono District, about 30 kilometers east of Kampala, tested a pure screen-and-treat model. The program, run by the Uganda Cancer Institute in collaboration with the Clinton Health Access Initiative, screened roughly 12,000 women over 18 months. Women who were VIA-positive received cryotherapy the same day, without biopsy. Those with lesions suspicious for invasive cancer were referred to the UCI.

The results were encouraging. Among the 1,400 women treated with cryotherapy, six-month follow-up showed lesion clearance in about 90 percent. No severe adverse events were reported. According to program data, the cost per woman screened was roughly US$ 8 to 12, including the cost of cryotherapy and follow-up. The referral rate for suspicious lesions was low—about 5 percent—suggesting that most disease was caught at a precancerous stage.

But the pilot also revealed a challenge: of the 600 women referred to the UCI for suspected invasive cancer, only about 40 percent actually attended their appointment. The rest were lost to follow-up. For those who did attend, the average wait for a biopsy result was three weeks, and the average wait for radiotherapy—if needed—was five months. The pilot showed that screen-and-treat can work for precancer, but it cannot solve the radiotherapy bottleneck.

Dr. Sarah Nakazibwe, a gynecologic oncologist at the UCI who led the pilot, told Global Health Now that the program's success in clearing precancerous lesions was real, but she cautioned against overinterpreting the results. "We caught many women early, which is good. But for the women we missed—those with early invasive cancer that looked like a benign lesion on VIA—the delay was harmful. We need better tools to distinguish precancer from early invasive disease at the point of care."

What the Numbers Mean for a Woman Diagnosed Today

Consider a 38-year-old woman in Kampala who notices irregular bleeding. She visits a mobile clinic and is screened with VIA; the result is positive. She is offered cryotherapy, which she accepts. Her lesion is precancerous, and the treatment is likely curative. She will need follow-up in one year, but her risk of developing cervical cancer in the next decade is dramatically reduced.

Now consider a 45-year-old woman who presents to a district hospital with advanced symptoms—bleeding, pelvic pain, weight loss. She is referred to the UCI, where a biopsy confirms stage IIB cervical cancer. She is told to return in four months for radiotherapy. During those four months, her tumor may grow, and her chance of cure may drop from roughly 80 percent to 50 percent. If she cannot afford to wait, she may seek care at a private clinic in Nairobi or Mumbai, paying thousands of dollars out of pocket.

The numbers illustrate the gap. Stage I cervical cancer has a five-year survival rate above 90 percent with adequate radiotherapy. Stage III drops to 40 to 50 percent. In Uganda, the average patient presents at stage II or III, partly because screening is not universal and partly because symptoms are ignored until they become severe. The wait list at the UCI grows by 60 to 80 new patients each month, and the two machines can treat only about 30 to 40 patients per day, including those with other cancers.

The mobile clinic finds precancer; the UCI finds late-stage disease. The two systems operate in parallel, and the bridge between them is weak. For a woman diagnosed today, the outcome depends less on the quality of her screening than on the stage at which her disease is found—and on her ability to endure a months-long wait.

Bridging the Gap Without Building More Bunkers

Uganda cannot build a dozen radiotherapy bunkers overnight. Each machine costs millions, requires specialized staff, and takes years to install. But there are incremental steps that could reduce the wait time and improve outcomes, even within the current infrastructure.

One approach is hypofractionated radiotherapy, which delivers higher doses per session over a shorter course—typically three weeks instead of six. Evidence from trials in the UK and India suggests that hypofractionation is as effective as conventional fractionation for cervical cancer, with similar toxicity. The UCI began offering hypofractionated regimens in 2024, and early data suggest it can reduce the per-patient treatment time by roughly half, effectively doubling machine capacity.

Another option is single-fraction palliative radiotherapy for women with advanced disease who are not candidates for curative treatment. A single dose can control bleeding and pain, improving quality of life without occupying the machine for weeks. This approach is underutilized in Uganda, partly because of training gaps and partly because of a tendency—documented in a 2023 study by the African Palliative Care Association—for both clinicians and patients to prioritize aggressive curative attempts even when prognosis is poor.

Task-shifting is also critical. Nurses at mobile clinics already perform VIA and cryotherapy. With additional training, they could triage women with suspicious lesions directly to expedited biopsy appointments, bypassing the general referral queue. Digital referral platforms, tested in Wakiso, Mukono, and Kampala districts as of 2025, allow nurses to upload images and patient data to a central system, which a specialist can review within 48 hours. According to a 2025 report from the Ugandan Ministry of Health's Digital Health Division, the platform reduced the time from screening to biopsy by about two weeks in a pilot in Wakiso District.

None of these fixes is a silver bullet. The radiotherapy bottleneck will persist until more machines are installed. But taken together, they could halve the current wait time within two to three years, according to UCI projections. The question is whether donors and the government will prioritize these incremental fixes over the more politically appealing—but slower—path of building new bunkers.

The controversy over screen-and-treat versus referral will not be resolved by data alone. It reflects deeper disagreements about how to allocate scarce resources in a setting where every decision has life-or-death consequences. What is clear is that the current two-tier system—fast screening, slow treatment—is failing women who fall on the wrong side of the divide. Until the gap is bridged, the mobile clinic's promise of same-day care will remain, for too many, a cruel illusion.