Application of implementation science methods and theories for cancer control planning in low-income and middle-income countries: a scoping review

Abstract

Introduction

Implementation science (IS) is increasingly recognised as vital in cancer control planning and integrating evidence-based interventions across the cancer care continuum. Contextual differences often cause variability in delivering optimised healthcare, which IS approaches could mitigate. While IS improves planning effectiveness, many programme and policy planners remain unaware of its benefits. To address this, we examined IS theories applied to national cancer control plans (NCCPs)/strategies across five domains: stakeholder engagement, situational analysis, capacity assessment, economic evaluation and impact assessment.

Methods

We conducted a scoping review using the Arksey and O’Malley framework to analyse NCCPs and strategies from 16 and 17 countries belonging to low and medium categories of Human Development Index (HDI), focusing on resource-constrained settings. We identified plans through the International Cancer Control Partnership portal, categorised them by WHO region and included only those available in English or French. We extracted data into a Microsoft Excel database and performed thematic analysis across five IS domains. Multiple IS experts, selected purposively based on their familiarity with resource-constrained settings, validated the findings, assessed policy relevance and helped develop a pathway for integrating IS into national cancer control planning. They reviewed structured questions in advance and provided feedback on analyses, practical utility, dissemination and simplifying IS application, which was used to refine the pathway and reach consensus.

Results

While many NCCPs incorporated key IS elements such as stakeholder engagement, situational analysis and impact measurement, these often needed to be more explicit and consistently applied. None of the plans assessed health system capacity to determine readiness for implementing new interventions. Although most plans described stakeholder engagement, it was typically unstructured and incomplete. Four low HDI and nine medium HDI countries included costed plans, generally using an activity-based approach. All plans included impact measures (eg, key performance indicators), but five lacked mechanisms for engaging stakeholders or responsible entities to achieve the targets. These findings informed a proposed pathway to integrate IS principles into cancer control planning.

Conclusion

Integrating IS into national cancer control planning offers a structured framework for achieving equitable and feasible cancer control policies, particularly in resource-constrained settings, by enabling realistic goal setting and benchmarking against regional and global standards.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Our study examined national cancer control plans (NCCPs)/strategies globally through an implementation science lens.

• We screened all 82 NCCPs/strategies available on the International Cancer Control Partnership portal.

• NCCPs/strategies were analysed from 16 and 17 countries belonging to low and medium categories of Human Development Index, respectively.

• Our final analysis was limited to plans in English and French due to language constraints and some included plans were older with concluded implementation periods.

• Expert selection was purposive and may not represent all regions or health system settings.

Introduction

Implementation science (IS) is an emerging concept in cancer control planning. Integration of evidence-based interventions into cancer care is complicated by different contextual elements across the patient pathway, different healthcare settings and geographical regions. This results in significant variability in the delivery of high-quality, evidence-based cancer care as well as shortcomings in quality and optimal resource allocation and utilisation that can be avoided with better cancer control planning using an IS-informed approach.¹ Effective cancer control planning must balance the needs for often complex and resource-intensive cancer prevention, diagnosis and treatment services against competing health priorities and limited resources.

IS promotes the uptake of evidence-based interventions into routine practice to improve health outcomes.² Using IS theories and frameworks to adapt evidence-based interventions to fit specific contexts while engaging stakeholders increases the likelihood of successful implementation and sustainment of interventions that contribute to improved cancer control planning. This includes decision-making based on well-structured situational analysis, involving stakeholders at each stage of strategy development and understanding barriers and facilitators to implementation. However, these best practices are rarely followed. Policy/programme planners are either unaware of the benefits of using IS during planning, implementation and evaluation of evidence-based interventions or how to use the concepts or both.

Effective application of IS in policymaking and programme delivery depends on how accessible and relevant the frameworks are to end users. The large number of frameworks, some being quite complex, can be overwhelming. Over 33 IS frameworks exist, with more than 20 focusing on healthcare and service delivery. Among these, only about 10 explicitly engage with the policy level and the implementation of evidence-based practices in complex health systems.³ This diversity shows the richness of the field but can also create confusion, especially for policymakers in limited-resource settings trying to choose the most appropriate framework.

In this paper, we examine how IS theories have been applied to national cancer control planning in resource-limited settings. Although national cancer control plans (NCCPs) are essential for guiding cancer prevention and treatment, little is known about how IS frameworks can strengthen their design and execution, especially in low-income and middle-income countries (LMICs). To address this gap, we conducted a scoping review of 33 NCCPs and national cancer strategies from countries across all WHO regions, categorised by Human Development Index (HDI). The HDI is a summary measure of average achievement in key dimensions of human development: a long and healthy life, educational attainment and having a decent standard of living.⁴ Using an IS lens, we identified which implementation elements were addressed or overlooked and generated practical insights to improve future plans. Based on these findings, we developed a pathway to help national policymakers integrate IS principles into cancer control planning, supporting more effective, equitable and context-appropriate decision-making.

Methods

For our scoping review, we used the methodological framework by Arksey and O’Malley (2005)⁵ that proposes six stages of conducting such reviews (online supplemental figure 1).

Framework stage 1: identifying the research question

Our research question was: How have IS domains been applied in NCCPs and strategies from low HDI and medium HDI countries? We drew on the Expert Recommendations for Implementing Change (ERIC) framework,⁶ which provides a pragmatic and standardised set of widely recognised implementation strategies, to shape our research question. Guided by the framework, we examined the NCCPs/strategies for five implementation domains (1) stakeholder engagement, (2) situational analysis, (3) capacity assessment/health technology assessment, (4) economic evaluation and (5) impact measurement. This framework is particularly relevant for national-level cancer control planning across diverse health systems.

Framework stage 2: identifying relevant NCCPs/strategies

NCCP is an actionable document that specifies how a country will implement its cancer control objectives detailing specific activities, timelines and resources whereas a strategy provides a high-level vision of what the country aims to achieve in cancer control, without outlining the operational detail. We searched the International Cancer Control Partnership (ICCP)⁷ portal that hosts countries’ NCCPs or national cancer control strategies. We reviewed available cancer control plans from all low and medium HDI countries (figure 1). We further categorised selected countries by their WHO region (African Region (AFR); Region of the Americas (AMR); South-East Asian Region (SEAR); European Region (EUR); Eastern Mediterranean Region (EMR); and Western Pacific Region (WPR)). In contrast to high HDI countries, low and medium HDI countries face more competing health priorities, a larger burden of disease, lower access to health services and more limited resources.⁸ These constraints make it crucial to develop high-quality and tailored approaches to cancer control to maximise impact. By focusing on resource-constrained settings, we address context-specific barriers to cancer control where limited resources hinder sustainable healthcare improvements.

Figure 1. Human Development Index (HDI) by country (2024).

Framework stage 3: strategy selection

Countries that had an NCCP/strategy available in English or French were included. For the low HDI countries (n=33), only 17 had NCCPs/strategies in the ICCP portal. Of these, one plan was in Portuguese and thus excluded. For the medium HDI countries (n=42), only 23 had NCCPs/strategies.

Framework stage 4: charting data

We developed a data charting form using MS Excel database. The form captured details on the country, region, NCCP/strategy name, year, process of development, key recommendations and implementation plans. These data were subsequently categorised into five implementation domains of the ERIC framework, as outlined above.

Framework stage 5: collating, summarising and reporting results

A basic numerical analysis of the type and distribution of NCCPs/strategies was included in the scoping review. Two of the authors (IK and FS) reviewed the NCCPs/strategies, highlighting sections that corresponded to each of the five implementation domains and indicating whether each method was included or not. If included, we added a description of each of the subcategories under each domain—stakeholder engagement, situational analysis, capacity assessment, economic evaluation and impact assessment. A thematic analysis was conducted to present the findings.

Framework stage 6: expert consultation

We identified six IS experts (included among the authors of this manuscript) based on their track record of peer-reviewed publications, involvement in advising low and medium HDI countries on national cancer control planning, and recognised expertise in conducting IS research in these settings. These individuals were selected through a combination of professional networks, relevant literature and prior collaborations. Based on the results of the scoping review, IK and PB developed a pathway for integrating IS in national cancer control planning, which was then presented to the rest of the coauthors. Consultations were conducted online, supplemented by email exchanges, and occurred only after framework stage 5 was completed. Findings from stage 5 informed the consultations. Experts were provided with a structured set of key questions in advance via email, and consensus was achieved during group online meetings. These questions aimed to elicit their perspectives on (1) additional areas of analysis that could strengthen the study, (2) the practical utility of findings from a policymaker’s perspective, (3) effective dissemination strategies and (4) ways to simplify the application of IS for national-level policymakers involved in cancer control planning. Their feedback informed the refinement of our proposed protocol and emphasised the need for actionable, context-relevant guidance to bridge the gap between evidence and policy implementation. As coauthors of this paper, they focused on reviewing and refining the proposed pathway, ensuring that their expertise directly informed its development. Their firsthand experience added methodological rigour and contextual relevance. The final pathway was reviewed and agreed on by all the experts.

Further, we mapped barriers and facilitators described in NCCPs and strategy documents against the WHO’s health system building blocks.⁹ These were then classified for both low and medium HDI countries and are presented in detail later in the paper.

Results

Of 33 low HDI countries, 17 had NCCPs/strategies. Of these, one plan was in Portuguese and thus excluded. Of 42 medium HDI countries, 23 had NCCPs/strategies. Of these, four plans were in Spanish, and one each in Russian and Arabic and were excluded (figure 2).

Figure 2. NCCPs/strategies included for analysis. HDI, Human Development Index; NCCPs, national cancer control plans.

16 low HDI and 17 medium HDI countries were included in the analysis (n=33). All 16 low HDI countries were from the AFR; 17 medium HDI countries were included in the analysis, 8 were from AFR; 5 from AMR; 4 from SEAR; 3 from WPR; 2 from EMR; and 1 from EUR, representing all 6 WHO regions. Cancer control and prevention were included either in the NCCP (low HDI (70.6%); medium HDI (69.6%)) or as part of the national cancer control strategy (low HDI (29.4%); medium HDI (30.4%)).

Results of the synthesis are categorised under the following ERIC implementation domains by HDI status of the countries (tables1 2).

Table 1. Status of application of implementation science methods for national cancer control plans/strategies in low HDI countries.

S.No.	Country (region)	Plan/strategy name	Stakeholder engagement			Situational analysis		Capacity assessment	Economic evaluation			Impact measurement
			Mapping	Role assignment	Mechanism of engagement	Assessing context	Addressing barriers and facilitators	Capacity of health system to introduce new interventions	Costing estimation	Investment case	Cost-effectiveness	Performance indicators	Definition of an indicator	Mechanism of engagement
1	Nigeria (AFR)	National Strategic Cancer Control Plan (2023–2027)	Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
2	Rwanda (AFR)	Rwanda National Cancer Control Plan (2020–2024)	Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
3	Tanzania (AFR)	National Cancer Control Strategy (2013–2022)	Yes	Yes	Yes	Yes	Yes	No	No	No	No	Yes	Yes	Yes
4	Sudan (AFR)	National Cancer Strategy (2012–2016)	Yes	Yes	Yes	Yes	Yes	No	No	No	No	Yes	Yes	No
5	Malawi (AFR)	National Cancer Control strategic plan (2019–2029)	Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
6	The Gambia (AFR)	Strategic plan for The Prevention and Control of Cervical Cancer in The Gambia (2016–2020)	Yes	No	Yes	Yes	Yes	No	No	No	No	Yes	Yes	No
7	Ethiopia (AFR)	National Cancer Control Plan (2016–2020)	Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
8	Liberia (AFR)	National Cancer Policy (2018–2022)	Yes	No	Yes	Yes	Yes	No	No	No	No	Yes	Yes	No
9	Togo (AFR)	Programme National de Lutte contre le cancer (2022–2025)	No	No	No	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
10	Mauritania (AFR)	Plan National de lutte contre le cancer (2018–2022)	Yes	No	No	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
11	Côte d'Ivoire (AFR)	Plan stratégique national de lutte contre le cancer (2022–2025)	Yes	No	No	Yes	Yes	No	Yes	No	No	Yes	Yes	No
12	Senegal (AFR)	Plan stratégique de lutte contre le cancer (2015–2019)	Yes	Yes	No	Yes	Yes	No	No	No	No	Yes	Yes	Yes
13	Benin (AFR)	Plan stratégique de lutte contre le cancer du col de l'utérus et les autres cancers gynécologiques et Mammaires au Bénin (2019–2023)	No	No	No	Yes	Yes	No	Yes	No	No	Yes	Yes	No
14	Madagascar (AFR)	Feuille de route pour la réduction de la morbidité et de la mortalité dues aux cancers gynécologiques (2018–2022)	No	No	No	Yes	No	No	Yes	No	No	Yes	No	No
15	Burkina Faso (AFR)	Stratégie nationale de lutte contre le cancer (2021–2025)	Yes	No	No	Yes	Yes	No	No	No	No	Yes	Yes	No
16	The Democratic Republic of Congo (AFR)	Stratégie nationale de lutte contre les cancers du col utérin et du sein en république démocratique du Congo (2015)	No	No	No	Yes	Yes	No	No	No	No	No	No	No

^*AFR - African region

Table 2. Status of application of implementation science methods for national cancer control plans/strategies in medium HDI countries.

S.No.	Country (region)	Plan/ strategy name	Stakeholder engagement			Situational analysis		Capacity assessment	Economic evaluation			Impact measurement
			Mapping	Role assignment	Mechanism of engagement	Assessing context	Addressing barriers and facilitators	Capacity of health system to introduce new interventions	Costing estimation	Investment case	Cost-effectiveness	Performance indicators	Definition of an indicator	Mechanism of engagement
1	Suriname (AMR)	National Cancer Control Plan (2019–2028)	Yes	Yes	Yes	Yes	Yes	No	No	No	No	Yes	Yes	Yes
2	Bhutan (SEAR)	Bhutan Cancer Control Strategy (2019–2025)	No	No	Yes	Yes	Yes	No	No	No	No	Yes	Yes	Yes
3	Bangladesh (SEAR)	National Cancer Control strategy and plan of action (2009–2015)	Yes	Yes	Yes	Yes	Yes	No	No	No	No	Yes	Yes	Yes
4	India (SEAR)	Operational guidelines— National Programme for Prevention and Control of Non-Communicable Diseases (2023–2030)	No	No	No	Yes	No	No	No	No	No	Yes	Yes	No
5	Micronesia (WPR)	Federated States of Micronesia Comprehensive Cancer Control Plan (2019–2024)	No	No	No	Yes	No	No	No	No	No	Yes	Yes	No
6	Eswatini (AFR)	National Cancer Prevention and Control Strategy (2019)	Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
7	Myanmar (SEAR)	Myanmar National Comprehensive Cancer Control Plan (2017–2021)	Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
8	Ghana (AFR)	National Strategy for Cancer Control in Ghana (2012–2016)	Yes	No	No	Yes	Yes	No	Yes	No	No	Yes	Yes	No
9	Kenya (AFR)	The National Cancer Control Strategy (2023–2027)	Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
10	Cambodia (WPR)	National Action Plan for Cervical Cancer Prevention and Control (2019–2023)	No	No	No	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
11	Cameroon (AFR)	National Strategic Plan for Prevention and Cancer Control (2020–2024)	Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
12	Zambia (AFR)	National Cancer Control Strategic Plan (2022–2026)	Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	Yes	Yes	No
13	Papua New Guinea (WPR)	Cancer Action Priorities (2017–2021)	No	No	No	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes
14	Uganda (AFR)	Strategic Plan for Cervical Cancer Control and Prevention in Uganda (2010–2014)	Yes	No	Yes	Yes	No	No	Yes	No	No	Yes	Yes	Yes
15	Zimbabwe (AFR)	National Cancer Prevention and Control Strategy for Zimbabwe (2014–2018)	No	No	No	Yes	Yes	No	No	No	No	Yes	Yes	Yes
16	Morocco (EMR)	Plan National du cancer de prévention et de contrôle (2020–2029)	No	Yes	No	Yes	No	No	Yes	No	No	Yes	Yes	No
17	Congo (AFR)	Plan Stratégique National de Lutte Contre le cancer (2022–2026)	Yes	No	No	Yes	Yes	No	Yes	No	No	Yes	Yes	No

AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-east Asia region; WPR, Western Pacific Region.

1. Stakeholder engagement

Low HDI countries: the majority (n=12) of low HDI countries mapped stakeholders using a multisectoral approach; either for NCCP/strategy development (n=3) or for implementation (n=9). Exceptions were Togo, Benin, the Democratic Republic of Congo and Madagascar.

Stakeholders included oncology experts, public health specialists, patient advocates, cancer survivors, cancer equipment manufacturers, other ministries apart from Ministry of Health (eg, Ministry of Finance, Ministry of Agriculture, Ministry of Labour and Finance, Ministry of Trade and Industry, Ministry of Education and Ministry of Sports and Culture), faith-based organisations, civil society organisations, community groups, private sector, religious leaders, researchers, scientific societies, private sector, insurance companies, pharmaceutical industry, training institutions, cancer registry management, academic institutions, traditional and complementary medicine centre and United Nations (UN) agencies. Stakeholder roles were clearly defined in the implementation process, except for the Gambia and Liberia. In Ethiopia, a complete stakeholder analysis that included mapping the stakeholder type, role, status, interest, influence, position and impact for implementation was performed. The Ministry of Health was responsible for the coordination and engagement of stakeholders in all these countries.

Medium HDI countries: nine engaged with stakeholders, while four engaged with them partially and four did not engage with any stakeholders. Engagement was done by mapping the stakeholders for development of the NCCP/strategy (n=3), implementation (n=5) or both (n=1).

Stakeholders included the Ministry of Health, other ministries, public health physicians/epidemiologists, health communication experts, oncologists, palliative care specialists, research/academic institutions, patient organisations, insurance companies, civil society organisations, patients and their families, regulatory bodies, the private sector and UN agencies. In Kenya, the NCCP was developed through a highly participatory and iterative process involving stakeholders in gap analysis, prioritisation exercise to identify and set goals and objectives and identification of specific interventions for cancer control in the country.

There was a clear role defined for the stakeholders in NCCP/strategy implementation among medium HDI countries, with the exception of Ghana, Uganda, Morocco and Congo. In Bhutan and India, there was no mapping or role assignment. The coordination and engagement of stakeholders was done through the Ministry of Health or a national cancer control taskforce barring Myanmar, Morocco, Congo and Ghana where no mechanism was specified.

• 2 aSituational analysis

We determined if the NCCPs/strategies considered any contextual analysis identifying barriers and/or facilitators to their implementation, in addition to the cancer burden.

Low HDI countries: all had a descriptive situational analysis regarding the cancer landscape, highlighting both barriers and/or facilitators to the implementation of cancer control efforts. Among them, Bhutan highlighted both facilitators and barriers, while four medium (Eswatini, Kenya, Congo and Zambia) and five low HDI (Togo, Mauritania, Senegal, Benin and Burkina Faso) countries conducted a strength, weakness, opportunity and threat (SWOT) analysis to examine barriers, facilitators, opportunities and threats to implementation of cancer control interventions. Madagascar did not highlight any barriers or facilitators.

Barriers outlined by the low HDI countries were related to service delivery, diagnosis, treatment, referral, patient navigation, health insurance, survivorship, delayed care seeking, access, infrastructure, palliative care, human resources, awareness, supply chain, surveillance, cancer registry, governance and leadership, health financing and limited country-specific cancer data (table 3). Facilitators included strong political commitment, establishment of dedicated frameworks, implementation of free screening measures for gynaecological and breast cancers, transformation of national programmes into specialised cancer control entities, supported by the creation of councils and secretariats, focused efforts on addressing cancer prevention and treatment, protocols for cervical and breast cancer screening, collaboration with civil society, media engagement, partnerships with international organisations, legislative measures, such as anti-smoking laws, integration of palliative care, decentralised healthcare system and potential funding opportunities.

Table 3. Common challenges and facilitators of NCCPs/strategies mapped across the WHO Health System Building Blocks.

Building blocks		Low HDI countries		Medium HDI countries
		Challenges	Facilitators	Challenges	Facilitators
Service delivery	Similar	Referral Patient navigation	Implementation of free screening measures for gynaecological and breast cancers	Referral Patient navigation	Availability of essential cancer services (cervical screening, HPV and HBV vaccinations, diagnostic tools)
	Different	Delayed care seeking Access Poor infrastructure	Protocols for cervical and breast cancer screening Integration of palliative care	Issues with provision of effective health services Alignment of treatment with international guidelines Quality assurance of diagnostic facilities Palliative care Focused approach to paediatric cancer diagnosis and treatment Survivorship	Key treatments (radiotherapy, chemotherapy, immunotherapy) Decentralised healthcare systems
Health workforce	Similar	Human resources (shortages or maldistribution of trained healthcare professionals) Awareness		Human resources (shortages or maldistribution of trained healthcare professionals) Awareness
	Different		Transformation of national programmes into specialised cancer control entities Collaboration with civil society to train community health workers to raise awareness	Structured psychosocial support for patients	Funding for specialist training Public–private partnerships for workforce development
Health information systems	Similar	Surveillance Inadequate or no cancer registry		Surveillance Cancer registry
	Different		Media engagement Protocols for cancer screening Collaboration with international organisations	Limited country-specific cancer data	Monitoring and data collection for cancer screening and treatment outcomes mHealth programmes (digital systems for improving access to information and services)
Access to essential medicines and technologies	Similar	Supply chain Treatment Diagnosis Drug procurement	Partnerships with international organisations	Supply chain Treatment Diagnosis Drug procurement	Support from international donors
	Different		Potential funding opportunities Legislative measures	Quality assurance of diagnostic facilities Radioactive waste disposal Essential medicines list Focused approach to paediatric cancer diagnosis and treatment	Availability of essential treatments and emerging therapies
Health financing	Similar	Inadequate financial resources and budget allocation for cancer care and control		Inadequate financial resources and budget allocation for cancer care and control
	Different		Potential funding opportunities Decentralised healthcare system Integration of palliative care	Health insurance Access	International donor support Public–private partnerships for funding
Leadership and governance	Similar	Organising and delivering comprehensive cancer care services	Strong political commitment Establishment of dedicated frameworks	Organising and delivering comprehensive cancer care services	Strong political commitment Involvement of national and parliamentary health commissions
	Different	Issues with provision of effective health services Limited country-specific cancer data	Transformation of national programmes into specialised cancer control entities Creation of councils and secretariats Legislative measures, such as antismoking laws	Poor infrastructure	Established frameworks for non-communicable diseases

HBV, Hepatitis B virus; HDI, Human Development Index; HPV, Human papillomavirus; NCCPs, national cancer control plans.

For medium HDI countries, Micronesia, Morocco, India and Uganda did not highlight any barriers and/or facilitators. Of those countries that performed a situational analysis, in addition to the challenges mentioned previously, health financing, alignment of treatment with international guidelines, structured psychosocial support for patients, drug procurement, essential medicines list, quality assurance of diagnostic facilities, radioactive waste disposal, and paediatric cancer diagnosis and treatment were highlighted.

Facilitators included established frameworks for non-communicable diseases and strong political will, which provided a solid foundation for cancer control, availability of essential cancer services—such as cervical screening, HPV and HBV vaccinations, and diagnostic tools like ultrasound and mammograms, key treatments, including radiotherapy, chemotherapy and emerging therapies such as immunotherapy, decentralised healthcare systems, funding for specialist training and public–private partnerships, international donor support and civil society engagement, and involvement of national and parliamentary health commissions that strengthened governance and policy support.

Based on further classification of the barriers and facilitators per the health system building blocks, common barriers in both low and medium HDI countries include inadequate financial resources, shortages of trained healthcare professionals, poor surveillance systems, challenges with supply chains for medicines and diagnostics, and patient navigation systems. Shared facilitators include political commitment, partnerships with international organisations and free cancer screening, which addresses gaps and improves cancer care outcomes across diverse settings.

• 3 aCapacity assessment

We ascertained if countries were assessing the capacity of their health systems to be able to introduce and sustain new interventions. None of the countries studied had done so and only described the capacity of their existing health system in terms of human resources and infrastructure availability.

• 4 aEconomic evaluation

Nine low HDI countries followed an activity-based costing approach, evaluating system efficiency and allocation of resources for their implementation plan, which was time-bound for a period ranging between 5 and 10 years. The remainder (n=7) did not perform any economic analysis. Of the medium HDI countries, 11 conducted an economic analysis of their NCCP/strategy implementation plan. They also used an activity-based costing approach, which was time-bound for a period ranging from 5 to 10 years. Cambodia mapped each costed activity under their implementation plan to a potential funding source. Others (n=6) did not perform any kind of costing analysis. Few of the reviewed NCCPs included detailed economic evaluations or budget lines for implementation, and only a small number outlined concrete plans to mobilise financial resources.

• 5 aImpact assessment

We assessed whether the NCCPs/strategies included a plan for measurement of impact while setting out their implementation plan. Low HDI countries, n=12 had a set of measurable and time-bound performance indicators for each of their plan objectives/activities. They also specified lead stakeholders for each of their strategic actions. However, in Sudan, the Gambia, Liberia, Benin, Madagascar and Burkina Faso, while the performance indicators and their timeframe were mentioned, a mechanism of engagement via stakeholders was not specified.

Like low HDI countries, the medium HDI countries also specified measurable performance indicators for each of their plan objectives/activities for a defined period with responsible key stakeholders. However, India, Micronesia, Morocco, Congo, Ghana and Zambia did not mention any mechanism of engagement for implementation.

Development of the pathway

Our analysis led to the development of a pathway for integrating IS in national cancer control planning. Insights from the review of 33 NCCPs and strategies highlighted which IS domains were being addressed and where important gaps remained. These findings were mapped into six sequential steps: situational analysis, defining goals, developing a strategic framework, formulating the plan, implementation, and monitoring and evaluation. The draft pathway, developed by IK and PB, was further refined through consultation with six IS experts, whose feedback emphasised the need for practical utility, dissemination strategies and simplified application in resource-limited settings. This process informed the integration of specific IS tools such as SWOT, AIM, SMART, activity-based costing and dissemination frameworks to enhance applicability. The final pathway (figure 3) presents a structured, step-by-step approach to systematically embed IS into the development, updating and execution of NCCPs.

Figure 3. Pathway to integrating implementation science in cancer control planning. AIIM, Alignment, Interest, and Influence Matrix; KPI, Key Performance Indicators; SMART, Specific Measurable Achievable Relevant and Timely; SWOT, strength, weakness, opportunity and threat.

Discussion

In this scoping review, we analysed 33 NCCPs and strategies from 16 low and 17 medium HDI countries to assess how IS principles were incorporated across five key domains: stakeholder engagement, contextual analysis, capacity assessment, economic evaluation and impact assessment. While none of the NCCPs/strategies explicitly defined an IS approach, four plans, each in low and medium HDI countries, had addressed four out of five domains barring capacity assessment, which none addressed.

LMICs face distinct challenges in implementing effective, resource-appropriate cancer control policies, such as limited funding, workforce shortages and inadequate infrastructure for cancer diagnosis and treatment. Our findings reveal that these barriers are often compounded by unstructured approaches to planning, which are less likely to achieve sustainable outcomes. The WHO stressed that ‘the systematic and equitable implementation of evidence-based strategies’ and ‘making the best use of available resources’¹⁰ should be the key characteristics of any NCCP. The theoretical underpinnings of IS frameworks appropriate to health systems describe elements such as capacity, needs assessments and absorptive capacity that align with contextual constructs; and programmatic leadership, inclusion of stakeholders and community-based decision makers that align stakeholder constructs with high relevance to cancer control planning. Our scoping review analysed NCCPs/strategies using an IS framework to identify strengths and areas for improvement, while highlighting best practices.

IS can play a critical role in guiding policymakers and planners in these settings by providing a structured, evidence-based framework for planning and execution. While IS principles have largely remained within academic research and are rarely applied systematically in cancer control planning, our analysis shows that some national plans have begun to incorporate key elements such as stakeholder engagement, situational analysis and impact measurement, suggesting an emerging but implicit recognition of structured planning approaches. This is a pattern observed in both low and medium HDI countries. However, none of them performed a capacity assessment of their health system to assess readiness in preparation for the introduction of new interventions. The absence of explicit references to IS suggests that planners recognise key concepts in structured cancer control but have yet to fully adopt these tools in a systematic, impactful way.

Our analysis found that while most NCCPs/strategies described stakeholder engagement, this was often not well-structured or sustained throughout the planning and implementation process. Few plans demonstrated comprehensive stakeholder mapping, role identification or clear mechanisms of engagement which are core components recommended in IS.^{11 12} A detailed stakeholder analysis should include not only identification of key actors but also their interests, influence, positions and roles in implementation, and this should be a continued activity beyond plan development.^{13 14} In most cases, engagement was limited to early-stage consultations without ongoing input or feedback loops. Ethiopia and Kenya emerged as strong examples, where NCCPs clearly articulated structured and sustained stakeholder involvement, institutional responsibilities and mechanisms for coordination. These practices reflect IS principles and are essential to ensure that NCCPs address priority areas, optimise resource use and are effectively translated into action by those responsible for delivery.^{15 16} Their models demonstrate how thoughtful stakeholder engagement can contribute to more feasible and equitable implementation of cancer control plans.

Drawing lessons from some medium HDI countries (eg, Bhutan, Eswatini, Kenya, Congo, Zambia) and low HDI countries (eg, Togo, Mauritania, Senegal, Benin, Burkina Faso), our analysis found that those NCCPs that incorporated comprehensive SWOT or situational assessments were better able to identify context-specific priorities and align implementation strategies accordingly. This suggests that a comprehensive SWOT analysis of existing programmes is essential to ensure that subsequent planning is pragmatic, feasible and sustainable.¹⁶ This analysis requires a structured assessment of barriers and facilitators within the health system building blocks, considering the social and political context unique to each country. IS underscores the importance of examining these factors across the health system’s building blocks, such as workforce, financing and service delivery. Drawing from our scoping review, we have listed in table 3 the common challenges and facilitators reported across the health system building blocks. Addressing these elements while designing the NCCP/strategy, tailored to the local context, is essential to achieve more equitable and sustained improvements across health services and health outcomes.

In our analysis, about four low HDI and nine medium HDI countries costed their plans using an activity-based approach. Economic evaluation plays a crucial role in strategic planning within IS, offering insights into the potential success and sustainability of interventions.¹⁷ It helps decision-makers assess the return on investment, guiding them on whether to allocate resources based on the projected impact and long-term benefits of the intervention.¹⁸ However, economic and financial evaluation frameworks to guide policymakers in developing affordable and equitable cancer control plans remain scarce in LMICs.¹⁹ It is essential for a NCCP/strategy to be costed for implementation.²⁰ Costs incurred include necessary infrastructure to support programme creation, engage stakeholders, implement the intervention and maintain it over time.²¹ A review of publicly accessible NCCPs revealed that 56% of countries identified the need to establish budgets for cancer-related plans, 42% provided some type of cost estimates, but only 10% included comprehensive budget details.²²

Implementation research methodology suggests different monitoring and evaluation frameworks that may be used while assessing an NCCP/strategy’s impact¹⁵ such as the RE-AIM framework (a tool used in IS to evaluate the public health impact of interventions by assessing five dimensions: Reach, Effectiveness, Adoption, Implementation and Maintenance). All reviewed plans had some sort of impact measures—KPIs, however, some (n=5) did not mention the mechanism of engagement for stakeholders/responsible entities to achieve the target(s). This was similar to the analysis by Bolous et al²¹ where they found limited references to such mechanisms in cancer-related plans, especially in LMICs.

Cancer control through NCCP can also benefit from cross-learning from IS in complex settings, such as humanitarian research, which operates in resource-constrained environments. Humanitarian implementation research emphasises adaptable, flexible interventions that ensure equitable access to care, continuous stakeholder engagement and sustainable health system integration.²³ Key lessons for cancer control planning include the ability to quickly modify interventions based on local contexts and challenges, adopt strategies to address health disparities, ensure underserved populations are reached, foster long-term partnerships with stakeholders, and employ scalable, flexible interventions. Additionally, continuous monitoring and real-time feedback mechanisms can help refine strategies, improving outcomes and ensuring efficient implementation in various settings.

The pathway proposed by us to integrate IS methodologies (such as stakeholder engagement, situational analysis and capacity assessment at the outset) in cancer control planning offers a mechanism to produce more robust and actionable strategies. The practical utility of this pathway lies in its potential to guide national planners as they revise and implement cancer control plans. One immediate opportunity for dissemination is through established global technical assistance mechanisms, such as the International Atomic Energy Agency’s Integrated Mission of programme of action for cancer therapy reviews.²⁴ This initiative, in collaboration with WHO and IARC, already supports countries in developing and strengthening their NCCPs. Embedding our pathway into such missions could provide a structured, evidence-informed approach to systematically address gaps identified during country assessments and to translate recommendations into actionable strategies. At the national level, the pathway could be incorporated into workshops, training modules and stakeholder consultations convened by ministries of health and partner organisations. To maximise its impact, complementary efforts are needed, including capacity building for policymakers in applying IS tools, development of adaptable templates and checklists, and sustained technical support for monitoring and evaluation. Together, these steps would ensure that the pathway not only informs the design of NCCPs but also strengthens their implementation in diverse health system contexts.

Strengths and limitations

Our analysis offers a novel application of IS to NCCPs/strategies drawing on a global pool of 82 NCCPs/strategies available on the ICCP portal. While we screened all available plans, our final analysis was limited to those written in English and French due to language constraints. This still allowed for a diverse, multiregional sample and provided valuable insights. Not all plans or strategies were current; as a result, some older plans with concluded implementation periods were included. An additional limitation is that the selection of experts was purposive and may not be fully representative of all regions or health system settings.

Conclusion

Integrating IS concepts and theories into cancer control plans is essential for improving equitable, sustainable and affordable outcomes. Our analysis highlights the need for a more structured approach in developing NCCPs/strategies, as the use of IS concepts and theories during the design process is inconsistent. A more systematic approach would enable more realistic planning and the establishment of feasible, achievable targets to reduce the cancer burden. This will require a more formalised approach to building expertise and experience into the national cancer control planning faculty for each country. More widely, this approach is capable of dovetailing into multiple streams framework approaches pioneered by Kingdom²⁵ to help countries benchmark their cancer policies against regional and international comparators. Thus, by more formally incorporating IS, planners in LMICs could benefit from a framework that enhances the likelihood of success in implementing cancer control policies tailored to their specific resource limitations.

Where authors are identified as personnel of the International Agency for Research on Cancer/WHO, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy, or views of the International Agency for Research on Cancer/WHO.

Data availability statement

Data are available upon reasonable request.