Prioritizing Surgical Care on National Health Agendas: A Qualitative Case Study of Papua New Guinea, Uganda, and Sierra Leone

Abstract

Little is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs. We undertook country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. We conducted 74 semi-structured interviews with stakeholders involved in health agenda setting and surgical care in these countries. Interviews were triangulated with published academic literature, country reports, national health plans, and policies. Data were analyzed using a conceptual framework based on four components (actor power, ideas, political contexts, issue characteristics) to assess national factors influencing priority for surgery. Political priority for surgical care in the three countries varies. Priority was highest in Papua New Guinea, where surgical care is firmly embedded within national health plans and receives significant domestic and international resources, and much lower in Uganda and Sierra Leone. Factors influencing whether surgical care was prioritized were the degree of sustained and effective domestic advocacy by the local surgical community, the national political and economic environment in which health policy setting occurs, and the influence of international actors, particularly donors, on national agenda setting. The results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even where other factors are unfavorable. National health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important. Improving human health is a key global concern. Three of the eight Millennium Development Goals agreed to by world leaders in 2000 and designed to eradicate extreme poverty globally by 2015 were directly concerned with public health improvement. And health is central to the Sustainable Development Goals adopted in 2015. But despite health being a global concern, individual countries are largely responsible for addressing the health needs of their populations. All countries have to weigh the health challenges that face their populations and decide which programs and services to prioritize within their national health systems. The allocation of scarce public resources to competing health and other priorities is a complex social and political process, especially in low- and middle-income countries (LMICs). Little is known about why governments channel resources towards some health challenges and not others or about why some health issues become embedded within national health policy while others—including those responsible for a large burden of illness—are largely ignored by national health systems. Surgical care provision is given low priority in the health systems of most LMICs. Only 6.3% of the world’s surgical procedures are undertaken in the poorest countries, where more than a third of the world’s population lives, and most premature deaths from untreated surgical conditions (diseases, illnesses, or injuries in which surgery can potentially improve the outcome) occur in LMICs. Moreover, surgical conditions kill more people every year than HIV/AIDS, tuberculosis, and malaria combined. Understanding why surgical care is a low priority within national health systems in LMICs could provide insights into the social and political processes that drive health agenda setting and resource allocation. In this qualitative case study, the researchers examine the factors influencing the position of surgical care in the national health agendas of Papua New Guinea, Uganda, and Sierra Leone. Although the provision of surgical care has recently improved in Papua New Guinea, all three of these LMICs have a high burden of surgical conditions and inadequate surgical services. A qualitative study examines peoples’ opinions, explanations, and motivations for a particular issue, in order to understand the “why” and “how” of decision-making. For their study, the researchers used “process tracing,” a qualitative approach that uses two or more methods to analyze change and causation. Specifically, the researchers conducted semi-structured interviews with surgeons, politicians, and other stakeholders to elicit information about how and why different health issues, including surgical care, are prioritized in each study country. They “triangulated” (combined) the information collected in the interviews with information about national health plans and policies and data from country reports and the academic literature. Finally, they analyzed the data using a conceptual framework with four components (actor power, ideas, political context, and issue characteristics) to identify the factors that influence surgical care prioritization. The researchers report that the priority of surgical care varied between countries but was highest in Papua New Guinea. In Papua New Guinea, surgical care was firmly embedded within the health system and received significant domestic and international resources. Notably, three dominant factors influenced whether surgery was prioritized—the level of advocacy by the local surgical community, the national political and economic environment, and the influence of donors and other international actors on national agenda setting. These findings provide insights into the process of national health agenda setting in Papua New Guinea, Uganda, and Sierra Leone and highlight the complex interplay of...