title: Generation of national political priority for surgery: a qualitative case study of three low-income and middle-income countries.
abstract: BACKGROUND
  Surgical conditions exert a major health burden in low-income and middle-income countries (LMICs), yet surgery remains a low priority on national health agendas. Little is known about the national factors that influence whether surgery is prioritised in LMICs. We investigated factors that could facilitate or prevent surgery from being a health priority in three LMICs.
  
  
  METHODS
  We undertook three country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. In total 72 semi-structured interviews were conducted between March and June, 2014, in the three countries. Interviews were designed to query informants' attitudes, values, and beliefs about how and why different health issues, including surgical care, were prioritised within their country. Informants were providers, policy makers, civil society, funders, and other stakeholders involved with health agenda setting and surgical care. Interviews were analysed with Dedoose, a qualitative data analysis tool. Themes were organised into a conceptual framework adapted from Shiffman and Smith to assess the factors that affected whether surgery was prioritised.
  
  
  RESULTS
  In all three countries, effective political and surgical leadership, access to country-specific surgical disease indicators, and higher domestic health expenditures are facilitating factors that promote surgical care on national health agendas. Competing health and policy interests and poor framing of the need for surgery prevent the issue from receiving more attention. In Papua New Guinea, surgical care is a moderate-to-high health priority. Surgical care is embedded in the national health plan and there are influential leaders with surgical interests. Surgical care is a low-to-moderate health priority in Uganda. Ineffectively used policy windows and little national data on surgical disease have impeded efforts to increase priority for surgery. Surgical care remains a low health priority in Sierra Leone. Resource constraints and competing health priorities, such as infectious disease challenges, prevent surgery from receiving attention.
  
  
  CONCLUSIONS
  Priority for surgery on national health agendas varies across LMICs. Increasing dialogue between surgical providers and political leaders can increase the power of actors who advocate for surgical care. Greater emphasis on the importance of surgical care in achieving national health goals can strengthen internal and external framing of the issue. Growing political recognition of non-communicable diseases provides a favourable political context to increase attention for surgery. Lastly, increasing internally generated issue characteristics, such as improved tracking of national surgical indicators, could increase the priority given to surgery within LMICs.
  
  
  BACKGROUND
  The Bill & Melinda Gates Foundation, King's Health Partners/King's College London, and Lund University.
authors: King's Centre for Global Health, King's Health Partners and King's College London, London, UK.
authors: Anna J
authors: AJ
authors: Dare
authors: Department of Global Health Sciences, University of California, San Francisco, CA, USA.
authors: Josh
authors: J
authors: Bleicher
authors: Department of Global Health Sciences, University of California, San Francisco, CA, USA.
authors: Katherine C
authors: KC
authors: Lee
authors: Department of Surgery, Mulago Hospital, Kampala, Uganda.
authors: Alex E
authors: AE
authors: Elobu
authors: Department of Surgery, Connaught Hospital, Freetown, Sierra Leone; Department of Surgery, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.
authors: Thaim B
authors: TB
authors: Kamara
authors: Department of Surgery, Port Moresby General Hospital, Papua New Guinea.
authors: Osborne
authors: O
authors: Liko
authors: Department of Anatomy, Makerere University College of Health Sciences, Kampala, Uganda.
authors: Samuel
authors: S
authors: Luboga
authors: Department of Surgery, Port Moresby General Hospital, Papua New Guinea.
authors: Akule
authors: A
authors: Danlop
authors: Department of Surgery, Port Moresby General Hospital, Papua New Guinea.
authors: Gabriel
authors: G
authors: Kune
authors: Department of Clinical Sciences in Lund, International Pediatrics and Pediatric Surgery, Children's Hospital, Faculty of Medicine, Lund University, Lund, Sweden.
authors: Lars
authors: L
authors: Hagander
authors: King's Centre for Global Health, King's Health Partners and King's College London, London, UK.
authors: Andrew J M
authors: AJ
authors: Leather
authors: Department of Global Health Sciences, University of California, San Francisco, CA, USA; Global Health Group, University of California, San Francisco, CA, USA. Electronic address: gavin.yamey@ucsf.edu.
authors: Gavin
authors: G
authors: Yamey