title: 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.
authors.affiliation: King's Centre for Global Health, King's College London and King's Health Partners, London, United Kingdom.
authors.forename: Anna J
authors.initials: AJ
authors.lastname: Dare
authors.affiliation: Global Health Group, Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America.
authors.forename: Katherine C
authors.initials: KC
authors.lastname: Lee
authors.affiliation: Global Health Group, Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America.
authors.forename: Josh
authors.initials: J
authors.lastname: Bleicher
authors.affiliation: Department of Surgery, Mulago Hospital, Kampala, Uganda.
authors.forename: Alex E
authors.initials: AE
authors.lastname: Elobu
authors.affiliation: Department of Surgery, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.
authors.forename: Thaim B
authors.initials: TB
authors.lastname: Kamara
authors.affiliation: Department of Surgery, Port Moresby General Hospital, Port Moresby, Papua New Guinea.
authors.forename: Osborne
authors.initials: O
authors.lastname: Liko
authors.affiliation: Department of Anatomy, Makerere University College of Health Sciences, Kampala, Uganda.
authors.forename: Samuel
authors.initials: S
authors.lastname: Luboga
authors.affiliation: Department of Surgery, Port Moresby General Hospital, Port Moresby, Papua New Guinea.
authors.forename: Akule
authors.initials: A
authors.lastname: Danlop
authors.affiliation: Department of Surgery, Port Moresby General Hospital, Port Moresby, Papua New Guinea.
authors.forename: Gabriel
authors.initials: G
authors.lastname: Kune
authors.affiliation: Department of Clinical Sciences-Lund, Lund University, Lund, Sweden.
authors.forename: Lars
authors.initials: L
authors.lastname: Hagander
authors.affiliation: King's Centre for Global Health, King's College London and King's Health Partners, London, United Kingdom.
authors.forename: Andrew J M
authors.initials: AJ
authors.lastname: Leather
authors.affiliation: Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.
authors.forename: Gavin
authors.initials: G
authors.lastname: Yamey
mesh_terms: D006285:Health Planning; D006291:Health Policy; D006801:Humans; D010219:Papua New Guinea; D011050:Policy Making; D011057:Politics; D012807:Sierra Leone; D012959:Socioeconomic Factors; D013514:Surgical Procedures, Operative / Q000331:legislation & jurisprudence*; D014454:Uganda