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

BACKGROUND: 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. METHODS AND FINDINGS: 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. CONCLUSIONS: 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.

Generation of national political priority for surgery: a qualitative case study of three low-income and middle-income countries.

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. FINDINGS: 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. INTERPRETATION: 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. FUNDING: The Bill & Melinda Gates Foundation, King's Health Partners/King's College London, and Lund University.

The bacterial flora of acute appendicitis at the Port Moresby General Hospital in Papua New Guinea.

Acute appendicitis is a common cause of acute abdomen requiring an emergency appendicectomy. Complications such as perforation and peritoneal contamination leading to peritonitis can result from delay in presentation and an emergency operation. This study prospectively recruited 101 patients diagnosed with acute appendicitis to correlate the bacterial flora with the severity of appendicitis. The results show that 90 patients had acutely inflamed or gangrenous appendicitis and 11 had perforated appendicitis. The ages ranged from 6 to 49 years with a median of 20 years. There were 59 females and 42 males. The commonest isolates were aerobic bacteria such as Escherichia coli, Group D streptococci and Klebsiella pneumoniae. Mixed infection with anaerobes such as Bacteroides fragilis was seen only in perforated appendicitis. The best choices of antibiotic were a fluoroquinolone, cephalosporin and aminoglycoside for aerobic organisms and metronidazole for anaerobes.

Diabetic foot ulcers in Port Moresby General Hospital 2003-2008: review of the principles of effective prevention and management of diabetic foot.

BACKGROUND: In the recent decade in Papua New Guinea and other Pacific countries there has been an increasing trend of lifestyle diseases, including obesity associated with diabetes mellitus. Foot ulceration and infection leading to amputation are common and feared complications of diabetes. Yet these are potentially the most preventable of all complications in diabetic patients. Several studies have shown that half of all diabetic foot ulcers can be prevented by education and simple foot care. The primary goal of this study was to depict the scale of the diabetic foot as a community health problem. The secondary goal was to review the current literature on diabetic foot in order to develop a more effective preventive strategy. METHODOLOGY: A retrospective study on the patients with diabetic foot admitted to the surgical unit at Port Moresby General Hospital (PMGH) in 2003 and 2008 was conducted. We also carried out an extensive online search on the prevention and management of diabetic foot ulcers. RESULTS: Our study showed an increasing trend of diabetic foot ulcers and infections from 1.4 to 2.2% of all surgical patients at PMGH over a 5-year period. Interestingly, over that period the representation of females increased from one-third to almost half of all patients with diabetic foot. Furthermore, the patients with diabetic foot complications showed a lower average hospital stay of 35 days in 2008 compared to 54 days in 2003. The literature review showed that the introduction of a diabetic podiatric team service providing simple education to diabetic patients in the form of one teaching session and/or preventive written materials, with a short explanation of diabetic foot pathology and simple preventive measures, reduced the number of amputations by half. RECOMMENDATION: The introduction of a comprehensive foot care education program and organizing a specialist foot clinic for diabetic patients can reduce bed occupancy and health expenditure on diabetic patients as well as the number of amputations and subsequent disability.

Diabetic foot ulcers in Port Moresby General Hospital 2003-2008: review of the principles of effective prevention and management of diabetic foot

In the recent decade in Papua New Guinea and other Pacific countries there has been an increasing trend of lifestyle diseases, including obesity associated with diabetes mellitus. Foot ulceration and infection leading to amputation are common and feared complications of diabetes. Yet these are potentially the most preventable of all complications in diabetic patients. Several studies have shown that half of all diabetic foot ulcers can be prevented by education and simple foot care. The primary goal of this study was to depict the scale of the diabetic foot as a community health problem. The secondary goal was to review the current literature on diabetic foot in order to develop a more effective preventive strategy.

The bacterial flora of acute appendicitis at the Port Moresby General Hospital in Papua New Guinea

Acute appendicitis is a common cause of acute abdomen requiring an emergency appendicectomy. Complications such as perforation and peritoneal contamination leading to peritonitis can result from delay in presentation and an emergency operation. This study prospectively recruited 101 patients diagnosed with acute appendicitis to correlate the bacterial flora with the severity of appendicitis. The results show that 90 patients had acutely inflamed or gangrenous appendicitis and 11 had perforated appendicitis. The ages ranged from 6 to 49 years with a median of 20 years. There were 59 females and 42 males. The commonest isolates were aerobic bacteria such as Escherichia coli, Group D streptococci and Klebsiella pneumoniae. Mixed infection with anaerobes such as Bacteroides fragilis was seen only in perforated appendicitis. The best choices of antibiotic were a fluoroquinolone, cephalosporin and aminoglycoside for aerobic organisms and metronidazole for anaerobes.

Variations of the middle thyroid vein in Papua New Guinean Melanesians.

The middle thyroid vein has been noted to be frequently absent during thyroidectomies in Papua New Guinea (PNG). To verify this and other known inconsistencies in the neck a total of 103 bodies were dissected at the Port Moresby General Hospital in 2002. The middle thyroid vein was absent in 59% of the cases. It would be to the advantage of surgeons in PNG to be aware of this.