Article Text
PDF
Abstract
Introduction Diseases addressed by surgical, obstetric, trauma and anaesthesia (SOTA) care are rising globally due to an anticipated rise in the burden of non-communicable diseases and road traffic accidents. Low- and middle-income countries (LMICs) disproportionately bear the brunt. Evidence-based policies and political commitment are required to reverse this trend. The Lancet Commission of Global Surgery proposed National Surgical and Obstetric and Anaesthesia Plans (NSOAPs) to alleviate the respective SOTA burdens in LMICs. NSOAPs success leverages comprehensive stakeholder engagement and appropriate health policy analyses and recommendations. As Uganda embarks on its NSOAP development, policy prioritisation in Uganda remains unexplored. We, therefore, seek to determine the priority given to SOTA care in Uganda’s healthcare policy and systems-relevant documents.
Methods and analysis We will conduct a scoping review of SOTA health policy and system-relevant documents produced between 2000 and 2022 using the Arksey and O’Malley methodological framework and additional guidance from the Joanna Briggs Institute Reviewer’s manual. These documents will be sought from the websites of SOTA stakeholders by hand searching. We shall also search from Google Scholar and PubMed using well-defined search strategies. The Knowledge Management Portal for the Ugandan Ministry of Health, which was created to provide evidence-based decision-making data, is the primary source. The rest of the sources will include the following: other repositories like websites of relevant government institutions, international and national non-governmental organisations, professional associations and councils, and religious and medical bureaus. Data retrieved from the eligible policy and decision-making documents will include the year of publication, the global surgery specialty mentioned, the NSOAP surgical system domain, the national priority area involved and funding. The data will be collected in a preformed extraction sheet. Two independent reviewers will screen the collected data, and results will be presented as counts and their respective proportions. The findings will be reported narratively using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews.
Ethics and dissemination This study will generate evidence-based information on the state of SOTA care in Uganda’s health policy, which will inform NSOAP development in this nation. The review’s findings will be presented to the Ministry of Health planning task force. The study will also be disseminated through a peer-reviewed publication; oral and poster presentations at local, regional, national and international conferences and over social media.
- SURGERY
- Health policy
- ANAESTHETICS
- OBSTETRICS
- Trauma management
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
STRENGTHS AND LIMITATIONS OF THIS STUDY
This scoping review is the first study to evaluate surgical, obstetric, trauma and anaesthesia prioritisation in Ugandan policy, adding to the limited knowledge base on global surgery in Uganda and the COSECSA region.
The search strategy includes electronic databases and various grey literature sources like governmental and non-governmental organisations, professional associations and councils, and religious and medical bureaus.
The scoping review will use established rigorous methodology from the manual of the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
However, the identification and characterisation of documents will be limited to articles that can be accessed, given that important documents were archived in hard copy form.
Background
Twenty-eight to thirty-two per cent of the global disease burden is treatable by surgical care1; however, approximately five billion people lack access to timely, safe and affordable surgical, obstetric, trauma and anaesthesia (SOTA) care when needed.2 This huge disparity exists mainly in low- and middle-income countries (LMICs), where 9 of 10 people do not have access to SOTA care.2
Until recently, surgery and anaesthesia were considered burdensome, luxurious and less cost-effective aspects of global health.3 The Lancet Commission on Global Surgery (LCoGS) in 2015 projected an increased need for SOTA care in LMICs to effectively address the burden of communicable and non-communicable diseases and road traffic accidents. Mindful of these challenges, a new term, ‘Global surgery,’ was adopted to describe a rapidly developing multidisciplinary field aiming to provide improved timely, safe and affordable SOTA care across international health systems with a focus on LMICs such as Uganda.4
This new term brought about numerous academic and policy stimuli. These included landmark publications such as the World Bank’s third edition of their Disease Control Priorities (DCP-3) and World Health Assembly (WHA) resolution 68.15, which was adopted unanimously by the World Health Organisation Member States in 2015. This resolution calls for strengthening emergency and essential surgical and anaesthesia services as a part of universal health coverage.5 The LCoGS, with its published seminal report, focused on workforce, training, education; healthcare delivery and management; information management; and economics and finance for SOTA care and championed the most significant stimuli in the same year.4 It proposed six indicators to be monitored, evaluated and reported by all countries and global health organisations.4 These efforts ultimately culminated in recommendations to develop National Surgical, Obstetric and Anaesthesia Plans (NSOAPs), using the facility-level and country-level data to drive health policy. Since then, governments, ministries, professional societies and on-the-ground clinicians have been interested in leading efforts to increase surgical, obstetric and anaesthesia care in their countries by developing the NSOAPs.6 7
Recognising current gaps in its surgical system’s six core health domains, the Zambian Ministry of Health implemented resolution 68.15 by developing an NSOAP in the country at the beginning of 2016. The goal was to integrate the NSOAP plan into the National Health Sector Strategic Plan of Zambia, 2017–2021.8 Following this, other sub-Saharan African countries, including Madagascar, Tanzania, Rwanda, Ethiopia and Nigeria, have developed similar NSOAP plans. Uganda currently has no active NSOAP plan.
Uganda, a low-income country with inadequate health budget allocation and a high burden of out-of-pocket expenditure of approximately 38% (National Health Accounts, 2018/19), faces several challenges in timely access and affordable and safe SOTA care.9 Most of the facilities lack surgical amenities to perform bellwether procedures.10 The surgical volume in 2011 was estimated at 241 per 100 000, which has not changed over the last 10 years.11 The mean national specialist surgical workforce density is about 1.05 for every 100 000 people.12 Moreover, poor remuneration and difficult working environments have led to poor retention of the surgical workforce within Uganda.13 Within an average catchment area of 23.99 km, the mean proportion of Ugandans living 30 min, 1 hour and 2 hours from a surgical facility is 64%, 87% and 98%, respectively.14 Furthermore, Ugandan SOTA patients face significant financial hardship. The risks of catastrophic and impoverishing SOTA-care-related expenditures are estimated at 65% and 69%, respectively.15 16 Regarding safety, the maternal mortality ratio was 375 per 100 000 live births in 2017. Also, the neonatal and under-5 mortality rates per 1000 births were estimated at 19 and 43, respectively, in 2020.17 18
In light of these challenges, the Ugandan Ministry of Health in 2020 embarked on developing NSOAP plans in collaboration with various stakeholders.19 NSOAPs are designed to strengthen surgical systems, covering every health system domain: infrastructure, surgical workforce, service delivery, information management, governance and financing in alignment with national health plans. In developing NSOAPs, existing health policies should be considered and analysed to avoid redundancy and identify opportunities for collaboration, pooling of resources and synergy. This analysis may also inform the development and review of evidence-based policies. Although there have been some research efforts in other countries to identify opportunities for SOTA (Takoutsing et al 2021, etc),20 no such efforts have focused on SOTA health policy analysis in Uganda. Thus, this study will seek to determine the priority given to SOTA care in Uganda’s healthcare policy and decision-making documents.
This protocol aims to describe the methodology of an up-to-date scoping review of existing Ugandan national health policies and related documents (strategies, plans, guidelines, rapid response summaries, health events, evidence briefs for policy and dialogue reports) and identify opportunities for SOTA policies. The primary and secondary aims of the review are described in Box 1. The findings from this study will inform the ongoing NSOAP development and implementation that commenced in 2020 and, as a result, may lead to progress towards adhering to the Global Surgery 2030 agenda.19
Primary and secondary aims of the review
Primary aim:
To determine the extent to which SOTA is prioritised in national health policy and systems documents.
Secondary aim:
To characterise all documents with SOTA as a focus area in terms of origin, type, year of production, target audience, health system domain covered and national priority areas.
SOTA, surgical, obstetric, trauma and anaesthesia.
Methods
Protocol design
Arksey and O’Malley’s framework informed the design of the proposed scoping review methodology, which in a health policy research context includes five stages to conducting a scoping review: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data and (5) collating, summarising and reporting the results. We will also draw insights from the PCC (Population, Concept, Context) framework to modify stage 2 to fit our design involving identifying policy documents. The future corresponding scoping review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review guidelines.21 22
Stage 1: Identifying the research question
After consultation with the entire research team, the overall research questions were:
Between 2000 and 2022, what proportions of different health policy and systems documents address specific SOTA aspects: surgery, obstetric, trauma, and anaesthesia care?
What prominence is SOTA given in key policy documents (plans, guidelines, strategies and policies)?
What is SOTA care’s volume and nature (type, content areas/scope, year of production, target audience/stakeholders and funding) in Uganda’s health policy documents between 2000 and 2022?
How are the SOTA-related policies distributed in the six domains of the surgical system: governance, infrastructure, service delivery, workforce, information management, and health financing?
What proportion of SOTA-related policies focuses on Bellwether or essential surgical procedures?
Did the advent of key Global Surgery stimuli in 2015 and COVID-19 in 2019 cast any changes in SOTA-related Uganda’s decision-making documents?
Stage 2: Identifying relevant policy documents
The PCC framework proposed by the Joanna Briggs Institute manual is adopted in this review, as demonstrated in table 1. According to this framework, the population is Ugandans of any age group requiring a surgical procedure. The concept is to prioritise surgical, obstetrics, anaesthesia and trauma care, whereas the context is SOTA care in a low-income setting, that is to say, Uganda.
PCC framework for scoping review
Databases and search strategy
We conducted a stakeholder mapping of all institutions involved in delivering SOTA care in Ugandatable 1 in online supplemental file 1). A targeted hand search/manual strategy will be executed on the websites of the above institutions. We shall use the Google Search engine to find such websites, which we then navigate using the tabs and menus available on the home page (eg, policy documents and guidelines, e-library, resources, publications, legislation). Since different websites are organised differently, we shall develop specific search strategies for each website depending on its navigability. In addition, we shall search Google Scholar and PubMed using the following keywords in various combinations with Boolean operators (and, or): Uganda, health policy, health system, policies, strategies, plans and reports (table 2). We shall inspect the reference lists of found documents to expand our list of included documents. Importantly, we shall use the websites from stakeholder mapping as an entry point to other repositories for national strategy documents. The above search strategy was adapted from Takoutsing et al 2022 and Mutatina et al 2017. Finally, we will contact key informants such as senior surgeons at Makerere University, the chief surgeon at Ministry of health and the librarian. This snow-ball approach is likely to accrue the most important documents to meet our research objectives.
Supplemental material
Pilot search strategy of Google Scholar and PubMed databases
Stage 3: Screening and selection of relevant documents
At this stage, BK and BDT will discuss and use the keywords incorporating the inclusion criteria. The search strategy will be developed by testing the keywords, and MESH terms, on the databases to search. Finally, all reviewing team members will discuss and determine the final search strategy.
To delineate the boundaries of SOTA health policy and systems research, we borrowed the Hoffman et al model to determine the documents relevant to health policy and systems to incorporate in this study.23
We shall therefore include all SOTA-related documents between 2000 and 2022 that address the following:
Issues related to health systems (ie, SOTA leadership and governance, financial and service delivery, health information systems and implementation strategies);
Policies on clinical issues, which include essential drugs, diagnostics and medical supplies, for example, blood transfusion for surgical operations; and
Policies on public/population issues such as breast cancer screening, and immunisation for cancer prevention, for example, HPV vaccine for cervical cancer.
We shall exclude documents that:
Have no national coverage (eg, NGO project reports covering only a few districts).
Are in the draft stage.
Are primary studies (case reports, series, reviews, cross-sectional and cohort studies).
The screening and selection will be conducted in three phases. First, all articles identified per our search will be exported to an Excel proforma sheet (Microsoft, Redmond, Washington, USA), and duplicates will be identified and deleted. Next, a calibration exercise will be carried out before screening to ensure an adequate understanding of the inclusion criteria by study screeners. At least two independent reviewers will review each policy document. The documents identified by either or both reviewers will be included for extraction. Disagreements will be discussed among the reviewers, and in case of no resolution, an appeal will be made to a senior authors (EAO, BM and EAE). A flow diagram will be presented to reflect the search process.
Stage 4: Charting the data
Key characteristics from the included studies will be extracted using a predefined data-extraction sheet in Microsoft Excel (Microsoft, Richmond, Virginia, USA). Data extraction will also be performed in two stages. First, a pilot stage consisting of all authors independently extracting and categorising data from 10 policy documents. This is to assure the reliability and standardisation of the extraction form and that all authors extract data homogeneously and accurately. Next, the authors will complete data extraction for all included documents, and discrepancies that were not resolved between the authors will be arbitrated by the senior authors (BM, EAO and EAE). The expected key information to be extracted is outlined in Box 2. A sample tabular extraction form is also illustrated in table 3.
Key information to be extracted
Year of publication of policy document
Type of document
Global surgery SOTA aspect focused on
Health system components involved
Stakeholders involved
Funding
Preliminary findings of the SOTA documents (full table in online supplemental material)
Stage 5: Collating, summarising and reporting the results
The SOTA scoping review results will be presented narratively, describing the documents’ scope and nature. The data will be summarised with descriptive statistics in graphs and tables; regarding types of documents, their focus, NSOAP domains and national priority areas or issues addressed in these documents. We shall also expose the trends, especially during the COVID-19 era and following the publication of key Global Surgery documents in 2015.
Patient and public involvement
No patient involved.
Discussion
We shall review all relevant health policy and decision-making documents about the Uganda health system and interventions on all available health databases produced from 2000 to 2022. We chose to commence from 2000 as this year was critical for health sector reforms. Before 1990, Uganda faced political instability. The focus of the new government was on restoring law and order. Funding and resources for social services such as health was limited and came mostly from external donors who focused on specific disease programmes in just a few districts. These efforts were unsustainable, and thus health outcomes stagnated between 1990 and 2000. The year 2000 marked the beginning of implementing important health sector reforms in Uganda with a sector-wide approach. These included the National Health Policy and Health Sector Strategic Plan (2000/01–2004/05).24 The study design and identification of relevant documents are adopted from previous health policy analysis by Mutatina et al, in which they attempted to establish a one-stop shop for health policy documents in Uganda.25
Ethics and dissemination
Ethical approval for this study will not be required because this study did not involve human participants. The dissemination will include the following: presenting the review’s findings to the Ministry of Health planning task force; publication of the protocol and the review in peer-reviewed journals; oral and poster presentations at local, regional, national, and international conferences; and dissemination over social media.
Ethics statements
Patient consent for publication
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @Bryan_ksg, @BerjoDongmo, @ekwaroobuku
Contributors BK, BDT and DB were responsible for conceiving the article. BK is the guarantor. BK, BDT and DB wrote the manuscript. EAE, DB, BM and EAO critically appraised the manuscript. All authors critically revised and approved the final protocol.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.