Prioritization of surgical, obstetric, trauma, and anesthesia care in India over seven decades: A systematic analysis of policy documents

Abstract

Improving access to surgical care in India requires policy-level prioritization of surgical, obstetric, trauma, and anesthesia (SOTA) care. We quantified SOTA care prioritization in the last seven decades by analyzing India's national policy and programmatic documents. Forty documents of national importance over seven decades (1946-2017) were screened for a set of 52 surgical and 6 non-surgical keywords. The number of mentions per keyword was used as a proxy for surgical prioritization. For thematic analysis, surgical mentions were further classified into five domains: Infrastructure, Workforce, Service Delivery, Financing, and Information Management. The total number of mentions was 4681 for the surgical keywords and 2322 for non-surgical. The number of mentions per keyword was 90.02 for surgical keywords and 387 for non-surgical. The older committee reports showed relatively higher SOTA care prioritization compared to the years after 2010. Among the domains, Service Delivery (897) had the maximum number of mentions followed by Infrastructure (545), Workforce (516), Financing (98), and Information Management (40). National Health Policy 2017, the most recent high-level policy, grossly neglected SOTA care. SOTA care is inadequately prioritized in Indian national health policies, especially in the documents after 2010. Concerted efforts are necessary to improve the focus on financing and information management. Prioritization can be improved through a stand-alone national plan for SOTA care along with integration into existing policies.

Fig 1. Flow diagram depicting study analysis steps.

Fig 2

A: Distribution of mentions by keywords included in the surgical group. Ten keywords with the most mentions are displayed while other keywords are clubbed under ‘Other’. Keywords with * refer to root keywords that can have multiple expanded forms. E.g., surg* can include surgical, surgery, surgeon, etc. B: Distribution of mentions by keywords in the non-surgical group.

Fig 3

A: Surgical and non-surgical mentions per keyword from 1946 to 2017. B: Number of documents published in each year from 1946–2017.

Fig 4. Document-wise comparison of surgical and non-surgical mentions per keyword.

The documents are ordered in the decreasing order of the gap between surgical vs. non-surgical mentions per keyword. Abbreviations: PC = Planning Commission, IPHS = Indian Public Health Standards, NHP = National Health Policy, HLEG = High Level Expert Group, NRHM = National Rural Health Mission, NUHM = National Urban Health Mission, NBP = National Blood Policy, NPPMBI = National Programme for Prevention and Management of Burns and Injuries, NPCBVI = National Programme for Control of Blindness and Visual Impairment, NPPC = National Programme for Palliative Care, NOTP = National Organ Transplant Program, NPHCE = National Programme for Health Care of the Elderly, NCCE = National Council for Clinical Establishments, NPCDCS = National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke.

Fig 5

Progression of relative prioritization assessed by mentions per keyword across A) Iterations of the National Health Policy of India across 1983, 2002, and 2017 and B) Planning Commission (PC) reports.

Fig 6. Distribution of mentions of surgical keywords across the five surgical care domains defined by the Lancet Commission on Global Surgery (LCoGS).

Fig 7. Heatmap showing the document-wise distribution of the mentions under the five LCoGS-defined surgical care domains (infrastructure, workforce, service delivery, financing, and information management) across 40 documents.

Fig 8. Heatmap showing the distribution of the LCoGS-defined domains across the eight subgroups of surgical keywords.