Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies

Abstract

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally; and (2) to contextualize these findings through an analysis of health policies for integrated management of noncommunicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines, South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically-derived, organized around 5 meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focussed on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care; (2) service delivery; (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

Applying the behavioural change wheel to guide the implementation of a biopsychosocial approach to musculoskeletal pain care

“…This can strengthen health systems to support high value musculoskeletal pain care ( 62 ). Examples of existing partnerships and collaboration may include: partnering with patient advocates from the Global Alliance of Partners for Pain Advocacy (GAPPA) task force ( 63 ) or people with lived experience of pain to create better outcomes in the understanding, research, teaching and management of musculoskeletal pain ( 64 – 66 ); partnering with consumer representatives from Cochrane musculoskeletal review group to develop meaningful and person-centred clinical practice guidelines ( 46 ); delivering biopsychosocial-informed education to promote improvements in insurance workers’ pain beliefs and helpful claims management behaviour ( 67 ); aligning country-level strategies to address the burden of pain to the newly developed global blueprint/framework for musculoskeletal health ( 68 , 69 ). Additionally, as highlighted by our previous qualitative review ( 15 ), there is a critical need within health systems to support interdisciplinary or multidisciplinary care, especially for complex and chronic pain presentations.…”

From Local Action to Global Policy: A Comparative Policy Content Analysis of National Policies to Address Musculoskeletal Health to Inform Global Policy Development

“…Global technical advice to support the establishment of MSK policy has been lacking but could contribute to increased efficiency in the development of MSK policies at the national level, and indeed, an empirically-derived strategic framework has been developed recently for this purpose, as well as more nuanced and context-specific recommendations for low- and middle-income settings. 2 , 17 , 18…”

“… 1 Despite MSK health conditions being the leading cause of disability worldwide representing 17% of the global years lived with disability in 2019, global strategy and policy guidance lags behind that for other non-communicable diseases (NCDs), particularly in low resource settings. 2 - 4 Global policy to guide action on MSK health is in a nascent phase. There is currently little global policy or strategic direction that serves as technical guidance to assist national governments in developing whole-of-system approaches to MSK health.…”

Pain Research and Treatment: Policy Implications

“…Similarly, caregivers of older adults with pain often are not given the necessary information to successfully manage the care regimen of their family members (Horgas et al, 2022). Globally, low income countries may not prioritize chronic pain, and thus express, specific pain policies may be absent (Briggs et al, 2023) while the United States has overtaken European countries in the severity of the opioid epidemic (Gomes et al, 2018). Countries are becoming increasingly diverse in terms of racial and ethnic makeup, prompting the need for medical pluralism in the context of health policy ( de-Graft Aikins et al, 2023).…”