National surgical, obstetrics, and anaesthesia plans in Sub-Saharan Africa: a comparative economic content analysis

INTRODUCTION: The introduction of National Surgical, Obstetrics, and Anaesthesia Plans (NSOAPs) in Sub-Saharan Africa (SSA) aims to address the region's significant gaps in access to surgical care. The financial implications of these plans, which are crucial for implementation and scaling, remain underexplored. This study presents a comparative analysis of the economic content of NSOAPs across ten SSA countries, highlighting financial strategies, costing, and proposed implementation frameworks. METHODS: A mixed-methods policy content analysis was conducted. Data were collected from published documents, followed by a qualitative thematic analysis of economic components. Quantitative analysis focused on the comparison of total and per capita costs, adjusted for purchasing power parity (i.e., in International dollars [I$]), and aligned against socio-economic indicators. RESULTS: There was significant variability in the economic content covered across the ten NSOAPs. Overall, most plans emphasised resource mobilisation and to a lesser extent financial protection, while purchasing was the most neglected. Nigeria and Tanzania provided the most comprehensive financing strategies, including innovative resource mobilisation, risk protection, and purchasing (at least implicitly); other countries like Rwanda and Madagascar lacked detailed financial protection and purchasing mechanisms. Total lifespan costs ranged from I$221 million (Senegal) to I$50.5 billion (Nigeria), with per capita costs varying widely. Annual costs as a percentage of Gross Domestic Product were modest, but in some countries, like Nigeria, implementation would require nearly 10% of the annual national budget. Involvement of (health) economics specialists and ministry of finance stakeholders was notably low, generally. CONCLUSION: NSOAPs represent an important policy tool for improving surgical care in SSA. However, inadequate economic planning and financing strategies present significant barriers to their implementation. Future plans should be developed through multi-disciplinary expertise and inter-sectoral engagement with a focus extending beyond resource mobilisation to encompass financial protection and purchasing to ensure sustainable investments in surgical care. Unbundling the plans into smaller, contextually prioritised packages may enhance their perceived financial feasibility and, consequently, their appeal to governments and funders.