Why does a public health issue (not) get priority? Agenda-setting for the national burns program in India.

There is growing scholarly interest in what leads to global or national prioritisation of specific health issues. By retrospectively analysing agenda-setting for India's national burn program, this study aimed to better understand how the agenda-setting process influenced its design, implementation, and performance. We conducted document review and key informant interview with stakeholders and used a combination of analytical frameworks on policy prioritisation and issue framing for analysis. The READ (Readying material, Extracting data, Analysing data and Distilling findings) approach was used for document reviews, and qualitative thematic analysis was used for coding and analysis of documents and interviews. The findings suggest three critical features of burns care policy prioritisation in India: challenges of issue characteristics, divergent portrayal of ideas and its framing as a social and/or health issue, and over-centralisation of agenda setting. First, lack of credible indicators on the magnitude of the problem and evidence on interventions limited issue framing, advocacy, and agenda-setting. Second, the policy response to burns has two dimensions in India: response to gender-based intentional injuries and the healthcare response. While intentional burns have received policy attention, the healthcare response was limited until the national program was initiated in 2010 and scaled up in 2014. Third, over-centralisation of agenda setting (dominated by a few homogenous actors, located in the national capital, with attention focussed on the national ministry of health) contributed to limitations in program design and implementation. We note following elements to consider when analysing issues of significant burden but limited priority: the need to analyse how actors influence issue framing, the particularities of issues, the inadequacy of any one dominant frame, and the limited intersection of frames. Based on this analysis in India, we recommend a decentralised approach to agenda setting and for the design and implementation of national programs from the outset.