Critical Examination of Structural Determinants of Preventable Surgical Mortality in Public Hospitals in North East and North West Nigeria: A Political Economy Analysis

Preventable surgical mortality in Nigeria's northern geopolitical zones is disproportionately high, yet its structural determinants are inadequately theorised beyond individual clinical factors. The political economy of surgical system failures, including underfunding, workforce maldistribution, procurement corruption, and governance deficits, has not been examined as an explanatory framework for surgical mortality disparities. This study critically examines the structural determinants of preventable surgical mortality in public hospitals in North East and North West Nigeria using a Critical Realist Political Economy methodology. The research design integrates retrospective analysis of surgical mortality records at ten public hospitals (five per zone) from 2018 to 2023, with a parallel interpretive qualitative study comprising 100 semi-structured interviews with surgeons, anaesthetists, hospital administrators, state health commissioners, and civil society health advocates. Document analysis of state health budgets, procurement records, and policy implementation reports complements the qualitative strand. Retroductive reasoning and context-mechanism-outcome configurations from Realistic Evaluation theory identify structural causal mechanisms. The Political Economy of Health framework and Farmer's structural violence theory provide the theoretical anchoring. Original contributions include a Structural Determinants of Surgical Mortality Model specific to northern Nigerian public health contexts, challenging clinical reductionism in surgical quality literature. Findings will provide evidence for advocacy on surgical public finance reform and health system accountability. Keywords: surgical mortality, structural determinants, political economy, North Nigeria, Critical Realism.