A Theoretical Framework for Universal Surgical Access in Low-Income States of Nigeria: Integrating Health Systems Strengthening and Surgical Workforce Theory

Universal surgical access remains an unrealized aspiration in Nigeria's low-income states, where geographical, financial, and workforce barriers converge to deny populations essential surgical care. This dissertation develops a theoretical framework for universal surgical access specifically adapted to low-income states in Nigeria, synthesizing health systems strengthening theory, surgical workforce planning models, and equity-focused service delivery frameworks. A sequential mixed-methods approach was employed across four purposively selected low-income states in the North East and North West geopolitical zones. Phase one consisted of a systematic review of global frameworks for surgical access; phase two comprised 40 expert interviews with surgeons, health policymakers, and community stakeholders; and phase three involved participatory framework validation workshops. The resulting framework integrates five structural domains: infrastructure readiness, workforce deployment, financial risk protection, community demand generation, and governance accountability. The framework assigns measurable indicators to each domain, enabling state-level benchmarking. Stakeholder validation confirmed high contextual applicability and implementation feasibility. Theoretical contributions include an original adaptation of Donabedian's quality framework to the surgical access context in Nigeria. The study recommends federal adoption of the framework as the basis for state surgical plans and National Surgical, Obstetric, and Anaesthesia Plan (NSOAP) implementation in low-income states. Keywords: universal surgical access, NSOAP, health systems, Nigeria, theoretical framework