Health systems and agendas in low- and middle-income countries: An arenas model analysis of communicable and noncommunicable disease priorities in Malawi and Zimbabwe

Public health problems compete for attention and resource allocations in a wide range of intersecting agenda setting arenas (including political, bureaucratic, media, international aid and research) that contribute to the effectiveness of health systems. This is the first study to use an arenas model to guide analysis of priority (health agenda setting outcomes) in low- and middle-income countries. Health systems building blocks are integrated into the model for analysis of priority in government arenas. The exploratory analysis conceptualizes, measures and compares communicable and noncommunicable (NCD) disease priority in six central health agenda setting arenas in Malawi (low-income) and Zimbabwe (low-middle-income), members of the Southern African Development Community with similarly proportional and converging disease burdens. The study is informed by analysis of data from strategies, reports and other documents; large databases; and key informant interviews (n = 55). HIV/AIDS, tuberculosis and malaria remained substantially higher priorities than four major NCDs across all arenas in both countries through 2024. In the health systems-focused bureaucratic arena, leadership, information management and service delivery were similar for the communicable diseases and somewhat more developed for NCDs in Malawi than Zimbabwe. The study shows how analysis of agenda setting outcomes may be sharpened by focusing on key priority indicators in myriad arenas in which health issues compete for attention and resources. Such an approach may strengthen claims scholars and other analysts make about the agenda status of health issues nationally, and the causal dynamics that underpin them.