Table 2 Contextual considerations relevant to musculoskeletal (MSK) health globally, relevant to Category 1 of the logic model

1. MSK health is afforded a relatively lower priority status compared with other health conditions and is poorly legitimised

1.1 MSK conditions are, and historically have been, considered a relatively lower health priority across all levels of society compared with other health conditions more closely associated with mortality and urgency.

“Certainly, in my region in Africa, I think the communicable diseases seem to take a priority and in terms of the NCDs, the cardiovascular diseases and perhaps the cancers seem to be on top of the list of priorities.” (ID11)

“I think that musculoskeletal conditions are not directly life-threatening diseases, so the importance of musculoskeletal conditions has been underestimated. I think that lower back pain and knee osteoarthritis are two major targets in musculoskeletal conditions, but many people feel that conditions such as knee osteoarthritis would be far less important compared to cancer or cardiovascular disease.” (ID1)

“I think that musculoskeletal disorders still remain rooted at the foot of the priority ladder when it comes to NCDs.” (ID7)

“My general thinking about musculoskeletal conditions is it seems like it is one of the forgotten or sidelined issues. The prevalence is really, really high and the contribution to disability is really high, but the focus given to the prevention and management of musculoskeletal conditions doesn’t really match …” (ID30)

1.2 MSK pain and specific MSK conditions are often poorly understood, recognised, measured, treated and legitimised in policy, practice and in community attitudes.

“The other issue that we’ve got particularly around inflammatory arthritis, you can’t see it anymore. Because we’ve come such a long way with the medications and the treatment options available, you don’t see the disfigurement, you don’t see the old people hunched over as much as you used to. You don’t see it, it’s become an invisible disease that is still as debilitating, it is still as painful, but because you don’t see it, it’s not front of mind, it’s not challenging people’s understanding of how horrible it is anymore, which has actually borne out a whole new issue for people who are dealing with this. Because it’s become an invisible disease, people don’t accept that there’s anything wrong with you.” (ID12)

“So, in terms of [MSK pain] management, we haven’t done that at all for the average adults. There is pain management for kids in the WHO but there is no pain management for adults, including low back pain which is a leading cause of disability. It’s very important to address not only the pharmacological interventions.” (ID24)

1.3 MSK health and pain care are relatively lower priorities for investment in service delivery, workforce and research by nations and donors.

“… countries with limited health budgets will still prioritise life-saving health measures and, as I said before, musculoskeletal disorders don’t kill enough people to make the government sit up and listen. I think that is one of the bottom lines. So while we know that they cause widespread disability, huge disability, they don’t cause death, and I think some of the funding for research and innovation is likely to be compromised for that reason.” (ID7)

“The other immediate thought that I have, and that is probably across the board, is the resourcing. I feel that the whole musculoskeletal pathway right through from talking about prevention to rehabilitation compared to some of the other long-term conditions is probably very poorly resourced, especially at the front end on the prevention side, that is.” (ID17)

I can boldly say that it’s not a priority health issue like, for example, in Ethiopia and other African countries. It’s not a priority health issue...other health issues like, for example, communicable diseases like HIV/AIDS and tuberculosis. The government budget, more budget goes to communicable diseases and these non-communicable diseases are not really considered a top priority issue. Currently, there are some changes of course, but still there is a huge gap. Like if you see the health policy and the health strategy, they give more weight to the communicable diseases than to the non-communicable diseases.” (ID30)

2. Improving MSK health is more than just healthcare

2.1 There is inadequate inter-ministerial cooperation and inadequate integration of MSK health into public policy to drive improvements in prevention and management of MSK health impairments. MSK health is relevant beyond healthcare and extends to other important areas such as industry, transport and infrastructure.

“So I would say at the national leadership level that a move like that is important. We have to get rid of the elephant in the room, it has to be treated at the same level because we are number one on the years lived with disability scores from the global burden of disease. So, it has to be included in every national plan about public health and any action to reduce absence from work etc. So that’s very important.” (ID2)

2.2 Built environments are often not conducive to preventing MSK health impairment, managing MSK health conditions and enabling participation and health promotion by people with MSK conditions.

“You may not really want to ever get out of your home because it’s really challenging to move around. Then you find where the road systems have improved, like in the capital city here we now have nice, really beautiful highways, but the highways actually have limited places where you can cross on foot. So, if you’re physically challenged and the vehicles are cruising at a high speed - or if there’s a crossing, it is very, very far away, it is so far that you can’t walk that distance. These are not major, but they are major to the quality of life.” (ID3)

3. Global guidance is needed for country-level health system strengthening

3.1 There is a need for a global strategy to improve prevention and management of MSK health.

“Because NCDs are not uniform, they don’t have uniform needs, so a specific MSK policy which will cater now for all the needs, like the issue of mobility, the issue of access, yes and that I think can be really actually promoted at a global level and then it’s for the individual governments worldwide to decide what level they’re able to adopt, according to their resources and political will.” (ID3)

3.2 External framing of MSK health with a focus on cost to governments and return on investment is needed.

“I think if you look at the numbers, the costs, they are huge, they are massive, and it’s comparable with major investments for defence. You can reframe the costs and illustrate them by this costs the same every year as it costs our marines to buy these four ships or things like that.” (ID2)

“I think also it’s fair to say that government action tends to follow economic pressure and if governments really feel the pressure of economic harm arising from a particular activity within society or a burden on society like musculoskeletal disorders then that may prompt them to take better action, but because they’re not asking the questions, possibly because they know what the answers are going to be, it gives them an excuse not to invest. I wonder whether that’s an issue as well.” (ID7)

3.3 Global leadership from the WHO in prioritisation of MSK conditions, through the development of a strategy, action plan or guideline, is essential to catalyse a global response to the burden of disease, particularly in LMICs and the activities of global clinical organisations.

“Yes, I believe that if that top-level strategy came from the WHO and trickled down - actually, maybe “trickled” is not the right world to use here. I think it needs to come down more forcefully, more authoritatively. It needs to come down through all the right channels with a proper and co-ordinated flow.” (ID31)

“I think there definitely needs to be a concerted effort at governmental level to prioritise MSK disorders within health systems globally. … without a global strategy the management of MSK disorders will continue to be suboptimal.” (ID7)

4. COVID-19 will have an impact on MSK health globally and opportunities for health systems strengthening

4.1 The global COVID-19 pandemic will likely increase financial and racial inequities in healthcare and reduce prioritisation of MSK health and pain care by governments on a background of a likely increase in MSK burden of disability.

“Like, for example, if you look at home rehabilitation services for people with disabilities, now because of COVID we are not able to provide home-based rehabilitation services because most rehabilitation services require physical contact. So, because of this, most rehab in institutions in Addis Ababa and some African countries, they’re almost not functioning at this point. This situation worsens the conditions for people with disabilities like, for example, children with cerebral palsy who need regular exercise, people who need regular rehab exercises. Since they’ve already stopped doing the exercise, their condition will worsen, and the same thing will happen in musculoskeletal and other disabling situations. So, the impact is really huge. I believe that there should be some mechanism, some research needs to be done or some kind of information or guidelines need to be developed on how this community can survive or can get services during the pandemic or something like that. That’s my thought.” (ID30)

4.2 The aftermath of COVID-19 will dictate how global organisations operate, which will influence global responses to healthcare.

“I have no opinion as to the competencies of the WHO, but what we have not seen is a global joined up response to the COVID-19 crisis. I suspect that we should anticipate a very intensive revision of just how global organisations are expected to perform and behave in the coming months and years. So, preparing a global strategy [one] will need to be cognisant potentially of changing international organisational structures.” (ID15)

5. There are multiple inequities associated with impaired MSK health

5.1 MSK conditions, pain and injury increase socioeconomic inequity in LMICs due to significant work and participation restrictions associated with MSK impairments and poor access to care.

“I’ve done some work in Botswana … and I recognise that when the breadwinner is compromised through musculoskeletal disorders then that has a real ripple effect throughout the whole family and into the community. I think particularly in areas where the social determinants of health are such that citizens are poorly supported, an inequity leads to an exacerbation of these musculoskeletal disorders.” (ID7)

“It is a big issue. For example, people with arthritis or who have bone problems, they experience huge pain, but they are still struggling to work. Even like, for example, if you don’t have some noticeable symptoms, employers don’t give you permission to go and take rest, so they keep pushing you to work even though you have those kinds of musculoskeletal problems.” (ID30)

6. Service delivery for MSK health is characterised by multiple complexities

6.1 Delivery of healthcare for MSK health is complex and perhaps more complex thanother health conditions. This is owing to the wide range of health professionals who manage people with MSK health impairments and often the requirement for a continuum of care over a protracted period. This breadth makes care co-ordination challenging, navigation of the health system by patients difficult, and developing systems reform initiatives inherently more complex.

“there is a lack of continuation of care from the inception to eventually the late stage, both in musculoskeletal and pain …” (ID4)

“… there is the fact that for all these other chronic conditions that you have said, a specific physician is treating them. In musculoskeletal conditions, apart from the fact it can be a physiatrist or as it happens in some countries directly a physiotherapist that can treat them, it can be a rheumatologist, it can be an orthopaedic surgeon. It’s also sometimes really difficult for the patient to understand who should take care of them.” (ID29)