Equitable access to quality trauma systems in low-income and middle-income countries: assessing gaps and developing priorities in Ghana, Rwanda and South Africa

Maria Lisa Odland, Abdul-Malik Abdul-Latif, Agnieszka Ignatowicz, Barnabas Alyande, Bernard Appia Ofori, Evangelos Balanikas, Abebe Bekele, Tony Belli, Kathryn M. Chu, Karen Ferreira, Anthony Howard, Pascal Nzasabimana , Eyitayo O. Owolabi, Samukelisiwe Nyamathe , Sheba Mary Pognaa Kunfah, Stephen Tabriri, Mustapha Yakubu, John Whitaker, Jean Claude Byiringiro, Justine DaviesThe EquiTrauma Collaborative

Research output: Contribution to journalReview articlepeer-review

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Injuries in low-income and middle-income countries are prevalent and their number is expected to increase. Death and disability after injury can be reduced if people reach healthcare facilities in a timely manner. Knowledge of barriers to access to quality injury care is necessary to intervene to improve outcomes. We combined a four-delay framework with WHO Building Blocks and Institution of Medicine Quality Outcomes Frameworks to describe barriers to trauma care in three countries in sub-Saharan Africa: Ghana, South Africa and Rwanda. We used a parallel convergent mixed-methods research design, integrating the results to enable a holistic analysis of the barriers to access to quality injury care. Data were collected using surveys of patient experiences of injury care, interviews and focus group discussions with patients and community leaders, and a survey of policy-makers and healthcare leaders on the governance context for injury care. We identified 121 barriers across all three countries. Of these, 31 (25.6%) were shared across countries. More than half (18/31, 58%) were predominantly related to delay 3 ('Delays to receiving quality care'). The majority of the barriers were captured using just one of the multiple methods, emphasising the need to use multiple methods to identify all barriers. Given there are many barriers to access to quality care for people who have been injured in Rwanda, Ghana and South Africa, but few of these are shared across countries, solutions to overcome these barriers may also be contextually dependent. This suggests the need for rigorous assessments of contexts using multiple data collection methods before developing interventions to improve access to quality care.

Original languageEnglish
Article numbere008256
JournalBMJ Global Health
Issue number4
Publication statusPublished - 11 Apr 2022

Bibliographical note

Funding Information:
Funding Funding for this study was provided by the National Institute of Health Research, NIHR, award number 130036.

Publisher Copyright:
© 2022 Author(s). Published by BMJ.


  • Health policy
  • Health services research
  • Health systems
  • Health systems evaluation
  • Traumatology

ASJC Scopus subject areas

  • Health Policy
  • Public Health, Environmental and Occupational Health


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