Governance for injury care systems in Ghana, South Africa and Rwanda: development and pilot testing of an assessment tool

Objectives: This study aims to evaluate health systems governance for injury care in three sub-Saharan countries from policymakers’ and injury care providers’ perspectives. Setting: Ghana, Rwanda and South Africa. Design: Based on Siddiqi et al’s framework for governance, we developed an online assessment tool for health system governance for injury with 37 questions covering health policy and implementation under 10 overarching principles of strategic vision, participation and consensus orientation, rule of law, transparency, responsiveness of institutions, equity, effectiveness or efficiency, accountability, ethics and intelligence and information. A literature review was also done to support the scoring. We derived scores using two methods—investigator scores and respondent scores. Participants: The tool was sent out to purposively selected stakeholders, including policymakers and injury care providers in Ghana, Rwanda and South Africa. Data were collected between October 2020 and February 2021. Primary and secondary outcomes: Investigator-weighted and respondent percentage scores for health system governance for injury care. This was calculated for each country in total and per principle. Results: Rwanda had the highest overall investigator-weighted percentage score (70%), followed by South Africa (59%). Ghana had the lowest overall investigator score (48%). The overall results were similar for the respondent scores. Some areas, such as participation and consensus, scored high in all three countries, while other areas, such as transparency, scored very low. Conclusion: In this multicountry governance survey, we provide insight into and evaluation of health system governance for trauma in three low- and middle-income countries (LMICs) in sub-Saharan Africa. It highlights areas of improvement that need to be prioritised, such as transparency, to meet the high burden of trauma and injuries in LMICs.