NIHR Global Health Group on Equitable Access to Quality Health Care for Injured People in Four Low or Middle Income Countries: Equi-injury

Injuries constitute 9% of global deaths; over 90% of these are experienced in low or middle income countries (LMICs) and many are avoidable with access to quality care. Improving outcomes for people who have suffered injuries requires intersectoral understanding – ascertaining the barriers that are experienced from the point of injury to seeking, reaching, and receiving care; assessing if care received is of good quality; and identifying the consequences (or outcomes) of not accessing quality healthcare. However, most research on care provision for injuries in LMICs is limited to care provided at the healthcare facility; this neglects the 40-50% of avoidable mortality that occurs prior to reaching the facility. Quality of care received is rarely rigorously studied. In this project, we build upon partnerships formed in a recent NIHR funded development grant (EquiTrauma). We will study equitable access to quality care after injury using integrated frameworks: the three delays approach (developed to improve maternal health outcomes), the WHO Health System Building Blocks, and the Institute of Medicine’s Quality Framework. The study will be done with partners in four LMICs: Rwanda, Ghana, South Africa, and Pakistan. In each setting, we will collect comprehensive quantitative and qualitative data on the barriers to equitable access to quality care and outcomes after injury. Using these data, we will develop and test an injury pathway model with the purpose of showing which barriers, in each country, can be overcome to produce maximal health gains. In each country, we will work to embed our findings in policy by involving multiple stakeholder groups (patients, community members, healthcare providers, policy makers, and civil servants) in our research. We will first engage with stakeholders to ascertain how to best embed research findings into policy and practice; with this learning, together with stakeholders, we will develop a strategy to deliver change. We will then work with stakeholders to ascertain which outcomes (for example, clinical outcomes, or respectful, safe, free, or inexpensive care) are priorities for them. Later, informed by the injury pathway model and knowledge of priority outcomes, we will work with stakeholders to achieve consensus on which barriers to access to quality care after injury are priorities to address and the solutions to overcome these barriers. These solutions will be developed for implementation and testing in future research. We will do transnational comparisons of all results to determine which are shared across all countries and are more likely to be transferable outside our study settings. We will engage with multilateral policy makers (e.g. WHO) from study inception to share results and facilitate global uptake of results. To ensure sustainability, we will form four country hubs for injury research in LMICs and additional hubs of methodological expertise. These hubs will be LMIC led at project end to facilitate South-South learning. Most methodologies used are feasible to deliver with minimal resources and, when used together, give extensive insights into health system functioning for injury and other conditions. By building capacity in these methodologies (training > 18 junior scientists) and forming hubs – which will be able to train others - the legacy of the project will extend beyond the countries in this partnership and to other conditions which require health system strengthening.