Introduction
This chapter proposes an overview of the challenges in meeting the increasing needs for trauma care in low- and middle-income countries (LMICs). The epidemiologic aspects of the burden of injuries are discussed elsewhere in this book (see Chapter 2 ), as well as nonsurgical management of fractures (see Chapter 6 ) so a special effort was made to keep overlaps to a minimum. Topics addressed include systematic approach to trauma care, barriers to access, resources, education, the role of the World Health Organization (WHO), management of common pediatric and adult injuries, with special mention of the Surgical Implant Generation Network (SIGN) system, and different avenues for orthopaedic volunteerism.
For most high-income country (HIC) surgeons, trauma care is synonymous with surgical treatment. This is not the case for LMICs: Most trauma care, at least initially, is provided in the informal sector (traditional healers, bone setters, nurses, pharmacists, etc.), and most of the care provided in the formal sector is conservative (i.e., nonsurgical). The benefits of appropriate surgical over conservative management, in appropriate environments, are well documented for many orthopaedic injuries, starting with this textbook. For myriad reasons detailed below, this is too often unavailable in resource-poor settings, where results of conservative treatment are standard of care. The worldwide increases in economic development, life expectancy, and motorization translate into an epidemiologic transition from communicable diseases to noncommunicable diseases and injuries (GBD 2010). There is proportionally less premature death and more life lived with disability. The burden of injuries is disproportionally shouldered by LMICs: The 2013 WHO report on global road safety showed that 94% of all traffic deaths and 90% of disability related to road traffic injuries (RTIs) occur in LMICs. Estimates are that RTIs alone killed more than 1,250,000 people in 2010, permanently disabled the same number, and temporarily disabled between 10 and 50 times more. An aging population comes with an increase in “insufficiency fractures” and degenerative joint disease (DJD) and inflammatory arthropathies (IAs). All these combine to create a “perfect orthopaedic storm,” and resources to manage it are woefully lagging behind. The following sections will discuss and analyze the necessary determinants to best meet these daunting challenges.
Improving Trauma Care Systemwide Globally: the World Health Organization’s Essential Trauma Care Project
Background
Injury has become a huge global health problem. Each year more than 5 million people die from motor vehicle crashes, violence, and other forms of injury. Ninety percent of these injury deaths occur in LMICs. In addition to the need for improvements in injury prevention, such as road safety, there is a need for improvements in trauma care globally. One study showed significant disparities in outcome after injury among countries at different economic levels. Case fatality rates for serious injuries (Injury Severity Score > 9) rose from 35% in high-income Seattle, Washington, to 55% in middle-income Monterrey, Mexico, to 63% in low-income Kumasi, Ghana. Thus, mortality rates for the seriously injured are nearly twice as high in low-income settings as in high-income settings. If we could eliminate these disparities and bring injury case fatality rates in LMICs down from their current high rates to the rates in high-income countries, we could potentially save 2,000,000 lives per year.
Many millions more people are left with temporary or permanent disabilities from their injuries. One of the leading causes of injury-related disability is extremity injury. One study from Ghana showed that the vast majority (78%) of injury related disability is due to extremity injuries, in comparison to a higher proportion of disability from more-difficult-to-treat neurologic injuries in HICs. Disabilities from such extremity injuries should be readily amenable to improvements in orthopaedic care and rehabilitation.
These discrepancies in outcome are due to several types of problems, such as deficiencies in human resources (skills, training, staffing) and physical resources (equipment, supplies). Improving these resources is often hampered by financial restrictions, with many countries having only small sums per capita per year to spend on health. Despite these barriers, many committed individuals and their institutions have been making notable progress, often working against considerable odds. A few brief examples are presented in the next section.
Case Studies of Individual Institutions
In the prehospital setting, an increased number of ambulance stations (to allow more rapid dispatch) decreased the response times to reach injured victims in Mexico. Improved training, in the form of more regular use of in-service courses, led to improved process of care in the field. The net result was a decrease in mortality from 8.2% to 4.7% among transported trauma patients.
In the hospital setting, regular use of continuing medical education for trauma care (in the form of the Advanced Trauma Life Support Course) led to significant improvements in the use of appropriate treatments for severely injured patients in Trinidad. The net result was a decrease in the mortality of such seriously injured patients at the main hospital caring for injured patients in Trinidad, from 67% to 34%.
In Thailand, the main trauma hospital in Khon Kaen instituted a basic trauma quality improvement program. This program identified a high rate of medically preventable deaths and several correctable problems, such as inadequate resuscitation for shock, delayed surgery for head injuries, and problems with record keeping and communications. Low-cost corrective action was instituted to target these problems, including improved communication within the hospital by use of radios, better supervision of junior doctors through increased senior staffing in the emergency department at peak times, and improved reporting on and monitoring of trauma cases. These improvements resulted in a decrease in mortality among all admitted trauma patients from 6.1% to 4.4%.
In terms of orthopaedic care, one hospital in Malawi instituted a protocol for open fractures that emphasized primary external fixation, scheduled sequential débridement, coverage of exposed bone through local muscle flaps, controlled secondary healing, and early mobilization, all low-cost techniques that could be practiced well in the local circumstances and within the economic resources available. They reported recovery of normal function in 80% of patients, functional results similar to those from HICs.
These are obviously just a few brief examples. Many of the readers of this textbook likely have similar success stories to report on from their own institutions. The question now is how to build on such individual institution experiences and make more progress globally.
Global Efforts to Improve Trauma Care
There are several potential avenues to pursue to promote improvements in trauma care globally, such as through international professional societies. Another avenue that has been increasingly influential but which many clinicians are not as familiar with is WHO. In this section, we highlight some of the work being done on trauma care by WHO.
In the past 10 years, WHO’s Department of Violence and Injury Prevention and Disability published two sets of policy recommendations, primarily aimed for ministries of health. Prehospital Trauma Care Systems gives recommendations on ways to institute or improve formal ambulance services (i.e., emergency medical services [EMS]). It also addresses steps that can be taken in areas where such formal ambulance systems are not affordable or feasible. This includes such efforts as building on existing, informal systems of prehospital transport and care, such as by providing training (and where appropriate providing equipment) and better organizing those members of society who are already providing prehospital first aid, such as fire service, police, commercial drivers, or other members of the lay public.
In terms of care at hospitals and clinics, WHO worked collaboratively with the International Society of Surgery and other partners to create the Guidelines for Essential Trauma Care. The goal of this project was to set reasonable, affordable, minimum standards for trauma care services worldwide and to define the resources needed to actually provide these services even in the poorest parts of the poorest countries. In part, this publication sought to do for trauma care globally what the Committee on Trauma (COT) of the American College of Surgeons (ACS) has done for trauma care in North America with its Resources for Optimal Care of the Injured Patient. However, the recommendations were oriented for countries that had only ten to hundreds of dollars per capita to spend for health, versus thousands of dollars per capita in HICs.
The Guidelines for Essential Trauma Care lays out 11 core essential services that every injured person should realistically be able to receive ( Table 3-1 ). The International Society of Surgery has endorsed these as the “Rights of the Injured.”
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To assure the availability of these services, the Guidelines for Essential Trauma Care delineate 260 individual items of human resources (skills, training, staffing) and physical resources (equipment and supplies) that should be in place at the range of healthcare facilities globally, going from small rural clinics, to small hospitals, to large hospitals, to tertiary centers. Items are designed as either essential, meaning they are applicable in countries at all economic levels, or designated as desirable, referring to those that are more costly, and more applicable in middle-income circumstances or in larger hospitals in low-income countries. These resource recommendations were intended to be a flexible matrix, to be adjusted based on the circumstances of the particular country. Addressed in these 260 items is the spectrum of trauma care, including initial resuscitation, definitive care of injuries to all body regions, and longer term rehabilitation. Orthopaedic issues are addressed in several sections of these recommendations, including extremity injury, spinal injury, and rehabilitation.
General examples of what these recommendations are trying to promote, first looking at low-income circumstances as in most of Africa and much of Asia are below:
- A.
Rural clinics caring for the injured should have capabilities for rapid basic first aid, which many do not. It is important to note that in rural areas of low-income countries, much of care of the injured, even seriously injured, does occur in such small rural facilities.
- B.
Smaller hospitals (such as those staffed by general practitioners) should have capabilities for placement of chest tubes, airway maintenance, and certain minimum blood transfusion capabilities, which many do not have.
- C.
Larger hospitals, including tertiary care centers, should have capabilities for endotracheal intubation on an emergency basis (which is problematic for many) and basic trauma quality improvement programs, which very few have.
- D.
Similar recommendations pertain to middle-income countries. However, there is greater emphasis on the resource items categorized as “desirable” given the higher level of resources available.
The Guidelines for Essential Trauma Care were intended to be part planning guide for individual hospitals and clinics and for ministries of health and part advocacy statement to be used by whoever wishes to promote improvements in trauma care in their area. Through both of these mechanisms, it was hoped that the Guidelines would serve as a catalyst to promote real, on-the-ground improvements in trauma care globally. Although much more does need to be done, there has been considerable progress in implementing the Guidelines. The Guidelines have received high-level political endorsement from a wide range of individual country professional groups, including the Ghana Medical Society, the Academy of Traumatology (India), and the Mexican Association for the Medicine and Surgery of Trauma, among others. They have been used in developing national health policy in Colombia, Mexico, Sri Lanka, and Vietnam.
The Guidelines have also been the basis for systemwide needs assessments in several countries, providing for the first time an internationally applicable metric for countries at all levels to use to assess their hospitals and trauma systems. These needs assessments give some idea of priorities for ways in which trauma care can be strengthened cost-effectively and systematically. These assessments have addressed orthopaedic care. Selected items of relevance to orthopaedics from these assessments are included in Table 3-2 . In terms of human resources, large hospitals were fairly well staffed by fully trained orthopaedic surgeons, except in Africa, where general surgeons did much of the orthopaedic work. At small hospitals, only those in better-resourced Mexico had partial coverage by orthopedists. At other smaller hospitals, either general surgeons or general practitioners provided care for orthopaedic injuries, with this level of hospital being solely staffed by general practitioners at the hospitals evaluated in Ghana.
| Small Hospital | Large Hospital | |||||||
|---|---|---|---|---|---|---|---|---|
| G | V | I | M | G | V | I | M | |
| Number of facilities evaluated | 8 | 8 | 14 | 4 | 2 | 5 | 1 | 7 |
| Human resources: acute care | ||||||||
| Nurse in emergency department | 2 | 3 | 2 | 2 | 2 | 3 | 3 | 2 |
| Doctor for emergency call * | 2 | 3 | 3 | 3 | 3 | 3 | 3 | 3 |
| General surgeon * | 1 | 2 | 1 | 2 | 2 | 3 | 3 | 3 |
| Orthopaedic surgeon * | 0 | 0 | 0 | 2 | 0 | 3 | 3 | 3 |
| CE course for doctors † | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 2 |
| CE course for nurses ‡ | 0 | 1 | 0 | 1 | 0 | 1 | 0 | 1 |
| Physical resources: extremity injury | ||||||||
| Skeletal traction | 1 | 1 | 0 | 1 | 2 | 3 | 3 | 3 |
| External fixation | 0 | 1 | 0 | 1 | 1 | 3 | 3 | 2 |
| Internal fixation | 0 | 2 | 0 | 1 | 1 | 3 | 3 | 2 |
| X-ray | 1 | 2 | 2 | 3 | 2 | 3 | 3 | 3 |
| Portable x-ray | 1 | 0 | 0 | 1 | 2 | 1 | 2 | 3 |
| Image intensification | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 |
| Limb prosthetics | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 |
| Physical resources: spinal injury | ||||||||
| Operative capabilities for spine management | NA | NA | NA | NA | 0 | 1 | 1 | 3 |
| Physical resources: wound care | ||||||||
| Skin grafting | 1 | 2 | 1 | 2 | 2 | 3 | 3 | 3 |
| Tetanus prophylaxis (toxoid and antiserum) | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 |
| Human resources: rehabilitation | ||||||||
| Specialized rehabilitative nursing | NA | NA | NA | NA | 0 | 1 | 0 | 2 |
| Physical therapy | 1 | 1 | 0 | 1 | 1 | 3 | 1 | 2 |
| Physical medicine and rehabilitation specialist | NA | NA | NA | NA | 0 | 2 | 1 | 2 |
| Administrative functions | ||||||||
| Trauma-related quality improvement program | NA | NA | NA | NA | 0 | 0 | 0 | 0 |
| Trauma cases integrated into broader quality improvement programs | 0 | 2 | 0 | 1 | 1 | 2 | 1 | 1 |
| Trauma registry with severity adjustment | NA | NA | NA | NA | 0 | 0 | 0 | 0 |
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* Available 24 hours per day, 7 days per week in hospital or promptly available on call from home.
† CE course on trauma care, such as Advanced Trauma Life Support, National Trauma Management Course, or local equivalent: ideal is that all doctors who provide first-line trauma care in emergency department and all general surgeons who provide trauma care are credentialed in such an in-service training course.
‡ CE course on trauma care, such as Trauma Nursing Core Course or local equivalent: ideal is that all nurses who provide first-line trauma care in emergency department are credentialed in such an in-service training course.
With nonspecialists providing much of the orthopaedic and other trauma care, continuing education courses are an important opportunity to strengthen such care. All four countries had such courses available, such as Advanced Trauma Life Support (ATLS) in Mexico, National Trauma Management Course (NTMC) in India, or other similar locally developed courses in the other countries. However, coverage by such courses was suboptimal. In small hospitals, far less than 50% of frontline trauma care providers (e.g., doctors working in the emergency department [ED] or surgeons taking trauma call) had such training. Even in large hospitals, in most countries, less than 50% of frontline trauma care providers had such training. The situation for continuing education for nurses was even lower (see Table 3-2 ).
Capabilities for rehabilitation were particularly deficient. Ratings showed significant deficiencies in the availability of human resources for rehabilitation, whether fully trained physician specialists or other providers such as physical therapists (PTs), were considered. PT coverage was especially limited in availability at small hospitals (see Table 3-2 ).
In terms of physical resources for care of extremity injuries, the main essential items for orthopaedic trauma care were fairly well supplied at big hospitals. Portable radiography was limited. Capabilities at small hospitals were much more limited. It should be pointed out that the ratings pertain to the level of care that would be expected for that level, not for the highest level. Hence, these are the ratings compared to the essential trauma care standard for small hospitals, not large. Related to the shortages of human resources for rehabilitation, availability of prosthesis for amputees was extremely limited in all circumstances (see Table 3-2 ).
Many times the problems with availability of physical resources were not the presence or absence of the equipment, but periods of inactivity while waiting for repairs, lack of supplies (such as film), or requirements for payment in advance before receiving services, which limited the availability of diagnostic tests to all who needed them. There were several instances in which mismatch of human and physical resources decreased availability of some services. For example, in Ghana, one large hospital had an image intensifier (C-arm). However, there were no staff trained to use it and the machine lay idle. In India, several small hospitals had radiography machines and trained staff. However, the facilities were greatly limited in the number of plates (films) which they received each month. Thus many persons needing radiographs could not receive them. Many such problems could be easily remedied cost-effectively by better organization and planning.
In all countries and at all levels, there was a dearth of administrative functions to monitor and assure the availability of trauma care, including trauma registries and trauma quality improvement programs.
In addition to pointing out opportunities for affordable and sustainable improvements in trauma care capabilities, these needs assessments have served as a stimulus for action. For example, a needs assessment conducted in the network of healthcare facilities managed by the Hanoi Health Department in Vietnam showed multiple deficiencies in low-cost but important items of human training and physical resources. These items were addressed by improved organization and planning, with no additional budgetary allotment for trauma care. Repeat assessments every 2 to 3 years since that time have documented steady improvement in availability of both skills levels and physical resources.
Further details of the development and implementation of the Guidelines for Essential Trauma Care and the related Essential Trauma Care Project are available on the WHO website ( www.who.int/violence_injury_prevention/services/en/ and www.who.int/violence_injury_prevention/services/traumacare/en/index.html ).
The Role of the World Health Organization: the World Health Assembly Resolution on Trauma and Emergency Care Services and the Creation of the Global Alliance for Care of the Injured
In an effort to promote greater implementation of improvements in trauma care, two additional actions have been taken: adoption of World Health Assembly Resolution 60.22 and creation of the Global Alliance for Care of the Injured.
In 2007, the World Health Assembly (WHA) adopted a resolution on trauma and emergency care services: WHA 60.22 “Health Systems: Emergency Care Systems.” The WHA is the governing board of the WHO. It consists of the ministers of health of all 194 member states. Its resolutions direct WHO’s activities and carry considerable influence on policies in individual countries, as well as actions of nongovernmental organizations (NGOs) and funders.
WHA Resolution 60.22 called on governments to improve care for victims of injury and other medical emergencies and listed 10 actions that governments could take to achieve this, including things such as identifying a core set of trauma services and developing methods to assure and document that such services are provided to all who need them (recommendations directly from the Guidelines for Essential Trauma Care).
This WHA resolution was probably the single greatest expression of support for trauma care from governments worldwide. WHA resolutions carry a lot of weight in orienting WHO’s own activities. However, they are taken up variably by country governments. They are most useful if concerned individuals and organizations use a resolution to advocate for and promote its recommendations. In this regard, readers are referred to a recent publication, which gives some suggestions about how the resolution can be used to promote increased political support for trauma care within country governments and to lobby for increased funding. It also contains the full text of the WHA resolution.
In 2012, WHO founded the Global Alliance for Care of the Injured, in collaboration with a number of other stakeholders. These include a number of international professional societies, NGOs, and country governments. The Global Alliance is primarily oriented toward promoting advocacy for increased attention to trauma care. Further information on the Global Alliance and ways in which to become involved with it can be found at the WHO website on violence and injury prevention ( www.who.int/violence_injury_prevention/services/gaci/en/ ).
There are many examples of successful innovative programs and efforts improving trauma care at individual hospitals in LMICs. There is a need to expand on what is being done and make more sustained progress globally. The WHO’s Guidelines for Essential Trauma Care represents a method to accomplish this by providing for the first time an internationally applicable metric for countries to use to evaluate and monitor resources for trauma care in their hospitals and systemwide. Further, WHA Resolution 60.22 on trauma and emergency care services provides high-level political endorsement for improvements in trauma care globally. Likewise, the creation of the WHO Global Alliance for Care of the Injured provides an avenue for increased political advocacy for increased attention to and investment in trauma care. Orthopedists and other trauma care clinicians can effectively use all of these in their own efforts to promote systemwide improvements in trauma care in the areas where they work.
In addition to the technical aspects, trauma care must be viewed within broader societal and economic considerations. Although much can be improved in trauma care by better organization, planning, and training, more extensive improvements are hampered by poverty. Most countries can spend only very little on health. In addition specific policies of international organizations compound the problem. For example, World Trade Organization rules keep many medicines unaffordable for the average person in the world. World Bank and International Monetary Fund policies often dictate restrictions on how much some governments can spend on healthcare as part of loan repayment conditions. Some African countries spend more on repaying debt than they do on healthcare.
Care of the injured would be strengthened by measures that would allow greater funding of the health sector, including many measures currently being discussed, such as debt relief, relaxation of restrictions on health sector financing, and requiring World Trauma Organization proceedings and rulemaking to be open and democratic, which they currently are not. In addition to our own technical work, we as individuals and as societies of professionals, need to be aware of and address these bigger global economic issues.
Barriers to Access
Only a fraction of the population in LMICs will ever receive treatment from a trained orthopaedic surgeon. Gross deficiencies in the availability, utilization, and/or quality of orthopaedic services result in an enormous burden of disability in LMICs, and the magnitude has yet to be quantified using existing health metrics. The barriers to accessing care for orthopaedic injuries are complex, often overlap, and relate to both an individual’s willingness to seek medical attention and the ability of the health system to provide timely, effective, safe, and affordable services. The relative importance of individual barriers will, of course, depend on the local context. Improving the delivery of musculoskeletal trauma care services will require a multidisciplinary, multisectoral effort aimed at eliminating these barriers by educating patients and their families and also addressing deficiencies at the level of the health system. Strong advocacy efforts, including the mobilization of key stakeholders and civil society, will be required to influence decision makers.
The definition of “access” has been debated, and several authors have attempted to describe it. McIntyre and colleagues suggested that access be viewed as a multidimensional concept based on the interaction of individuals and the health system, and defined access based on availability (spatial access), affordability (financial access), and acceptability (cultural access). Obrist and colleagues suggested availability, affordability, acceptability, accessibility, and adequacy, highlighting the importance of the quality of services. A systematic review concerning barriers to surgical care suggested that these be grouped according to (1) social/cultural, (2) financial, and (3) structural. The authors emphasized the importance of cultural factors, and stressed the need to overcome financial and geographic accessibility.
From a practical standpoint, barriers may be characterized based on the individual and the health system, which resonates with a health system framework promoted by WHO. This focuses on the interrelationship between people (demand) and six system “building blocks” (supply) including (1) governance, (2) service delivery, (3) human resources, (4) medicines and technologies, (5) financing, and (6) information. Table 3-3 illustrates a host of barriers according to this scheme, as well as measures that may be considered to address these barriers.
| Barriers | Possible Solutions | |||
|---|---|---|---|---|
| Demand side | Patient and family | Culture and/or religious beliefs |
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| Financial |
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| Geographic | Distance |
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| Terrain | ||||
| Season and weather | ||||
| Mechanism of transportation | ||||
| Supply side | Health system | Governance | Policies |
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| Monitoring and oversight |
| |||
| Lack of trauma care guidelines | ||||
| Service delivery | Infrastructure |
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| Physical resources and supplies |
| |||
| Mechanisms for transport and referral |
| |||
| Convenience or hours of business |
| |||
| Human resources | Number of providers |
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| Distribution of providers |
| |||
| Education of providers or quality of service |
| |||
| Gender |
| |||
| Job dissatisfaction |
| |||
| Medicines and technology | Lack of essential equipment and supplies |
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| Health information system (HIS) | Inadequate data on orthopaedic burden of disease and epidemiology |
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| Lack of monitoring (disease burden, service availability, outcomes) |
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| Financing | Inadequate government expenditure on health |
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Factors which lead a patient and/or his or her family to use health services have received less attention than system-level barriers. In the absence of formal medical services, a sizeable percentage of the rural population in LMICs likely prefer to have their injured cared for by traditional healers and bonesetters for a variety of reasons. Out-of-pocket expenses commonly serve as a deterrent to using formal health services, and thousands of families in LMICs are pushed below the poverty line each year because of unforeseen healthcare costs. In some settings there may be a fear of hospitals or of receiving surgical care. These issues can only be addressed by first studying perceptions concerning injuries and facilities-based care within the local communities, and then engaging the community in discussions and perhaps educational programs. Another solution may be to engage the traditional practitioners, gain a better understanding of their treatment methods, and then work with them to develop the system for service delivery. Any such efforts will fall short of expectations unless quality services are available to the public.
On the health system side, with regard to governance, few countries have included surgical care in their national health plans, and we estimate that few countries have developed, implemented, and monitored the policies and regulations to support the provision of trauma care services. As such, mandates at the local, regional, and global levels should be sought to promote and enforce such standards. Political support will be required to move the agenda forward, and this may also be viewed as a barrier. Shiffman has developed a conceptual framework to explain why certain global health issues receive attention and others do not, based on (1) the power of the actors, (2) the power of ideas portraying the issue (frames), (3) the political contexts in which the actors operate, and (4) the nature of the issue itself. Insufficient data concerning the burden of musculoskeletal injuries, and a lack of metrics to capture the burden, precludes our ability to document the magnitude of the problem and capture the attention of decision makers and health planners. The global surgical community has been fragmented, and no single body has emerged to push an initiative to achieve universal access to essential surgical and trauma care. Musculoskeletal injuries are diverse, and fall within the larger initiative of trauma care, making it difficult to find a way to “frame” the issue. While the millennium development goals may be viewed as an excellent policy window, and improvements in musculoskeletal trauma care would certainly impact those goals related to alleviating poverty, maternal health, and child health, the window has yet to be captured.
Recognizing the importance of injury prevention, service delivery remains the cornerstone of musculoskeletal trauma care services. This requires an organized system including prehospital care, in-hospital care, and rehabilitation. Mechanisms for communication, transportation, and referral between tiers of the health system are critical. While healthcare programming over the past few decades has focused on “vertical” or disease-specific initiatives (human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), tuberculosis, maternal health, etc.), improvements in health indicators have been realized but have often come at the expense of overall health system function. This has led to renewed interest in “horizontal” programming, efforts aimed at strengthening the health system, and promotion of universal access to extend services to the more remote and marginalized segments of a population. While surgical care has traditionally been neglected by the public health community because of the perception that it is resource intensive, costly, and benefits only a fraction of the population, evidence is amassing to refute these perceptions. As such, a worthy goal is to provide universal access to a package of “essential” musculoskeletal trauma care. These services are priority interventions that address conditions with the largest public health burden, are highly successful, and are cost-effective. Essential surgical care, including trauma care, certainly resonates with the concepts of horizontal programming and health systems strengthening. The question, of course, is how they can be integrated into health systems. Specific interventions for musculoskeletal injuries will vary depending on the local context, but should likely include irrigation and débridement for open fractures, the closed treatment of common fractures and dislocations, skeletal traction, fasciotomy, and amputation. The use of more sophisticated treatments and/or technologies may be appropriate at secondary or tertiary referral facilities, depending on the local resources. WHO has developed guidelines to assist health planners with prehospital care and trauma care guidelines and also developed a basic training package for the delivery of surgical and anesthetic services for the primary referral level of district hospital. These materials serve as a starting point and can be augmented by other educational programs and training materials. Strengthening the delivery of services will require improvements in the availability of skilled providers, and also the provision of adequate infrastructure and physical resources to allow practitioners to care for patients. Mechanisms for financing must be available to support the delivery of services and minimize out of pocket expenses for patients. Recognizing that the development of insurance programs would be desirable, innovative financing solutions that are contextually relevant will need to be pursued such as public-private partnerships, or partnering with NGOs and/or global health initiatives. For example, stakeholders interested in maternal and child health might be interested in strengthening care for the injured to help reach those millennium development goals relating to child and maternal health.
Deficiencies in human resources have received the greatest attention in the literature, and relate to not only the absolute number of trained surgical providers, but also their distribution. The few surgeons tend to be located at tertiary centers in major cities, leaving most of the population without access to a trained surgical provider. Reasons cited for the problems with distribution include inadequate resources to deliver services, poor remuneration, few opportunities for continuing medical education and for career advancement, and limited opportunities for other family members, including education for their children. A sizeable number of patients will be treated by traditional healers. Strategies to address this human resource crisis have included the training of general surgeons, medical doctors, and/or paraprofessionals to provide surgical care (task shifting). Orthopaedic clinical officers (OCOs) care for the majority of orthopaedic problems in rural Malawi and surgically trained paraprofessionals are active in several other countries in sub-Saharan Africa including Uganda and Mozambique. Surgeons from resource-rich countries may also contribute to the education and training of health providers caring for orthopaedic patients.
Even if caregivers have the appropriate knowledge and skills, they must have the resources, or medicines and technologies, to use their training. A host of studies have identified gross deficiencies in the availability of essential surgical services at the district hospital level in LMICs, including infrastructure and physical resources and supplies, in addition to human resources. One report noted the similarities between modern-day facilities in LMICs and hospitals at the time of the U.S. Civil War. Having a qualified surgical provider is hardly enough; he or she must have safe anesthesia, the basic equipment required to care for the injured, and the ability to adequately monitor the patient whether or not a surgical procedure is required.
Finally, the health information system (HIS) is responsible for data collection and analysis, as well as the dissemination of information to inform allocation of resources and the delivery of services. There is limited information on the burden of musculoskeletal injuries in LMICs, their economic impact, and on the efficacy and cost-effectiveness of interventions aimed at reducing the burden. Such knowledge is required to assess the burden of disease and unmet need for trauma care, the educational requirements for caregivers, the quality of service delivery, the impact of programs to strengthen the delivery of trauma care, and others. Research must be supported, and monitoring and evaluation frameworks can be used to inform decision making, resource allocation, and track progress with health system interventions such as the integration of essential surgical care.
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