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

Abstract: 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. _x000D_ _x000D_ 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. _x000D_ _x000D_ 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._x000D_ _x000D_ 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._x000D_ _x000D_ 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.

Lay abstract: Each year 5 million people die due to injuries like road traffic accidents, burns, falls, or violence. 90% of these deaths are in low- or middle-income countries (LMICs). For people in LMICs who survive injury, disability is unacceptably high, with between 40-50% of people disabled or unable to work after injury. Delays that occur from the point of injury to receipt of quality care cause nearly 50% of avoidable deaths and substantial disability after injury. Given that young and economically productive people are most often injured, reducing death and disability after injury would reduce economic losses for individuals and the families that they support, as well as at country and global levels. The World Health Organisation has stated that strong health systems that provide quality care for people who are injured are urgently needed to prevent death and disability due to injury. However, evidence that could lead to reduced delays in access of quality care after injury is lacking._x000D_ _x000D_ In this project, we will build on partnerships in Ghana, South Africa, Rwanda, and Pakistan. Together we will use the “three delays framework” – which looks at both access to and quality of care provided - to ask what are the delays to equitable access of quality care after injury and how can these be overcome to reduce death or disability? We will collect information on delays and their effects on patient outcomes. We will then develop a visual model to show where to intervene to reduce delays suffered after injury and produce maximum health benefits. By partnering with stakeholders in each country we will develop solutions for future study in these, and other similar, countries._x000D_ _x000D_ The diversity of cultures, economies, and injuries in partner countries will allow identification of delays and solutions consistent across different settings and others which are unique to individual countries. This will suggest which findings are transferable outside of the four countries of this study._x000D_ _x000D_ We will train 4 PhD students and >14 junior researchers in a variety of methods which are feasible to use in low resource settings, will lead to answers to improve health services for injury, and are transferable for use in other conditions. Training will be done via development of 4 country and 6 methods-based hubs in partner countries. Our aim is that these established country partnerships and methodological hubs will continue to interact and train future LMIC researchers well beyond this project’s end._x000D_ _x000D_ We will also work closely with stakeholder groups of patients, community members and leaders, healthcare providers, and policy makers to understand the barriers that they face in trying to improve access to quality care for people who have been injured. It is well known that advocacy and grass roots community engagement are strong facilitators for improved political priority for healthcare. However, in partner countries, advocacy and community engagement to improve care after injury is exceedingly rare. From our understanding, in partnership with stakeholders, we will develop a strategy to facilitate engagement across stakeholder groups and with policy makers to ensure that the results of our study are used to reduce delays and improve outcomes after injury. In comparing the barriers faced by stakeholders across partner countries, we will show where there are common barriers and likely strategies to overcome these barriers which are transferable to other countries.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: INJURIES AND ACCIDENTS