Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review

Current Trauma Reports
Barnabas Alayande1, Kathryn Chu2, Desmond T. Jumbam3, Oche Emmanuel Kimto4, Gambo Musa Danladi4, Alliance Niyukuri5, Geoffrey A. Anderson6, Deena El-Gabri6, Elizabeth Miranda6, Mulat Taye7, Ngyal Tertong8, Tolgou Yempabe9, Faustin Ntirenganya10, Jean Claude Byiringiro10, A Z Sule11, Olive Kobusingye12, Abebe Bekele7, Robert Riviello13
1Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
2Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
3Department of Policy and Advocacy, Operation Smile, Accra, Ghana
4Surgical Equity and Research Centre, Jos, Nigeria
5Hope Africa University, Bujumbura, Burundi
6Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
7School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
8International Fellow, Paediatric Orthopaedic Surgery Department of Orthopaedics, Sheffield Children's Hospital, Sheffield, UK
9Orthopaedic and Trauma Unit, Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
10University Teaching Hospital of Kigali, Kigali, Rwanda
11Jos University Teaching Hospital, Jos, Nigeria
12Makerere University School of Public Health, Kampala, Uganda
13Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.

Tóm tắt

Abstract Purpose of Review Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model. Recent Findings A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda. Summary Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action.

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