Equitable Access to Quality Trauma Systems in Lower- and Middle-Income Countries: Assessing Gaps and Developing Priorities in Rwanda

Abstract

INTRODUCTION: The global burden of trauma is highest in low- and middle-income countries where injury care services need to be prioritized to address this burden. We explored barriers to accessing quality injury care in Rwanda using the “4 delay” framework. METHODS: Using qualitative methods, barriers to assessing trauma care in Rwanda were assessed. In-depth, semi-structured interviews and focus group discussions were conducted with purposively selected individuals from rural and urban communities who had recently accessed injury care or cared for injured people in the previous 6 months and community leaders. All interviews and focus groups were audio recorded and transcribed. Transcripts were read by a core research team to identify the barriers and facilitators to quality trauma care and develop initial codes. The subsequent thematic analysis was developed iteratively with reference to the “4 delay” framework. RESULTS: We did 20 in-depth interviews and 4 focus group discussions (FGDs), equally spread between rural and urban areas. Multiple barriers were identified, cutting across all levels of the “4 delays” framework of seeking, reaching, receiving, and remaining in care (Table). The lack of community health insurance, limited access to ambulances, insufficient trauma care specialists, and overcrowded facilities were the most mentioned barriers. The rigid referral process and lack of decentralized rehabilitation services were also identified as important barriers. Table. - Barriers to Trauma Care Access in Rwanda Using the 4 Delays Framework Level of delay (4 delays framework) Representative barrier Level 1: Barriers to seeking trauma care Pre-injury financial challenges and social vulnerability, underestimation of the severity of the injury, shared decision making (dependence on community leaders or a community organization for decisions on whether or not to go to hospital), perceived inaccessibility of the “right” hospital or acute care facility, lack of awareness of health care and injury care systems, religious beliefs and preference for alternative health care Level 2: Barriers to reaching definitive trauma care Poor road infrastructure, limited geographical coverage of ambulance services, cost of transport to hospital and between hospitals, unavailability of transportation, unwillingness of passers-by to assist, limited access to ambulances, ignorance of ambulance call process and emergency numbers, fear of legal complications for intervening private car owners, high urban road traffic density, fear of spending on private transport cost, poorly coordinated interfacility transfers, long wait times at care facilities Level 3: Barriers to receiving trauma care Lack of financial means, loss of earnings due to entering or remaining in care, absence of health insurance, COVID related delays (restriction of movement, facility shutdowns), cumbersome facility invoicing and cost recovery system, unavailability of some community health insurance staff during work hours, unavailable equipment/medication within facilities, unaffordable materials and medication in non-government funded facilities, inability to use community health insurance in private pharmacies Level 4: Barriers to remaining in trauma care Poor patient counseling by healthcare workers, traditional healers counselling patients against returning for follow-up, previous unsatisfactory experience of health facility care, perceived early discharge in an unsatisfactory health condition, complications of alternative home-based care which may limit movement, lack of transportation for follow-up, difficult terrain between home and location for rehabilitation or physiotherapy, limited opening hours of some facilities, cumbersome referral system for follow-up appointments, poor follow-up process for discharged patients CONCLUSION: Future interventions to improve injury care access in organizing health facilities, implementing health insurance, and designing trauma systems interventions for Rwanda need to be informed by the identified barriers along the spectrum of care from injury to rehabilitation.