Rationale
Trauma represents a major global health problem with injuries accounting for more deaths than TB, malaria and HIV combined and with 90% of these deaths occurring in low- and middle-income countries (LMICs) [
1]. Along with other non-communicable diseases, death from trauma is set to increase with some projecting road traffic collisions to be the third leading cause of death by 2030 [
2]. Non-fatal injuries are common, with 1 billion people sustaining an injury in 2013 that warranted health care [
3]. There is also considerable global variation in injury-related morbidity. Disability-adjusted life years (DALYs) in children are 9 times greater in sub-Saharan Africa compared to those in high-income Asia Pacific counterparts [
3], likely due to both differences not only in preventative measures but also in the injury care available from health systems. Indeed, if the survival rates following injury in LMICs were to be improved to the rates seen in HICs, the estimated one third of annual global trauma deaths could be avoided [
4].
Considering and developing the whole system of trauma care from point of injury to rehabilitation services has resulted in significant improvements in trauma care in high-income country (HIC) settings. Such improvements were particularly amongst the most severely injured [
5‐
7]. Although prevention is rightly a key focus on reducing the global burden of injuries, better trauma care through system improvement could lead to major reductions in global trauma associated mortality and has been strongly advocated [
4,
8]. Furthermore, trauma care has been considered a tracer condition that can be useful in assessing wider emergency health system performance [
9,
10]. The World Health Organization (WHO) advocates that promoting essential trauma care will concurrently promote wider health care system improvements beneficial for other urgent surgical and non-surgical emergencies [
11]. The Lancet Global Health Commission on High Quality Health Systems has highlighted the disparity between global burden of injuries and the lack of available data on care quality provided by health systems. Better assessment of such care is one of the commission’s stated research priorities [
10].
The WHO defines health systems as the “organisations, people and actions whose primary intent is to promote, restore or maintain health” [
12]. Health systems have been described as complex adaptive systems that may respond in non-linear, unpredictable ways to interventions [
13]. Health systems consist of an intricate web of relationships between the component parts, embedded within social institutions with human behaviours influencing performance and function [
14]. Understanding existing health systems, through their assessment, is important to inform impactful health system improvement efforts [
15]. Many different frameworks for describing and understanding health systems exist. Such frameworks have their origins in differing paradigms of understanding and sociopolitical backgrounds [
16]. Whilst a universal framework for understanding such complex systems may therefore not exist, choosing a particular health system framework of understanding should be done to fit a purpose [
16]. One particular framework that has had success in improving understanding and outcomes in maternal mortality is the “Three Delays” model. It was developed to help evaluate the delays to care driving adverse outcome in maternal mortality in LMICs [
17]. The framework has been widely adopted in the field of maternal, neonatal and child health in an attempt to evaluate and drive improvements in care [
18‐
22]. It has also been proposed as a framework through which to evaluate emergency healthcare in LMICs including trauma [
23]. The Three Delays framework considers the barriers that result in delays in seeking care (delay 1), reaching care (delay 2) and receiving appropriate care (delay 3) [
17].
In order to inform the development of future trauma care health system assessment, we will undertake a review of the existing literature on assessing trauma care health systems. Applying the Three Delays framework of analysis to this literature review will allow future development of a health system assessment strategy based on this approach.