Suggesting global insights to local challenges: expanding financing of rehabilitation services in low and middle-income countries.

Purpose: Following the rapid transition to non-communicable diseases, increases in injury, and subsequent disability, the world-especially low and middle-income countries (LMICs)-remains ill-equipped for increased demand for rehabilitative services and assistive technology. This scoping review explores rehabilitation financing models used throughout the world and identifies "state of the art" rehabilitation financing strategies to identify opportunities and challenges to expand financing of rehabilitation. Material and methods: We searched peer-reviewed and grey literature for articles containing information on rehabilitation financing in both LMICs and high-income countries. Results: Forty-two articles were included, highlighting various rehabilitation financing mechanism which involves user fees and other innovative payment as bundled or pooled schemes. Few studies explore policy options to increase investment in the supply of services. Conclusion: this paper highlights opportunities to expand rehabilitation services, namely through promotion of private investment, improvement in provider reimbursement mechanism as well as expanding educational grants to bolster labor supply incentive, and the investment in public and private insurance schemes. Mechanisms of reimbursement are frequently based on global budget and salary which are helpful to control cost escalation but represent important barriers to expand supply and quality of services.

Integration measurement and its applications in low- and middle-income country health systems: a scoping review.

BACKGROUND: Despite growing interest in and commitment to integration, or integrated care, the concept is ill-defined and the resulting evidence base fragmented, particularly in low- and middle-income countries (LMICs). Underlying this challenge is a lack of coherent approaches to measure the extent of integration and how this influences desired outcomes. The aim of this scoping review is to identify measurement approaches for integration in LMICs and map them for future use. METHODS: Arksey and O'Malley's framework for scoping reviews was followed. We conducted a systematic search of peer-reviewed literature measuring integration in LMICs across three databases and screened identified papers by predetermined inclusion and exclusion criteria. A modified version of the Rainbow Model for Integrated Care guided charting and analysis of the data. RESULTS: We included 99 studies. Studies were concentrated in the Africa region and most frequently focused on the integration of HIV care with other services. A range of definitions and methods were identified, with no single approach for the measurement of integration dominating the literature. Measurement of clinical integration was the most common, with indicators focused on measuring receipt of two or more services provided at a single point of time. Organizational and professional integration indicators were focused on inter- and intra-organizational communication, collaboration, coordination, and continuity of care, while functional integration measured common information systems or patient records. Gaps were identified in measuring systems and normative integration. Few tools were validated or publicly available for future use. CONCLUSION: We identified a wide range of recent approaches used to measure integration in LMICs. Our findings underscore continued challenges with lack of conceptual cohesion and fragmentation which limits how integration is understood in practice.

Prioritizing rehabilitation in low- and middle-income country national health systems: a qualitative thematic synthesis and development of a policy framework.

BACKGROUND: There is a large and growing unmet need for rehabilitation - a diverse category of services that aim to improve functioning across the life course - particularly in low- and middle-income countries. Yet despite urgent calls to increase political commitment, many low- and middle-income country governments have dedicated little attention to expanding rehabilitation services. Existing policy scholarship explains how and why health issues reach the policy agenda and offers applicable evidence to advance access to physical, medical, psychosocial, and other types of rehabilitation services. Drawing from this scholarship and empirical data on rehabilitation, this paper proposes a policy framework to understand national-level prioritization of rehabilitation in low- and middle-income countries. METHODS: We conducted key informant interviews with rehabilitation stakeholders in 47 countries, complemented by a purposeful review of peer-reviewed and gray literature to achieve thematic saturation. We analyzed the data abductively using a thematic synthesis methodology. Rehabilitation-specific findings were triangulated with policy theory and empirical case studies on the prioritization of other health issues to develop the framework. RESULTS: The novel policy framework includes three components which shape the prioritization of rehabilitation on low- and middle-income countries' national government's health agendas. First, rehabilitation lacks a consistent problem definition, undermining the development of consensus-driven solutions which could advance the issue on policy agendas. Second, governance arrangements are fragmented within and across government ministries, between the government and its citizens, and across national and transnational actors engaged in rehabilitation service provision. Third, national legacies - particularly from civil conflict - and weaknesses in the existing health system influences both rehabilitation needs and implementation feasibility. CONCLUSIONS: This framework can support stakeholders in identifying the key components impeding prioritization for rehabilitation across different national contexts. This is a crucial step for ultimately better advancing the issue on national policy agendas and improving equity in access to rehabilitation services.

Patient-centered care and geriatric knowledge translation among healthcare providers in Vietnam: translation and validation of the patient-centered care measure.

BACKGROUND: People are living longer, and the majority of aging people reside in low- and middle-income countries (LMICs). However, inappropriate healthcare contributes to health disparities between populations of aging people and leads to care dependency and social isolation. Tools to assess and evaluate the effectiveness of quality improvement interventions for geriatric care in LMICs are limited. The aim of this study was to provide a validated and culturally relevant instrument to assess patient-centered care in Vietnam, where the population of aging people is growing rapidly. METHODS: The Patient-Centered Care (PCC) measure was translated from English to Vietnamese using forward-backward method. The PCC measure grouped activities into sub-domains of holistic, collaborative, and responsive care. A bilingual expert panel rated the cross-cultural relevance and translation equivalence of the instrument. We calculated Content Validity Indexing (CVI) scores at both the item (I-CVI) and scale (S-CVI/Ave) levels to evaluate the relevance of the Vietnamese PCC (VPCC) measure to geriatric care in the Vietnamese context. We piloted the translated instrument VPCC measure with 112 healthcare providers in Hanoi, Vietnam. Multiple logistic regression models were specified to test the a priori null hypothesis that geriatric knowledge is not different among healthcare providers with perception of high implementation compared with low implementation of PCC measures. RESULTS: On the item level, all 20 questions had excellent validity ratings. The VPCC had excellent content validity (S-CVI/Ave of 0.96) and translation equivalence (TS- CVI/Ave of 0.94). In the pilot study, the highest-rated PCC elements were the holistic provision of information and collaborative care, while the lowest-rated elements were the holistic attendance to patients' needs and responsive care. Attention to the psychosocial needs of aging people and poor coordination of care within and beyond the health system were the lowest-rated PCC activities. After controlling for healthcare provider characteristics, the odds of the perception of high implementation of collaborative care were increased by 21% for each increase in geriatric knowledge score. We fail to reject the null hypotheses for holistic care, responsive care and PCC. CONCLUSION: The VPCC is a validated instrument that may be utilized to systemically evaluate the practice of patient-centered geriatric care in Vietnam.

Scoping 'sex' and 'gender' in rehabilitation: (mis)representations and effects.

BACKGROUND: Researchers have highlighted a large-scale global unmet need for rehabilitation. While sex and gender have been shown to interact with each other and with other social and structural factors to influence health and wellbeing, less is known about how sex and gender shape rehabilitation participation and outcomes within health systems. METHODS: Using an intersectional approach, we examine literature that explores the relationship between sex and/or gender and rehabilitation access, use, adherence, outcomes, and caregiving. Following a comprehensive search, 65 documents met the inclusion criteria for this scoping review of published literature. Articles were coded for rehabilitation-related themes and categorized by type of rehabilitation, setting, and age of participants, to explore how existing literature aligned with documented global rehabilitation needs. Responding to a common conflation of sex and gender in the existing literature and a frequent misrepresentation of sex and gender as binary, the researchers also developed a schema to determine whether existing literature accurately represented sex and gender. RESULTS: The literature generally described worse rehabilitation access, use, adherence, and outcomes and a higher caregiving burden for conditions with rehabilitation needs among women than men. It also highlighted the interacting effects of social and structural factors like socioeconomic status, racial or ethnic identity, lack of referral, and inadequate insurance on rehabilitation participation and outcomes. However, existing literature on gender and rehabilitation has focused disproportionately on a few types of rehabilitation among adults in high-income country contexts and does not correspond with global geographic or condition-based rehabilitation needs. Furthermore, no articles were determined to have provided an apt depiction of sex and gender. CONCLUSION: This review highlights a gap in global knowledge about the relationship between sex and/or gender and rehabilitation participation and outcomes within health systems. Future research should rely on social science and intersectional approaches to elucidate how gender and other social norms, roles, and structures influence a gender disparity in rehabilitation participation and outcomes. Health systems should prioritize person-centered, gender-responsive care, which involves delivering services that are responsive to the complex social norms, roles, and structures that intersect to shape gender inequitable rehabilitation participation and outcomes in diverse contexts.

Framing rehabilitation through health policy and systems research: priorities for strengthening rehabilitation.

BACKGROUND: Recent estimates report that 2.4 billion people with health conditions globally could benefit from rehabilitation. While the benefits of rehabilitation for individuals and society have been described in the literature, many individuals, especially in low- and middle-income countries do not have access to quality rehabilitation. As the need for rehabilitation continues to increase, it is crucial that health systems are adequately prepared to meet this need. Practice- and policy-relevant evidence plays an important role in health systems strengthening efforts. The aim of this paper is to report on the outcome of a global consultative process to advance the development of a research framework to stimulate health policy and systems research (HPSR) for rehabilitation, in order to generate evidence needed by key stakeholders. METHODS: A multi-stakeholder participatory technical consultation was convened by WHO to develop a research framework. This meeting included participants from selected Member States, rehabilitation experts, HPSR experts, public health researchers, civil society and other stakeholders from around the world. The meeting focused on introducing systems approaches to stakeholders and deliberating on priority rehabilitation issues in health systems. Participants were allocated to one of four multi-stakeholder groups with a facilitator to guide the structured technical consultations. Qualitative data in the form of written responses to guiding questions were collected during the structured technical consultations. A technical working group was then established to analyse the data and extract its emerging themes. This informed the development of the HPSR framework for rehabilitation and a selection of preliminary research questions that exemplify how the framework might be used. RESULTS: A total of 123 individuals participated in the multi-stakeholder technical consultations. The elaborated framework is informed by an ecological model and puts forth elements of the six WHO traditional building blocks of the health system, while emphasizing additional components pertinent to rehabilitation, such as political priority, engagement and participatory approaches, and considerations regarding demand and access. Importantly, the framework highlights the multilevel interactions needed across health systems in order to strengthen rehabilitation. Additionally, an initial set of research questions was proposed as a primer for how the framework might be used. CONCLUSIONS: Strengthening health systems to meet the increasing need for rehabilitation will require undertaking more HPSR to inform the integration of rehabilitation into health systems globally. We anticipate that the proposed framework and the emerging research questions will support countries in their quest to increase access to rehabilitation for their populations.

Paper Versus Digital Data Collection Methods for Road Safety Observations: Comparative Efficiency Analysis of Cost, Timeliness, Reliability, and Results.

BACKGROUND: Roadside observational studies play a fundamental role in designing evidence-informed strategies to address the pressing global health problem of road traffic injuries. Paper-based data collection has been the standard method for such studies, although digital methods are gaining popularity in all types of primary data collection. OBJECTIVE: This study aims to understand the reliability, productivity, and efficiency of paper vs digital data collection based on three different road user behaviors: helmet use, seatbelt use, and speeding. It also aims to understand the cost and time efficiency of each method and to evaluate potential trade-offs among reliability, productivity, and efficiency. METHODS: A total of 150 observational sessions were conducted simultaneously for each risk factor in Mumbai, India, across two rounds of data collection. We matched the simultaneous digital and paper observation periods by date, time, and location, and compared the reliability by subgroups and the productivity using Pearson correlations (r). We also conducted logistic regressions separately by method to understand how similar results of inferential analyses would be. The time to complete an observation and the time to obtain a complete dataset were also compared, as were the total costs in US dollars for fieldwork, data entry, management, and cleaning. RESULTS: Productivity was higher in paper than digital methods in each round for each risk factor. However, the sample sizes across both methods provided a precision of 0.7 percentage points or smaller. The gap between digital and paper data collection productivity narrowed across rounds, with correlations improving from r=0.27-0.49 to 0.89-0.96. Reliability in risk factor proportions was between 0.61 and 0.99, improving between the two rounds for each risk factor. The results of the logistic regressions were also largely comparable between the two methods. Differences in regression results were largely attributable to small sample sizes in some variable levels or random error in variables where the prevalence of the outcome was similar among variable levels. Although data collectors were able to complete an observation using paper more quickly, the digital dataset was available approximately 9 days sooner. Although fixed costs were higher for digital data collection, variable costs were much lower, resulting in a 7.73% (US $3011/38,947) lower overall cost. CONCLUSIONS: Our study did not face trade-offs among time efficiency, cost efficiency, statistical reliability, and descriptive comparability when deciding between digital and paper, as digital data collection proved equivalent or superior on these domains in the context of our project. As trade-offs among cost, timeliness, and comparability-and the relative importance of each-could be unique to every data collection project, researchers should carefully consider the questionnaire complexity, target sample size, implementation plan, cost and logistical constraints, and geographical contexts when making the decision between digital and paper.

Cost-effectiveness of strategies to prevent road traffic injuries in eastern sub-Saharan Africa and Southeast Asia: new results from WHO-CHOICE.

BACKGROUND: Road safety has been receiving increased attention through the United Nations Decade of Action on Road Safety, and is also now specifically addressed in the sustainable development goals 3.6 and 11.2. In an effort to enhance the response to Road Traffic Injuries (RTIs), this paper aims to examine the cost effectiveness of proven preventive interventions and forms part of an update of the WHO-CHOICE programme. METHODS: Generalized cost-effectiveness analysis (GCEA) approach was used for our analysis. GCEA applies a null reference case, in which the effects of currently implemented interventions are subtracted from current rates of burden, in order to identify the most efficient package of interventions. A population model was used to arrive at estimates of intervention effectiveness. All heath system costs required to deliver the intervention, regardless of payer, were included. Interventions are considered to be implemented for 100 years. The analysis was undertaken for eastern sub-Saharan Africa and Southeast Asia. RESULTS: In Southeast Asia, among individual interventions, drink driving legislation and its enforcement via random breath testing of drivers at roadside checkpoints, at 80% coverage, was found to be the most cost-effective intervention. Moreover, the combination of "speed limits + random breath testing + motorcycle helmet use", at 90% coverage, was found to be the most cost-effective package. In eastern sub-Saharan Africa, enforcement of speed limits via mobile/handheld cameras, at 80% coverage, was found to be the most cost-effective single intervention. The combination of "seatbelt use + motorcycle helmet use + speed limits + random breath testing" at 90% coverage was found to be the most cost-effective intervention package. CONCLUSION: This study presents updated estimates on cost-effectiveness of practical, evidence-based strategies that countries can use to address the burden of RTIs. The combination of individual interventions that enforces simultaneously multiple road safety measures are proving to be the most cost-effective scenarios. It is important to note, however, that, in addition to enacting and enforcing legislation on the risk factors highlighted as part of this paper, countries need to have a coordinated, multi-faceted strategy to improve road safety.

Caregiving for Uganda's elders with disability: Using cross-sectional surveillance data to identify healthcare service gaps in low- and middle-income settings.

BACKGROUND: Disability is highly prevalent in low-and-middle-income countries (LMICs), but there is a relative dearth of disability and caregiving research from LMICs. OBJECTIVE: To examine type and severity of disability experienced by individuals 60 years and older, caregivers and type of caregiving assistance, and the interrelationships between sociodemographic factors involved in Uganda. METHODS: Data was collected from two Eastern Ugandan districts using the WHO Disability Assessment Schedule 2.0. Data on availability of caregiver was analyzed for 816 participants with disability. Group comparisons and regression analyses examined differences based on caregiver availability. RESULTS: Approximately 66% of individuals with disability had a caregiver. The mean age of those with a caregiver (74.7 ±â€¯8.9 years) was statistically significantly (p = .0004) higher than that of individuals without caregiver (72.4 ±â€¯8.2 years). Significant differences based on caregiver availability were found relative to sex (p = .009), age (p≤.001), education level (p≤.001), occupation (p≤.001) and head of household status (p≤.001). The most frequent types of disability were related to vision (78.4%) and ambulation (71.7%). Caregiving most often fell to family members. Logistic regression results showed that individuals over the age of 80 years were 2.51 times more likely to have a caregiver compared to those 60-69 years (p≤.001). Those in the highest wealth quintile were 1.77 times more likely to have a caregiver. CONCLUSIONS: Findings demonstrate gaps in caring for aging individuals with disabilities in LMICs and highlight the importance of understanding caregiver access in generating effective healthy aging initiatives and long-term care systems.

Adolescent and Young Adult Injuries in Developing Economies: A Comparative Analysis from Oman and Kenya.

BACKGROUND: Adolescence is a distinct period of rapid and dramatic biological, cognitive, psychological, and social development. The burden of injuries among young people (aged 10-24) is both substantial and maldistributed across regions and levels of economic development. OBJECTIVES: Our objective was to compare sociodemographic correlates of injury cause, intentionality, and mortality between Kenya and Oman, 2 countries with different levels of economic development and position in the demographic and epidemiologic transitions. METHODS: Data on 566 patients in Oman and 5859 in Kenya between 10 and 24 years old were extracted from 2 separate multicenter trauma registries. Multivariable log binomial and Poisson regressions were used to evaluate social and demographic factors associated with injury cause, intentionality, and mortality. Literature on adolescent development was used to parameterize variables, and Akaike information criteria were used in the final model selections. FINDINGS: The trauma registry data indicated a substantial burden of adolescent and young adult injury in both Oman and Kenya, particularly among males. The data indicated significant differences between countries (P < .001) in age category, gender distributions, level of education, occupation, cause of injury, and place where injury occurred. Consistent with other literature, road traffic injuries emerged as the most common type of injury as well as the most severe and fatal, with interpersonal violence also resulting in severe injury across contexts. Both road traffic injuries and interpersonal violence were more common among older adolescents and young adults. Education and being in school were protective against injury, after controlling for gender, age category, occupation, and country. CONCLUSIONS: A rising burden of injuries among young people has been documented in every region of the world, irrespective on income status or level of development. Cost-effective injury control measures targeting this age group exist, including involvement in educational, vocational, and other prosocial activities; environmental alterations; and road safety measures.

Helmet regulation in Vietnam: impact on health, equity and medical impoverishment.

BACKGROUND: Vietnam's 2007 comprehensive motorcycle helmet policy increased helmet use from about 30% of riders to about 93%. We aimed to simulate the effect that this legislation might have on: (a) road traffic deaths and non-fatal injuries, (b) individuals' direct acute care injury treatment costs, (c) individuals' income losses from missed work and (d) individuals' protection against medical impoverishment. METHODS AND FINDINGS: We used published secondary data from the literature to perform a retrospective extended cost-effectiveness analysis simulation study of the policy. Our model indicates that in the year following its introduction a helmet policy employing standard helmets likely prevented approximately 2200 deaths and 29 000 head injuries, saved individuals US$18 million in acute care costs and averted US$31 million in income losses. From a societal perspective, such a comprehensive helmet policy would have saved $11 000 per averted death or $830 per averted non-fatal injury. In terms of financial risk protection, traffic injury is so expensive to treat that any injury averted would necessarily entail a case of catastrophic health expenditure averted. CONCLUSIONS: The high costs associated with traffic injury suggest that helmet legislation can decrease the burden of out-of-pocket payments and reduced injuries decrease the need for access to and coverage for treatment, allowing the government and individuals to spend resources elsewhere. These findings suggest that comprehensive motorcycle helmet policies should be adopted by low-income and middle-income countries where motorcycles are pervasive yet helmet use is less common.

Characterizing disability at the Iganga-Mayuge Demographic Surveillance System (IM-DSS), Uganda.

PURPOSE: There is a need to better measure disability as an outcome to understand the magnitude of the problem and its impact on health and socio-economic status. The aim of this study was to characterize the physical disabilities present at the Iganga-Mayuge Demographic Surveillance Site (IM-DSS) in Uganda. METHODS: WHODAS 2.0 was used to examine the consequences of disability on activity limitations and participation in society. One thousand five hundred and fourteen individuals over the age of 18 at the IM-DSS with previously identified physical disabilities were included. Total and domain scores were calculated, and regression analyses examined differences by age, sex, education, occupation and SES. RESULTS: The mean total score was 40.72. Domain 2 - getting around, had the highest mean score (57.21), followed by household activities (55.18). Domains 5.2 (work/school activities) and 6 (participation in society) also had relatively high mean scores - 47.71 and 49.44, respectively. CONCLUSION: This study serves as an indication of what the major limitations are among individuals in rural Uganda with physical disabilities. In general, individuals with disabilities had the most trouble on getting around, life activities and participation in society. This can guide public health planners and policy-makers on priorities to ameliorate the impact of disabilities in this population. IMPLICATIONS FOR REHABILITATION: This study found that in general, individuals with disabilities had the most trouble on getting around, life activities and participation in society. This can guide public health planners and policy-makers on rehabilitation priorities to ameliorate the impact of disabilities in this population. Efforts can be made to develop and implement rehabilitation programs that cater to the needs of vulnerable populations including females and older individuals. Programs that focus on education and employment for physically disabled individuals ought to be given priority. These could include legislative changes, and modification of the physical environment, among others.

Trauma systems in Kenya: a qualitative analysis at the district level.

Injury is a leading cause of death and disability in low- and middle-income countries. Kenya has a particularly high burden of injuries, accounting for 88.4 deaths per 100,000 population. Despite recent attempts to prioritize injury prevention in Kenya, trauma care systems have not been assessed. We assessed perceptions of formal and informal district-level trauma systems through 25 qualitative semi-structured interviews and 16 focus group discussions with Ministry of Health officials, district hospital administrators, health care providers, police, and community members. We used the principles of theoretical analysis to identify common themes of prehospital and hospital trauma care. We found prehospital care relied primarily on "good Samaritans" and police. We described hospital care in terms of human resources, infrastructure, and definitive care. The interviewers repeatedly emphasized the lack of hospital infrastructure. We showed the need to develop prehospital care systems and strengthen hospital trauma care services.

The role of NGOs in child injury prevention: an organizational assessment of one network of NGOs.

Unintentional injuries are estimated to claim the lives of more than 875,000 children each year; millions more live with long-term consequences and permanent disabilities. The epidemiology of injuries has become clearer in the past decade. NGOs need to work in concert with each other to address the global burden of injuries by sharing information. Several NGOs have heeded this call, and the field has seen the emergence of global organizations aimed at highlighting the burden of injuries and streamlining injury prevention activities worldwide. Safe Kids Worldwide Inc. (SKWW) is a global network in 16 countries whose mission is to address the burden of injuries in children under 15 by harnessing the potential of local NGOs. An organizational assessment was conducted of SKWW which included structured organizational assessment, functional organizational mapping and contextual analysis that allowed for an in-depth examination of the strengths and challenges of SKWW's injury prevention approach. Over one year, primary and secondary data were collected and analyzed from headquarters and individual country offices. SKWW appears to be an effective model and has experienced a strong momentum and growth over the last two decades. Global NGOs that address the burden of injuries should start by defining a clear and universal strategic goal, build on local successes, maximize their strengths, and create avenues for stronger country engagement.

A new screening instrument for disability in low-income and middle-income settings: application at the Iganga-Mayuge Demographic Surveillance System (IM-DSS), Uganda.

OBJECTIVE: The measurement of disability in low-income countries is recognised as a major deficiency in health information systems, especially in Africa. The Iganga and Mayuge Demographic Surveillance System (IM-DSS) in Uganda provides a special opportunity to develop population-based data to inform national health policies and evaluate innovations in assessing the burden of disability in Uganda. In this study, we apply a new instrument to screen for physical disabilities at the IM-DSS. The study utilised a modified version of the short set of questions proposed by the Washington Group on Disability Statistics. The instrument was applied at the household level and information was collected on all individuals over the age of 5, who were residents of the IM-DSS. SETTING: The study was based at the IM-DSS, which covers the parts of Iganga and Mayuge districts in Eastern Uganda. PARTICIPANTS: 57,247 individuals were included in the survey, with 51% of the study population being women. PRIMARY OUTCOMES: Activity limitations RESULTS: The overall prevalence of physical disability at the IM-DSS was 9.4%, with vision being the most common type of difficulty reported in this population, and communication being least prevalent. Disability was less likely to be observed among males than their female counterparts (OR 0.75; 95% CI 0.71 to 0.81; p<0.001). Statistically significant associations were found between disability and increasing age, as well as disability and decreasing household wealth status. CONCLUSIONS: This study shows that the modified short set of questions can be readily applied in a DSS setting to obtain estimates on the prevalence and types of disability at the population level. This instrument could be adapted for use to screen for disability in other LMIC settings, providing estimates that are comparable across different global regions and populations.

Injuries and violence in the Eastern Mediterranean Region: a review of the health, economic and social burden.

We review current literature and data on the burden of injury and violence in the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO), with a special focus on the health, economic and social burden they impose on individuals, families and society. Injury-associated mortality and disability is on the rise in EMR, especially among economically productive adults, young males and vulnerable road users. In particular, road traffic injuries, the leading cause of injuries, account for 27% of the total injury and violence mortality in EMR according to WHO. Violence including suicide, homicide and war-related injury has also been increasing over the past two decades for both females and males. There is need for greater interest and efforts in slowing and ultimately halting the trend through interventions, legislative actions, and research that examine the special needs and challenges in the Region.

The cost of injury and trauma care in low- and middle-income countries: a review of economic evidence.

INTRODUCTION: Injuries are a significant cause of mortality and morbidity, of which more than 90% occur in low- and middle-income countries (LMICs). Given the extent of this burden being confronted by LMICs, there is need to place injury prevention at the forefront of public health initiatives and to understand the costs associated with injury. The aim of this article is to describe the extent to which injury-related costing studies have been conducted in LMICs. METHODS: A review of literature was performed to explore costing data available for injury and/or trauma care in LMICs. Study quality was described using recommendations from the Community Guide's quality assessment tool for economic evaluations. RESULTS: The review identified 68 studies, of which 13 were full economic evaluations. Cost of injury varied widely with mean costs ranging from US$14 to US$17 400. In terms of injury-prevention interventions, cost per disability adjusted life year averted for injury-prevention interventions ranged from US$10.90 for speed bump installation to US$17 000 for drunk driving and breath testing campaigns in Africa. The studies varied in quality, ranging from very good to unsatisfactory. DISCUSSION: There is a lack of injury-related economic evidence from LMICs. Current costing research has considerable variability in the costs and cost descriptions of injury and associated prevention interventions. The generalizability of these studies is limited. Yet the economic burden of injury is high, suggesting significant potential for cost savings through injury prevention. A standardized approach to economic evaluation of injury in LMICs is needed to further prioritize investing in injury prevention.

Assessing trauma care at the district and provincial hospital levels: a case study of hospitals in Kenya.

Trauma is a major cause of death and disability worldwide, of which more than 90% occur in low- and middle-income countries. Given the magnitude of this inequality, there is a need to devise and use tools to assess the capacity of facility-based trauma care. This study used two tools, hospital flowcharts and the World Health Organization's Trauma Care Checklist, to describe trauma care capacity at two hospitals in Kenya and ways in which this capacity can be strengthened. We found these hospitals had a large volume of trauma, but due to the lack of intensive care units, specialized trauma units, and axillary services, such as orthopedics and neurosurgery, the hospitals had a limited ability to provide definitive care for injured patients in critical condition. Additionally, organizational capabilities, such as trauma registries, trauma-specific training, and quality improvement programmes were lacking. The state of trauma care at district and provincial levels in Kenya demonstrates a strong case for national and global investment in clinical and systemic interventions.