Facility readiness for injury care in Low and Middle-Income Countries: a survey of 18 hospitals in Ghana, Rwanda, Pakistan and South Africa

In the landscape of global health, the ability of a hospital to treat a severe injury is not merely a matter of having a building with a sign that says "Emergency." It is a complex web of readiness that requires the right people, the right tools, and the right systems to work together at any hour of the day. For decades, experts have understood that low- and middle-income countries bear a disproportionately heavy burden of injury-related deaths, often because their health systems lack the specific capacity to manage trauma effectively. To measure this capacity, researchers have developed checklists that act as a standard way to see if a hospital has the essential ingredients for saving lives: trained staff, functioning equipment, necessary medicines, and the ability to perform critical procedures. These tools move beyond simple questions of whether a hospital exists, focusing instead on whether it is truly prepared to handle the chaos of a major accident when it arrives.

A team of researchers recently took this concept of readiness and applied it across four distinct nations: Ghana, Rwanda, Pakistan, and South Africa. Their goal was to look inside eighteen hospitals, ranging from smaller secondary facilities to large tertiary centers, to see if they were truly ready to care for patients with moderate to severe injuries. The team used a specific assessment tool known as the International Assessment of Capacity for Trauma, or INTACT. This tool functions like a detailed inventory list, checking for forty essential items grouped into five categories: the physical infrastructure of the hospital, the supplies on hand, the medical procedures the staff can perform, the equipment available, and the specialized personnel on duty. The researchers calculated a score for each hospital based on what was present, aiming to see how many facilities met a standard considered acceptable for saving lives.

The study involved a rigorous process where researchers did not just ask hospital administrators what they had; they walked through the facilities to verify the existence of these items with their own eyes. They checked for the presence of things like computed tomography scanners, which create detailed images of the body, and essential supplies like tourniquets to stop bleeding. They also asked a crucial question that goes beyond a simple inventory: if a patient arrived at 3:00 a.m., would these resources actually be available? This distinction between having a machine in the building and having it ready to use at any moment became a central theme of their findings. The researchers surveyed six hospitals in Ghana, four in Rwanda, four in Pakistan, and four in South Africa, capturing a snapshot of injury care readiness across different economic and cultural contexts.

The results revealed a picture of mixed success. Out of the eighteen hospitals surveyed, fifteen achieved a score that fell within the range deemed acceptable for providing injury care. Six of these hospitals, including five large tertiary centers and one secondary facility, reached the maximum possible score. These top-performing hospitals were located in South Africa, Pakistan, and Ghana. In Rwanda, no hospital reached the perfect score of 10, though the lowest score recorded was 8.75, which falls within the acceptable range. However, the study also highlighted significant gaps. Two secondary hospitals in Ghana received the lowest scores, indicating a more substantial lack of readiness. When the researchers looked closely at what was missing in the hospitals that did not reach the top score, a pattern emerged. The most common missing items were computed tomography scanners, tourniquets, the ability to perform specific surgical procedures like releasing contracted muscles, endoscopes for looking inside the body, and the presence of a physician-level anesthesiologist.

Perhaps the most revealing part of the study was the difference between what hospitals claimed to have and what the researchers actually found during their walkthroughs. In some cases, items listed as available were either not present or not functioning. At one tertiary hospital, the researchers found no electricity, a non-operational CT scanner, and missing urinary catheters and sterilizers. At a secondary hospital, they could not find intravenous infusion sets, and the blood bank was not working. Even in hospitals where items were present and working at the time of the visit, the researchers found that 24-hour access was not guaranteed. Some hospitals lacked round-the-clock access to electricity, X-ray services, CT scans, ultrasound machines, or laboratory services. This meant that while a hospital might be ready during the day, it could be effectively blind and powerless during the night, a critical failure for trauma care which often strikes without warning.

The researchers also examined additional factors that are vital for trauma care but were not part of the standard scoring system. They looked for the presence of high-dependency units, specific life-saving medications like mannitol and tranexamic acid, and the speed at which hospitals could receive blood when needed. While most hospitals could analyze basic blood tests, many lacked a machine to analyze blood gases, and several did not have a high-dependency unit for critically ill patients. When it came to blood, most hospitals could deliver it within an hour of a request, but a few took significantly longer, with one secondary hospital taking more than three hours. Only four of the six hospitals that had a perfect score on the main assessment also had all these additional critical items verified and available.

The study concludes that while many of the hospitals surveyed have a solid structural foundation for injury care, there are subtle and marked challenges that affect the actual delivery of care. The presence of a building and a list of equipment does not automatically mean a hospital is ready to save a life at any time of day. The researchers found that even the highest-level hospitals, which are supposed to be the most well-resourced, face functional gaps and continuity issues. They noted that in some countries, the variability in readiness is slight, while in others, it is quite pronounced. The authors suggest that to truly improve injury care, policymakers and hospital leaders must look beyond simple checklists. They need to establish robust systems to monitor not just what is present, but what is actually working and accessible around the clock. Without these mechanisms to identify and report gaps, the promise of a ready hospital may remain just that—a promise, rather than a reality for the patients who need it most.