A health system may be defined as “all the activities whose primary purpose is to promote, restore, or maintain health” [34
]. Health systems have evolved considerably over the past century. In the early 20th century, the goal in some countries was to provide universal healthcare services. The fundamental premise of universal services was and is that healthcare is a right, not a privilege. However, this laudable early goal was unattainable due to economic constraints. In the midportion of that century, emphasis was placed on the provision of primary healthcare to provide a basic level of services at the population level. The goal of many later 20th century health systems has been to provide universal access to a group of “essential services.” Given the financial constraints on health systems, this approach implies that services must be prioritized, and that not all interventions will be financed. How do stakeholders determine which services or interventions are essential? In addition to understanding the disease burden (local or national), interventions must be judged on their effectiveness, costs, and social acceptability [13
Deficiencies in musculoskeletal trauma care may be viewed as a failure of the healthcare system to deliver the necessary services to prevent or reduce death and disability. Using the definition cited above, a health system is charged with prevention, treatment, and rehabilitation following injuries. Injury prevention efforts include improvements in road infrastructure, such as building sidewalks and installing speed bumps, using reflective devices, public education programs, and appropriate legislation to influence driving behavior. Efforts to improve treatment may be aimed at prehospital care, the provision of services once a patient reaches a healthcare facility, and then rehabilitation to maximize function and promote social reintegration.
The World Health Report 2000 emphasized the importance of health systems in promoting good health, responding to the demands of the population, and ensuring that personal financial contributions are commensurate with the ability to pay (prevent impoverishment from personal healthcare expenditures) [34
]. A health system has four functions, namely stewardship, financing, resource generation, and service provision [34
]. Barriers to the delivery of musculoskeletal trauma care may arise within each component of the system. Adequate musculoskeletal trauma services are often available at private facilities in urban centers, but may be lacking for the majority of the population who have limited financial resources and reside in rural communities.
The stewardship function is most important, and is carried out by governments and their ministries of health. There may also be limited contributions from the private sector and from other sources. In addition to allocating resources for healthcare delivery, the government is responsible for establishing and overseeing health sector policies. A broad range of policies are covered, including the allocation of finances for the health system, regulatory measures (businesses, the pharmaceutical industry, private voluntary organizations and nongovernmental organizations), setting health standards and guidelines, and raising awareness of key health issues [13
]. In addition, governmental actions and policies in other areas, including those relating to poverty, education, and the environment, may also have an impact upon health [34
]. The development of policies and guidelines pertaining to the prevention and treatment of injuries would seem essential if we are to reduce the burden of injuries and improve care for the injured. The importance of advocacy cannot be understated; global efforts to raise awareness of the burden of injury are essential, and initiatives that aim to strengthen health systems from the standpoint of both prehospital care and treatment in a medical facility should be developed and supported by governments and the global health community. If we are to advocate for system-level changes to improve musculoskeletal trauma care, we must convince the “stewards” that the burden of injuries is large and should be a priority, and that their investment in the prevention and treatment of musculoskeletal injuries will reduce death and disability at a reasonable cost. Epidemiologic data concerning musculoskeletal injuries and their sequelae are lacking in most low- and middle-income countries, despite the fact that injury is now recognized as a global public health concern. Such data will be essential to collect to properly prioritize national goals.
Adequate financing involves both capital investments (one-time startup costs) and recurrent costs (long-term investments to maintain the system) [34
]. The basic capacity to deliver services, including infrastructure, physical resources, and human resources, must be available and maintained. Treatment facilities must be adequately equipped and functional. The equipment and supplies needed to care for musculoskeletal injuries (plain radiographs, closed management, irrigation and débridement, skeletal traction, and others) must be maintained. In terms of human resources, there must be an adequate number of trained providers (capital investment). These individuals must be retained (adequate compensation, opportunities for career development) and their knowledge and skills must be maintained and enhanced through continuing education (recurrent cost). There has been a human resource crisis in low- and middle-income countries; in addition to a paucity of trained surgeons, migration of health professionals both within and between countries (brain drain) has been a major problem. Rather than training specialists, many countries have emphasized the provision of multiskilled professionals, especially in rural areas.
Adequate financing must be available to support musculoskeletal trauma care services for each level of health facility, and when governmental sources are insufficient, consideration should be given to public-private partnerships and/or other means of securing funds. Resource generation applies to the basic inputs to the health system, such as physical capital and consumables (for example pharmaceuticals) [34
Service provision is the main function of each health system, and from a population-based standpoint, the interventions selected must be appropriate to the local pathology, must be affordable and sustainable, and must be socially acceptable. Given a large number of competing health priorities and a limited budget, allocation of resources may be a challenge. Regarding musculoskeletal trauma care, the system must address prehospital care, services during admission to a treatment facility, and rehabilitation of the injured following definitive treatment. Systems issues related to prehospital care include the delivery of services at the scene of injury and transport to a treatment facility. In addition to basic life support, responders at the scene should be able to identify major musculoskeletal injuries and prepare patients for transport. A mechanism for communication must be available. There must be adequate road infrastructure and vehicles for transport (ambulance or informal mechanism such as family, taxis, etc.). Once the patient arrives at a treatment facility, depending upon the level of service provided, there must be the capacity to evaluate, stabilize, and ideally treat the injury. When definitive care cannot be provided, there must be a reliable mechanism for referral to higher levels of service. A core group of specific interventions must be developed and supported based upon the level of the health facility and focusing on the nonoperative management of musculoskeletal injuries. While it may be unreasonable to promote locked nailing for fractures of the femur or tibia in resource-constrained environments, the skilled use of skeletal traction should be safe, effective, and affordable. Adequate wound toilet to prevent osteomyelitis following open fractures should be emphasized. A host of other treatments should be well within the capacity of primary health facilities in low- and middle-income countries.