Musculoskeletal injuries needing urgent care are often amongst the commonest conditions at the first referral health facilities (health centers, district, rural or community hospitals). Often these facilities lack specialists such as orthopaedic and trauma surgeons, general surgeons, anesthesiologists, and emergency physicians. These conditions require timely emergency, and essential surgical and anesthesia interventions to reduce death and disability.

At these primary healthcare facilities the urgent care is usually provided by nonspecialist doctors, nurses, clinical officers/technicians, and paramedics. Often these caregivers work in very difficult, isolated circumstances, with limited equipment and supplies, with limited capability for urgent referral to more specialized centers, and with limited opportunity for continuing medical education. In order to help strengthen surgical care at such locations, WHO has responded by establishing the Clinical Procedures Unit in the Department of Essential Health Technologies. This unit was created to address the deficiencies in the provision of emergency and essential surgical care, including care of musculoskeletal injuries, as well as other surgically treatable conditions such as infections, pregnancy-related complications, acute abdominal conditions, and congenital anomalies.

WHO developed an Integrated Management for Emergency and Essential Surgical Care toolkit (IMEESC) [23] toolkit based on the WHO reference manual Surgical Care at the District Hospital [24]. The Emergency and Essential Surgical Care (EESC) Project employs an integrated comprehensive training package, the IMEESC toolkit, aimed at building capacities for health care providers in resource constrained settings, through “training of trainers” workshops held in collaboration with the Ministry of Health, supported by both local and international partners (Fig. 1).

Fig. 1 The Emergency and Essential Surgical Care training workshop being held as joint undertaking of Ministry of Health and WHO in Tanzania is shown. Such collaborative training workshops have been held in 24 countries.

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Programs have been initiated in 24 countries: Mongolia, Vietnam, Philippines; Bangladesh, DPR Korea, India, Maldives, Nepal; Kyrgyzstan, Tajikistan; Afghanistan, Oman; Pakistan; Guyana; Ethiopia, Cote d’Ivoire, Gambia, Ghana, Kenya, Malawi, Mozambique, Tanzania, Uganda, Zambia; workshop reports are available at www.who.int/surgery.

The workshops utilize various methods for information transfer including lectures, role playing, “hands on” skills, local adaptations of training materials and e-learning sessions. Teaching materials include the WHO IMEESC toolkit, and the WHO reference manual Surgical Care at the District Hospital. Orthopaedic components of this toolkit and program include teaching power point slides, guidelines in disaster management, emergency and trauma care, splinting and casting techniques, closed treatment of fractures, management of open fractures and soft tissue wounds, and techniques for traction. In addition for a comprehensive package applicable to a first level referral health facility, some components are relevant to musculoskeletal injuries such as hand washing, antibiotic and tetanus prophylaxis, medical records, patient consent, sterilization of equipment, wound management, protocols on safe anesthesia and surgical procedures, prevention of HIV, postoperative care, and pain relief.

In December of 2005, a Global Initiative for Emergency and Essential Surgical Care (GIEESC) was launched with the goal of fostering collaboration amongst stakeholders to promote the delivery of safe and appropriate emergency, surgical and anesthesia services at resource limited health care facilities. Key components of the GIEESC include strengthening capacities through training and education, supporting policy and implementation of EESC, advocacy, research, and the development and dissemination of appropriate technologies for primary health facilities in resource challenged environments. People interested in GIEESC may find more information on the project’s website at: http://www.who.int/surgery/globalinitiative/en/.

Several years ago, WHO’s Department of Violence and Injury Prevention and Disability Department came out with two sets of recommendations, primarily oriented at the policy and Ministry of Health planning level, on ways to strengthen care of the injured, in both prehospital and hospital based settings. Prehospital Trauma Care Systems [18] gives recommendations on ways to institute formal Emergency Medical Services (EMS) e.g. usually encompassing ambulance systems. It also discusses what to do in circumstances where this is not affordable or possible, such as by building on the existing, albeit informal, system of prehospital care and transport. This can include better organizing, training, and equipping first responders, such as police, fire service, and members of the lay public.

In terms of care at fixed facilities, including clinics and hospitals, WHO has worked collaboratively for several years with the International Society of Surgery on the Essential Trauma Care Project. This project has sought to set reasonable, affordable, minimum standards for trauma care services worldwide and to define the resources necessary to actually provide these services even in the lowest-income countries. A basic theme of the project is that considerable improvements in trauma care and its outcome can be achieved through improved organization and planning at a minimal increase in cost. Finally, this project seeks to actually catalyze such improvements in countries worldwide.

A key point to be emphasized is that the essential items should not just be physically present. Essential resources and services should actually be provided to all who need them in a timely fashion, without regard of ability to pay. Having a piece of equipment cannot be said to have met essential status if the equipment is nonfunctional for long periods of time while awaiting repairs, nor if it is unused due to insufficient staffing during periods of time (e.g. nights and weekends) when most injured patients need it. Having medications or other supplies in stock cannot be said to have met essential status if their use depends on payment in advance, a stipulation which many of the injured cannot meet. These stipulations do not rule out the need for billing or cost-recovery later, after essential items of care have been rendered. However, cost-recovery should not prevent rendering such essential care.

The Guidelines is intended to be part planning guide for ministries of health or individual facilities and part advocacy document to be used by whoever wishes to push for improvements in trauma care. The legitimacy of this document for such advocacy is increased by the fact that it was created by the two bodies in the world that have the most credibility to do so, WHO and the International Society of Surgery, as well as by the fact the Guidelines was created with the review and other input of an additional thirteen organizations, including a variety of international subspecialty organizations (such as Orthopaedics Overseas and SICOT), as well as, several national organizations (such as the Academy of Traumatology of India).

With nonspecialists providing much of the orthopaedic and other trauma and surgical care, continuing education courses become an important opportunity to strengthen such care, especially at first level health care facilities. All four countries had such courses available, such as Advanced Trauma Life Support in Mexico, National Trauma Management Course in India, or other similar locally developed courses in the other countries. However, coverage by such courses was very much suboptimal. In rural clinics, no one had such training. In small hospitals, far less than 50% of front line trauma care providers (e.g. doctors working in the ED or surgeons taking trauma call) had such training. Even in large hospitals, in most countries, less than 50% of front line trauma care providers had such training. The situation for continuing education for nurses was even lower.

Although ratings for such acute and definitive care showed some need for improvement, the situation with rehabilitation was even more difficult. Ratings showed significant deficiencies in the availability of human resources for rehabilitation, whether fully trained physician specialists or other providers such as physical therapists (PT), were considered. PT coverage was especially limited in availability at small hospitals.

In terms of physical resources for care of extremity injuries, fundamental items of orthopaedic trauma care were fairly well supplied at big hospitals. Portable X-ray was limited. Capabilities at small hospitals were much more limited. Related to the previously noted shortages of human resources for rehabilitation, availability of prosthesis for amputees was extremely limited at all levels.

Regarding the deficiencies noted for physical resources, often the problems were not the presence or absence of the equipment, but periods of inoperation while waiting for repairs, lack of supplies (such as film), or requirements for payment in advance before receiving services, which limited the availability of diagnostic tests to all who needed them. There were several instances in which mismatch of human and physical resources decreased availability of some services. For example, in India, several small hospitals had functioning X-ray machines and trained staff. However, the facilities were greatly limited in the number of plates (films) which they received each month. Thus many persons needing X-rays did not receive this service. In Ghana, one large hospital had an image intensifier (C-arm). However, there were no staff trained to use it and the machine lay idle. Many such problems are prime targets for improvement through strengthened organization and planning [11].

In all settings, there was a dearth of administrative functions to assure quality trauma care, including trauma registries, trauma-related quality improvement (medical audit) programs.

This study and the broader Essential Trauma Care Project have identified several specific ways in which trauma care could be improved in an affordable and sustainable fashion. Much is being done well by many dedicated people working hard to confront the resource restrictions in their own environments. There are several ways in which their efforts could be aided. Several important, low-cost resources could be better provided at clinics/small hospitals in middle-income countries and at most facilities in low-income countries. More generally, in all settings, training and organization of trauma care could be improved, including such items as regular in-service training. Every country should define a core set of essential equipment and supplies (including those needed for musculoskeletal injury) and then assure and monitor the availability of such resources to all who need them. This is what is recommended by the Guidelines for Essential Trauma Care, which offers the first internationally-applicable standard for countries to use to assess their trauma systems. In so doing, the Guidelines offers a way to promote realistic, minimum standards for trauma care, in a comprehensive fashion worldwide.

In an effort to promote greater efforts to strengthen trauma care, the WHA last year (2007) passed a resolution on trauma and emergency care services: WHA 60.22: “Health systems: emergency care system.” The WHA is the governing board of the WHO. It consists of Ministers of Health of all 193 Member States. Its resolutions direct WHO’s activities and carry considerable influence on actions of individual countries, as well as non-government organizations and funders. Last year, it passed for the first time ever a resolution encouraging governments worldwide to increase their efforts at providing care for trauma and other emergency conditions. The resolution listed 10 actions that Member States could take to achieve this, including measures like: “Identifying a core set of trauma services and developing methods to assure and document that such services are provided to all who need them.” The full text of the resolution is available in all six UN languages on the WHO website at: www.who.int/gb/ebwha/pdf_files/WHA60/A60_R22.en.pdf.

Those who have attended the ABJS/C.T. Brighton Workshop on Trauma in the Developing World and the readership of Clinical Orthopaedics and Related Research at large are making considerable progress in carrying out such real world improvements. The authors of this article hope that some of the information presented will assist their efforts. For example, some of the WHO publications mentioned [10, 18, 23, 24] might be of assistance, whether for training efforts, trauma system planning, or other such efforts to improve the overall surgical services, especially at primary health care facilities. Some clinicians might find it beneficial to link up with those in the GIEESC. Likewise, some of the data on the extent of the burden of musculoskeletal injuries and information on the WHA Resolution on trauma and emergency care services might be of use in advocacy to increase attention to this problem.

Finally, these health care issues cannot be considered separately from broader societal and economic issues. Although much can be improved through improved organization and planning, more extensive improvements are hampered by economic constraints. Most countries can spend only very small sums on health. Increasing health expenditures is limited by overall poverty and often by restrictions imposed by the World Bank and other international financial institutions as part of loan repayment policies (formerly called structural adjustment policies). Care of the injured would be strengthened by measures that would allow greater funding of the health sector, including many measures being debated currently, such as debt relief, relaxation of restrictions on health system financing, and promoting a more equitable world economic order, such as by requiring the World Trade Organization proceedings and rule making to be open and democratic [6]. In addition to our own technical work, clinicians as individuals and as societies of professionals need to address these bigger global economic issues.