Trauma governance and system maturity: A cross-national analysis of authority, funding, enforcement, and surveillance in 37 countries.

Authors

Divya Kewalramani, Justin Benton, Rachel L Choron, Amanda Teichman, Zachary Englert, Chaia Gelster, Julianne Goncalves, Elizabeth Skobelev, Daniel Whitley, Julie Goswami, Joseph Hanna, Gautam Singh, Piyush Tewari, Philip Barie, Mahesh C Misra, Mayur Narayan

Published in

Injury. Pages 113742. Oct 01, 2026. Epub Oct 01, 2026.

Abstract

Organized trauma systems reduce mortality, yet most countries lack such systems and among those that exist, maturity varies widely. While the World Health Organization (WHO) emphasizes governance components including authority, funding, enforcement, and surveillance, empirical evidence linking these elements to measurable system outcomes is absent. We hypothesized that trauma governance entities (TGE) would demonstrate a dose-dependent association with WHO's Trauma System Maturity Index (TSMI) scores after adjusting for macro-economic resources.
WHO reports, peer-reviewed literature, and national trauma registry publications spanning 2017-2024 were used to perform a cross-sectional analysis of 37 countries representing all World Bank regions and three income tiers (lower-middle, upper-middle, high). TSMI scores were assigned to four TSMI domains: prehospital care, facility-based care, education/training, quality assurance. For each nation, a composite mean TSMI score was calculated. A novel TGE score (0-4) was created to assess four domains: authority, funding, enforcement, surveillance (AFES). Spearman correlation and multivariable ordinary least-squares regression adjusting for income level, injury mortality rate (IMR), and system type were employed to assess associations between AFES and system maturity. The primary effect estimate was the contrast between countries with any governance component present (AFES≥1) and countries with none (AFES=0).
Of 37 nations, 15 (41%) nations had a TGE. Nations with a TGE demonstrated lower median IMR per 1000 persons (6.9 [IQR 5.2-8.1] vs 22.2 [IQR 8.7-34.9], p = 0.002) and higher composite TSMI scores (3.50 [IQR 3.25-4.00] vs 3.00 [IQR 1.81-3.44], p = 0.003). TSMI did not increase monotonically across AFES categories (median 2.25, 3.25, 3.88, 2.50 and 3.50 for AFES=0 through AFES=4). In an adjusted OLS model, countries with any governance components present (AFES≥1) had TSMI scores 0.66 points higher than countries with no governance components (β=0.66, 95% CI [0.13, 1.18], p = 0.016).
Trauma governance, operationalized through establishment of AFES domains, is strongly associated with trauma system maturity with the difference concentrated between countries that have no formal governance and those that have any. Establishing any formal governance structure may be a particularly high-yield, scalable target to improve trauma system outcomes, especially in high-burdened, lower-middle income nations.
Prognostic and Epidemiological; Level III.

PMID:
42838817
Bibliographic data and abstract were imported from PubMed on 07 Oct 2026.

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