South Africa faces one of the world’s heaviest trauma burdens. Associate Professor Sa’ad Lahri explores how innovation, training, and system reform are bridging deep inequalities in trauma care.

Trauma Care in South Africa: Bridging Inequality Through Systems Development

Associate Professor Sa’ad Lahri 
Head ,Division of Emergency Medicine
Faculty of Medicine and Health Sciences
Tygerberg | South Africa

Introduction

South Africa remains one of the world's most unequal societies, where the legacy of apartheid continues to manifest in profound healthcare disparities. Interpersonal violence dominates the South African injury profile, with injuries being the second-leading cause of years of healthy life lost (1). The socio-political determinants of health are starkly evident in trauma epidemiology, where young males aged 15 to 19 experience the highest injury rates whilst children aged 0 to 4 face the highest injury-related mortality (2). Despite these challenges, emerging evidence suggests that innovative approaches to trauma care delivery can achieve remarkable outcomes even in resource-limited settings.

The Burden of Interpersonal Violence

 Interpersonal violence accounts for over 1.5 million hospitalisations globally, with South Africa bearing a disproportionate burden (3). Research from Chris Hani Baragwanath Academic Hospital reveals that 92 percent of penetrating trauma victims were young males aged 29 to 40, with stabbings comprising 71.8 percent of cases (4). Among children, interpersonal violence prevalence exceeds that of comparable low- and middle-income countries and represents a deeply concerning pattern (5). High levels of morbidity and long-term disability persist, with repeat trauma episodes reflecting a cycle of violence and vulnerability. The geographical distribution reflects broader inequalities. Region D in Johannesburg, encompassing Soweto, accounted for 51.9 percent of cases, with the oldest townships identified as trauma "hot spots" (4).

Innovative Care Delivery Models

 Despite resource constraints, South African facilities are achieving outcomes that challenge traditional paradigms. District-level emergency centres, typically considered inappropriate for complex trauma management, demonstrate remarkable results. Emergency centre thoracotomy at two Cape Town district facilities showed 24 percent survival to discharge (32 percent for stabs), with most procedures performed by non-specialists (6). At Mitchells Plain Hospital, firearm injuries required 19.6 percent surgical intervention, accounting for 413 theatre hours, yet achieved survival rates comparable to international standards (7). These successes reflect more than clinical intervention alone, they point to the importance of dedicated teaching, structured training, effective supervision, and timely referral systems. A functional ecosystem of care, even in under-resourced environments, enables non-specialists to perform complex procedures safely and effectively.

Systems Development and Emerging Solutions

 Electronic trauma registries in KwaZulu-Natal and the Western Cape are enabling evidence-based quality improvement. The Pietermaritzburg Metropolitan Trauma Service database allows clinicians to map outcomes, guide interventions, and advocate for system reform (8).

Emergency medical services are undergoing significant reform. None of the nine provinces meet the national norm of one ambulance per 10,000 people, and equipment shortages persist. New regulations promulgated in 2017 and 2022 establish quality standards, while the National Emergency Care Education and Training Policy is aligning education with national frameworks (9). Helicopter emergency medical services, operating across seven provinces, support long-distance transfers and inaccessible terrain.

Addressing System Failures and Prevention

Recent findings from the EpiC study provide critical insights. Forty-five percent of pre- and in-hospital trauma deaths were deemed preventable, primarily due to delays in accessing surgical care, poor recognition of critical illness, and insufficient team-based care (10). However, this represents opportunity rather than defeat. Nearly half of trauma deaths could be prevented with improved systems. Strengthening trauma care requires more than clinical protocols; it demands investment in medical education, outreach, and mentorship. Locally based trauma courses, including those tailored for district hospitals, are equipping providers with context-specific skills. Ongoing support and knowledge sharing from tertiary centres to frontline facilities are helping build a resilient and skilled workforce capable of responding effectively to complex trauma.

Prevention strategies show promise. During COVID-19 alcohol restrictions, trauma admissions dropped significantly highlighting alcohol's role in interpersonal violence and showing that multisectoral approaches addressing social determinants can significantly reduce injury burden (11).

The Role of Technology and Communication

The introduction of the 112-emergency number in 2019 and ongoing standardisation of Emergency Communication Centres represent important advances (9). Despite current disparities between provinces in dispatching systems, these developments lay the groundwork for integrated emergency response. Telemedicine and mobile health initiatives offer potential for bridging geographical barriers, especially in rural and under-resourced areas.

Building Resilient Systems

 South Africa's approach demonstrates that effective trauma care does not require high-income country resources. Key principles include decentralised competency through training non-specialists to perform life-saving procedures, data-driven improvement using electronic registries, coordinated care pathways linking district and tertiary services, and prevention strategies that address upstream determinants of violence.

The integration of emergency services within the broader healthcare delivery platform provides a framework for universal health coverage, despite ongoing implementation challenges (9). Reforms in governance, training, and technology indicate a system evolving toward greater efficiency and equity.

Conclusion

Trauma care in South Africa reflects broader societal inequalities but also demonstrates innovation and resilience. From district-level thoracotomies achieving international survival rates to electronic registries enabling evidence-based care, there is growing proof that equitable trauma care is achievable. The finding that 45 percent of trauma deaths are preventable presents a powerful call to action.

Sustained investment in healthcare infrastructure and the social determinants of health is essential. This includes scaling up proven models of care, strengthening emergency services, advancing prevention strategies, and addressing the root causes of violence. Trauma care in South Africa is both a clinical priority and a moral imperative, central to building the equitable society the country aspires to become.

References

1. Matzopoulos, R., Prinsloo, M., Pillay-van Wyk, V., Gwebushe, N., Mathews, S., Martin, L. J., Laubscher, R., Abrahams, N., Msemburi, W., Lombard, C., & Bradshaw, D. (2015). Injury-related mortality in South Africa: a retrospective descriptive study of postmortem investigations. Bulletin of the World Health Organization, 93(5), 303–313. https://doi.org/10.2471/BLT.14.145771
2. Massyn N, Day C, Ndlovu N, Padayachee T, editors. District Health Barometer 2019/20. Durban: Health Systems Trust; 2020. Available from: https://www.hst.org.za/publications/District%20Health%20Barometers/DHB%202019-20%20Complete%20Book.pdf (Accessed 14 July 2025)
3. World Health Organization; United Nations Development Programme; United Nations Office on Drugs and Crime. Global status report on violence prevention 2014 [Internet]. Geneva: World Health Organization; 2014 [cited 2025 Jul 14]. 274 p. Available from: https://www.who.int/publications/i/item/9789241564793
4. Bhana M, Fru P, Plani F. A long walk to freedom: the epidemiology of penetrating trauma in South Africa – analysis of 4,697 patients over a six-year period at Chris Hani Baragwanath Academic Hospital. S Afr J Surg. 2022;60(2):77–83. https://doi.org/10.17159/2078-5151/SAJS3800
5. Biswas A, Rhee DS, Laytin AD, Zhao YJ, Ko J, Chidiac C, Clarke DL, Kong VY. Interpersonal Violence-Related Trauma Among South African Children. J Surg Res. 2024 Oct;302:150-159. doi: 10.1016/j.jss.2024.06.047. Epub 2024 Aug 2. PMID: 39096743.
6. Sittmann JC, Gool F, van Koningsbruggen C, Evans K. Emergency centre thoracotomy for penetrating trauma: insights from two South African district-level emergency centres. Injury. 2025;56:112083. https://doi.org/10.1016/j.injury.2024.112083
7. Bush L, Hendrikse C, van Koningsbruggen C, Evans K. The burden and outcomes of firearm injuries at two district-level emergency centres in Cape Town, South Africa: a descriptive analysis. S Afr Med J. 2024;114(2):101–108. https://doi.org/10.7196/SAMJ.2024.v114i2.16535
8. Clarke DL. Trauma quality improvement: The Pietermaritzburg Metropolitan Trauma Service experience with the development of a comprehensive structure to facilitate quality improvement in rural trauma and acute care in KwaZulu-Natal, South Africa. S Afr Med J. 2015;105(2):92-95. Published 2015 Jan 3. doi:10.7196/samj.8792
9. Govender, S., Khaliq, O. P., Naidoo, R., & Moodley, J. (2024). The current state of emergency medical services in South Africa: A review. South African Journal of Science, 120(7/8). https://doi.org/10.17159/sajs.2024/16138
10. Dixon J, de Vries S, Fleischer C, et al. Preventable trauma deaths in the Western Cape of South Africa: a consensus-based panel review. PLOS Glob Public Health. 2024;4(5):e0003122. https://doi.org/10.1371/journal.pgph.0003122
11. Zsilavecz A, Wain H, Bruce JL, Smith MTD, Bekker W, Laing GL, Lutge E, Clarke DL. Trauma patterns during the COVID-19 lockdown in South Africa expose vulnerability of women. S Afr Med J. 2020 Oct 28;110(11):1110-1112. doi: 10.7196/SAMJ.2020.v110i11.15124. PMID: 33403988.