Technical Priorities for Orthopaedic Trauma Care Development in Malawi

Kiran J. Agarwal-Harding¹, Kush Mody¹, Lahin M. Amlani¹, Kenneth Nanyumba¹, Linda Chokotho², Leonard N. Banza³, Nicholas Lubega⁴, Jeremy (Jes) Bates⁵, Sven Young⁶, Nyengo Mkandawire⁵

1. Harvard Global Orthopaedics Collaborative, Boston, MA, USA
2. Malawi University of Science and Technology
3. Lilongwe Institute of Orthopaedics and Neurosurgery, Kamuzu Central Hospital, Lilongwe, Malawi
4. Beit Cure International Hospital, Blantyre, Malawi
5. Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi
6. Department of Orthopedics, Haukeland University Hospital, Bergen, Norway

Abstract
Introduction
Malawi has a high and rising incidence of musculoskeletal injuries and inadequate orthopaedic trauma care capacity, which must be urgently addressed.
Methods
We performed a scoping literature review to define essential goals and challenges to musculoskeletal trauma care delivery in Malawi pertaining to the following domains: injury prevention, prehospital care, rural health centres, district hospitals, and central hospitals. For each domain, essential goals were ratified and challenges were prioritized by a panel of experts on Malawian orthopaedic trauma care.
Results
The five highest priorities pertained to injury prevention (2), central hospital-level definitive treatment (2), and district hospitallevel initial fracture management (1). We believe the next steps are to use the prioritized list of challenges to form working groups with the goal of examining and developing strategies to address each challenge. For the top priority challenges in each domain, we recommend the following: 1) Prevent road injuries by law enforcement, children’s education, civic engagement, and road infrastructure development; 2) Improve pre-hospital transportation by scaling up emergency dispatch systems, fixing broken ambulances, and training public transportation workers in basic first aid; 3) Provide health workers in Rural Health Centres with basic training in musculoskeletal injury management and triage; 4) Improve diagnostic x-ray capacity at District Hospitals by fixing/replacing broken
machinery and ensuring stable power supply; 5) Improve operative capacity at Central Hospitals by increasing operating theatre availability, efficiency, and utilization, and supporting specialist surgical training programmes.
Discussion
We hope that this manuscript will serve as a practical, actionable guide for policymakers, donors, health system leaders, educators and orthopaedic trauma care providers. Through this process, we also hope to create a replicable methodology and framework that can be applied to other clinical departments in Malawi, and for similar work in other low- and middle-income countries.