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. 2013 Oct 5;29(6):795–808. doi: 10.1093/heapol/czt064

The cost of injury and trauma care in low- and middle-income countries: a review of economic evidence

Hadley K H Wesson 1,2, Nonkululeko Boikhutso 3, Abdulgafoor M Bachani 1, Karen J Hofman 4, Adnan A Hyder 1,*
PMCID: PMC4153302  PMID: 24097794

Abstract

Introduction Injuries are a significant cause of mortality and morbidity, of which more than 90% occur in low- and middle-income countries (LMICs). Given the extent of this burden being confronted by LMICs, there is need to place injury prevention at the forefront of public health initiatives and to understand the costs associated with injury. The aim of this article is to describe the extent to which injury-related costing studies have been conducted in LMICs.

Methods A review of literature was performed to explore costing data available for injury and/or trauma care in LMICs. Study quality was described using recommendations from the Community Guide’s quality assessment tool for economic evaluations.

Results The review identified 68 studies, of which 13 were full economic evaluations. Cost of injury varied widely with mean costs ranging from US$14 to US$17 400. In terms of injury-prevention interventions, cost per disability adjusted life year averted for injury-prevention interventions ranged from US$10.90 for speed bump installation to US$17 000 for drunk driving and breath testing campaigns in Africa. The studies varied in quality, ranging from very good to unsatisfactory.

Discussion There is a lack of injury-related economic evidence from LMICs. Current costing research has considerable variability in the costs and cost descriptions of injury and associated prevention interventions. The generalizability of these studies is limited. Yet the economic burden of injury is high, suggesting significant potential for cost savings through injury prevention. A standardized approach to economic evaluation of injury in LMICs is needed to further prioritize investing in injury prevention.

Keywords: Injury, trauma, economic evaluation, costs, developing countries

KEY MESSAGES.

  • The economic burden of injury and trauma care is high in LMICs, suggesting significant potential for cost savings through injury prevention.

  • A standardized approach to economic evaluation of injury in LMICs is needed to further prioritize investing in injury prevention.

Introduction

Injuries are a significant cause of mortality and morbidity, accounting for ∼5.8 million or 10% of global deaths per year (World Health Organization, 2008). The magnitude of the burden of injury is alarming when compared to other diseases: there are 32% more deaths from injuries than from AIDS, tuberculosis (TB) and malaria combined (World Health Organization, 2008). More than 90% of these injury-related deaths occur in low- and middle-income countries (LMICs).

Given the extent of this burden being confronted by LMICs, there is need to place injury prevention at the forefront of public health initiatives. Yet this is not happening. Efforts to promote injury prevention have not received the attention and prioritization of diseases such as HIV/AIDS, TB and malaria. If injury mortality and morbidity data have failed to convince policy-makers to invest in injury prevention, there is a need to explore alternative ways to advocate for injury prevention. One approach is to consider the costs associated with injury and the cost-effectiveness of injury-prevention interventions.

Nearly half of injury-related mortality occurs in individuals aged 15 to 44 years during their most economically productive years (Nilsen et al., 2006). This makes the financial burden of injuries far exceed the immediate medical costs associated with the injury. As such, more comprehensive injury-related cost studies that describe not only medical costs, but also those related to the consequences of injury to the individual, family and society, such as productivity losses, can be used to inform policies and interventions at the local and national levels.

In addition to describing the cost of injuries, there is also a need to describe the cost-effectiveness of injury-prevention initiatives. While a key first step in injury prevention requires obtaining evidence on the effectiveness of interventions, potential effectiveness is only part of a policy-maker’s decision to invest in a prevention programme (Zaza et al., 2005). With limited resources and competing health needs, the costs of an intervention in relation to the benefits must also be taken into account.

The increased use of cost calculations to implement injury-prevention efforts has been encouraged by the World Health Organization (WHO) and the Disease Control Priorities Project (DCPP) (World Health Organization, 2011a; Jamison et al., 2006). While systematic reviews have explored the cost-effectiveness of injury prevention in high income countries (HICs), this represents less than 10% of the global burden of injury and conclusions drawn from reviews from HICs may not be transferable to LMICs (Gyllensvard, 2010; Waters et al., 2004; Scuffham, 2008).

There is a need to review the literature in the context of LMICs; to the best of our knowledge, this has not previously been done. The aim of this article is thus to describe the extent to which injury-related costing studies have been conducted in LMICs. The specific objectives of this article are 3-fold: to summarize the body of economic evidence on injury in LMICs; to assess the quality of cost-effectiveness studies using standard methods to highlight the role of economic data as a tool for injury-prevention advocacy; and to provide recommendations regarding economic evaluations in LMICs.

Methods

We searched Medline/PubMed (National Library of Medicine, 2013), EconLit (American Economic Association, 2013), Econbase (Elsevier Inc., 2013a), Embase (Elsevier Inc., 2013b) the Cochrane Library (The Cochrane Collection, 2013) and the National Health Service Economic Evaluation Database (National Institute for Health Research, 2013) to identify articles published before February 2013 that pertained to costs associated with injury in LMICs using key words presented in the Appendix. Citations and reference lists were reviewed to identify any additional studies (Littell et al., 2008). Since this was a review of published literature only, the ‘grey’ literature was not searched.

We assessed each study for inclusion using three criteria. First, included studies had to use costing data from LMICs. We defined a LMIC according to the World Bank’s classification of a country with a gross national income per capita of less than US$12 195 in 2011 (World Bank, 2011). Second, studies had to describe either injuries, an injury classification (i.e. road traffic injures (RTIs), burns, falls, drowning and violence), or trauma care defined as pre-hospital and hospital-based trauma care services (World Health Organization, 2008). Third, studies had to use either a cost-related partial evaluation or full economic evaluation. We included cost-related partial evaluations in our review because they represent important initial work in LMICs to describe the economic burden of injury (Drummond et al., 2005). These partial economic evaluations were grouped into four categories: 1) ‘cost description’ which examined only costs without a comparison to alternative outcomes; 2) ‘cost analysis’ which compared alternatives in terms of costs only; 3) ‘cost-outcome description’ which examined both costs and outcomes, but did not compare alternatives; and 4) ‘outcome analysis’ which compared alternatives in terms of outcome only (Drummond et al., 2005). Full economic evaluations included cost-effectiveness analysis, cost-utility analysis and cost-benefit analysis (Drummond et al., 2005).

Review articles, commentaries and editorials were excluded. Studies that did not report the currency unit for the reported costs were excluded. To avoid double counting, duplicate data presented in multiple publications were excluded; in these instances, the earlier publication was included. For the purposes of this review, we excluded poisoning, occupational injuries and disaster-related injuries given that the underlying causes of these injury classifications and the associated costs were too broad for the scope of this review. Injuries that were defined according to an anatomical location were excluded. This included head (including traumatic brain injuries), spinal cord and orthopaedic-related injuries. Studies that looked at only one type of cost, such as the cost of a particular dressing or wound care, were excluded as these costs were too narrow for this review.

Information regarding the study design and findings in terms of costs and outcomes was extracted and tabulated. To maximize comparisons among studies, we standardized costs when applicable. All costs were converted to US dollars (US$) for 2010 using gross domestic product (GDP) deflators and purchasing power parities (Shemilt et al., 2009).

For partial evaluation studies, mean costs were reported in the units described by the individual study, such as the cost per hospitalization or the cost per injury. The cost per hospitalization differed from cost of injury depending on whether the study included costs that would be incurred outside of the injured patient’s hospital admission. To describe this, the types of costs presented by the partial evaluation studies were tabulated into three categories: direct medical costs, direct non-medical costs and indirect costs. Medical costs are those costs incurred during the hospital inpatient stays, out-patient stays, hospital stay, medicine, surgery, emergency department visits, prostheses and wound-care dressings, radiological, laboratory and specialist consultation costs. Direct non-medical costs included administration costs (which included the medico-legal costs, cost administration, costs of police activity and insurance administration, funeral costs, transportation, non-medical material costs, and food and accommodation of the patient and/or family members. Indirect costs include loss of income, cost of premature death, pain and suffering and the cost of restricted activity (Drummond et al., 2005).

We tabulated the median and range of reported mean costs for partial evaluation studies, describing this in terms of those studies that reported costs as (1) direct medical costs only, (2) direct medical and non-medical costs and (3) direct medical and non-medical costs and indirect costs. To further compare costs among partial economic studies, when applicable, costs were reported as a percentage of GDP per capita for 2010, as reported by the World Bank (World Bank, 2013).

For full economic studies, costs were reported in units of costs per disability-adjusted life year (DALY) averted, per death averted and per years of life gained, as defined by the individual study. We described the quality of these studies using recommendations from the Community Guide’s quality assessment tool for economic evaluations (Community Guide, 2010). Of note, because this tool is designed for full economic evaluations, we did not apply the Community Guide to the partial evaluations. Quality was systematically assessed across five categories: study design, cost data, outcome measure, effects and analysis. A quality score was assigned to each study using the Community Guide quality assessment criteria. For full economic evaluation studies that did not require expert opinion, the respective categories were labelled as not applicable and the quality assessment score was adjusted to account for this. The score was then converted into ratings of very good, good, satisfactory and unsatisfactory. Following the Community Guide’s recommendations that stipulate studies with an unsatisfactory score should be discarded, we assessed studies that achieved a score of satisfactory or higher to then determine if the intervention was cost-effective (Community Guide, 2010). For those studies that reported costs in terms of life year saved or DALY averted, the interventions were described as very cost-effective, cost-effective or not cost-effective using World Health Organization Choosing Interventions that are Cost Effective (WHO-CHOICE) guidelines. These guidelines define a ‘very cost-effective’ intervention as an intervention that produces a healthy year of life for less than the GDP per capita, a ‘cost-effective’ intervention as producing a health year of life for less than three times GDP per capita and a ‘non-cost-effective’ intervention as producing a health year of life for more than three times GDP per capita (World Health Organization, 2003).

Given the lack of generalizability among studies, we did not conduct a meta-analysis (Drummond and Pang, 2001). We used the results to summarize the strength of the body of the evidence regarding injury in LMICs and identify research gaps.

Results

Sixty-eight of the initially identified 1196 unique citations met our inclusion criteria (Figure 1). Fifty-five studies were partial evaluations and 13 were full economic evaluations. Nearly half of partial evaluation studies were hospital based (n = 27/55; 49%), of which the majority were single-centre studies (n = 21/27; 78%). Fifteen studies described injuries in general; in terms of types of injury, the majority of studies described RTIs (n = 31/68; 46%), followed by burn injuries (n = 11/68; 16%). Six studies described trauma care, of which four described pre-hospital trauma care. While most studies were conducted in urban settings (n = 51), used national data (n = 6), or used data from both urban and rural areas (n = 8), three studies were exclusively set in rural areas.

Figure 1.

Figure 1

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Literature review flowchart

Partial evaluation studies included 48 cost description studies, two cost-outcome description studies, three cost-analysis studies, and two outcome analysis studies that focused on RTIs, burns, violence and injuries (Table 1). Costs were presented in units of cost per hospitalization (n = 30 including one study of emergency room visits), cost per injury (n = 17), cost per fatality (n = 1), cost per safety intervention or device (n = 3), years of potential life lost (n = 1), years of lost productivity (n = 1) and total cost of injury (n = 2).

Table 1.

Partial evaluation studies of the costs of injuries, treatment and prevention in LMICs (n = 55)

Author, year Study location Study setting Study sample Outcome Cost (US$ 2010) Unit (mean cost per) Cost as a % of GDP/ capita Direct medical costs Direct non- medical costs Indirect costs
1. RTIs (n = 25)
Cost description
    Jadaan, 1989 Jordan Urban (one hospital) N/A N/A $99 Per hospitalization 2% X
    Arokiasamy and Krishnan, 1994 Malaysia National 2354 fatal RTIs N/A $129 000 Per injury 1484% X
    Al-Masaeid et al., 1999 Jordan Urban and Rural 552 fatal RTIs N/A $4200 Per fatality 96% X X X
 Olukoga, 2004 South Africa Urban and Rural N/A N/A Minor: $3970 Per injury 55% X X X
Major: $14 800 200%
Fatal: $64 700 890%
    Anh et al., 2005 Vietnam National 26 925 RTIs N/A $8,770 Per injury 717% X X X
 De Leon, 2005 Philippines National N/A N/A Minor: $1560 Per injury 73% X X X
Major: $16 100 752%
Fatal: $75 900 3546%
    Hassan et al., 2005 Kenya Urban (one hospital) 136 RTIs N/A $140 Per hospitalization 18% X
    Jianping et al., 2006 China Urban 420 RTIs N/A $720 Per hospitalization 16% X
    Yan-Hong et al., 2006 China National N/A N/A $766 million Total RTI costs N/A X X X
    Hung et al., 2008 Vietnam Urban 656 MCIs N/A $10 Per motorcycle helmet 1% N/A
    Riewpaiboon et al., 2008 Thailand Urban (one hospital) 200 RTIs N/A $3000 Per hospitalization 65% X X X
    Reddy et al., 2009 India Urban (five hospitals) 95 RTIs N/A $23 100 Per hospitalization 35% X X
    Juillard et al., 2010 Nigeria Urban 127 RTIs N/A $28 Per injury 2% X X
    Mashreky et al., 2010 Bangladesh Urban and Rural (16 hospitals) 7732 RTIs N/A $110 Per hospitalization 16% X X
    Perez-Nunez et al., 2010 Belize National 964 RTIs N/A $10 300 Per injury 254% X X X
    Kudebong et al., 2011 Ghana Rural 556 MCIs N/A $2220 Per injury 168% X X X
    Li et al., 2011 China Urban 550 bicycle injuries N/A $4330 Per injury 98% X X
    Razzak et al., 2011 Pakistan Urban (five hospitals) 341 RTIs N/A $355 Per injury 35% X X X
    Perez-Nunez et al., 2011 Mexico Urban (four hospitals) 60 RTIs N/A $810 Per hospitalization 9% X X X
    Sangowawa et al., 2011 Nigeria Urban 44 MCCs N/A $75 Per injury 5% X X
    Nguyen et al., 2012b Vietnam Urban (one hospital) 477 RTIs N/A $363 Per injury 30% X X X
Cost analysis
 Bishai et al., 2003 Uganda, Pakistan National N/A N/A Uganda: $0.12 Per road safety 0.02% N/A
Pakistan: $0.09 >0.01%
 Hendrie et al., 2004c 8 LMICsa Urban Retail stores and internet vendors N/A Car seat: $100 Per safety device N/A N/A
Booster seat: $219
Bicycle helmet: $16
 Hijar et al., 2004 Mexico Urban (four hospitals) 233 RTIs N/A Uninsured: <$25 Per hospitalization <0.3% X X
Insured: >$123 >1.3%
Outcome analysis
    Naci and Baker, 2008 Turkey Urban N/A N/A $360,571 Years of potential life lost N/A N/A
2. Burn Injuries (n = 12)
Cost description
    Nursal et al., 2003 Turkey Urban (one hospital) 109 burns N/A $6310 Per hospitalization 601% X
    Mashreky et al., 2008 Bangladesh N/S (61 health facilities) 791 burns N/A $267 Per hospitalization 675% X X
    Kai-Yang et al., 2009 China Urban (one hospital) 178 paediatric burns N/A $1070 Per hospitalization 24% X
    Ogundipe et al., 2009 Nigeria Urban (one hospital) 69 burns N/A $297 Per hospitalization 21% X
    Yin et al., 2010 China Urban (one hospital) 201 elderly burns N/A $3860 Per hospitalization 87% X
    Ahachi et al., 2011 Nigeria Urban (one hospital) 52 burns N/A $1390 Per hospitalization 96% X
    Allorto et al., 2011 South Africa Urban (one hospital) 450 burns N/A $9800 Per hospitalization 135% X
    Sahin et al., 2011 Turkey Urban (one hospital) 43 burns N/A $15 400 Per hospitalization 153% X X
    Alinia et al., 2013 Iran Urban (one hospital) 723 firework burns N/A $227 Per hospitalization 2% X
Cost analysis
    Hendrie et al., 2004c 8 LMICsa Urban Retail stores and internet vendors N/A Smoke alarm: $61.8 Per safety device N/A N/A
Cost-outcome description
 Zhou et al., 2003b China Urban (one hospital) 40 burns treated with: Plasma concentration Per hospitalization X
1. Glutamine 1. 591 1. $9200 207%
2. Control 2. 399 2. $10 100 228%
 Muangman et al., 2010 Thailand Urban 70 burns treated with: Time to wound closure: Per hospitalization X X
1. Siler sulfadiazine 1. 13.7 days 1. $94 2%
2. Aqualcel Ag 2. 10 days 2. $53 1%
3. Injuries from Violence (n = 4)
Cost description
    Mansingh and Ramphal, 1993 Jamaica Urban (one hospital) 640 violent injuries N/A $36 to $56 Per hospitalization 0.7–1.1% X
    Mendonca et al., 2002 Brazil Urban 9220 violent injuries N/A $285 Per hospitalization 3% X
    Allard and Burch, 2005 South Africa Urban (one hospital) 21 firearm injuries N/A $17,400 Per hospitalization 239% X
    Ward et al., 2009 Jamaica National 8468 violent injuries N/A $59.2 million Per injury N/A X X X
4. Injury, not specified (n = 15)
Cost description
    Kaya et al., 1999 Turkey Urban (one hospital) 347 injuries N/A $2,190 Per hospitalization 209% X
    McDonald et al., 1999 Jamaica Urban (one hospital) 22,311 injuries N/A $97 Per hospitalization 2% X
    Zhao et al., 2002 China Urban (eight hospitals) 5876 injuries N/A $624 Per hospitalization 14% X
    Gurses et al., 2003 Turkey Urban (one hospital) 91 paediatric injuries N/A $493 Per hospitalization 47% X
    Thanh et al., 2003 Vietnam Urban and rural 1740 non-fatal unintentional injuries N/A $17 Per injury 1% X X X
 Mock et al., 2003 Ghana Urban and rural 1609 injuries N/A Urban: $38 Per injury 3% X
Rural: $14 1%
    Li et al., 2005 China Rural 902 injuries N/A $1033 Per injury 23% X X X
    Melione and Mello-Jorge, 2008 Brazil Urban (one hospital) 976 injuries N/A $188 Per hospitalization 2% X
    Joshi and Shrestha, 2009 Nepal Urban (six health centres) 505 injuries N/A $128 Per injury 24% X
    Rodrigues et al., 2009 Brazil National N/A N/A $868 million Total cost of injury N/A X X X
    Soyer et al., 2009 Turkey Urban (one hospital) 146 paediatric injuries N/A $169 Per emergency room visit 16% X
    Bildik et al., 2010 Turkey Urban (one hospital) 118 injuries N/A $78 Per hospitalizaitonb 1% X
    Plummer et al., 2010 Jamaica Urban 715 injuries N/A $357 Per hospitalization 7% X
    Nguyen et al., 2012a Vietnam Urban (one hospital) 892 injures N/A $366 Per injury 30% X X X
Outcome analysis
    Zhou et al., 2003a China National N/A N/A $12.6 million years of lost productivity N/A N/A
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RTI: road traffic injury; N/A: not applicable; N/S: not specified.

a Eight LMICs include: Albania, China, Philippines, Brazil, Thailand, Venezuela, Vietnam, and South Africa. As this study describes costs of both burn and RTI prevention, it is listed in both sections but counted once.

b Cost reported as median.

c Study listed twice under RTI and burn injury, respectively.

In terms of the breakdown of the costs of injury, of the applicable partial evaluation studies—excluding outcome analysis studies (n = 2) and studies that reported the costs of safety devices (n = 4)—all but one study (n = 48/49) reported direct costs. Twenty-one studies (42%) reported direct non-medical costs and 21 other studies (42%) reported indirect costs. Sixteen studies (32%) reported all three types of costs. As shown in Table 2, costs included within these categories varied widely. For example, while 21 studies included the cost of hospital stay, two studies defined in terms of direct medical costs only as hospital stay, while five studies defined direct medical costs as hospital stay, surgical services, laboratory investigations and medicine. Twenty-five studies (51%) did not specify how direct medical costs were defined. Twenty-one studies (42%) reported indirect costs, of which six defined indirect costs as income loss only.

Table 2.

Type of injury costs variables included in partial economic studies

Cost Variables Partial economic studies (n = 49)a
Direct medical cost (n = 48)
    Hospital stay 21
    Pre-hospital care 2
    Emergency department visit 6
    Surgical services 11
    Specialist consultation 4
    Rehabilitation/physical therapy 3
    Out-patient follow-up 3
    Wound care/prostheses 11
    Laboratory investigations 8
    Radiological investigations 9
    Blood and blood products 2
    Medicine 16
    Not specified 25
Direct non-medical costs (n = 21)
    Administrative 6
    Transportation 10
    Property damage 6
    Food 5
    Accommodation 5
    Funeral cost 3
    Not specified 4
Indirect costs (n = 21)
    Income loss 15
    Cost of premature death 8
    Pain and suffering 3
    Restricted activity (not work related) 2
    Not specified 3
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a Includes studies that reported unit cost as per injury, hospitalization and total injury.

The range of injury costs per hospitalization and per injury varied widely (Table 3). Of the 22 studies that reported only direct costs per hospitalization, the median cost was US$291, but costs ranged from US$14 to US$17 400. The median cost as a percentage of GDP was 15%. In terms of specific types of injuries, the highest reported median direct medical costs were for burn injuries. Six studies reported direct medical and non-medical costs, ranging from less than US$25 to US$15 400. Thirteen studies reported direct medical, direct non-medical and indirect costs; the median cost of these studies was US$4085 or 97% of GDP per capita.

Table 3.

Median and range of injury costs per hospitalization and per injury described by cost description studies (n = 41; US$ 2010)a

Injury type Direct medical costs per hospitalization
 Direct medical and non-medical costs per hospitalization
 Direct medical, direct non-medical, and indirect costs per injury
Studies (n) Median cost (range) Median cost as % of GDP (range) Studies (n) Mean cost (range) Median cost as % of GDP (range) Studies (n) Median cost (range) Median cost as % of GDP (range)
Injury (not specified) 9 $178.5 (14–2190) 11% (1–209%) 0 – – 3 $91 (17–366) 16% (1–30%)
RTI 3 $140 (99–720) 16% (2–18%) 3 $117 (<25–23 100) 9% (<0.3–1680%) 10 $4200 (355–10 300) 98% (9–717%)
Burn 7 $1390 (227–9800) 87% (2–601%) 3 $181 (53–15 400) 21% (1–153%) 0 – –
Violence 3 $ 285 (36–17 400) 3% (0.7–239%) 0 – – 0 – –
Total 22 $291 (14–17 400) 15% (0.7–239%) 6 $125 (<25–15 400) 9% (<0.3–1680%) 13 $4085 (17–10 300) 97% (1–717%)
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a Excludes three studies that reported costs as a unit of total costs (Rodrigues et al., 2009; Ward et al., 2009; Yan-Hong et al., 2006), three studies that reported the costs of safety programmes or devices (Bishai et al., 2003; Hendrie et al., 2004; Hung et al., 2008), one study that reported only indirect costs (Arokiasamy and Krishnan, 1994) and two studies that reported only direct medical costs and indirect costs (Joshi and Shrestha, 2009; Juillard et al., 2010).

Three partial evaluation studies described the cost of safety interventions or devices, including road safety, car and booster seats, motorcycle and bicycle helmets, and smoke detectors, ranging from US$0.09 for a national road safety programme to US$219 for a booster seat.

Thirteen full economic evaluations explored costs associated with RTIs, drowning, and pre-hospital and hospital-based trauma care (Table 4). Some studies calculated cost per outcome using primary data (n = 6) and others applied secondary data from other published studies to epidemiological models (n = 7). Different units were used to describe effectiveness, including cost per death averted (n = 5), cost per DALY averted (n = 6), cost per life year saved (n = 1) and willingness to pay (n = 1). Costs per death averted ranged from US$30 for enhanced traffic enforcement to US$596 000 for a citywide pre-hospital system based on a North American emergency response model. The cost per DALY averted from injury-prevention interventions ranged from US$10.9 for speed bump installation to US$12 800 for legislation and enforcement of motorcycle helmets in the WHO's African (AFRO) region. In terms of hospital-based surgical care for trauma victims, costs ranged from US$30 to US$226 per DALY averted in Cambodia and Haiti, respectively.

Table 4.

Full economic evaluation studies of injuries and trauma care in low- and middle-income countries (n = 13)

Author, year Study location Study setting Study sample Intervention Cost (US$ 2010) Unit (Cost per) Cost-effectiveness
1. Road traffic injuries (n = 6)
    Harris, 2005 (Harris and Olukoga, 2005) South Africa Urban Model using data from 7567 injured patients Seat belt enforcement $17 400 Per death averted N/A
 Bishai, 2006 (Bishai and Hyder, 2006) LMICs Urban Model using data from Bangladesh, Brazil, China, Ghana, and Philippines 1. Traffic enforcement $78.8 Per DALY averted Very cost-effective
2. Speed bumps at locations that cause 25% of junction deaths $10.9 Per DALY averted Very cost-effective
3. Motorcycle helmet legislation and enforcement $575 Per DALY averted Very cost-effective
    Bishai, 2008 (Bishai et al., 2008) Uganda Urban Model using data from 10 police stations Enhanced traffic enforcement $30 Per life year saved Very cost-effective
    Pham, 2008 (Pham et al., 2008) Vietnam Urban 414 households Willingness to pay among 63% of respondents $9.38 Per motorcycle helmet N/A
 Chisholm, 2012 (Chisholm and Naci, 2012) AFRO, SERO Urban and rural Model 1. Speed cameras AFRO: $4230; SERO: $5540 Per DALY averted AFRO and SERO: Very cost-effective
2. Drink-driving and breath testing campaigns AFRO: $5670; SERO: $9530 Per DALY averted AFRO and SERO: Cost-effective
3. Seatbelt usea AFRO: $11600; SERO: $8730 Per DALY averted AFRO and SERO: Very cost-effective
4. Motorcycle helmetsa AFRO: $17000; SERO: $5920 Per DALY averted AFRO: Cost-effective; SERO: Very cost-effective
5. Bicyclist helmetsa,b AFRO: $3130; SERO: $12800 Per DALY averted AFRO: Very cost-effective; SERO: Cost-effective
 Ditsuwan, 2013 (Ditsuwan et al., 2013) Thailand Urban and rural Model 1. Selective breath testing $367 Per DALY averted Very cost-effective
2. Random breath testing $403 Per DALY averted Very cost-effective
3. Mass media campaign $291 Per DALY averted Very cost-effective
4. Selective breath testing with mass media $353 Per DALY averted Very cost-effective
5. Random breath testing with mass media $376 Per DALY averted Very cost-effective
2. Drowning (n = 1)
    Rahman, 2012 (Rahman et al., 2012) Bangladesh Rural 76918 children in 3 rural regions Drowning prevention programme including a preschool education system and a child swim programme 362 Per DALY averted Very cost-effective
3. Pre-hospital trauma care (n = 4)
    Hauswald, 1997 (Hauswald and Yeoh, 1997) Malaysia Urban Model using data from 467 injury-related deaths Development of pre-hospital system, based on a North American model $596,000 Per death averted N/A
    Arreola-Risa, 2004 (Arreola-Risa et al., 2004) Mexico Urban 20 pre-hospital providers PHTLS training $1020 Per death averted N/A
    Arreola-Risa, 2007 (Arreola-Risa et al., 2007) Mexico Urban 35 pre-hospital providers EMT training $212 Per death averted N/A
    Jayaraman, 2009 (Jayaraman et al., 2009) Uganda Urban Model using estimates of 9000 lay first responders Pre-hospital training $1820 Per death averted N/A
4. Hospital-based trauma care (n = 2)
    Gosselin, 2008 (Gosselin and Heitto, 2008) Cambodia Urban (one hospital) 957 injured patients Surgical care for traumatic injuries $30 Per DALY averted Very cost-effective
 Gosselin, 2010 (Gosselin et al., 2010) Nigeria and Haiti Urban (two hospitals) 6745 injured patients 1. Surgical care in Nigeria $174 Per DALY averted Very cost-effective
2. Surgical care in Haiti $226 Per DALY averted Very cost-effective
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AFRO: World Health Organization African Region; DALY: Disability-adjusted life year; EMT: Emergency Medical Technician; LMICs: Low- and middle-income countries; PHTLS: PreHospital Trauma Life Support; SEARO: World Health Organization South-East Asia Region

a Legislation and enforcement

b In children less than 15 years old.

Based on the Community Guide’s criteria, two full economic evaluation studies were unsatisfactory in their methods to explore the costs associated with injuries (Table 5). Of the studies that achieved a rating of satisfactory or greater and reported costs per DALY averted, the level of cost-effectiveness was described (n = 7; Table 4). These studies show many interventions to be very cost-effective, such as legislation and enforcement of bicycle helmets in the AFRO region, speed bumps at junctions with 25% or more mortality, and surgical trauma care in Cambodia, Nigeria and Haiti.

Table 5.

Quality assessment of full economic studies on costs of injury in LMICsa

Quality indicator Full economic evaluation (n = 13)
Described Not described Not applicable
Study design
    Study population 12 1 –
    Study question(s) 13 – –
    Alternative interventions 7 6 –
    Study perspective specified 6 (7 inferred) – –
    Societal perspective specified 4 (3 inferred) 6 –
    Time frame defined 12 1 –
    Analytic horizon defined 3 10 –
Costs
    Data sources reported 12 1 –
    Data sources appropriate 10 3 –
    Quantities of resources reported 13 – –
    Programme costs included 9 4 –
    Cost of illness included 6 7 –
    Future costs discounted 7 6 –
    Price base-year reported 11 2 –
Outcome measures
    Outcome measures specified 13 – –
    Outcome measures consistent 11 2 –
    Future outcomes discounted 6 7 –
    Outcomes included other effects 6 7 –
Effects
    Effect information provided 13 – –
    Criteria reported 6 7 –
    Expert opinion appropriate 1 – 12
Analysis
    Analytical model reported 10 3 –
    Sensitivity analysis of discounted rate 6 7 –
    Sensitivity analysis of effect size 10 3 –
    Sensitivity analysis of any other parameter 8 5 –
    Summary measure used correctly by study 9 4 –
Rating
    Very good 5
    Good 1
    Satisfactory 5
    Unsatisfactory 2
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a Based on the Community Guide Quality Assessment Criteria.

Discussion

Our study found that there are a relatively significant number of studies that have explored the cost of injury or the cost of hospitalizations from injury in LMICs. Yet only 13 studies performed full economic evaluations in 14 of 144 LMICs as classified by the World Bank. It is difficult to generalize the costs of injury at a regional or global level, as the currently available data are country and context-specific and heterogeneous in their definitions of costs.

Our review showed LMIC injury-related costing research may not reflect the distribution of the burden of injury across regions and injury type. For example, only 12% of the studies included in our review were conducted in Southeast Asia, although the region accounts for 36% of injury-related deaths among LMICs (Figure 2) (World Health Organization, 2008). Conversely, 28% of studies were conducted in the Western Pacific Region although the region accounts for only 18% deaths from injury. In terms of injury type, only 4 of 68 studies examined the costs associated with intentional injuries, although they make up 26% of DALYs lost to injuries in LMICs (World Health Organization, 2008). In terms of demographics, only three studies used primary data collected from a rural setting, despite estimates that more than half of people in LMICs live in rural areas (The World Bank, 2012). Some studies set in urban referral hospitals may have captured injuries that occur in rural areas given the nature of referral hospitals, but this was not been specifically studied.

Figure 2.

Figure 2

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Comparison between the number of papers published on costs of injury in LMICs (%) and injury-related deaths in LMICs by region and type of injury1

Source: WHO, Global Burden of Disease 2004 Update.

1As a percentage of total injuries

*Region defined using WHO classification

Unfortunately, a lack of representative data is not limited to these studies; even data from the WHO are limited. For example, estimates from the WHO on injuries per DALY for LMICs show that of the 144 LMICs, 74 countries (52%) lacked complete, country-specific data for these calculations, and therefore used modelled estimates (World Health Organization, 2011b).

In addition to gaps in data collection, our review found considerable variability in the costs and cost descriptions of injury. Costs and outcomes were often not reported nor measured in a systematic way. As there are no standard definitions for direct medical, direct non-medical and indirect costs, studies were left to their own discretion to decide which cost variables to include. Some studies did not even describe which cost variables were included in their estimates. This limits the ability to generalize costs across studies.

In addition to the limitations of the reported data, our review was limited in that we only searched published literature; additional costing studies may be available among the grey and unpublished literature. The study was further limited in that our search was conducted using English-language-based databases.

Despite these limitations, the economic burden of injury is indisputable. As shown in our review, the median cost of direct medical costs from injury was US$291 or 15% of GDP per capita. This estimate increased 14-fold to US$4085 or 97% of GDP per capita when studies included direct medical, direct non-medical and indirect costs. This shows not only the devastating financial impact of injury, but also the need to invest in injury prevention. Yet in a time of global budget constraints and competing social sector priorities, policy-makers and public health planners are increasingly faced with having to maximize available resources, and cost-effectiveness of interventions or programmes often comes into play.

Our review showed encouraging findings among the cost-effectiveness studies that achieved a quality-assessment rating of satisfactory or higher: many interventions could be cost-effective or very cost-effective in decreasing the burden of injury. These interventions include traffic enforcement, installation of speed bumps, motorcycle helmet legislation, breath testing campaigns and drowning prevention programmes. The provision of surgical care was also shown to be very cost-effective, suggesting a significant potential for cost savings through injury prevention and trauma care. Care, however, should be used when generalizing these interventions to national, regional and global contexts. This is also important as seven studies adopted a societal perspective and six used a provider perspective, highlighting heterogeneity among the costs included in each study. This concern is not unique to our review and prior literature has explored why results from economic studies may not be reproducible in different settings and times (Drummond and Pang, 2001; Sculpher et al., 2004).

Costs are often considered the ‘tie-breaker’ when decisions are made regarding how and where to prioritize health interventions. To make an impact in the future, we need to better understand the costs of injury and injury prevention in LMICs. Through multi-sectoral collaboration with Departments of Health, Transport and other stakeholders, injury prevention advocates in LMICs can generate economic data to advocate for greater investments in injury prevention. This may finally enable injury prevention to be placed on regional, national and district policy agendas.

Funding

H.K.H.W., A.B. and A.A.H. were funded by various grants to the Johns Hopkins International Injury Research Unit (www.jhsph.edu/IIRU), including the JHU Center for Global Health, Bloomberg Philanthropies, and Fogarty International Center of the US National Institutes of Health. N.M. and K.H. were funded by the Bill & Melinda Gates Foundation through the Disease Control Priorities Network (DCPN) Project though a subcontract to the Department of Global Health at the University of Washington, Seattle and by the Fogarty International Center at NIH. The study was undertaken under the auspices of PRICELESS SA (Priority Cost Effective Lessons for Systems Strengthening—South Africa) www.pricelesssa.ac.za.

Conflict of interest

None declared.

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