As patients move through injury care, well-intentioned changes can backfire
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Global health policymakers should focus on the way entire health care systems work together, argue researchers in new findings. Improving one element does not always create better outcomes if the wider system is not ready.
In the work appearing in BMJ Global Health, an international research team led by the University of Birmingham, Nottingham Trent University and Stellenbosch University reveals how well-intentioned changes to one part of a health care system can lead to worse patient outcomes. This is one of the first studies to capture the full complexity of a health system delivering injury care, in which researchers mapped how patients move through care, from seeking and reaching help to receiving treatment and remaining in care for recovery.
They found almost 1,000 interconnected factors that influence patient survival after injury in low- and middle-income countries (LMICs), which account for around 85% of injury-related deaths worldwide. However, health systems are highly complex and interconnected—improving one part can unintentionally create pressure elsewhere.
Researchers discovered that among several possible interventions, enhancing trust in the health care system had the greatest impact on clinical outcomes. When trust is high, more people seek care and outcomes can improve, but if too many people come in and services cannot cope, quality drops and trust can fall again.
Lead author Justine Davies, professor of global health research at the University of Birmingham, said, "Our work clearly shows that improving care results in increased demand on the health system, but this must be matched by greater capacity and higher-quality services to prevent services becoming overwhelmed. Increased demand can quickly lead to delays, reduced quality of care, and declining trust, ultimately undermining the very improvements those changes were intended to achieve."
The study analyzes interactions spanning multiple pathways of care, including patient and community factors, such as beliefs, ability to pay, and trust; health service factors, including quality of care, staffing and funding; and wider societal context, such as poverty, infrastructure and policy.
Senior author Antuela Tako, professor of operations research at Nottingham Business School, noted, "Patient trust, perceptions of care quality, and people's willingness to seek treatment were among the most influential factors shaping health outcomes. However, addressing these factors in isolation is not enough. For example, increasing trust can encourage more people to seek care earlier, improving recovery and reducing mortality and disability."
The research calls for a fundamental shift in how health systems are understood and strengthened through multisector approaches, linking health policy with investments in workforce capacity, transport, education, communities and economic development.
Kathryn Chu, professor of global surgery at Stellenbosch University, said, "Conventional approaches are insufficient to deliver sustained improvement. Things can only be truly improved through a whole-system approach that considers wider social and economic factors and places patient trust, system design and equity at the center of reform."
Publication details
A systems approach to understand injury care in LMICs using causal loop diagrams, BMJ Global Health (2026).
Journal information: BMJ Global Health
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Quality of Health CareTreatment Outcome
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