Surgical Desertification: A New Index to Prioritize Trauma System Investments Globally

Background: Trauma is a major cause of mortality and disability in low- and middle-income countries (LMICs), yet receives inadequate financial prioritization, with less than 5% of Current Health Expenditure (CHE) in most LMICs dedicated to injuries in 2019 (WHO GHED, 2019). This underinvestment has created "surgical deserts," where gaps between emergent surgery demand and capacity result from insufficient funding, facilities, and personnel. Methodology: We analyzed WHO GHED 2019 data from 47 countries reporting disease-specific health expenditures, injury mortality rates, and financing source breakdowns. To quantify neglected trauma care, we developed a Surgical Desertification Index (SDI) using the formula: SDI = Injury Mortality % of total deaths × (1−% CHE spent on injuries) × Out-of-Pocket (OOP) % of CHE. This index captures the intersection of high injury prevalence, poor trauma financing, and high OOP costs. Countries with high SDI scores should be prioritized for trauma system improvements. Results: Injury expenditure nearly always accounted for <5% of CHE, while injuries represented 10-14% of overall mortality. External donor support for trauma care was negligible (<1%), and OOP spending usually covered over 40% of CHE. Haiti and Nigeria had high trauma mortality, the lowest injury-specific spending, and high OOP costs, resulting in higher SDI scores. These regions show pronounced "surgical deserts," where trauma patients face systemic barriers to surgical interventions. Conclusion: The SDI is a practical, evidence-based tool for identifying countries severely affected by underfunded trauma care systems. SDI rankings can inform policymakers and funders investing in emergency surgical infrastructure, national insurance for trauma care, and surgical workforce development.