'A race against time': a photovoice study on priorities for quality of injury care with patients, health workers and policymakers in four low- and middle-income countries

INTRODUCTION: The Lancet Commission on High Quality Health Systems called for quality measures grounded in user experience. Studies of how stakeholders interpret and prioritise these frameworks are rare for injury care in low- and middle-income countries (LMICs). OBJECTIVES: The objective was to identify how patients, healthcare providers and policymakers in four LMICs prioritise quality of care after injury using Institute of Medicine (IoM) quality domains (safety, effectiveness, patient-centredness, timeliness and equity). METHODS: We conducted a Photovoice study across eight urban and rural sites in Ghana, Pakistan, Rwanda and South Africa. Focus group discussions (n=39) convened patients/community members, healthcare providers and policymakers (n=116), supplemented by policymaker interviews (n=6). Participants photographed aspects of injury care, developed captions and used deliberative dialogue to rank these against the IoM domains. RESULTS: Stakeholders prioritised timeliness, safety and effectiveness, with rankings varying by local system capability. In settings with significant trauma system gaps (Ghana, Pakistan), timeliness ranked highest: immediate survival, getting to care quickly across transport, referral and facility processes. Safety was also emphasised: avoiding additional harm from unsafe and unreliable environments and resources. In settings with more established access to basic emergency care (Rwanda, South Africa), priorities shifted towards effectiveness, understood in terms of clinical, functional and psychosocial recovery. Across all contexts, equity (fair access and financial protection) was interpreted as foundational rather than as a discrete domain, shaping delays, access, treatment continuity and catastrophic costs. Overall, quality was considered cumulative and relational: early failures in care pathways amplified avoidable downstream complications including disability and impoverishment. CONCLUSIONS: Stakeholders shared systems understandings of injury care quality, with priorities varying by local capabilities. Timeliness and safety were seen as necessary for survival, enabling effectiveness in clinical and recovery outcomes, while equity operated across care pathways. The findings support aligning emergency quality indicators and improvement strategies with context-specific stakeholder priorities.