Police as de facto first responders in trauma systems in low- and middle-income countries: Training, governance, and the impact of insecurity.

Trauma remains a leading cause of death globally, with the greatest burden borne by low- and middle-income countries (LMICs), where prehospital systems are often underdeveloped, fragmented, or constrained by insecurity. In these settings, injured patients frequently reach care through informal pathways, and police officers commonly function as de facto first responders-providing initial assistance, coordinating evacuation, and, in some cases, directly transporting patients to hospitals. Despite their central role, police involvement in trauma care is rarely formalized or integrated into trauma system frameworks. Evidence from LMICs shows that police and other lay responders often lack formal training in trauma first aid, yet targeted, low-cost training programs can significantly improve knowledge, confidence, and willingness to provide care. In parallel, increasing violence and insecurity-such as in the Western Cape, South Africa-have further embedded police within prehospital care pathways. This article argues that the key limitation is not the absence of responders, but the absence of systems that define, train, equip, and govern their roles. We propose a pragmatic, scalable framework for integrating police into LMIC trauma systems, emphasizing defined roles, competency-based training, essential equipment, governance, and data integration to improve early trauma care and system resilience.