Journal of Rehabilitation Medicine: Special Issue 50-4bokBW | Page 69

Disability and rehabilitation in low- and middle-income countries
Table II. Number of potential challenges and facilitators
(reported by the participants) in implementation of the
Global Disability Action Plan (GDAP) objectives by country
Potential
challenges/
barriers
GDAP objectives
Madagascar
Nigeria
Mongolia
Pakistan
Potential
facilitators/
enablers
1 2 3 1 2 3
34
30
42
62 25
23
51
68 11
18
20
29 42
37
31
51 33
27
44
55 15
16
18
28
Pakistan) are categorized as LMICs (GNI per
capita: US$1,046–4,125) (25). There are signifi-
cant disparities amongst the countries in terms of
capacity, infrastructure and level of governance.
Overall spending on healthcare by all 4 govern-
ments is low, with total mean expenditure not
exceeding 3.5% of gross development product
(GDP). Household out-of-pocket expenditure
remains the largest source of health expenditure.
Amongst the 4 countries, Madagascar has the
highest prevalence rate of disability of 7–8%,
while Nigeria has the lowest at 2.3%. There is
limited epidemiological data on disability and
disability-related burden in all 4 countries. In terms
of PM&R needs and services, the picture is vague,
due to lack of routinely collected disability data,
limited information about the needs and unmet
needs of PwD, and variability in definitions and/
or ambiguous categories used for disability (e.g.
physical, mental, behavioural, intellectual). In all
4 countries, the national development policies do
not adequately address the concerns of PwD or
include comprehensive PM&R and supportive
services. Table I compares data on disabilities,
disability legislation, healthcare infrastructures
and resources, and support services in 4 LMICs
of interest.
Findings from interactive workshops based on
the Global Disability Action Plan
All participants (n = 196) contributed to group
discussions and the consensus method. Many
(nurses, social workers) were not familiar with the
GDAP, and had limited knowledge of disability
programmes in Nigeria. The participants agreed
that the GDAP provides comprehensive summary
actions for the government, policymakers, clinici-
ans and PwD. The participants provided multiple
responses across each GDAP objective. For GDAP
objective 1, participants specified 30 potential
challenges/barriers and 37 potential facilitators/
enablers; for objective 2: 23 challenges/barriers
371
and 27 facilitators/enablers; and for objective 3: 18
challenges/barriers and 16 facilitators/enablers. As
expected, there was significant overlap in respon-
ses regarding themes in the 3 GDAP objectives.
(The complete set is available from the authors
upon request).
Comparative analyses between 4 low- and
middle-income countries (Madagascar,
Mongolia, Nigeria and Pakistan)
Overall, 335 healthcare professionals participated
in the GDAP reports, although the number of
participants varied amongst countries: Mada-
gascar = 29; Mongolia = 77; Nigeria = 196 and
Pakistan = 33. Participants were a diverse range
of healthcare professionals from various PM&R
and healthcare centres. At all tim es, the authors
as facilitators focused on appropriate strategies
specific to the local situation and context, as the
status of PwD differed between the countries. The
number of responses across each GDAP objecti-
ves provided by participants varied amongst the
countries (Table II).
Despite variations in the healthcare systems
(including PM&R) and practices amongst the 4
countries (Table I), many challenges reported by
participants were common at both the macro- (go-
vernmental, policymakers) and micro-level (com-
munity, social, individual). Based on participant
feedback and consensus agreement from each
workshop, several common suggestive “themes”
were coded, and a set of common themes were then
collated using responses from all 4 workshops. The
final set of common themes included 57 potential
RES
challenges/barriers and 56 potential facilitators/
enablers categorized under specific headings (sum-
marized in Table III).
DISCUSSION
This paper reports potential barriers and facili-
tators for the implementation of the GDAP in
Nigeria and compares the findings with those
from other LMICs: Madagascar, Mongolia and
Pakistan. The aim was to gather information using
a “bottom-up” approach in the context of national
PM&R and disability status, met and/or unmet
needs in rehabilitation care and potential enablers/
facilitators in improving functioning and quality of
life of PwD. The data include direct reports from
the field with participants’ personal experiences in
their specific health services, their perspectives of
various challenges and specific barriers/problems
relating to service provision, attitudes/approaches
J Rehabil Med 50, 2018