372 F . Khan et al .
Table III . Common potential challenges and facilitators in implementation of the World Health Organization ( WHO ) Global Disability Action Plan 2014 – 2021 in Madagascar , Mongolia , Nigeria and Pakistan
Potential challenges / barriers
Potential facilitators / enablers in the next 5 – 6 years
Governance , policy and planning
• Lack of strong leadership and a central body for developing governance
• Lag in implementation of health policies & enforcement of the legislation policy for employment / education / health for PwD
• Poor coordination / collaboration among different government sectors & ministries and healthcare agencies
• Health priority more driven towards acute sector & communicable disease
• Limited coordination / collaboration among different healthcare sectors ( hospitals ( private , public ), primary , Charity & Community organizations , INGOs & NGOs )
• Unstable political & economic situation , poor political commitment
• Corruption
Rehabilitation-inclusive healthcare infrastructure / human resources
• Limited government commitment , inadequate investment for health sector , particularly rehabilitation
• Limited funding or underfunded programmes
• PM & R services not well integrated with acute services & limited and / or lack of inpatient rehabilitation facilities
• Poor provision of PwD friendly infrastructure , environment public places & transport
• Limited or lack of specialized PM & R centres , e . g . for stroke , spinal cord injuries , etc .
• Lack of knowledge / misconception about disability
Health information and referral systems
• Lack of process involving stakeholders ( including PM & R professionals , PwD , communities ) in policy development
• Few or lack of specific disability-rehabilitation standards or key performance indicators ( not up to date )
• Lack of structured standard referral systems from acute to subacute care and to community
• Lack of multidisciplinary team approach & systems / models of care
• Lack of knowledge about different health professions ( such as PM & R , OT , speech therapy )
• Lack of clear definition for disability and / or ambiguous disability categories
• No specific accreditation standards or criteria for rehabilitation facilities & for staff
Education and Awareness
• Poor education / knowledge about disability / PM & R amongst policymakers , government authorities etc .
• Poor disability awareness , misconception & cultural belief
• Lack of evidence-base guidelines & disability centred measures
• Limited undergraduate courses in PM & R in medical institutions , professional courses / training programmes
• No staff development or appraisal systems in hospitals or community settings
• Limited access to education / web-based learning , professional development , training in therapy & innovation
• Poor awareness amongst healthcare professionals about disability & PM & R
• Limited or lack of family / carer education & limited provision of inclusion of caregivers of PwD and / or PwD in care programmes , decision making
Service delivery and costs
• Limited access to healthcare , specifically specialized rehabilitation
• Maldistribution of human resources ( PM & R professionals more centralized in capital & urban areas ); demoralized workforce
• Lack of emergency assistance programmes for PwD
• Minimal information available to public about access to PM & R
• Out-of-pocket payment system
• Long waiting time , so patients may seek alternative therapy
• Lack of strategies for improved access to affordable quality care & essential assistive devices / technologies
• High costs for assistive devices or low standard devices
• Language barriers
• Lack of SOPs
• Lack or poor coverage of health insurances , particularly for PwD
• Establishment of legislative & central governing body
• Education / awareness programmes about disability & PM & R for policymakers , government authorities , hospital administrators
• Inclusion of PM & R personnel in policy development
• Development of Key Performance Indicators , Standards of Care & accreditation criteria for rehabilitation facilities by Ministry of Health
• Active role of PM & R departments in facilitating leadership skills & governance
• Establishing healthcare standards / policies , implementation & evaluation
• Strengthening government accountability & regulatory frameworks at all levels
• Adequate resource allocation & international cooperation & support
• Development of new rehabilitation infrastructure & reevaluation of existing services
• Strengthening PM & R capacity , public-private partnerships
• Increasing health expenditure for disability & PM & R
• Development of inpatient rehabilitation units , & specialized rehabilitation facilities ( including in remote areas )
• International cooperation & support for PM & R development & training
• Expansion of allied health services ( OT , Speech therapy , P & O services )
• Establishing a body for evaluating & monitoring accessibility in all sectors of human endeavours for PwD
• Facilitation of clear policy direction in health development
• Development of guidelines & mechanisms for a functional & standard referral system at all levels
• Development of Key Performance Indicators , Standards of Care & accreditation criteria for rehab facilities & staff
• Involvement of clients & patients in decision-making processes
• Proper patient education & counselling earlier
• Coordination & communication between governmental bodies , healthcare sectors , various INGOs / NGOs & community organisation
• Development of evidence-based guidelines / protocols & outcome measures for disability
• Improvement of the health sector information base
• Scaling of heath workforce education & accreditation
• Development of Continuous Medical Education programmes for PM & R professionals , skill training & education
• Training & educational programme for PwD (& families )
• Initiatives / programmes for development of allied health
• Collaboration with international partners for staff education / training
• Public awareness / educational programmes through media , awareness programmes , lobbying
• Establishment of national health workforce registry
• Integration of health promotion / public awareness strategies into community health programmes , curricula in educational institutions / schools
• Occupational empowerment & employment programmes
• Developments of SOPs
• Improvement of social welfare , livelihood & benefits
• Adaptation of Universal Health Insurance scheme , innovative financing approaches
• New medical equipment / technology for local needs
• Development of vocational rehabilitation programme ( jobs , education , etc .) for PwD
• Development of mobile PM & R Units to deliver care in remote areas
• Development of telerehabilitation , innovative programmes using locally available technologies ( mobile )
• Adequate financial support & advocacy for assistive devices ; technology expansion to rural areas
• Development of interpreters www . medicaljournals . se / jrm