Disability and rehabilitation in low- and middle-income countries 373
Table III cont . Potential challenges / barriers
• Limited numbers of community healthcare facilities , disability services , particularly in rural areas
• Limited adequate primary care & community rehabilitation services
• Lack of continuum of care including regular follow-ups
• Belief in traditional or native healers
• Poverty , high illiteracy
• Poor or lack of volunteering systems
• Scarcity of disability-related data ( inaccurate data ; underestimation & underrepresentation of disability prevalence , cost data , etc .)
• Limited funding for research & training of PM & R workforce ; research not identified as a priority
• Lack of national health research policy & priorities
• Lack of national health research forum
• Lack of measurement tools , poor awareness of standardized frameworks , such as ICF
• Poor attitude toward research
• Lack of time , education & funding for research
• Inadequate trained human resource to conduct research
Potential facilitators / enablers in the next 5 – 6 years
Community-based rehabilitation and consumer groups
• More active role of National Society of PM & R
• Promotion of CBR
• Development of consumer organizations ( including PwD at national & local level )
• More CBR services linked with main hospital networks , inclusion of carers , PwD in decision-making processes
• Skill training for carers
• Expansion of community-based rehabilitation through inclusion of carers in decision-making processes
• Establishment of community volunteer services
Research and evidence-based information
• Development of standard data collection systems ( training ICF )
• Mandatory data collection systems at all levels
• Development of innovative teaching models , using interactive problem-based learning & clinical capacity through organized educational activities
• Building of research capacity in PM & R by training & educating medical staff in research methodology
• Development of research , data collection methods / measurement tools in disability & rehabilitation
• Involve government & academic institutions to establish national research centre / foundation
• Training / retraining of healthcare professionals
• Collaboration with international partners in research & development
• International aid / assistance in research capacity building
CBR : community-based rehabilitation ; HCP : healthcare professionals ; ICF : International Classification of Functioning , Disability and Health ; IT : information technology ; INGO : international non-governmental organization ; NGO : non-governmental organization ; OT : occupational therapist ; PM & R : Physical Medicine and Rehabilitation ; PwD : persons with disability ; SOP : standardized operating procedures ; WHO : World Health Organization .
to PwD , rehabilitative care , education , etc ., in line with the GDAP . The authors envisaged that this process would help build national PM & R capacity , and provide a much-needed conceptual framework for successful implementation of the GDAP .
Consistent with the worldwide pattern of population health transition , all 4 countries of interest are in a stage of epidemiological transition from communicable diseases to NCDs , which account for a predominant share of morbidity and mortality . Despite prioritization of PM & R as a key agenda by the governments , the level of funding , human resources and health infrastructure is suboptimal in all 4 countries , particularly in rural areas . Despite the exponential growth and development of healthcare facilities and programmes in many LMICs , the systems are explicitly hospital-centred , resulting in a fragmented and inefficient hospital sector ( 26 ). The primary healthcare sector and community-based services ( such as PM & R services ) are yet to develop optimally ; with inadequate financing systems , human resources , planning and regulatory processes ( 26 ). For example , though PM & R departments exist in many major hospitals in Pakistan and Mongolia , most are ambulatory and operate in silos and most programmes are not integrated with other healthcare systems and processes . While PM & R services are mostly conjoint with and / or subjugated by traditional medicine in Mongolia , they are mostly based within military services in Pakistan , while in Nigeria and Madagascar comprehensive rehabilitation programmes are in their infancy . None of the countries have a universal healthcare system . In Mongolia PM & R is not covered by insurance . In all 4 countries , the national PM & R services are not well integrated within acute care systems and / or rural health departments , non-governmental organizations DISC ( NGOs )/ international non-governmental organizations ( INGOs ) and the private sector . Many provide these services mostly through verticallymanaged disease-specific mechanisms ( 16 – 18 ).
ACKN
Similar to most developing countries , REF care of PwD ( including CBR ) in all 4 countries is predominantly funded by NGOs / INGOs and charitable organizations at a community level . There is poor coordination amongst these INGOs / NGOs working in the field of disability management and existing PM & R services . This is compounded by discernible urban-rural disparities in healthcare delivery and health workforce ( 27 ).
Common potential challenges and enablers for implementation of the Global Disability Action Plan
All 4 countries Madagascar , Mongolia , Nigeria and Pakistan have made some progress in building
J Rehabil Med 50 , 2018