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