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national health capacity in the acute healthcare sector , public health emergency preparedness , infection prevention and control . However , great disparities in health status exist and PM & R is less prioritized ( 16 – 18 , 23 ). There appear to be contrasts and imbalances within operational healthcare systems in many LMICs , including in Madagascar , Mongolia , Nigeria , Pakistan , in terms of policies , funding structure / infrastructure , healthcare systems and capacity , human and physical resources , technology , etc . ( Table I ). Data for disability are scarce and there is variability in definitions and ambiguous categories used for disability . Despite these variations , many challenges for the PM & R sector in terms of implementation of the GDAP seem to be common to most LMICs . Key common potential challenges and / or enablers reported by the participants from 4 countries of interest in this report for implementation of the GDAP , particularly for PM & R service provision , are summarized below :
Governance , policy and planning . Similar to many LMICs , legislation for overall management of PwD has been adapted in all 4 countries ; however , existing policies are under-funded , there is lag in implementation of PM & R policies and / or overall delivery of such services , as well as lack of coordination and collaboration amongst different sectors . Key barriers in healthcare service provision include lack of political commitment , inadequate funding and corruption .
There is need for a strong leadership role by national disability authorities to coordinate and provide standards for rehabilitative care , develop key performance indicators for PM & R to enhance capacity of national healthcare organizations , develop inter-disciplinary and inter-sectoral partnerships of all stakeholders for longer-term care planning of PwD . The GDAP recommendations need to be tailored to suit the local environment for relevance to mainstream services , policymakers and administrators .
Rehabilitation-inclusive healthcare infrastructure and human resources . Many PwD require specialized , efficient management and health services , which are often limited or lacking in most LMICs , particularly in rural areas . The PM & R services across countries vary , and most LMICs have limited or no organized PM & R services ( 1 ). Various PM & R services for PwD are funded by INGOs / NGOs and charitable organizations . There are limited sub-specialized PM & R services ( such as stroke units , spinal cord injury ( SCI ) centres ), and many such units , as in Pakistan and Mongolia , are restricted to urban areas ( 28 ). There is limited or lack of modern equipment ( therapeutic and diagnostic ), which hinders the provision of service delivery . Available resources , including workforce , in most LMICs are inadequate and inequitably distributed ( 1 , 29 ). There is limited financial support for development of the PM & R workforce , with a shortage of allied health professionals ( OTs , speech therapists , prosthetics , etc .) and few educational / training facilities for PM & R capacity building .
The LMICs need to develop a self-sustaining rehabilitation-inclusive healthcare capacity ( at various levels ) to cater for the needs of PwD . There is a critical need to build a system , integrating and linking healthcare services with other emerging sub-specialties including PM & R . Furthermore , there is a need to improve infrastructure for disabled access for transport and buildings , social support systems at a national level with leadership from government and relevant authorities for training and empowerment programmes for the PM & R workforce .
Health information and referral systems . Data on disability and PM & R are fragmented and often not disaggregated from other healthcare services information . Improvement in accessibility and overcoming information barriers are a priority for optimal planning and resource allocation . There is need for a system for collection of data by relevant services , with a lead governing agency facilitating and coordinating this information for dissemination to relevant authorities . An appropriate referral mechanism for PwD is lacking at many levels ; this results in gaps in appropriate services and the care continuum in the community for PwD .
Education and awareness . Despite evidence of growing public acceptance of PwD in many LMICs widespread stigma and discrimination against these people persist and many are ostracized . Due to poor education and lack of appropriate information , many PwD are unaware of specialities such as rehabilitation . This hinders their active societal participation and opportunities to interact with their able-bodied counterparts ( 30 ). There is minimal awareness regarding rehabilitation amongst the general population and it is often confused with traditional or alternative medicine . Lack of trust of medical practitioners by PwD is prevalent in some cultures , particularly in rural areas , where many seek help from religious and traditional healers ( 1 , 31 ).
Strong policy measures will eliminate discrimination , prejudice and barriers to the sociopolitical and economic well-being of PWDs . Increased public awareness and active inclusion of PwD ( and their families ) in decision-making www . medicaljournals . se / jrm