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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