Journal of Rehabilitation Medicine: Special Issue 50-4bokBW | Page 73

Disability and rehabilitation in low- and middle-income countries
and goal-setting is required. Capacity building for
disability/consumer organizations on the rights
of PWDs is needed in line with the UN CRPD.
Service delivery and costs. Whilst there are
limited PM&R services in rural areas, access to
such facilities in urban areas is often costly, time-
consuming and difficult (32). The cost of access
to PM&R services is a significant barrier, as most
services are available only as an out-of-pocket
payment. There is lack of universal health insu-
rance systems and many private health insurance
systems do not cover rehabilitation. This results
in financial hardship and inequity in utilization of
healthcare services (28, 33). There is still a large
gap in provision of basic equipment and assistive
devices (canes, crutches, prostheses, wheelchairs,
etc.). Strengthening national capacity for integra-
ted PM&R services at all levels by the national
governments is required.
Community-based rehabilitation and consumer
groups. There are a limited number of commu-
nity-based rehabilitation facilities, professional,
caregiver and consumer groups. The needs of
PwD are often overlooked and many remain mar-
ginalized and their capabilities underestimated.
Various community-based initiatives should be
in place to empower and strengthen community-
based organizations for longer-term rehabilita-
tion of PwD. Governments should ensure the
socio-economic security of these individuals and
communities, where possible.
Research and evidence-based information. There
is limited research capacity for disability issues in
the majority of LMICs, preventing development
of comprehensive country-specific policies and
programmes. Furthermore, access to evidence-
based information is not optimal. More funding
and promotion for research should be initiated
and all expertise/stakeholders (and related orga-
nizations) should be considered for knowledge
transfer and education. Multi-stakeholder part-
nerships (national and international) can build
and implement evidence-based management
approaches. Governments should collaborate
with healthcare organizations, academic and com-
munity organizations to implement existing and
new research programmes.
Limitations
This study has some limitations. It is a cross-sec-
tional study and does not test specific hypotheses
through systematic analysis. A content analysis
technique was used to summarize subjective data
derived from the interactive feedback based on
375
personal opinions, interpretations, clinical prac-
tices, points of view and judgement from partici-
pants attending organized workshop programmes.
This study was intended as a preliminary compa-
rative study, with the aim of comparing PM&R
efforts in 4 different LMICs based on the GDAP,
and to identify barriers/challenges and facilitators
from perspective of participants for the implemen-
tation of GDAP. Participants were invited by local
institutions and many other relevant stakeholders
(such as governmental, social work organizations,
organizations of PwD) may have been missed,
which may limit the generalizability and validity
of findings. However, the study cohort, covered
PM&R professionals from a wide geographical
population in the country, and represented the
health professionals currently operational in the
community (both urban and rural). A modified
Delphi method allowed all participants to ex-
press their views and contribute their opinion on
potential barriers/challenges for successful im-
plementation of the GDAP. Cultural and/or social
demographic impact of the participating countries
could not be assessed; this was beyond the scope
of this article. Participant feedback was positive,
and most were satisfied with the overall consen-
sus process. Multidisciplinary input within the
groups was beneficial, as groups were diverse in
their areas of expertise. The group heterogeneity
was reflected in the broad participant responses.
Group discussion and consensus rounds served
to remove duplicate or similar themes/issues
and to formulate a final set of common barriers
and facilitators. The authors believe the findings
reflect the current issues faced by the PM&R
workforce in LMICs.
Conclusion
In summary, there is a strong impetus to improve
disability care and the PM&R sector in these
countries. The GDAP provides comprehensive
summary actions for disability and offers the
government authorities, policymakers and other
relevant stakeholders a blueprint for implemen-
ting new comprehensive programmes for long-
term care of PwD. The UN and WHO are key
global players for the care and management of
PwD in LMICs. The Int ernational Society of
Physical and Rehabilitation Medicine (ISPRM)
(and the ISPRM-WHO-Liaison Committee) can
play a role in the ISPRM-WHO Collaboration
Plan (2014–2017) to develop appropriate, ef-
fective sustainable policies, strategies and plans
to strengthen the provision of rehabilitation,
specifically in LMICs (34).
J Rehabil Med 50, 2018