11 | Care in Low and Middle-Resource Countries

Challenges to Comprehensive Care in a Middle-Income Country

General Introduction

The World Health Organization (WHO) estimates that 80 percent of people with disabilities live in developing countries. In fact disability rates are disproportionally higher in lower than in higher-resource countries.1 2

Read more: General Introduction

Healthcare Provision After Injury

Mr. Dee's Story

Mr. Dee, a 41-year old farmer, lived and worked in a rural area of Northern Thailand. A fall resulted in a spinal cord injury (SCI) that had a drastic impact on his life and livelihood.

Read more: Mr. Dee's Story

Interviewing Mr. Dee


Mr. Dee and the rehabilitation team began the assessment of his functioning status by identifying problems and needs as seen from his own perspective as well as from the perspective of the health professionals on his rehabilitation team. For the health professionals' perspective, a list of ICF categories was used as a guide.

Read more: Assessment

Moving Around Using Equipment

Assignment and Intervention

Every intervention target that was determined during the assessment phase was allocated to corresponding member(s) of the rehabilitation team during the assignment phase of the Rehab-Cycle®. The respective team member was responsible for addressing the intervention targets with specific interventions during the intervention phase.

Read more: Assignment and Intervention


After about six weeks of rehabilitative interventions, Mr. Dee's functioning was re-evaluated to see how well he had progressed.

Read more: Evaluation

Living Situation in Rural Thailand


The case study of Mr. Dee highlights some strengths and limitations of spinal cord injury (SCI) rehabilitation in low and middle-resource countries.

Read more: Discussion


  1. World Health Organization. Promoting Access to Healthcare Services for Persons with Disabilities. Geneva, 2006
  2. World Health Organization. WHO Global Disability Action Plan 2014-2021: Better health for all people with disability. Sixty-seventh World Health Assembly 4 April 2014: World Health Organization; 2014; Available from: http://www.who.int/disabilities/actionplan/en/
  3. World Health Organization, International Labour Office, UNESCO. CBR - a Strategy for Rehabilitation, Equalization of Opportunities, Poverty Reduction and Social Inclusion of People with Disabilities - Joint Position Paper. Geneva, 2004
  4. World Health Organization, UNESCO, International Labour Office, International Disability Development Consortium. Community-based rehabilitation: CBR guidelines. Introductory booklet. Khasnabis C, Heinicke Motsch K.(eds.) Geneva, Switzerland: World Health Organization. 2010
  5. World Health Organization, World Bank. World report on disability (WRD). Geneva, Switzerland: WHO Press; 2011.
  6. Ito N. Convention on the rights of persons with disabilities and perspectives of development assistance: A case study of Thai disability policy. Asia Pacific Disability Rehabilitation Journal. 2010; 21(1): 43-59.
  7. United Nations (UN). Convention on the rights of persons with disabilities (CRPD). Geneva, Switzerland: United Nations; 2006.
  8. Bickenbach J, Officer A, Shakespeare T, von Groote P. Eds. International perspectives on spinal cord injury (IPSCI). Geneva, Switzerland: World Health Organization; 2013.
  9. Rahimi-Movaghar V, Sayyah MK, Akbari H, Khorramirouz R, Rasouli MR, Moradi-Lakeh M, Shokraneh F, Vaccaro AR. Epidemiology of traumatic spinal cord injury in developing countries: a systematic review. Neuroepidemiology. 2013; 41(2): 65-85.
  10. Hagen EM. Still a need for data from developing countries on traumatic spinal cord injury. Neuroepidemiology. 2013; 41(2): 86-87.
  11. Rathore FA. Spinal cord injuries in the developing world. In: Stone JH, Blouin M, Eds. International Encyclopedia of Rehabilitation. Buffalo, New York, USA: Center for International Rehabilitation Research Information and Exchange (CIRRIE); 2010. Available online: http://cirrie.buffalo.edu/encyclopedia/en/article/141/. Accessed November 2015.
  12. Stucki G, Cieza A, Melvin J. The International Classification of Functioning, Disability and Health (ICF): A Unifying Model for the Conceptual Description of the Rehabilitation Strategy. J Rehabil Med. 2007; 39(4): 279-285.
  13. Lidal IB, Huynh TK, Biering-Sørensen F. Return to work following spinal cord injury: A review. Disabil and Rehabil. 2007; 29(17): 1341-1375.
  14. Murphy G, Middleton J, Quirk R, De Wolf A, Cameron ID. Prediction of employment status one year post-discharge from rehabilitation following traumatic spinal cord injury: An exploratory analysis of participation and environmental variables. J Rehabil Med. 2009; 41(13): 1074-1079.
  15. Escorpizo R, Trenaman LM, Miller W. Spinal cord injury: Vocational rehabilitation and disability evaluation. In: Escorpizo R, Brage S, Homa D, Stucki G. Eds. Handbook of vocational rehabilitation and disability evaluation: Application and implementation of the ICF. New York: Springer; 2015. p. 239-261.
  16. Suttiwong J, Vongsirinavarat M, Chaiyawat P, Vachalathiti R. Predicting community participation after spinal cord injury in Thailand. J Rehabil Med. 2015; 47(4): 325-329.
  17. World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization; 2001.
  18. Avellanet M, Selb M, Stucki G, Cieza A. Utility of using the ICF Core Sets in clinical practice. Rehabilitación. 2015; 49: 197-201.
  19. World Bank. Press Release: Thailand became an upper-middle income economy in 2011. [Internet] 2 August 2011. Available from: http://www.worldbank.org/en/news/press-release/2011/08/02/thailand-now-upper-middle-income-economy. Accessed November 2015. 
  20. World Health Organization. International Statistical Classification of Diseases and Related Health Problems (ICD). Geneva: World Health Organization; 2011.
  21. United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP). Disability at a glance 2012: Strengthening the evidence base in Asia and the Pacific. Bangkok, Thailand: United Nations; 2012.
  22. United Nations Development Programme (UNDP). Human development report 2014. Sustaining human progress: Reducing vulnerabilities and building resilience. New York, United States: United Nations Development Programme. 2014.
  23. Tangcharoensathien V, Limwattananon S, Patcharanarumol W, Thammatacharee J. Monitoring and evaluating progress towards universal health coverage in Thailand. PLOS Medicine. 2014; 11(9): e1001726.
  24. Reich MR, Harris J, Ikegami N, Maeda A, Takemi K, Evans TG. Moving towards universal health coverage: Lessons from 11 country studies. Lancet. 2015; In press.
  25. United Nations Development Programme (UNDP). Human development report 2001. Making new technologies work for human development. New York, United States: United Nations Development Programme. 2001.
  26. Miller W, Chan C. Spinal Cord Independence Measure (SCIM). [Internet] 1 February 2013. Available from: http://www.scireproject.com/outcome-measures-new/spinal-cord-independence-measure-scim. Accessed 2015.
  27. Brasil, AV, Coelho DG. The neurological outcome of acute spinal cord injury in a neurosurgical hospital of a developing country. Spinal Cord. 1998; 36(5): 353-356.
  28. Chinchai P, Marquis R, Passmore A. Functional performance, depression, anxiety, and stress in people with spinal cord injuries in Thailand: A transition from hospital to home. Asia Pacific Disability Rehabilitation Journal. 2003; 14(1):30-40.

ICF Research Branch CoordinatorICF Research Branch in cooperation with the WHO Collaborating Centre for the Family of International Classifications in Germany (at DIMDI)

Swiss Paraplegic Research
Guido A. Zäch Strasse 4
6207 Nottwil (Switzerland)

Tel. +41 41 939 66 31
Fax +41 41 939 66 40

Swiss Paraplegic Research © 2018 All Rights Reserved