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

A vicious cycle seems to exist between poverty and disability – poor people are more likely to experience disability and in turn, persons with disability have an increased risk of sliding into poverty.3 4 Regardless of the country or region, a relationship between poverty and poor health conditions, high costs of healthcare and a reduced capacity to earn a living can be found.56{cs11-fn}

Across the world, people with disabilities have poorer health outcomes, ... and higher rates of poverty than people without disabilities.

Dr. Margaret Chan, Director-General of the World Health Organization (WHO) and Robert B. Zoellick, President of the World Bank Group 5

A Call For Access to Quality and Comprehensive Healthcare

The eradication of poverty related to disability, access to affordable healthcare and the promotion of employment opportunities are among the many issues addressed in the United Nation’s Convention on the Rights of Persons with Disabilities (or "the Convention" from now on).7 The Convention outlines a range of basic rights for people with disabilities, and promotes the establishment of national legislation and policies that strive to meet the objectives of the Convention and to protect the rights of persons with disability.1 6 7 Thailand's Persons with Disabilities Empowerment Act of 2007 is one example of national legislation that modified existing disability legislation to satisfy the objectives of the Convention better. With this legislation, Thailand took the first steps toward improving the lives of persons with disability in Thailand.6 To support and facilitate the efforts of countries, especially low and middle-resource countries like Thailand, toward implementing the Convention, WHO endorsed the recommendations put forth by the World Report on Disability 5 and detailed in the Global Disability Action Plan 2014-2021.2 In these documents, WHO recognises the continued need for better access to quality and comprehensive healthcare and rehabilitation services, especially in low and middle-resource countries.

""WHO recognises the continued need for better access to quality and comprehensive healthcare and rehabilitation services, especially in low and middle-resource countries.""

Consistent with the higher disability rates in low/middle-resource, there are more barriers to accessing quality and comprehensive healthcare and rehabilitation services in low and middle-resource countries than in high-resource countries.1 2 4 5 This disparity is clearly shown in the situation of persons living with spinal cord injury in low and middle-resource countries.8

SCI in Low and Middle-Resource Countries

Spinal cord injury (SCI) affects individuals around the world, impacting families and societies.8 Unfortunately, no established national SCI registry exists in low and middle-resource (developing) countries. Moreover, there is limited epidemiological data on SCI in low and middle-resource countries.8 9 10 However, a recent systematic literature review of 64 studies from 28 low and middle-resource countries revealed that a large majority of persons with SCI are male, paraplegia is more common than tetraplegia, complete SCI is more frequent than incomplete SCI. In addition, the leading cause of SCI in low and middle-resource countries are motor vehicle accidents and falls. Interestingly, pressure ulcers and urinary tract infections seem to be the most common secondary complications in both low and middle-resource as well as in high-resource countries. Due to the varied reporting and data collection methods in the studies, the authors of this systematic literature review considered the results as preliminary, warranting future studies that follow a standard reporting and data collection protocol.9

In most low and middle-resource countries pre-hospital management i.e. first aid at the injury site and transport to the hospital is generally inadequate. While ambulatory care services are available in major cities only, transport to the next healthcare facility is often done with unsuitable means, such as auto rickshaws, carts, jeeps or animals. Moreover, first responders in rural areas are often persons with no first aid training. Thus, appropriate spinal immobilisation is normally not implemented. This may be the reason that complete SCI is more common than incomplete SCI in low and middle-resource countries.11

""...[there is a] lack of healthcare facilities in low and middle-resource countries that offer specialised care for persons with SCI...""

Due to a lack of healthcare facilities in low and middle-resource countries that offer specialised care for persons with SCI, most SCI cases are managed in the neurosurgical, orthopaedic or general surgical wards. In addition, the number of health professionals with training in rehabilitation medicine or SCI management is still quite low. Consequently, rehabilitation is limited to addressing mobility issues, such as providing gait training and use of gait aids. Essentials of comprehensive rehabilitation such as bladder and bowel management training, psychological interventions, skin care, vocational rehabilitation, etc. are often not addressed.11 This has an impact on the fulfilment of rehabilitation's ultimate goal i.e. the optimisation of functioning, including community reintegration, and minimisation of a person's experience of disability. With this goal in mind, rehabilitation interventions should be comprehensive, multisectorial and multidisciplinary.5 12

Rehabilitation for Persons with SCI from a Human Rights Perspective

Article 26 of the Convention underscores this comprehensive, multisectorial and multidisciplinary approach to rehabilitation by calling on countries to "take effective and appropriate measures, including through peer support, to enable persons with disabilities to attain and maintain maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life..." and "...shall organize, strengthen and extend comprehensive...rehabilitation services and programmes, particularly in the areas of health, employment, education and social services..." 7

""...take effective and appropriate measures, including through peer support,...rehabilitation services and programmes, particularly in the areas of health, employment, education and social services...""

Irrespective of the economic and socio-cultural situation in a country, healthcare and rehabilitation systems for persons with SCI should ensure the following: 8

• Prompt access to specialised care after injury or onset of SCI
• Access to rehabilitation provided on a continuum from an inpatient to a community setting (including follow-up care after discharge from the hospital)
• Access to a range of assistive technologies
• Provision of mainstream and specialised care to address secondary complications of SCI, such as pressure ulcers and urinary tract infections
• Availability of coordinated, integrated and multidisciplinary provision of healthcare/rehabilitation including involvement of persons with SCI and their families
• Education and capacity-building of persons with SCI and their families

Given that employment is a key rehabilitation outcome and elements of successful community reintegration, rehabilitation interventions should also address work participation issues. In high-resource countries, employment rates among persons with SCI is relatively low, between 30-50%. Unfortunately, there is a lack of comparable data on employment of persons with SCI in low and middle-resource countries.8 11 13 14 15 In high-resource countries major barriers to employment reported were discrimination by employers, and inaccessibility to and at the workplace i.e. inaccessible transportation especially in rural areas, and lack of workplace accommodation.8 13 These barriers may also be relevant in low and middle-resource countries.11 16

Accessibility is among many challenges faced by persons with SCI living in low and middle-resource countries in transitioning from inpatient hospital or rehabilitation back to the community. One approach to tackle accessibility issues and other challenges is community-based rehabilitation.