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

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. 5 6{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.

Box 1 | Community-Based Rehabilitation

Initially, community-based rehabilitation (CBR) was initiated by WHO to improve the access to rehabilitation services for persons with disability in low and middle-income countries by optimising the use of local resources. The CBR concept has broadened its scope, and is now a multisectorial strategy to ensure the participation and inclusion of persons with disability in society as well as to improve their quality of life. The current CBR concept is also a concrete demonstration of how the Convention can be implemented. 3 4 7

With emphasis on human rights and active involvement of persons with disability, CBR is implemented through the concerted efforts of various stakeholders including persons with disability, their families, organisations at the national, regional and local level, and governmental as well as non-governmental entities that provide health, educational, vocational, social and other services. 3 4

WHO proposes that CBR programmes are developed and strengthened according to a four-stage management cycle and planned following a structured logical framework. 4 12


Figure 1. Management Cycle for CBR

The structured logical framework requires that CBR programmes:

  • determine the goals that the programme wants to achieve
  • state the purpose for which the programme is designed
  • define the activities and outcomes that are expected to meet theses goals
  • set concrete indicators that will determine whether the goals were achieved
  • determine the means for verifying goal attainment
  • identify potential problems and risks that may occur in the implementation of the programme

CBR and the ICF

In WHO's International Classification of Functioning, Disability and Health (ICF) functioning and disability are presented as the human experience related to the dynamic interaction between the health condition, body functions and structures, activities and participation, personal and environmental factors. 17 Of special relevance to CBR are the ICF categories related to participation in major life activities, community, social and civic life, as well as the environmental factors. For this reason, the ICF is an ideal framework for conceptualising CBR programmes, and can be used in comprehensive rehabilitation management. The ICF also encourages the involvement of the person with disability in the rehabilitation process. 18

A Case Study of SCI in Thailand

One of the first Asian countries to ratify the Convention,((6,7)) Thailand, a middle-income country((19)) has made strides in improving the lived experience of persons with disability through legislation and community-based programmes. Despite this, the situation of persons with disability living in rural areas of Thailand has not shown much improvement. 6 This case study of Mr. Dee will illustrate some of the challenges, including the realities faced in returning to a rural community, as well as the potential of comprehensive rehabilitation for persons with SCI in Thailand.

Box 2 | Disability in Thailand

According to the United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP)  – data derived from the 2007 national disability survey, the national census and the database of the National Office for Empowerment of Persons with Disabilities  – 2.9% of the total population in Thailand or 1,900,000 persons have a disability. These numbers were based on the the definition of disability that reflects the ICF framework: 21((DA NR. 20 FEHLT BIS JETZT, BITTE DIESE REF-NR. 20 UMNUMMERIEREN))

Persons with disabilities are considered those who are limited in their ability to perform daily activities or to fully participate in society due to visual, hearing, mobility, communication, mental, emotional, behavioural, intellectual, learning and/or other impairments. The Ministry of Social Development and Human Security has further elaborated the types of disabilities and the criteria for determining disability.((bitte Ref-Nr. 20 hier reinschreiben und verlinken))

Persons with disability tend to come from rural areas, and an increasing gap between rural and urban areas with regards to poverty and social inclusion is becoming more apparent.6-Ito 2010((BITTE NOCH VERLINKEN, WAR NICHT VERLINKT)) The majority of low-income people living in rural areas in the world are dependent on agriculture. 22 ((BITTE DIESE REF-NR. 21 UMNUMMERIEREN))