11 | Care in Low and Middle-Resource Countries

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.

Earning an income is really important for me and for my family. Being a farmer, I’m very worried about making enough money in the future to support us all. I need to regain enough ability to continue working…

Mr. Dee

Mr. Dee had spent all his life in a small, rural village. While he had some formal education, he had never completed his studies and instead learned the farming trade as a teenager. At 41, he still farmed, growing mangos and other fruit seasonally for his main source of income. Additionally, he worked as a local manual laborer in the dry season to supplement his income to support his wife and daughter. This extra income enabled Mr. Dee’s daughter to attend university, working towards a degree in business.

As is common in Southeast Asia where heavy rains are frequent, Mr. Dee and his family lived in a small house which was elevated on bamboo stilts to accommodate rising water levels. A pit toilet was situated about 20 metres away. As this case study will show, the architectural set-up of Mr. Dee's housing posed accessibility implications for his community reintegration planning.

Mr. Dee's Accident

Walking in the local mountain range, Mr. Dee suddenly fell and roughly tumbled a short distance down an incline. The fall resulted in immediate paralysis with no sensitivity in his extremities.

"In such remote locations no emergency services are available."

In such remote locations no emergency services are available. Luckily, four friends of Mr. Dee were able to transport him down the mountain utilising a blanket as a gurney. In a friend’s car Mr. Dee was driven to a regional hospital as quickly as possible. Unfortunately, the hospital was unable to treat injuries like Mr. Dee’s. The nearest hospital able to surgically treat SCIs was 300 kilometres away at a university in Chiang Mai Province. Subsequently, Mr. Dee was transported by ambulance to the specialty unit at that hospital.

Upon admission, Mr. Dee was diagnosed with a traumatic disc herniation at C5-C6 and a spinal cord contusion at C3-C4,20 ((SOLL REF-NR. 22 SEIN. VERLINKUNG IST ABER IN ORDNUNG AUF WHO/ICD)) American Spinal Injury Association (ASIA) Impairment Scale Grade C. This meant that he had motor function at the level of the elbow and below, and that he was able to actively move more than 50% of key muscles in that body region with full range of motion but not against gravity.

The medical team in the specialty unit decided to perform spinal surgery where his 5th and 6th vertebrae were plated, and after the surgery Mr. Dee was fitted with a soft collar. Post-surgery treatment two weeks after the accident proceeded without complications, and he was referred to an early post-acute unit within the hospital.

Since healthcare in Thailand is provided for free by a government insurance programme, the Dee family fortunately did not have to worry about covering healthcare expenses. 23

Box 3 | Healthcare in Thailand

Thailand has universal healthcare coverage (UHC) that offers access to healthcare to its entire population, considerably reducing coverage inequalities. Given that UHC in Thailand is supported by strong political leadership and citizen demand, efforts are now focused on improving financial sustainability and quality of services. 24

Factors that impact on improving the quality of services include the capacity to deliver health services and the availability of a qualified health workforce. The shortage of health professionals is a globlal issue.24-Reich 2015 ((BITTE DIESE ALS REF-NR. ZEIGEN))To tackle this workforce shortage Thailand employed several strategies, such as establishing mid-level training programmes (to train for example multi-purpose or profession-specific assistants who provide services under supervision), and recruiting and training persons from the local community, especially in rural and remote areas. Another strategy employed was community-based rehabilitation group meetings that facilitated the collaboration between persons with disability, their families, and community members to manage rehabilitation problems. 5

These and other measures employed in Thailand seem to have made a difference. In 2001 the United Nations Development Programme (UNDP) Report indicated that there were 24 physicians for every 100'000 people. 25 In the 2014 UNDP Report, this number increased i.e. 30 physicians for every 100'000 people. 22((BITTE ÄNDERN. DURCH DIE UMNUMMERIERUNG SOLL JETZT DIESE REF-NR. 21 SEIN))

At admission in the early post-acute rehabilitation unit a six-week Rehab-Cycle® was planned. In order to establish a more accurate prognosis for rehabilitation success, to define goals and determine the appropriate interventions, a comprehensive assessment of Mr. Dee's functioning status was required.

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