Challenges to Comprehensive Care in a Middle-Income Country

The World Health Organization (WHO) estimates that 80 percent of people with disabilities live in developing countries,1 a figure that illustrates the fact that “poverty leads to disability and disability in turn leads to increased poverty.”2 Regardless of the country or region, a relationship between poverty and poor health conditions, high costs of health care and a reduced capacity to earn a living can be found.3

At an international level, efforts have been undertaken to establish fundamental rights for those with disabilities as well as to promote reintegration. The United Nation’s Convention on the Rights of Persons with Disabilities ensures a range of basic rights for people with disabilities.4 More specifically, the WHO continues to work on national action plans that “promote appropriate integration of people with disabilities.” However, access to quality and comprehensive treatment and rehabilitation services is still needed for many.

Read more: General Introduction

An income is really important for me and for my family. With my livelihood as 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, a 41-year old farmer and father, lived and worked in a rural area of northern Thailand. A short fall resulted in a spinal cord injury that would have a drastic impact on his life and livelihood.

Read more: Mr. Dee's Story

The Rehab Cycle - Functioning status

Mr. Dee and his healthcare team began the assessment by determining his functioning status, identifying his problems and needs through his own perspective as well as those of the health professionals. For the health professionals’ perspective, a list of ICF categories was used as a guide.

Two weeks following the accident, his healthcare team found decreased joint mobility in his ankles, muscle tone functions that showed severe spasticity in the lower extremities and severely reduced muscle power functions in Mr. Dee’s legs, arms and trunk. As a result of these limitations, he had generally reduced involuntary movement reactions.

Read more: Assessment

Based upon Mr. Dee’s functioning state, a Global Goal was defined as economic self-sufficiency with a more immediate Service Program Goal of independence in daily living. Three Cycle Goals were selected to help achieve these:

  1. Prevention of secondary complications – for his overall health status
  2. Improved mobility – based upon his limitations walking and transferring
  3. Improved self-care – based upon his limitations washing and caring for himself
Read more: Goal setting/determination of intervention targets


Each of the intervention targets was assigned to a member of the healthcare team which included a physician, a nurse, both a physical and an occupational therapist, and a social worker. As a team they planned and implemented appropriate interventions intended to improve the specific targets.

Table 3 gives a detailed view of targets, interventions and their assignments. Each intervention would be evaluated at the end of the six-week cycle.

Read more: Assignment and Intervention

After about six weeks of rehabilitative interventions, Mr. Dee was evaluated to see how he had progressed. Functionally, he had made great improvements related to the recovery of the spinal cord. The new ASIA measurements showed that both motor functions and sensitivity had improved in hands, arms, and legs, moving him up an impairment grade from C to D (meaning at least half of the key affected muscle groups have a grade of 3 or higher). These improvements also translated to increased SCIM scores (from 21 pre-Cycle to 72), where one can see the manifestation of the gains in functioning.

Read more: Evaluation

This case study highlights some strengths and limitations of spinal cord injury rehabilitation in lower-income countries. Mr. Dee’s rehabilitation supports the findings of the Brazilian study that demonstrated neurological outcomes in low- and middle-income countries can result in recoveries comparable to those in industrialized nations.27

In Mr. Dee’s case, his type and level of injury, access to high-quality healthcare services (based on government policies and a socialized health insurance system), and a team that was trained and knowledgeable about the treatment and rehabilitation of SCI, all collectively contributed to his positive functional recovery.

Read more: Discussion