Neurorehabilitation in Developing Countries: Challenges and the Way Forward

Research Article

Phys Med Rehabil Int. 2015; 2(9): 1070.

Neurorehabilitation in Developing Countries: Challenges and the Way Forward

Khan F1,2,3,4,5*, Amatya B1,5, Mannan H³ and Rathore FA5,6

¹Department of Rehabilitation Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia

²Department of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia

³Nossal Institute for Global Health, University of Melbourne, Parkville, Victoria, Australia

4School of Public Health and Preventive Medicine, Monash University, Victoria, Australia

5Committee for Rehabilitation Disaster Relief (CRDR), International Society of Physical and Rehabilitation Medicine (ISPRM), Geneva, Switzerland

6Department of Rehabilitation Medicine, CMH Lahore Medical College, University of Health Sciences, Lahore, Pakistan

*Corresponding author: Fary Khan, Department of Rehabilitation Medicine, Royal Melbourne Hospital, 34- 54 Poplar Road Parkville, Melbourne VIC 3052, Australia

Received: November 03, 2015; Accepted: November 25, 2015; Published: November 27, 2015


Neurological disorders affect one billion people worldwide and have significant disability-burden with longer-term functional and psychosocial issues that need comprehensive management, including rehabilitation. The prevalence of disability due to neurological conditions is escalating worldwide. These add to the economic burden for healthcare systems (particularly in lowresourced countries), where despite improved acute health care systems, health policies have not extended to include rehabilitation. Neurorehabilitation is interdisciplinary and cross-sectorial, requiring collaborative coordinated effort of diverse sectors, professions, patients and community. This article provides a narrative overview of literature on neurorehabilitation in developing countries and highlights some of the challenges in implementation of the World Health Organization’s Global Disability Action Plan (DAP), focusing on rehabilitation (Objective 2) within the context of neurological conditions. Several issues related to neurorehabilitation are discussed for a systematic approach to build horizontal health care systems that are sustainable and responsive; involvement of bilateral agencies using multi-sectorial approach, new partnerships, strategic collaboration; provision of technical assistance, research and development; and capacity-building for a strong interdisciplinary workforce. Other factors that need to be addressed include governance for strengthening health care systems through logistics, surveillance and service delivery; and adequate scaling. The DAP provides comprehensive summary actions to tackle global disability, including neurological disorder-related disability, and offers governments, policy-makers and other relevant stakeholders a blueprint for implementing recommendations of the World Disability Report and the Convention on the Rights of Persons with Disabilities, and facilitate social inclusion of persons with neurological conditions, in countries at all stages of development.

Keywords: Disability, rehabilitation; Neurological disorder; Developing country; World Health Organisation


CBR: Community-Based Rehabilitation; COAG: Council of Australian Governments; CP: Cerebral palsy; CRPD: Convention on the Rights of Persons with Disabilities; CT: Computer Tomography; CVD: Cardio-Vascular Disease; DALY: Disability Adjusted Life Years; DAP: Disability Action Plan; HDI: Human Development Index; GDP: Gross Domestic Product; GNI: Gross National Income; ICF: International Classification of Functioning, Disability and Health; LTNCs: Long-Term Neurological Conditions; MRI: Medical Resonance Imaging; NCDs: Non-Communicable Diseases; NDA: National Disability Agreement; NGO: Non-Governmental Organisation; OECD: Organisation for Economic Co-operation and Development; OT: Occupational Therapists; PM&R: Physical Medicine and Rehabilitation; P&O: Prosthetics and Orthotics; PT: Physiotherapists; PwD: Person with Disability; RCI: Rehabilitation Council of India; SCI: Spinal Cord Injury; SLTs: Speech and Language Therapists; TBI: Traumatic Brian Injury; UN: United Nations; WHO: World Health Organization; US: United States; WFN: World Federation of Neurology.


The World Report on Disability estimates over one billion people with disabilities globally, which equates to15% of world population or 1 in 7 people (based on 2010 global population estimates) [1]. Of these 110-190 million have significant difficulties, such as inability to walk, perform self-care, or communicate, or to participate in education or employment [1]. The prevalence of disability is significantly higher in low-income than in high-income countries, with an estimated 80% persons with disability (PwD) living in low-income countries [2]. Disability prevalence rates are also associated with poverty and personal wealth, with 20.7% of PwD in the lowest-wealth compared with 11.0% in the highest-wealth quintile [1,3].

The world-wide prevalence of disability is escalating, potentially due to global trends in population ageing, rise in chronic conditions (including Non-Communicable Diseases, NCDs such as cardio vascular diseases, diabetes etc.) and upsurge in natural/man-made disasters [1,2]. Persons aged 60 years and above are projected to increase from 675 million in 2005 to 1.9 billion by 2050 globally [4]. Over next 30 years, the estimated increase in number of older people with profound disability by 70% [5]. The estimation-based data is sparse, particularly for developing countries, making it difficult to gauge trends and causes over time. Further, national estimates vary considerably amongst countries and are generally difficult to compare [1]. Economic and social costs of disability are difficult to quantify and to date; there is no inclusive estimate data for overall cost [1]. The reasons for this includes: variation in definitions of disability, different data collection and reporting methods, variation in type/content of disability services/programs; limited data on the cost components of disability; lack of standardized methods for costestimation; lack of routine data collection and national registries for disability and others. However, available data suggests that economic and social costs of disability to individuals, families, communities and nations (direct and indirect costs) are significant [1]. The estimated cost of disability is around 10% of public social expenditure across Organisation for Economic Co-operation and Development (OECD) (up to 25% in some countries) [1,6].

The majority of PwD is economically deprived and experience difficulties in accessing basic health services (including rehabilitation) [2]. Only 3% of individuals who need rehabilitation globally receive the service [7], and this is significantly higher for PwD in low-income compared with high-income countries [1]. It is estimated that people needing prostheses or orthotic-related services represent 0.5% of the population in developing countries, and 30 million people alone in Africa, Asia, and Latin America require over 180,000 rehabilitation professionals [8,9]. A global survey of government action (n = 114 countries) in 2006, on the implementation of the United Nations (UN) Standard Rules on the Equalization of Opportunities for PwD reported significant gap in service provision [10]. Rehabilitation policies were not adopted in 48 UN member states (42%); legislation on rehabilitation for PwD not passed in half (50%); and rehabilitation programs not established in 46 countries (40%) [10]. Further, in 2005, one-third of countries globally did not allocate any specific budget for rehabilitation services [1].

Though musculoskeletal conditions (such as arthritis trauma) are prevalent and major cause of disability, neurological insults are more complex, and have a greater disability burden (due to concurrent physical, speech, cognitive and behavioral issues) over longer period of time [11]. Neurological disorders affect up to 1 billion people worldwide and constitute 6.3% of the global burden of disease [12]. Nervous system disorders have significant diseaseburden worldwide with an estimated 92 million disability-adjusted life-years (DALYs) in 2005, which is projected to increase by 12% to 103 million in 2030 [12]. The estimated DALYs for neurological disorders were highest for lower-middle and low-income countries [12]. Of these, cerebrovascular diseases (CVD) such as stroke, infarcts/hemorrhages, contribute more than half of the burden in DALYs, followed by Alzheimer and dementia (12% each) [12]. Further, neurological disorders constitute 12% of total deaths globally, with CVD contributing almost 85% of deaths [12], which is significantly higher in lower-middle income countries compared with high-income countries (16.8% vs. 13.2%) [11]. DALYs per 100,000 population and deaths attributable to 10 most common neurological disorders in 2005 in low-income and low-middle income countries according to the World Bank is tabulated in Table 1.