Challenges and Perspectives for Physical Medicine and Reha

12 Pages·2017·0.34 MB·English

J Rehabil Med 2017; 49: 10–21
SPECIAL REPORT
M WORLD HEALTH ORGANIZATION GLOBAL DISABILITY ACTION PLAN 2014–
2021: CHALLENGES AND PERSPECTIVES FOR PHYSICAL MEDICINE AND
R
REHABILITATION IN PAKISTAN
J
Fary KHAN, MBBS, MD, FAFRM (RACP)1–4, Bhasker AMATYA, MD, MPH1,4, Tahir M. SAYED, MBBS, FCPS5, Aamir W. BUTT,
MBBS, FCPS5, Khalid JAMIL, MBBS, FCPS5, Waseem IQBAL, MBBS, MSc (Pain Medicine), FCPS5, Alaeldin ELMALIK,
e MBBS, FAFRM (RACP)1, Farooq A. RATHORE, MBBS, FCPS, OJT4,6 and Geoff ABBOTT, MBBS, FARM (RACP), Dip MSM1
n
ci From the 1Department of Rehabilitation Medicine, Royal Melbourne Hospital, Parkville, 2Department of Medicine (Royal Melbourne
di Hospital), The University of Melbourne, Parkville, 3School of Public Health and Preventive Medicine, Monash University, Victoria, Australia,
e 4Committee for Rehabilitation Disaster Relief (CRDR), International Society of Physical and Rehabilitation Medicine (ISPRM), Geneva,
M Switzerland, 5Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan and 6Department of Rehabilitation Medicine,
Combined Military Hospital Lahore Medical College, Lahore, Pakistan

n
o
ti
a
bilit Ooubtjleinctei vpeo: teTnot iparl obvaidrrei earsn aunpdd afateci loitna todrissa fboirli tiym palned- Thdiesraeb ialritei easn ( PewstDim) ainte tdh e6 A5s0i am-Piallciiofinc preegoipolne (6w5i%th
a
h mentation of the World Health Organization Global of the total global disability population), equating to
e
R Disability Action Plan (GDAP) in Pakistan. 1 in every 6 persons (1–3). The United Nations (UN)
f Methods: A 6-day workshop at the Armed Forces In- Convention on the Rights of Persons with Disabilities
o
al stitute of Rehabilitation Medicine, Islamabad facili- (CRPD) recognizes that “disability is an evolving con-
n tated by rehabilitation staff from Royal Melbourne cept that results from the interaction between persons
r
u Hospital, Australia. Local healthcare professionals
o with impairments and attitudinal and environmental
J (n = 33) from medical rehabilitation facilities identi-
barriers that hinder their full active participation in
fied challenges in service provision, education and
society on an equal basis with others” (4). This “para-
attitudes/approaches to people with disabilities,
digm shift” in attitudes to PwD, views PwD as active
using consensus agreement for objectives listed in
members of society with equal rights (4) and delivered
the GDAP.
a normative framework for disability, ratified by 147
M Results: Respondents agreed on the following chal-
member states including Pakistan (3). Despite this
lenges in implementing the GDAP: shortage of skil-
R led work-force, fragmented healthcare system, poor commitment from UN Member states, there remains
J coordination between acute and subacute healthca- a significant gap in service provision for this cohort
re sectors, limited health services infrastructure and in the community in terms of healthcare and access to
funding, lack of disability data, poor legislation, lack services. The implementation of rehabilitation policies
of guidelines and accreditation standards, limited and legislation are not optimal in many countries (1).
awareness/knowledge of disability, socio-cultural In the South-Asia region (similar to other developing
e perceptions and geo-topographical issues. The main countries) (5), non-communicable diseases (NCDs),
n
ci facilitators included: need for governing/leadership environmental factors, road trauma, disasters and man-
di bodies, engagement of healthcare professionals and made conflict are key factors contributing to disability
e
M institutions using a multi-sectoral approach, new prevalence (3).
partnerships and strategic collaboration, provision Pakistan is the sixth most populous country in the
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o of financial and technical assistance, future policy world (population > 180 million, area approximately
ti direction, research and development.
a 800,000 km2) (6), bordered by India, Afghanistan,
bilit Cidoennctliufiseido n:h eTrhee bhaigrrhileigrsh tt o tihmep leemmeerngtiinngg tphreio GriDtiAePs Iran and China. Pakistan comprises 5 main provinces:
a Punjab, Khyber-Pakhtunkhwa, Sindh, Balochistan
h and challenges in the development of rehabilitation
e and, relatively smaller, Gilgit-Baltistan; and 3 territo-
R medicine and GDAP implementation in a developing
ries: Federally Administered Tribal Areas, Islamabad
f country. The GDAP summary actions were useful
o Capital Territory and Kashmir (6). Punjab and Sindh
planning tools to improve access and strengthen re-
al are the most densely populated regions (7); however,
n habilitation services.
r approximately 64% of the Pakistani population live
u
o Key words: disability; rehabilitation; Pakistan; World Health in remote and rural areas (7). There are significant
J Organization.
disparities amongst the provinces in terms of capa-
Accepted Aug 17, 2016; Epub ahead of print Dec 8, 2016 city, infrastructure and level of governance, due to
topography, security issues and/or natural disasters (3).
J Rehabil Med 2017; 49: 10–21
The median age of the population of Pakistan is 23
M Correspondence address: Fary Khan, Department of Rehabilitation years (with over 35% of the population being younger
Medicine, Royal Melbourne Hospital, 34-54 Poplar Road Parkville, Mel-
bourne VIC 3052, Australia. E-mail: [email protected] than 14 years). Life expectancy at birth is 65 years
R
J
This is an open access article under the CC BY-NC license. www.medicaljournals.se/jrm
doi: 10.2340/16501977-2149 Journal Compilation © 2017 Foundation of Rehabilitation Information. ISSN 1650-1977
Challanges in implementation of WHO Global Disability Action Plan in Pakistan 11
M (8). The literacy rate among adults aged 15 years and of 2.5%. This is significantly lower than the “world-
over is just above 56% (6, 8). According to World wide” disability prevalence rate estimation of 15% (or
R
Bank income classification, Pakistan is categorized as 1 in 7 people) based on the World Report on Disability
J a “low-middle” income country, and is ranked 146th (1). Based on this reported prevalence of disability and
(out of 186 countries) in the Human Development a population of 185.1 million (2014) (7), the number
Index, with gross national income per capita (in 2013) of PwD in Pakistan may exceed 27 million people.
e of US $2,880 (6, 8). Pakistan remains impoverished NCDs remain a significant cause of overall burden of
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ci and underdeveloped, with 60.2% of the population disease in Pakistan, contributing an estimated 40.3%
di living below US$2 dollars a day (9). Gender inequi- of overall disability-adjusted life years (DALYs) in
e
M ties, particularly in marginalized populations, are 2012, followed by injuries, which account for 11% of
prominent, with 58% of females over the age of 15 DALYs (15). Amongst NCDs, DALYs attributed to
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o years being illiterate compared to 33% of males (6, 9). cardiovascular disease (CVD) is the highest (7.3%),
ti
a Universal education is yet to be achieved in Pakistan. followed by behavioural conditions (5.1%), cancer
t
bili Compared with other member countries of the South (4.5%), and neurological conditions (3.6%) (15).
a Asian Association for Regional Cooperation (SAARC) NCDs contribute to 50% of overall mortality, with
h
e (Afghanistan, Bangladesh, Bhutan, India, Maldives, 19% due to CVD alone; while communicable diseases
R
Nepal and Sri Lanka), Pakistan has low net primary contribute 39% and injuries 11% (8). Consistent with
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o (72.5% in 2012) and tertiary education enrolment rates other SAARC countries, the prevalence of disability

al of only 9.5% (9). in Pakistan is increasing due to natural disasters and
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ur Overall spending on healthcare by the government conflict, cultural factors, political instability, increase
o
J of Pakistan is low, with total expenditure on health per in chronic conditions, an ageing population and econo-
capita of US $126 (in 2013), or 2.8% of total expen- mic down-turn (3, 13). Despite the lack of conclusive
diture of gross development product (GDP) (6, 8). The data, the economic and social costs of disability are
majority of PwD in Pakistan, as in many developing significant for PwD (their families), the community
countries (5, 10, 11), are economically deprived and and the nation (1).
M experience difficulties in accessing basic health servi-
ces, including rehabilitation services (7, 12). Similar Disability policies and legislation
R
to other SAARC countries, much effort has gone into
J improving the acute care sector, while post-acute National development policies in many South-Asian
countries have not adequately addressed the concerns
care (including rehabilitation), is still undeveloped
of PwD. In response to the UN’s International Year of
at many levels (7, 12). Overall, key determinants of
Disability 1981, the government of Pakistan initiated
poor health include: literacy, unemployment, gender
their first law dealing specifically with disability: the
inequality, social exclusion, rapid urbanization, and
e “Disabled Persons (Employment and Rehabilitation)
n environmental degradation (3, 6). Furthermore, war/
ci Ordinance 1981”, to promote equal working rights,
di conflict, terrorism, chronic insecurity, frequent disas- focusing on employment and segregated education
e ters (both natural and man-made), intertwined with
M for PwD (13). The Ordinance specified that all go-
political instability, poor governance and dependency
vernment agencies and companies with more than 100
n on foreign assistance compound the lack of an effec-
o employees were required to ensure that at least 1% of
ti tive healthcare system in Pakistan. Despite attempts to
a their workforce consisted of PwD or pay a levy; this
t introduce various policies for PwD, they continue to
bili have difficulty exercising their civil and political rights, law, however, is poorly implemented. After a hiatus
a of 20 years, in consultation with the health, education,
h and gaining access to education and employment (13).
e labour, housing and science and technology ministries,
R An estimated economic loss of approximately US
f $11.9–15.4 billion or 4.9–6.3% of Pakistan’s GDP is as well as relevant non-governmental organizations
o (NGOs) and local organizations, the first “National
attributed to exclusion of PwD as productive members
al Policy for Persons with Disabilities” was approved in
n of society (13, 14).
ur An overview of disability and current rehabilitation 2002 (13). The policy advocates rights of PwD for ac-
o
J status in Pakistan is set out below. cess to medical and rehabilitation services, education,
employment and social participation and systemati-
cally specifies guiding principles and strategies, with
Burden of disability
the focus on empowering PwD. In 2006, the “National
There is limited epidemiological data on disability Plan of Action” was introduced to provide a roadmap
M and disability-related burden in Pakistan. Based on the for implementing the national policy, with short- and
1998 population census, there are an estimated 3 mil- long-term measures. However, due to the amended
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lion PwD in Pakistan, and a disability prevalence rate Constitution and division of legislative powers (from
J
J Rehabil Med 49, 2017
12 F. Khan et al.
M federal to provincial government), including social visitors currently registered in Pakistan (3, 6). To date,
welfare, mental illness, workers’ welfare, employer 48 physicians have qualified as physical medicine and
R
liability and education, the policy was not endorsed rehabilitation (PM&R) fellows, the majority (n = 32) of
J (13, 16). In 1990, the Pakistan “Convention on the whom work in military facilities; while the remainder
Rights of the Child” was ratified for rights of children work in the private and public sectors, which service
with disabilities (Article 2, Article 23). The “Natio- the majority of PwD in Pakistan (18). Currently, there
e nal Plan of Action for Children (2006 to 2015)” was are an estimated 1,700 physiotherapists in Pakistan,
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ci further ratified, for rights of children with disabilities with 1,300 expected to graduate annually. There are
di and PwD (17). The “Convention on the Elimination of approximately 200 trained occupational therapists,
e
M all Forms of Discrimination against Women”, ratified 250 speech and language therapists, and no formally
in 1996, however, did not directly address the rights trained nurses in rehabilitation. There is a significant
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o of women with disabilities. Similarly, the “National shortage of trained and available healthcare profes-
ti
a Education Policy” (2009) did not contain any direct sionals with inequitable staff distribution across
t
bili objective to address the needs of children and women rural areas (particularly in the rehabilitation sector)
a with disabilities (17). Pakistan signed the UNCRPD in (7). Importantly, there is still no formal professional
h
e 2008 and ratified the convention in 2011 (3). Further- organization representing PM&R specialists. PM&R
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more, the UNCRPD Secretariat for the Implementa- staff from various rehabilitation settings are focusing
f
o tion of the Convention was established in 2012 and a on building interdisciplinary teams, communication

al formulation of a Core Committee followed to monitor/ and decision-making processes in order to operate as
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ur coordinate with all stakeholders for implementation of cohesive teams.
o
J the Convention (17).
Policy approaches to disability have largely impro- Service delivery
ved in the last few years in Pakistan, and there is better
Since the adoption of the CRPD in 2011, there has been
collaboration between acute and rehabilitation facilities
an increased awareness of the disability-inclusive na-
and various NGOs, who provide social care for PwD.
tional development strategies, goals and programmes
M More work, however, is needed for the government
in Pakistan. However, the health system in Pakistan
to implement better laws and policies, for services
R has faced enormous challenges in recent decades, due
to be efficient and effective, and for organizations
J working with PwD to adopt a co-ordinated approach to sectoral conflicts, natural disasters, poverty, politi-
cal uncertainty and a decrease in international aid. In
to communicate their needs. There is much to be done
2010, there were 989 public hospitals and 800 private
with regard to disabled access to buildings, parking,
hospitals, 596 rural health centres and 4,910 basic
transportation, and access to advocacy, provision of
health units at the primary healthcare level (19, 20).
assistive devices, aids, counselling, social welfare and
e According to the World Health Organization (WHO),
n assistance to PwD. In general, there is lack of public
ci there are a mean of 6 hospital beds per 10,000 popu-
di awareness of economic and social implications for lation (3). Rehabilitation services are increasing sig-
e PwD. The CRPD offers a blueprint for a rights-based
M nificantly in Pakistan, compared with its counterparts
approach to mainstreaming PwD, underlining the
in the region. There are 3 established rehabilitation
n government’s commitment to protecting the civil, po-
o centres, 15 departments of rehabilitation medicine,
ti litical, social and economic rights of PwD. However,
a 32 physiotherapy departments (mainly in the army)
t many agree that little has changed in accordance with
bili the framework, set up in the CRPD framework (7, 13), currently operational in Pakistan (7). In addition, there
a are 4 smaller regional facilities that provide supportive
h and millions of PwD remain excluded from healthcare,
e rehabilitation, including community-based rehabilita-
R rehabilitation, and social participation.
tion programmes. There are however, only 2 institutes
f
o of PM&R in the country: the Armed Forces Institute of
al Human resources Rehabilitation Medicine (AFIRM) primarily catering
n
ur There are an estimated 8 physicians per 10,000 popu- for the military, and another in private sector (21). It is
o
J lation in Pakistan, which is significantly higher than estimated that PM&R is being practiced at 23 locations
other SAARC member countries, except India (with in the country; however, most of these centres do not
16 physicians per 10,000 population) (3). (Table I). follow a multidisciplinary approach (7). There are also
Overall, it is estimated that there are more than 200,000 some centres for spinal cord injuries run by NGOs and
doctors, 33,793 specialist doctors (more than 170 trai- physiotherapists (7, 21). In 1997 the College of Phy-
M ned neurologists) registered with the Pakistan Medical sicians and Surgeons of Pakistan recognized PM&R as
and Dental Council (as of October 2015) (18). There a specialty and provided the fellowship training pro-
R
are an estimated 46,000 nurses and 4,500 lady health gramme in PM&R. Currently, along with the AFIRM,
J
www.medicaljournals.se/jrm
Challanges in implementation of WHO Global Disability Action Plan in Pakistan 13
JRMJRMJRMJRMournal of ehabilitation edicineournal of ehabilitation edicine mary of current health systems/resources for disability in South Asian Association for Regional Cooperation member countries AfghanistanBangladeshBhutanIndiaMaldivesNepalPakistanSri Lanka b30.6 million156.6 million0.75 million1.2 billion 0.35 million27.8 million21.3 million185.1 million (2014)bGNI per capitaGNI per capita: GNI per capita: GNI per capita: GNI per capita (2013): GNI per capita: $2,030; GNI per capita: $9,470; GNI per capita (2013): : $4,920; $2,260; Total $8,110; Total $5,350; Total $7,210Total expenditure on Total expenditure on $2,000Total expenditure on expenditure on expenditure on health: expenditure on health: health: 3.7% of GPDhealth: 3.4% of GPDhealth: 2.8% of GPDTotal expenditure on Total expenditure health: health: 6.0% of GPD10.8% of GPD4.2% of GPDhealth: 3.6% of GPD43% living below poverty HDI rank: 928.1% of GPDHDI rank: 146HDI rank: 157HDI rank: 104HDI rank: 136line (US$ 1.25/day) HDI rank: 140Annual disability HDI rank: 175Annual disability spending: Annual disability Annual disability Annual disability HDI rank: 146; Annual spending: Lankan rupee Annual disability Annual disability Pakistani rupee 366 millionspending: no spending: no spending: Indian rupee disability spending: no 25 millionspending: no spending: US$34.8 informationinformation4.8 billioninformationinformationmillionPhysicians: 6.8/10,000 Physicians: 8/10,000 Physicians: Physicians: 16/10,000 Physicians: 7/10,000 Physicians: Physicians: 3.6/10,000 Physicians: 2.3/10,000 people; currently people (113,700 doctors, 0.21/10,000 people people; nurses: people;0.074/10,000 people; people;people;employed in 21,800 specialist doctors); (2004)44.4/10,000 people; nurses/midwives: several national Currently active: PM&R No specific specialization government hospitals: Nurses 6/10,000 people PT: 22 (2005)0.3/10,000 peopleNo information institutions and physicians: 200. PT: 1300; in PM&R363 PTs; 107 OTs and (46,000 nurses and 4500 on rehabilitation No information 250 private No information PT assistants: 600; SLTs: No data on other 35 S&LTs; 8,000 of the lady health visitors); professionalson rehabilitation institutions conduct on rehabilitation 33; P&O technicians: very healthcare and allied 14,000 CBR volunteers;PM&R specialists: 38 (25 in professionalstraining courses professionalsfew; over 900 persons health personnelNo trained PM&R armed forces) for rehabilitation completed CBR training physicianspecialistscourses5 rehabilitation 989 public, 800 private 19 medical colleges, 1 main referral general 5 composite, 4 32 hospitals, 192 Approximately 4 Access to health centres: hospitals; 50 base and hospitals, 596 rural health >100 paramedical public hospital, 6 regional and 120 basic health units, 48 beds/10,000 people; 51% and hospital: district hospitals with centres and 4910 basic institutions, no regional public general district rehabilitation indigenous hospitals piloting 68 Integrated 32.4%;PT units, 8 physical health units at the primary rehabilitation hospitals, 13 hospitals, centres, institutions and over 550 outreach Disability Service Centres Many rehabilitation rehabilitation centres in healthcare level (2010).professionals.132 healthcare centres, at intermediary and clinics, free healthcare in 64 districts, with 323 services funded by NGOs 6 districts produce P&O 108 health posts. Many district level exist for services to cover 90% PTs, 83 OTs, 37 P&O and 15 departments of Many rehabilitation and charitiesdevices.rehabilitation services PwD population (2012). 19 speech therapists. Many rehabilitation medicine, 32 services funded by PT services: 44/364 funded by NGOs and No information on rehabilitation services PT departments (mainly NGOs and charitiesdistricts; CBR and charitiesrehabilitation centresfunded by NGOs and in army)outreach programmescharitiesApproximately 6 implemented: 80/364 beds/10,000 peopledistricts; orthopaedic centres: 13/34 provincesPwD; 0.3 million, PwD: 9,216; Disability PwD: 0.1 million, PwD: 3.3 million,PwD: 0.02 million; PwD: 22 million, PwD: 13.3 million; PwD: 0.9 million; Disability prevalence: prevalence: 3.4 (2002)Disability prevalence: Disability prevalence: Disability prevalence: Disability prevalence: 9.0 Disability prevalence: 2.7 Disability prevalence: 2.5% 1.6 (2001); 0.5 (2001)3.4 (2005)2.1 (2001)(2008); (approximately (2005); 4.8% of total (1998)750,000 persons) of the populationApproximately 105,000 Proportion of PwD population in need of P&O persons require P&O to total population servicesservices1.8–2.1%; Physical: 55.3%, Physical: 18.9%, visual: Visual: 33.2%, speech: Physical: 39.3%, Movement: 27.9%, Physical (mobility): Physical: 22.5%, visual: Physical: 36.5%, visual visual: 25.2%, hearing/8.1%, hearing: 7.4%, 28.6%, Mental: blind: 15.9%, deaf: visual:48.5%, hearing: 17.4%, visual: 23.5%, 13.7%, hearing: 16.8%, and hearing: 25.5%, speech: 26.7%, mental: intellectual: 7.6%, mental: 27.8%, others 10.4%24.6%, mental 5.8%, speech: 7.5%, hearing: 35.7%, intellectual (memory loss): intellectual: 18.8%, 25.1%%6.4%, multiple: 8.2%, (retarded): 12.7%, mental: 10.3%speech: 17.8%, 10.1%, mental: 12.8%, mental: 9.7%, multiple: others 43.4%multiple: 7.5%mental: 5.5%others 24.2%9.4% CRPD signed 2007; CRPD signature 2008, CRPD signed 2008 CRPD signed 2007 and CRPD signed and CRPD signed 2007; no CRPD signed and ratified: CRPD ratified: 2012; Protection of the ratification 2011; National and ratified:2010; ratified 2010; Law on ratified: 2007; PwD information in regards 2007; Disability Welfare Comprehensive national Rights of Persons with Policy for PwD: 2002; Person with Disability Protecting the Rights Equal Opportunities, to laws and policies Act (2001); National Policy disability policy 2003; Disabilities ActNational Plan of Action Welfare Act 2039; of People with Special Protectionfor PwDon Disability (2004); National Disability Action 2006–2025; the Disabled Person with Disability Needs and Financial NationalPlan (2008–2011); (1996); RanaViru Seva of Rights and Full Persons (Employment Welfare Regulation Assistance (2009); National Priority Act (1999); Visually Participation Act Action Plan on Disability and Rehabilitation) 2051, National National Disability Programme “Health for Handicapped(1995); Mental Health(2006); Disability Rights Ordinance1981; Disability Policy Policy; Strategic Action and Protection Act (2013); All Afghans” from 2012; Trust Fund Act (1992); Act (1987); National Convention on the Rights of 2006; National Plan 2009–2013; signatory to the Asian and Physical Rehabilitation Disabled Persons’ Policy for Persons with the Child 1990; Convention Disability Action Plan Action Plan for Children Pacific Decade of PwD StrategyAccessibility Regulation Disabilities (2006); on Elimination of all 2006–2016with Disabilities (2002–2012) and (2003); National Policy Rehabilitation Council Discrimination against 2008–2013(2013–2022)on Disability (2003); of India Act (1995)Women 1996Action Plan for PwD (2011)
JRM Table I. Sum Country aPopulation Economic statistics Human resources (healthcare) Health services/infrastructures Disability data Disability type Disability legislation for PwD
J Rehabil Med 49, 2017
14 F. Khan et al.
M there are 5 other departments/institutions for fellow-
JRJRMJRMJRMJRMournal of ehabilitation edicineournal of ehabilitation edicine Table I cont CountryAfghanistanBangladeshBhutanIndiaMaldivesNepalPakistanSri Lanka No informationSupport scheme Financial support only to Allowances programme: No informationDisability pension for Home for people No informationBenazir Income Support for PwDpersons with war-related 300 Taka per person/persons living below with special needs Programme; Financial disabilities; services monththe poverty line, aged (psychiatric and assistance through Pakistan available for all PwD18–59 years, with geriatric patients); Bait ul Mal; Free medical severe (>80%) or monthly financial treatment to PwD and their multiple disabilityallowance for persons dependent family members with visual disability in Federal/Provincial (totally blind)Government hospitals/dispensaries; 50% concession in air/train fare for PwD; 2% employment quota reserved in public and private sector; 10-year age relaxation in upper age limit for Government service Research in No research in No research in Currently an upward trend No research in Currently an upward Research and Limited research in Research in rehabilitation rehabilitation limited rehabilitation field rehabilitation field in research in the medical rehabilitation field trend in research in the evaluationrehabilitation field field limited to acute care mostly to acute care rehabilitationmedical rehabilitation. outcomes. Member of outcomes.Member of ISPRMISPRM Main sources: WHO Country Profile; WHO Health Statistics 2011; WHO Disability and rehabilitation status 2004 (14); ESCAP 2012.abPopulation in millions in 2013 unless stated otherwise; Statistical Yearbook for Asia and the Pacific 2014. CRPD: Convention on the Rights of Persons with Disabilities; HDI: Human Development Index; GDP: gross domestic product; GNI: gross national income; ISPRM: International Society of Physical and Rehabilitation Medicine; OT: occupational therapists; NCDs: non-communicable diseases; P&O: prosthetics and orthotics; PM&R: physical medicine and rehabilitation; PT: physiotherapists; PwD: persons with disability; SLTs: speech and language therapists; WHO: World Health Organization; CBR: community-based rehabilitation. sKirlaSSTpiG(lwseTeGbadKaOftfrmrbbPAAmtn2pabtMwiSspohnhisenooeeTeusxsnthaiiyeya rnsctrahtA eunFihrrlhssee cusersarogloOemohu spudtaot ticaiisrTd6eecn eoaitised hltP aIheaneetdrgpcrier ,tstaaAdhsuubhA vvaeashR-e ewn aabinoidsbo ik1biit carortf a sectcdbdet ryelorr t cdai ltasicolcc bgrleMiou uitRaewpsclyooeikua ad srloiaarnoa moi u MrcemAanpirchianthpthl,el lebolnnl ralgyip ates( tgihnls sCpI h .u eaeri a krvgia aHstyiiN oFr nu mpbjDtr,himI iiit tto paaIh,dnnsAo fes Mtatastsi elshhe na )m Intptatrajciei cr6eioaP utIihttc ohitMerRnw.efniltieocqo etetsoscns.hicniast o -hvdaycnseeatab,o oitper tIni ntun,ta A,cxdioddM eafcahayonamIedea(rriubie tn eil psurl iaaegt tnna2Fynbqt rso ,ipto nvomadhbiu icbnrnuptohaa itstiskPal scnyslpd ulip hlKddooaavbeitras emcGesal,itige e, lndgaeoibscoai eus a tetesettt rmolnn srenl j nas,ea irprpoohrigakwefeuie iyraveur, tmea (hesnl dpaueoonev niPttl atrlatre fBre-7oin cetsdnseiociReceyl- ct owts manacPdenfer(iaaowrmn2sithl.geuhieCi3rrAdlrttdtsiAac5chao rldlramrknn n uaasdor0MoayiioApidoui3coa.noe pito eeepzeowa vm ,vizagn adsF1ellmtl dachld ddeasc f( rnoiellr osssr eeg cnbeG phneiRs5noIsa dl,&tMinkaeeuiprig ann Hea g Ixwe aRtetne tenw)s lydrstdiiatilnetrsnaoAfrltsigdgtpgr npihn n i mhnn a sehRge ttb earaMeoohat sn f,Esyamtln iae aeiaeo Malero,d accreh etlty:ni Ptneirndot encaed ri:. P4hhoT tisin tAdes thkc )er G dtdihgd paaoalndttspnit1ac o, uoa muaentTouo quc asfeth2u PHnrAri enEtMb pelobpbD4u bio(unsdhrt.aladaut,kzhesneaomd tp i d le eholdaila)af ttccrrerpoansOtia eIsAialNelaamaineh d cMmur sreyerlesrtic nnu nclrpswAacc-sneafilooeotheoienoei ece.ePtGts nbukD asetftlfzm s ennpenehtddrenhfgr nTrtgeriuian fae atL eot eesdsdi eoosdrruOfm(dine ai areirdsfidpSnhainsd,trny2sPoroeut caG cednc tcaiibnbr ua cF tdkaaihnag si(hec gs65 nfrrssn r ctoc(ta,namsi imhFt mwCrioefenbtiId eoeadeiDdGele a l rthutowgtentrmslrsaiOeosyniKrodleti s erh iae mite uobeeelmt tti vonHcxsirrcaaGAcF utio D nhoraanrihcdhtprramnw,Hi herbreiniin etnupoePhre vmo oart,nQtttpaaliieeeb.eiseyrsgDPs ,ioBkrgrseiiono oni ibr ,rn b rcadxa o lssneHtea c ai) Itedtwct2b i nrfasc)sii otaAignitpeltpk,Anis.antlinheavbkcolchese lp esu e sih hlet,oivtsfPas i(saganr eiotnasosss rot, nerutansitttrtPo t,s sat2eo2pssama rwo t aadh aa uldoondsiwtsns2Gtaieft, rra.Pil vlt twkhnt0ctg,fohnuei iunoareaeid lulpd0a a ih inefbvaenoiPiodyAo.orefo1sdrsetocr1g p nen satr1s ydiesvasrumeedsn fa Pmesaenno.er)rtn 4hmlcai n ,5i tl t ,m io1a eaie gke W mns s es agdesgeol taAreOcg–n)M r Awpwnp rdteeitraoestetal ;vrtnaf eeieoshe,iirs ps2 eFatnhrm ag atbAE nnfHnoaHuauaettocRweipheao settrncodtaa0fI,lnictndhrvrhtcniido) hret isstRraihoednew iaiouk Ozolsio t2tidomnihcmadtvseetno st haibuicet, a,rarnerMmehf ndtnha1oe ceeettt ierguorkyaatnt’tr steiriysddynore3yoheoudgdddesesseac-)srsfsf-----)tt.,,,
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Challanges in implementation of WHO Global Disability Action Plan in Pakistan 15
M Table II. World Health Organization Global Disability Action Plan discussed with participants. Known experts in this field were
2014–2021: Better health for all people with disability (22) also contacted for further information on disability-related
R The action plan provides a comprehensive list of specific actions and policies and legislation in Pakistan.
metrics of success to achieve the plan’s following 3 objectives:
J
1. Remove barriers and improve access to health services and programmes;
2. Strengthen and extend rehabilitation, assistive technology, assistance RESULTS
and support services, and community-based rehabilitation;
e 3. Strengthen collection of relevant and internationally comparable data on All participants (n = 33) contributed actively to group
n disability and support research on disability and related services.
ci discussions and the consensus method. Most were
di not familiar with the GDAP, and reported a lack of
e based on the objectives listed in the GDAP. Prior to the detailed
M available information about the current developments
workshops, the authors summarized the state of evidence in
n the field of rehabilitation in the form of multiple plenary and and programmes with regards to disability. The parti-
o interactive panel sessions. The teaching sessions included basic cipants provided multiple responses (in writing) across
ati principles of rehabilitation, evidence-based practices, disability each GDAP objective. The participants agreed that
bilit creacreo rpdl asnynsitnemg, sl iwnkitihn ga icnuftoer mhoastpioitna lt ercehfnerorleorgsy a, ndda tath aonsde hine atlhthe the GDAP provides comprehensive summary actions
a for PwD and offers the government, policymakers,
h community; capacity building; leadership skills development
e and nursing and symptomatic management (spasticity, pain, and other relevant stakeholders a blueprint for imple-
R
wound care, etc.). The “host” hospital lead medical and allied menting the recommendations of the World Disability

of health team also provided presentations on their health servi- Report. Overall, for GDAP objective 1: participants
al ces, including specific challenges faced by their rehabilitation indicated 62 potential challenges/barriers and 51
n staff. All information volunteered was supplemented with more
r potential facilitators/enablers; for GDAP objective
u specific recorded data during the workshop settings. During the
o 2: 68 challenges/barriers and 55 facilitators/enablers;
J workshops the participants were divided into 3 panels to ensure
that the various specialist and skill base were evenly distributed. for GDAP objective 3: 29 challenges/barriers and 28
Each panel focused on 1 of the 3 GDAP objectives and were facilitators/enablers. Based on participants’ feedback,
provided with a printed overview of the GDAP with blank cor- consensus agreement and collation of data, a number
responding columns to complete their responses. Based on their
of common suggest “terms” were coded. The final set
experiences and the issues they faced in service delivery, the
of “terms” were formulated, which included for GDAP
M participants in each panel were then asked to work out and dis-
cuss their views and perspectives of various problems that were objective 1: 50 potential challenges/barriers and 49 po-
R highlighted relating to service provision, attitudes/approaches tential facilitators/enablers; objective 2: 54 challenges/
J to PwD, gaps in service provision, education, related challenges barriers and 55 facilitators/enablers and objective 3:
and potential barriers and solutions designed for these issues.
19 challenges/barriers and 20 facilitators/enablers. The
At all times the GDAP was used as a blueprint for discussion
final set of the potential facilitators and challenges in
and allowed the authors to educate the audience, many of whom
were not familiar with the GDAP document (mainly nurses and implementation of the proposed standard actions in the
some allied health). Each panel included 2 speakers who pre- GDAP for rehabilitation are summarized in Table III.
e sented on behalf of their designated panel, followed by a large
n
ci group discussion for opportunity to brainstorm additional and
di emerging issues. Finally, a formal iterative decision-making DISCUSSION
e and consensus process (with ≥80% of the participants agreeing)
M
was conducted, tabulating potential challenges and facilitators Pakistan has a multi-tiered, mixed healthcare delivery
n in implementation of the GDAP. system, which includes both state and provincial, and
o
ti profit and not-for-profit service provisions. Similar to
a
t Data collection and analysis other SAARC member countries, although communi-
bili Throughout the workshops, participants submitted their respon- cable diseases still account for a predominant share of
a
h ses in writing for each GDAP objective. They were encouraged morbidity and mortality, Pakistan is in a stage of an
e
R to document any emerging issues and present these in the large epidemiological transition due to the increasing preva-
group interactive session. The author-facilitators recorded ad-
f lence of NCDs (3). The Pakistani Health Department
o ditional information, comments and recommendations provided
al by the participants, where possible. All data were collated has prioritized NCDs and rehabilitation as 1 of the key
n using content analytical technique (23). Two authors (FA, BA) agendas (6). Levels of funding, human resources and
r
u scrutinized each response and coded the information using a health infrastructure are largely poor, particularly in
o
J line-by-line process, which were further clustered into a com- rural areas of Pakistan (7). In past decades, healthcare
mon suggestive “term”. When no consensus was met about
facilities and programmes have grown exponentially in
the possible “term”, a final consensus was made by discussion
amongst all the authors. Four authors (FA, BA, GA, AE) dis- most areas of Pakistan. However, many are fragmented
cussed the final content analysis and reviewed the preliminary and/or work in isolation, and many programmes run
version of terms for refinement. only on a time-limited basis (6). There is duplication
M
In addition, a literature search of academic and grey literature
and wastage of resources, as many healthcare initia-
using available internet search engines and websites was con-
R tives/facilities are supported or funded by different
ducted for relevant publications (including academic articles,
J reports, related website contents, etc.), and relevant information levels of government and/or development partners
J Rehabil Med 49, 2017
16 F. Khan et al.
JRMJRMJRMJRMJRMournal of ehabilitation edicineournal of ehabilitation edicine Table III. Potential challenges and facilitators in implementation of the World Health Organization Global Disability Action Plan 2014–2021 in Pakistan (n = 33) ActionsPotential challenges/barriersPotential facilitators/enablers in the next 5–6 years Objective 1: Remove barriers and improve access to health services and programmes1.1 Develop and/or reform • Lack of definition for disability• Knowledge management capacity-building initiatives for policymakers, government authorities through media, health and disability laws, awareness programme, lobbying• Low priority of health in legislative processpolicies, strategies and plans • Adequate resource allocation• Health priority more driven towards acute sector and NCDs• Review existing policy documentation and surveillance systems• Unstable political and economic situation • Governing body to develop health policies from coordination to implementation; sectoral approach for alignment • Poor political commitmentin disability care• Existing policies underfunded • Input from rehabilitation physicians in policy, • Lack of coordination/collaboration amongst different government • Strengthen management capacity, public-private partnerships through legislation and regulationsectors and ministries • Establish a secondary level body of advocacy/oversight for implementation and evaluation of policies• Lag in implementation of existing policies• Coordination and communication between central and provincial bodies• Lack of consensus on who is responsible for enforcing and/or • Strengthen National Health Information systemsfunding new legislations/policies • Involve rehabilitation physicians, PwD and community organization in policy, legislation, programme • Lack of education/knowledge about disability amongst policymakers, development government authorities, etc. • Linkage with SAARC regional organizations• Lack of disability-related data • International cooperation and WHO support • Establishment of legislative and central capacity building body which included governmental authorities, health • Lack of central body for developing governance 1.2 Develop leadership and professionals, PwD and families, representative form regional health departments, quality of services, NGOs governance for disability-• Lack of coordination/collaboration among different government and DPOsinclusive healthsectors, hospitals (private and public), DPOs, NGOs• Capacity-building for educators for health work-force• Lack of process to involve all stakeholders (including rehabilitation • Implement plan for quality control and health inputsmedical professionals) in policy development • Coordinate and link various NGOs and DPOs with hospitals• No disability-rehabilitation standards or key performance indicators • More active role of rehabilitation medicine departments in facilitating leadership skills and governance• No specific accreditation standards or criteria for rehabilitation facilities and for staff• Improve web-based access to evidence-based guidelines/protocols and outcome measures for disability• Limited workforce leadership development programmes • Development key performance indicators and Standards of Care and accreditation criteria for rehabilitation facilities and staff • Increased health budget expenditure 1.3 Remove barriers to financing • Budget deficit and inadequate financial supportand affordability for PwD• Develop health insurance policies and coverage for PwD• Lack of accurate data; underestimation and underrepresentation of disability prevalence, cost data, etc. • Proper utilization of exiting social security systems such as “Zakat” • Decreased international aid• Use indigenous resources• Lack of rehabilitation facilities in public sectors• More international financial assistance• Out-of-pocket payment for services and assistive devices/aids• Training and educational programme for PwD – build workforce • Lack of government/private insurance• Improvement of social welfare, livelihood and benefits for PwD• Lack of enforcement and evaluation of legislation policy for employment/education/health for PwD • Accountability of resource allocation1.4 Remove barriers to service • Lack of infrastructuredelivery • Development of infrastructure and awareness of existing services• Non-disability friendly public places and transport • Development of comprehensive counter-terrorism and conflict policies• Corruption • Structured standard referral systems: acute to sub-acute• Conflicts/war and terrorism • Promotion of community-based rehabilitation• Topography of Pakistan distinct rural hard to access setups • Development of Mobile Units to deliver care in remote areas• Lack of rehabilitation for specific conditions such as stroke, spinal cord injuries etc.• Train healthcare workers for home-based/community-based care• Lack of multidisciplinary team approach and systems/models of • Telerehabilitation and local technologycare• Improve provision of disability friendly public facilities and transportation• Lack of integration with acute hospitals• Public awareness and educational programmes • Public-private sector partnership for service provision
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Challanges in implementation of WHO Global Disability Action Plan in Pakistan 17
M y
or
at
R v
JJRMJRMRMournal of ehabilitation edicineournal of ehabilitation edicine Potential challenges/barriersPotential facilitators/enablers in the next 5–6 years • Central body to implement national health policy• Limited access to disability services, particularly in rural areas • Enhance interdisciplinary interaction• Lack of adequate referral system • Decentralization of healthcare facilities including rehabilitation• Lack of human resources • Minimization of cultural stigma through public campaigns/awareness programmes • High illiteracy, poverty • Skill training and educational programmes for healthcare staff• Discrimination and stigma • Development of consumer organizations for advocacy (including PwD at national and local level) • Poor awareness of health services • Development of strategies for engagement of staff and PwD (and families)• Misconception and cultural belief about disability • Belief in traditional or native healers • Lack of adequate primary care services • Lack of follow-ups • Assessment and evaluation to identify need to mobilize resources• Lack of infrastructure and human resources • Coordination of intervention• Lack of emergency assistance programmes for PwD • Build healthcare infrastructure and human resource capacity• Lack of access to healthcare services, public transports etc. • Inclusion of emergency responses in resettlement plans for PwD• Minimal collaboration and/or referrals between emergency staff and rehabilitation personnel in tertiary facilities• Improve communication systems and collaboration between acute and rehabilitation staff• Lack of disability-centred measures paramedical services/disaster • International cooperation in humanitarian crisesmanagement plans • Lack of adequate primary care services • Lack of follow-up end rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation • Same as 1.1 above• Same as 1.1 above • Inadequate financial support and budgetary constrain• More active role of Department of Rehabilitation Medicine • • Establishment of the formal National society of PM&RLack of accurate data; underestimation and underrepresentation of disability prevalence, cost data, etc.• Public awareness through national forum• Lack of awareness of extent of problems/issues facing disability • Same as 1.2 above• Same as 1.2 above • Acute care driven healthcare system• Improvement of social welfare and livelihood • limited skill base interdisciplinary workforce • Develop a strategic workforce development plan by the government and establishment of national obserfor human resources• Lack of undergraduate courses in rehabilitation in medical schools• More funding and opportunity to develop a skilled workforce• Limited infrastructures and professional courses/training • More courses on rehabilitation in academic institutions and hospitalsprogrammes in academic institution • Development of strategies for upskilling, empowerment and staff engagement • No educational standards or key performance indicators for rehabilitation or continuous medical education evaluation • Develop teaching models, using interactive problem-based learning• No staff development or appraisal systems in hospitals or • Increase clinical capacity through organized educational activities, e.g. journal clubs, grand rounds. etc.community settings• Motivation of clinical staff• Lack of guidelines/protocols• Promotion of interdisciplinary teaching and interaction• Limited access to education or IT-based learning• Establish workforce management and retention programmes• Limited opportunity for training in new innovations and therapy • Collaboration with international partners for staff training overseas• Inadequate distribution of healthcare professionals – mostly urban setting • Poor awareness amongst healthcare professionals about workforce development • Demoralised workforce
JJRM Table III cont. Actions 1.5 Overcome specific challenges to the quality of healthcare experienced by PwD 1.6 Meet the specific needs of PwD in health emergency risk management Objective 2: Strengthen and ext 2.1 Provide leadership for developing policies, strategies and plans 2.2 Provide adequate financial resources 2.3 Develop and maintain a sustainable workforce
J Rehabil Med 49, 2017
18 F. Khan et al.
M
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JRJRMJRMJRMJRMournal of ehabilitation edicineournal of ehabilitation edicine Table III cont. ActionsPotential challenges/barriersPotential facilitators/enablers in the next 5–6 years • Development of accreditation standards for rehabilitation facilities and key performance indicators 2.4 Expand and strengthen • No accreditation standards or key performance indicators for rehabilitation services ensuring rehabilitation • Develop rehabilitation services within the existing health infrastructureintegration, across the • Rehabilitation services included with other general hospital services • Improved profile of rehabilitation services in acute hospitals and integration of these services with other acontinuum of carenot well integrated nor identified for attentioncare sectors• Lack of structured standard referral systems from acute to sub-• More community-based rehabilitation services linked with main hospital networksacute care to community• Incentives and mechanisms for retaining healthcare personnel especially in rural and remote areas• Lack of healthcare delivery models for Rehabilitation services• Use of IT systems, telemedicine and web-based services for improving awareness and access• Minimal integration of community based programmes with acute • Provision of equipment and technology for therapy in rehabilitation services • Poor follow-up after discharge from acute facility and rehabilitation hospitals • Lack of family/carer education • Adequate financial support2.5 Make available appropriate • Lack of government services and health insuranceassistive technologies • Advocacy for assistive technology funding • Private insurance does not include cover for rehabilitation mobility aids (wheelchairs, cane, and walker), or those for activities of daily • Inclusion of PwD and consumer organizations to raise awareness about technologyliving, orthotics, or prosthetic devices• Expansion of assistive technologies to rural areas• Lack of awareness• Development and/or establishment of allied health rehabilitation services within the existing health • Lack of human resources and infrastructureinfrastructure • Development of Mobile Units • Campaign/awareness programme involving DPOS, NGOs and other charitable/consumer organizations 2.6 Promote access to a range of • Minimal information available to public about access to assistance and support services rehabilitation services • Develop Mobile Units to deliver care in remote areas • Lack of coordination with NGOs, DPOs and other charitable • Expansion of community-based rehabilitationconsumer/organization• International aid including WHO• Lack of insurance/government support for accessing rehabilitation • Develop research programmesservices • Involvement and education of caregivers in rehabilitation settings2.7 Engage, support and build • Exclusion of caregivers of PwD in care servicescapacity of PwD and caregivers • Improve awareness of existing services/benefits for PwD/carers • Poverty • Development of consumer support organizations for PwD at national and local level • High illiteracy • Skill training for carers • Misconception and cultural belief about disability • Expansion of community-based rehabilitation through inclusion of carers in decision-making processes.• Belief in traditional or native healers • Pursuit of social support by PwD • Lack of social security • Lack of family support Objective 3: Strengthen collection of relevant and internationally comparable data on disability and support research on disability and related services • Promotion of operational research in disability and health systems • Lack of universal coding system3.1 Improve disability data collection (survey)• Set a minimal data set for rehabilitation• Lack of trained human resource • Set a universal coding system • Lack of reporting and information-gathering systems • Improve processes relating to clinical documentation/measurement tools• Unreliable timely access to patient medical records • Commence medical staff training in research methodologies • Rehabilitation workforce minimally trained in research methodology including data collection• Establish hospital-based IT systems for data entry • Cultural barrier/misconception – unwilling to disclose• Disability specific registries in the future• Logistical/ethical issues • Implementation and training in ICF model3.2 Reform national data • Lack of standard data collection systemscollection systems based on • Develop standard data collection systems• Minimal awareness and no incentive for hospitals or staff to the ICFparticipate• Mandatory data collection across all sectors • Limited staff training and support for ICF usage• Linkage of performance indicators to health outcomes• Lack of national registries• Involvement and active participation of National Federations, NGOs, DPOs• Lack of financial support
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Challanges in implementation of WHO Global Disability Action Plan in Pakistan 19
RM ormation peration; wpvriinothcviiiansli ooanvn eadrt l dathpisept rifniecgdt ethroaeplao lltgehvr aedple hipsiac frartlam gaemreneatsns, t (em2d4i, l)wi.t aSitrehyr vpairncode-
J ealth; IT: infRegional Coo spdoirsoceviaaisld eis-nesgcp uesreciritfivyic ci mnesse tmcithuoatsintoliysnm st,hs rN (o7Gu,g O1h2s v) .ae Mnrtdiac npayrlli ypv-hamtyesa isnceaiacgnteosdr,
Medicine Disability and HAssociation for pamFnauedrrntt iNthc aeuGrrlemaO rwolsy row erP,ko Mirdnki&gisn ciRgen r iinsnspio btelhlaceeti i aofiulinersb ltwdsa ,nio t-Ihfrn udltieritsartalnle ba dictliioiostopynra admrli inatNianeGtasigo Oienns-.
JRMJRournal of ehabilitation • Potential facilitators/enablers in the next 5–6 years • Involve government and academic institutions to conduct research • Train research professionals • Improve access to IT and web-based programmes • Build research capacity in rehabilitation • Cooperation with international partners in research and development • Involvement and active participation of National Federations • International aid/assistance in research capacity building • Establish national research centre/foundation DP: Gross Domestic Product; ICF: International Classification of Functioning, Medicine and Rehabilitation; PwD: persons with disability; SAARC: South Asian hwhPiimcacaastsrlsmmhaetiewiconceaiooacheeruAalmdakppalnkrmlv artll i ekrrgleat ebypishcotehdbcfo le thi rohenovsaicisleeenfonni,naeyernea rsh teuc lga fsawdasr retrcuegsleh t tiuh afntoehi n sic haohrcrclonsmeudoeef as oracni dtrpng enmlvarPhm.a a l lu taetseriseisarrwSrumree bpv eie atkdlipe tpdrolit ealsmtiititisuur riitsurythcinos,noeciyncnti ns goaaldfgfioitg aa“tadtbe nnue asrolw psnr srie e,rm)rtn rolh deseh e aht(idcdafoisoy tms2e rao oiny ebpf.e san 1b anom ado aiT yonra)ionmoarvi tel .ldhtppnchti lifemhihtscaeh aOosioeraaem inh err aroanteub(texea raiulnhr2 sbdoa nlidinglimb lyes5aypeatnsd diethro wtl) vn y iea m laaiah.endidde nrb nitnmm egadyRtliepa ta pchooaen, entrorri eercla pngtodvretlntoohe o i i irhb eseimgogndtmaaameonlchlrsnrgnb toexsafe ueeaitp dimpu et trdrdmrlcdtrehi eerni hcien o idtcmSe cdwimdeseahcunip iAa istsielniphnh (enribnhu.teneoAeouset hegi”iedrss T naflabm ( i Rhapeiitef7ell lbthvhloa tetisayiCst)yhhceeaess---rl.,,
ons; Gysical hdeisatlrtihcct alreev esly siste fmra gitmseelfn taetd t.h Ae tf ethdee rcaol,m pmrouvninitcyi alle vaneld,
nizatiR: Ph care of PwD (including community-based rehabilita-
JRMJRMournal of ehabilitation edicine Table III cont. • Potential challenges/barriersActions 3.3 Strengthen research on • Research not identified as a priority for rehabilitation priority issues in disability• Lack of awards or recognition for research works • Limited support and IT available for research • Limited staff capacity and training for research • Lack of available research professionals • Limited guidance and/or mentorship • Lack of funding for research Sources: WHO Country Cooperation Strategy at a Glance: Pakistan May 2014; WHO Country Profile: Pakistan; IOM Country Fact Sheet: Pakistan 2014; WHO Health Statistics 2011; ESCAP Statistical Year Book for Asia and the Pacific 2014; WHO Global Infobase; WHO Bulletin; UN Human Development Report 2014. CRPD: Convention on the Rights of Persons with Disabilities; DPOs: Disabled People’s Orgatechnology; NCDs: non-communicable diseases; NGO: non-governmental organization; PM&WHO: World Health Organization. togIRpcomflpsctaacfrtTiiihmeneyoococrraefoooheraelget sctDnrmnmnonepPseedij tvcaeiflrv ove)rd, eiwt ezmpanse nPshemhriaisrCpsalrcicsa Da ae,enaaoz eptto n t.brtt itpnksi athn hPo.aieLomiaao i orctive cerl Fastnsniensiiheitnunrmaoenkcktttddisu eeaaatyrscw noee i or-aeaaPkWslintii wsntfw,vnmopiitnltlhea i ,tesa tte dtoa idChahhek,d sdneisp i nairvnairsociueirmh sinkeems stuste anal,cahgrsiott ei admsnrptgaiohabnc ouochpssie)etlnrrn i.ngrmt vtulm e lroal oepie ywpse iser (aasswfvart, oa ari 1ro oyf onnshtlonenPatrnpuiyr 9fc r dhiynb o emua(a nc B-i)r teabD gelawesckhrlahdi.e nleaaleg d toci Nmieeimua yntCrssdnsfyhtmd hintetuui Wtaaoi d th(aauo, aolp sbrbtlpb1 n tiqenpitvnltv ortiylMru)osh tinua coieesdeo.rsu s nnie nd.N iadll rsTimlufi rnidtraassck-dsuo ca f GhP optl nsyie ferefyDpr lseifl,ee oCos eO smodo ae- oalirr,stcrGnlecnio osdscssn ptiaasu aae of i,lr hiDdaapklaf elge mdbmnnaeremInb roex Amiipoantdsecsdinprlerei,larmlitait sPtsn g hall ieteticun Hse ttdyuv at erc Pyhpi,tanmspnin aea onaaeRma rwsg/iaet dnalndm ogtaerioaetnreyt Daioddehvb norimiftipd kooncmn aic iigtt acoOd lihitaabdaent,orinnnh eaerererrntaliaifrtgdpdydgeeceeessr---tl.
J Rehabil Med 49, 2017