Elsevier

The Lancet

Volume 396, Issue 10260, 31 October–6 November 2020, Pages 1443-1451
The Lancet

Series
Stroke systems of care in low-income and middle-income countries: challenges and opportunities

https://doi.org/10.1016/S0140-6736(20)31374-XGet rights and content

Summary

The burden of stroke is higher in low-income and middle-income countries (LMICs) than in high-income countries and is rising. Even though there are global policies and guidelines for implementing stroke care, there are many challenges in setting up stroke services in LMICs. Despite these challenges, there are many models of stroke care available in LMICs—eg, multidisciplinary team care led by a stroke neurologist, specialist-led care by neurologists, physician-led care, hub and spoke models incorporating stroke telemedicine (ie, telestroke), and task sharing involving community health workers. Alternative strategies have been developed, such as reorganising the existing hospital infrastructure by training health professionals to implement protocol-driven care. The future challenge is to identify what elements of organised stroke care can be implemented to make the largest gain. Simple interventions such as swallowing assessments, bowel and bladder care, mobility assessments, and consistent secondary prevention can prove to be key elements to improving post-discharge morbidity and mortality in LMICs.

Section snippets

Stroke burden in low-income and middle-income countries

Stroke has emerged as an important global health problem and is now the third leading cause of death and disability.1 Deaths due to stroke have risen globally from 5·3 million (95% uncertainty interval 5·22–5·40) in 2007 to 6·2 million (6·04–6·33) in 2017.2 Despite a global decline in the age-standardised stroke death rate, the decline has been slower in low-income countries (LICs) and lower-middle-income countries (21–23%) than in middle-income countries and high-income countries (HICs;

Current challenges in establishing stroke services in LMICs

The available data, although scarce, reflect the status and challenges of service provision across the stroke-care continuum, rapid access to care, acute stroke care, rehabilitation, community support, and secondary prevention. We have summarised these issues in the table, on the basis of work from the systematic review by Pandian and colleagues,10 and we also included data on rapid access to care.

Models of stroke care in low-resource settings

Stroke care models have emerged from data gathered in high-resource settings and focus on issues ranging from recognition of stroke, course of stay in hospital, discharge planning, community reintegration and end-of-life care. However, these models are not easily to implement in resource-poor settings. To adapt to the various challenges in LMICs' health-care systems, alternative models of care involving the various components in the stroke–care continuum have been studied.

Prehospital models of stoke care

The Indian Government, in affiliation with a public–private partnership, has established free ambulance services in 29 states, of which the Dial 108 model is the most popular.10 In Pakistan, both private and government organisations offer standard of care ambulance services with trained paramedics and emergency drugs, but they are largely used for accidents and rescues.51, 52 In China, two emergency ambulance numbers are used, the 120 system and the 999 system. However, these services are still

Stroke care models in LMICs

Five existing models of stroke care are commonly used in resource-poor settings (figure).

Additional considerations for post-stroke rehabilitation

Rehabilitation services in LMICs are limited by low availability, poor accessibility, and low affordability for most stroke survivors. Identification of cost-effective ways to rehabilitate people with disability is an important challenge. There is growing emphasis on using technology to provide patients with information to enable easier access to self-evaluation and self-management strategies. These strategies can be used in areas where large distances or poor accessibility are barriers to

Limitations of our literature review

There are some limitations to the methods we used to identify the studies included in this Series paper. First, we focused our search on studies from LMICs. However, economic disparities within HICs could result in a low-resource setting existing within a HIC, and we did not capture studies done in such settings. Second, because our paper is descriptive, we did not exclude studies on the basis of their methodological quality; we included the data and indicated if methodological issues could

Tips to establish stroke services in low-resource settings

Despite the disparities in wealth, education, baseline health indicators, and funding of health-care expenditures in LMICs, with a few adaptations and some infrastructural remodelling, stroke services can be improved. With this in mind, a few tips are given in the panel.

Future perspectives

The future of stroke care in low-resource settings is to define which key elements across the care continuum will confer the most benefit. Gaps need to be bridged between existing LMIC health-care system challenges and expected post-stroke outcomes (eg, door-to-needle time, stroke unit access, mortality, hospital admissions, discharge rates,78 and wages lost). This will make it possible to track the system's performance by verifying whether the target goals have been met.

Therefore, improving

Conclusions

Despite the challenges, several models of stroke care are available in LMICs that hold promise for improving outcomes. Successful models have involved local and national governments in implementation. A common barrier to many efforts is funding. Effective treatments such as thrombolysis and thrombectomy will only become accessible with government-subsidised funding. Even if these treatments are not available, implementation of modified stroke units that include professionals with specialised

Search strategy and selection criteria

We searched PubMed, Google Scholar, and MEDLINE, using the Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines, to find articles published between Jan 1, 2004, and Dec 31, 2019, that described stroke care in low-income and middle-income countries (LMICs). We used the 2019 World Bank classification of country economies by gross national income (GNI) per capita. According to this classification, in 2018, a GNI per capita of US$1025 or less classified a country as low

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