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