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  • 1. NEUROLOGY ATLAS presents for the first time, the most comprehensive collection and compilation of information on neurological resources across 109 countries. The results confirm that the available resources including services for neurological disorders are markedly insufficient; in addition, there are large inequities across regions and income groups of countries. Urgent action is required to enhance the resources available to address the increasing burden of neurological disorders. This report is the result of a collaborative effort between the World Health Organization and the World Federation of Neurology. World Health Organization Programme for Neurological Diseases and Neuroscience ISBN 92 4 156283 8 Department of Mental Health and Substance Abuse Avenue Appia 20 1211 Geneva 27 Switzerland World Health Organization World Federation of Neurology Website: Geneva London
  • 2. ANNE X E S Results of a collaborative study of the World Health Organization and the World Federation of Neurology Programme for Neurological Diseases and Neuroscience Department of Mental Health and Substance Abuse World Health Organization Geneva 1
  • 3. WHO Library Cataloguing-in-Publication Data Atlas : country resources for neurological disorders 2004. 1.Nervous system diseases 2.Health resources 3.Health manpower 4.Atlases I.World Health Organization II. World Federation of Neurology. ISBN 92 4 156283 8 (NLM classification: WL 17) © World Health Organization 2004 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Marketing and Dissemination, at the above address (fax: +41 22 791 4806; email: The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or bounda- ries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omis- sions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Printed in France Designed by Tushita Graphic Vision Sàrl, CH-1226 Thônex For further details on this project or to submit updated information, please contact: Dr L. Prilipko Programme Leader Neurological Diseases and Neuroscience Department of Mental Health and Substance Abuse World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Tel: +41 22-791 36 21, Fax: +41 22-791 4160, e-mail: 2
  • 4. FO REWOR D Neurological disorders constitute a large and neurological disorders represents a unique collaborative increasing share of the global burden of disease. Stroke, effort between WHO and the World Federation of Neurol- dementia, epilepsy and Parkinson’s disease are important ogy (WFN), which is committed to improving human health factors determining mortality and morbidity in all socie- worldwide by promoting prevention and care of persons ties. However, the resources and services for dealing with with nervous system disorders. WHO and WFN have these disorders are disproportionately scarce, particularly in been working closely for many years on activities related developing countries. While neurological service in West- to prevention and control of noncommunicable and com- ern countries varies from 1 to 10 neurologists per 100 000 municable neurological diseases. This publication is another inhabitants, neurology either does not exist or is only mar- product of their close collaboration. ginally present in major parts of the world. The results obtained from the study of country resources for Over the years, programmes, projects and other activi- neurological disorders confirm that the available resources ties of the World Health Organization (WHO) in the areas for neurological services in most countries of the world are of mental health and neurological disorders have been insufficient compared with the global need for neurological closely linked. During the past decade WHO has launched care. The Neurology Atlas presents the facts and figures and a number of global public health projects, including the highlights the large inequalities across regions and coun- Global Initiative on Neurology and Public Health, in order tries, with low-income countries having extremely meagre to increase professional and public awareness of the global resources. burden of neurological disorders and to emphasize the need The availability of information will lead to greater awareness for provision of neurological care in first-level and referral among policy-makers of the gaps in resources for neuro- health facilities. The outcomes of these endeavours have logical care. It will assist health planners and policy-makers revealed a paucity of information regarding national and to identify areas that need urgent attention and to plan the subnational policies, programmes and resources for the upgrading of resources in those areas. The data also serve treatment and management of neurological disorders. as a baseline for monitoring the improvement in availability WHO is responsible for providing technical information of resources for neurological care. We hope that personnel and advice to its Member States to help them to improve involved in caring for people with neurological disorders, the health of their citizens. This task is facilitated by col- including health professionals and nongovernmental organi- laboration with various scientific and professional groups zations, will use the Neurology Atlas data in their advocacy that have similar goals. The study of country resources for efforts for more and better resources for neurological care. Dr Benedetto Saraceno Dr Johan A. Aarli Director First Vice-President Department of Mental Health and Substance Abuse World Federation of Neurology World Health Organization 3
  • 5. 4
  • 6. CO NTE N TS The project team and partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Executive summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Results by themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1. Neurological disorders in primary care – reported frequency. . . . . . . . 16 2. Neurological services in primary care . . . . . . . . . . . . . . . . . . . . . . . . . 18 3. Therapeutic drugs in primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4. Neurological disorders in specialist care – reported frequency . . . . . . . 22 5. Neurological beds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 6. Sub-specialized neurological services . . . . . . . . . . . . . . . . . . . . . . . . . 26 7. Neurologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 8. Neurological nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 9. Neurosurgeons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 10. Neuropaediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 11. Neurological training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 12. Financing for neurological services . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 13. Disability benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 14. Neurological information gathering system . . . . . . . . . . . . . . . . . . . . 42 15. Neurological associations and NGO's . . . . . . . . . . . . . . . . . . . . . . . . . 44 Brief review of selected topics . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Cerebrovascular diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Parkinson’s disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Multiple sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Training in neurology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 List of Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 5
  • 7. T H E P R OJE CT T EA M A N D PA RT NERS The Atlas of Country Resources for Neurologi- handled the many requests for clarification arising from the cal Disorders is a project of WHO headquarters, Geneva, data. The list of the respondents is included at the end of supervised and coordinated by Dr Leonid Prilipko and Dr the Atlas. Shekhar Saxena. Dr Benedetto Saraceno provided vision A number of leading experts in the field of neurology and guidance to the project. The project was carried out in reviewed the project report and provided comments. They close collaboration with the World Federation of Neurology include Dr Leontino Battistin, Dr Donna C. Bergen, Mrs (WFN) coordinated by its First Vice-President Dr Johan A. Hanneke de Boer, Dr Pedro Chana, Dr Amadou Gallo Diop, Aarli. Dr Aleksandar Janca provided technical guidance Dr M. Gourie-Devi, Dr Jin-Soo Kim, Dr Ashraf Kurdi, Dr and supervision and was involved in the development of Najoua Miladi, Dr Elisabeth Müller, Dr Michael Piradov, Dr the survey design and questionnaire, data collection and Donald Silberberg and Dr Wenzhi Wang. Various special- project management. Dr Tarun Dua was responsible for ists contributed short reviews of selected areas in relation completion of the data collection, data analyses and overall to neurology, as follows. Epilepsy: Dr Jerome Engel Jr; Cer- project management beginning 2004. Dr Dua also took the ebrovascular diseases: Dr B. Piechowski-Jozwiak and Dr J. primary responsibility of writing this report. Kathy Fontanilla Bogousslavsky; Headache: Dr Timothy J. Steiner; Parkinson’s helped in data management and provided administrative disease: Dr Bhim S. Singhal; Dementia: Dr Martin Prince; support. Technical and methodological support was kindly Multiple sclerosis: Dr Jürg Kesselring; Training in neurology: provided by Dr Pratap Sharan and Dr Pallab Maulik. Dr Donna C. Bergen. Key collaborators from WHO regional offices include: Dr A number of colleagues at WHO gave advice and guidance Custodia Mandlhate and Dr Therèse Agossou, African during the course of the project, in particular Dr José Bertol- Regional Office; Dr Claudio Miranda and Dr Jose Miguel ote, Dr Michelle Funk and Dr Vladimir Poznyak. Caldas de Almeida, Regional Office of the Americas; Dr Ahmed Mohit and Dr R. Srinivasa Murthy, Eastern Mediter- The contribution of each of the team members and part- ranean Regional Office; Dr Wolfgang Rutz and Dr Mat- ners, along with input from many other unnamed people, thijs Muijen, European Regional Office; Dr Vijay Chandra, has been vital to the success of this project. South-East Asia Regional Office; and Dr Helen Hermann and Dr Xiangdong Wang, Western Pacific Regional Office, Assistance in preparing the Atlas for publication was all of whom made significant contributions during the received from Tushita Bosonet (graphic design), Steve Ewart development of the project, the identification of focal (maps) and Barbara Campanini (editing). experts in the area of neurology in Member States, and the review of the results. The information from various countries, areas and territo- ries was provided by key persons working in the field of neurology identified by WFN, WHO regional offices and the offices of WHO Representatives. The respondents also 6
  • 8. PREFACE There is considerable information available The Neurology Atlas illustrates the current status of neuro- that the global burden of neurological disorders is large logical services and provision of neurological care in various and increasing. Very little is known, however, about the parts of the world. In general, results obtained objectively resources available within countries to meet this burden. confirm that the available resources for neurological dis- Most information about resources for the care of people orders in most countries of the world are insufficient com- with neurological disorders pertains to a few developed pared with the known significant burden associated with countries; little is known at present about the situation in these disorders. In addition, there are large inequalities the vast majority of countries, and the information that is across regions and income groups of countries, with low- available is not comparable across different countries or income countries having extremely scanty resources. over time. We believe that the information presented in this volume To fill this knowledge gap, Project Atlas was launched by will be useful for a large range of readers including policy- WHO in 2000 with the object of collecting, compiling and makers, health planners and specialists on international as disseminating relevant information on health-care resources well as national level. The results of the Neurology Atlas in countries. The first publication of the project provided clearly establish the need for substantial increase in the regional and world figures on mental health resources in an neurology services especially in low and low-middle income illustrated Atlas of Mental Health Resources in the World countries to decrease the inequity. This would only be 2001. WHO decided to expand the Atlas project into the possible with significant increase in allocation of financial area of neurology and neurological services, as the next log- resources for these services. The data also demonstrate the ical step in the work of WHO in assessing country resources role of international collaboration and partnerships in mak- – and consequently country needs – to control mental and ing a concerted effort to improve the neurological care. neurological disorders. At the country level, the data summarized in the Neurology All information and data contained in the Atlas of Country Atlas may be used for building up national programmes Resources for Neurological Disorders (the Neurology Atlas) and development of strategies to improve control of were collected from a large international study carried out in neurological disorders, as well as their implementation at 2001–2003, which included 109 countries spanning all six country level. In addition, the Neurology Atlas provides the WHO regions and covering over 90% of the world popula- opportunity for comparative analysis of available resources tion. The World Federation of Neurology (WFN) collabo- for neurological disorders across geographical regions and rated closely in the collection and analysis of the data and countries. the development of the Neurology Atlas, with the active The material presented is a first snapshot of the actual glo- participation of leading experts in neurology all over the bal situation, and we are aware of gaps in information and world and valuable assistance from WHO regional advisers possible inaccuracies. We are planning to continue our work and WHO country representatives. in this direction to provide more complete, accurate and comparable information in the coming years. Dr Leonid Prilipko Dr Shekhar Saxena Programme Leader Coordinator Neurological Diseases and Neuroscience Mental Health: Evidence and Research Department of Mental Health and Substance Abuse Department of Mental Health and Substance Abuse World Health Organization World Health Organization 7
  • 9. E X E CU T I VE SU MMA RY Very little information exists regarding the coun- cal inpatient facility as a part of general hospital is, however, try resources available to cope with the known burden of needed to provide comprehensive neurological management. neurological disorders, which is large by all accounts. To fill Specialized services and personnel are essential to provide this knowledge gap, some important information was col- comprehensive neurological care. They are also important for lected by the headquarters of the World Health Organiza- providing training, support and supervision to primary health- tion (WHO) working in close collaboration with its regional care providers in neurological care. The median number of offices and the World Federation of Neurology (WFN). This neurologists is 0.91 per 100 000 population in the respond- work was undertaken under WHO’s Project Atlas, ongoing ing countries. This deficiency is particularly evident in the since 2000. The Atlas of Country Resources for Neurologi- African, South-East Asia, Eastern Mediterranean and Western cal Disorders (the Neurology Atlas) describes the global and Pacific Regions. In terms of the population covered, only one regional analyses of the country resources for neurological quarter has access to more than one neurologist per 100 000 disorders from 106 Member States of WHO, one Associate population. The median number of neurologists per 100 000 Member (Puerto Rico), one Special Administrative Region population is also much lower for low-income countries (0.03) (Hong Kong, China) and one territory (West Bank and Gaza compared with high-income countries (2.96). Recommen- Strip), covering 90.1% of the world population. The infor- dations regarding the required number of neurologists in a mation is primarily gathered from key experts in the area of country are available from countries in the European Region neurology in each country identified by WFN as their official and the Region of the Americas, varying between 1 and 5 delegates and, in some cases, by WHO regional offices. It is per 100 000 population. The number of available neurologists one of the most comprehensive compilations of neurological in the low-income countries is very much lower than any of resources ever attempted. Limitations are to be kept in mind, these recommendations. however, when interpreting the data and their analyses. The key persons were among the most knowledgeable persons in The availability of other types of highly specialized personnel their countries, but the possibility remains of the data being is also limited, with median numbers for neuropaediatricians incomplete and in certain areas even inaccurate. The draft and neurosurgeons being 0.10 and 0.56 per 100 000 popula- report was reviewed by leading experts in the field of neurol- tion, respectively. Again, this deficiency is particularly evident ogy and regional advisers of the six WHO regions, and their in Africa, South-East Asia, the Eastern Mediterranean and the comments were incorporated. The available literature regard- Western Pacific. In terms of population covered, more than ing some of the themes was also reviewed, and the evidence one neuropaediatrician and neurosurgeon per 100 000 popu- is summarized. lation are available for only 2.2% and 15.1% of the popula- tion, respectively. Such a situation is particularly evident in The analyses of the reported frequency of neurological dis- low-income countries, with only 0.002 neuropaediatricians orders showed that epilepsy, cerebrovascular diseases and and 0.03 neurosurgeons available per 100 000 population. headache are among the most common neurological condi- tions encountered in both specialist and primary care settings Neurological nursing does not exist as a specialty in 41% of globally, as well as in all WHO regions. The other neurological the responding countries. Three quarters of the responding disorders reported frequently include Parkinson’s disease, neu- countries have access to less than one neurological nurse roinfections, neuropathies and neurological problems attrib- per 100 000 population. The median number of neurological utable to vertebral disorders. Alzheimer’s disease and other nurses in the responding countries per 100 000 population is dementias were also among the most frequent neurological 0.11. While training for neurologists is being pursued, special- conditions encountered by neurologists in high-income coun- ized neurological nursing training has been neglected even in tries. The programmes dealing with prevention, health care, developed countries. training of personnel and research in the countries need to be based on locally prevalent disorders. The presence of subspecialized neurological services indicates the level of organization and development of neurology in a An important resource is the availability of hospital beds country. Subspecialized neurological services are important, for neurological disorders. Designated neurological beds, because many neurological disorders require highly specialized though not essential, are an important indicator of the level skills for appropriate diagnosis and management. Such servic- of organization of neurological services in a country. The es also provide the basis for conducting research and training median number of neurological beds available in the respond- for various neurological disorders. The respondents reported ing countries is 0.36 per 10 000 population. Two thirds of the availability of subspecialized neurological services (paediatric responding countries have access to less than one neurologi- neurology, neurological rehabilitation, neuroradiology and cal bed per 10 000 population. In terms of population cov- stroke units) in at least two thirds of the responding countries ered, only 8.8% have access to more than one neurological for each of these areas. All the subspecialized services are bed per 10 000 population. Neurological beds are particularly especially deficient in the African Region, while stroke units deficient in the African and South-East Asia Regions. The are also deficient in the Eastern Mediterranean Region. Like median number of neurological beds per 10 000 population all other neurological resources, the availability of subspecial- in low-income countries (0.03) is much lower than in high- ized services is much lower for the low-income countries. income countries (0.73). Separate neurological hospitals with In interpreting these data, however, an important limitation a large number of beds may not be desirable, but a neurologi- should be kept in mind: respondents may have replied posi- 8
  • 10. EXECUTIVE SUM MARY tively to the question of availability of subspecialized neuro- payments in a quarter of responding countries. Out-of-pocket logical services in the country even when only a very limited expenses are particularly important in Africa and South- number of such facilities are available in a few large cities, as East Asia. Tax-based funding is the most important source no information on the type, quality and estimate of number of financing neurological care in the Americas, the Eastern of the facilities was obtained from the respondents. Mediterranean, South-East Asia and the Western Pacific. Social insurance is the most important source of financing in Basic neurological care, including availability of common the European Region (58.3% of the responding countries). drugs, is expected to be available in primary health-care Private insurance plays very little role in financing neurologi- settings. The results show, however, that in 15.6% of the cal care. Out-of-pocket expenditure is the most important responding countries, not even one antiepileptic drug is avail- method of financing in low-income countries. This is likely to able through primary care; the same situation exists in 25% result in more inequity in the utilization of neurological servic- of the low-income countries. Other results show that at least es. Some form of disability benefit is available in 70.5% of the one drug for Parkinson’s disease is available through primary responding countries. However, two thirds of the low-income care in 60.6% of the responding countries, but 83% of the countries have no disability benefits available. This deficiency low-income countries do not have even a single anti-Par- is particularly evident in Africa and South-East Asia. kinsonian drug available through primary care. No follow- up treatment or emergency care for neurological disorders A reporting and information-gathering system for health con- is available at primary care level in 24% and 26% of the ditions assists in monitoring the situation over time, alerts the responding countries, respectively. health system to emerging trends, and facilitates planning. A reporting system for neurological disorders does not exist in Training facilities for neurology are considered an essential one quarter of the responding countries and a data collection part of the health-care system for this specialty in order to system does not exist in half of the responding countries. The continuously improve delivery of neurological care. Although information collection systems are often not in place in the facilities for postgraduate training in neurology exists in 76% African, South-East Asia and Western Pacific Regions. of the responding countries, no such facility exists in half of the low-income countries and few are available in Africa and Professional, user and carer groups are among the most influ- the Eastern Mediterranean. The median number of medical ential advocates to improve the quality of health services in graduates obtaining a specialist degree in neurology every a country. Of the responding countries, 87% have a national year is 0.04 per 100 000 population. The number is much neurological association; however, only half of the responding lower in Africa, the Americas, the Eastern Mediterranean and countries in the African Region have a national neurological South-East Asia. Although training facilities are available in a association. These associations are mainly involved in organ- large number of countries, the number of postgraduates who izing professional meetings and conferences and advising obtain a specialist degree is clearly inadequate. government. Nongovernmental organizations for neurological disorders exist in 71.7% of the responding countries. There Adequate financing of neurology services is essential to pro- are no nongovernmental organizations for neurological dis- vide the needed care for this group of patients. However, only orders in more than half of the responding countries in the 10.4% of the responding countries have a separate budget Eastern Mediterranean. No such organizations exist in 35% of for neurological illnesses within their health budgets. The pro- the low-income countries. portion of the overall health budget allocated for neurological disorders is not specified. Although a separate budget for On the whole, the Neurology Atlas data shows that the avail- neurological services is not essential, when present it assists able resources for neurological disorders in the world are in earmarking the resources and planning the services more insufficient when set against the known significant burden effectively. Common methods of financing neurological care associated with these disorders. In addition, there are large include social insurance and tax-based funding (each in one inequities across regions and income groups of countries, with third of the responding countries), followed by out-of-pocket low-income countries having extremely meagre resources. 9
  • 11. 10
  • 12. INTRO DUCT ION Fostering cooperation among scientific and pro- able to neurological disorders and raised the issue of restoring fessional groups that contribute to the advancement of or creating life of acceptable quality for people who suffer health is one of the key constitutional responsibilities of the from their consequences. World Health Organization (WHO) (1). In order to fulfil its In order to increase professional and public awareness of the constitutional obligation, WHO has been collaborating with frequency, severity and costs of neurological disorders and numerous governmental and nongovernmental organizations to emphasize the need for provision of neurological care at and launched a number of international projects that helped all levels including primary health care, over the past decade health professionals and policy-makers prioritize health needs WHO launched a number of global public health projects and design evidence-based health programmes all over the including the Global Initiative on Neurology and Public Health world. (4). The outcomes of this large international endeavour, which One of the most remarkable collaborative endeavours was involved health professionals in numerous countries all over the Global Burden of Disease study, which was a result of the the world, clearly indicated that there was a paucity of infor- coordinated effort of WHO, the World Bank and Harvard mation on the prevalence of neurological disorders as well as School of Public Health. The Global Burden of Disease report a lack of policies, programmes and resources for their treat- drew the attention of the international health community to ment and management. the fact that the burden of mental and neurological disorders In view of these findings and in order to fill the information had been seriously underestimated by traditional epidemio- gap in the area of neurological disorders and services, in 2001 logical methods that took into account only mortality, not dis- WHO decided to expand the Atlas Project into the area of neu- ability rates. This report specifically showed that while mental rology and to conduct a study of Country Resources for Neuro- and neurological disorders are responsible for about 1% logical Disorders. The main objectives of this large international of deaths, they account for almost 11% of disease burden study were to obtain the following expert information: worldwide (2). ◆ the most common neurological conditions and their distri- As the world became aware of the massive burden associated bution in primary care and specialist settings; with mental and neurological disorders, it also recognized that the resources and services for these disorders were dis- ◆ availability of neurological procedures, treatments and proportionately scarce, particularly in developing countries. services; Furthermore, there has been a large body of evidence show- ◆ number and types of health professionals involved in the ing that, in the years to come, policy-makers and health-care delivery of neurological care; providers in developed and developing countries alike may be unprepared to cope with the predicted rise of the prevalence ◆ characteristics of postgraduate teaching in neurology; of mental and neurological disorders and the disability associ- ◆ budget for and financing of neurological care, including ated with them. In order to respond to this worrisome fact, in the types of health insurance and disability benefits; 2001 WHO coordinated a large international project aimed at collecting, compiling and disseminating information and ◆ availability,role and involvement of national neurological data on the existing resources and services for people suf- associations and other nongovernmental organizations in fering from mental disorders. This project was carried out by advocacy to raise public and professional awareness of neu- WHO headquarters and involved all six WHO regional offices rological disorders and their participation in the treatment, as well as 191 WHO Member States. The main outcome of rehabilitation and prevention of neurological disorders. the project was the publication of the Atlas: Mental Health The study of Country Resources for Neurological Disorders Resources in the World ( represents a unique collaborative effort, which involved WHO evidence/atlas/) that mapped mental health services around headquarters and regional offices and the World Federa- the world and provided a snapshot of the situation on the tion of Neurology (WFN). Although launched under severe ground regarding this important public health matter (3). staff and budgetary constraints in both WHO and WFN, the Over the years, WHO programmes, projects and activities project created much enthusiasm and mobilized more than in the areas of mental and neurological disorders have been 100 WHO Member States and WFN member societies. The closely linked. Many such disorders are chronic and progres- main outcome of the project is the present Atlas of Country sive in nature and fulfil criteria to be recognized as a global Resources for Neurological Disorders (the Neurology Atlas), public health problem; moreover, they are frequent and which provides an illustrative presentation of data and infor- disabling, and they represent a significant burden on com- mation on the current status of neurological services and munities and societies all over the world. The extension of life neurological care in different parts of the world. It is hoped expectancy and the ageing of the general populations in both that the Neurology Atlas will serve as a useful reference guide developed and developing countries are likely to increase to both health professionals and policy-makers and assist the prevalence of many chronic and progressive physical and them in planning, developing and providing better health care mental conditions, including neurological disorders. However, and services to people suffering from neurological disorders the increasing capacity of modern medicine to prevent death, throughout the world. and the development of new, more effective treatments have changed the frequency and severity of impairment attribut- 11
  • 13. M E T H O D O LOG Y All the information and data contained in the Neu- more) (5). The countries were also categorized according to rology Atlas have been collected in a large international study the population figures published in The World Health Report which was carried out in the period 2001–2003 and included 2003 (population data 2002) as: Category I (0–1 million), more than 100 countries spanning all WHO regions and con- Category II (1–10 million), Category III (10–100 million) tinents. and Category IV (>100 million) (6). The published literature regarding some of the themes was also reviewed and the evi- Data collection dence summarized. The results of the analysis were presented in a draft report which was reviewed by leading experts in The Neurology Atlas is based on the information and data the field of neurology and regional advisers of the six WHO collected by WHO and WFN. At WHO, the work was led by regions, and their comments were incorporated. headquarters in close collaboration with the regional offices. The first step in the development of the Neurology Atlas was to identify specific areas where information related to neuro- Representativeness of data collected logical resources and services was lacking. In order to obtain this information, a questionnaire was drafted in English in Completed questionnaires were received from various WHO consultation with a group of WHO and WFN consultants. A Member States, areas and territories: 106 Member States, one glossary of terms used in the questionnaire was also prepared Associate Member (Puerto Rico), one Special Administrative in order to ensure that the questions were understood in the Region (Hong Kong, China) and one territory (West Bank same way by different respondents. Subsequently, the draft and Gaza Strip), which are henceforth referred to as countries questionnaire and glossary were reviewed by selected experts. for the sake of convenience. The data were collected from The questionnaire was piloted in one developed and one 16 countries in the African Region (34.8%), 14 countries developing country and some necessary changes were made. in the Region of the Americas (40%), 18 countries in the The questionnaire and the glossary were then translated Eastern Mediterranean Region (85.7%), 43 countries in the into some of the other official languages of WHO – Arabic, European Region (82.7%), 6 countries in the South-East Asia French, Russian and Spanish. Region (54.5%) and 9 countries in the Western Pacific Region (33.3%). In terms of population covered, the data pertain to The questionnaire and glossary were sent to the official del- 90.1% of the world population; 52.3% of the population in egates of all the 90 member societies of WFN. In addition, Africa, 89.3% in the Americas, 84.1% in the Eastern Medi- WHO regional offices were also asked to identify a key per- terranean, 97.2% in Europe, 96.8% in South-East Asia and son working in the field of neurology in those countries where 97.1% in the Western Pacific. the WFN liaison person was not available or not responsive. The key persons were requested to complete the question- naire based on all possible sources of information available to Limitations them. All respondents were asked to follow closely the glossa- ◆ The most important limitation of the dataset is that only ry definitions, in order to maintain uniformity and comparabil- ity of received information. The Neurology Atlas project team one key person in each country was the source of all responded to questions and requests for clarification. Repeat information. Although the respondent was a WFN liaison requests were sent to the key persons in cases where there officer and had access to numerous official and unofficical was delay in procuring the completed questionnaire. In the sources of information and was able to consult other neu- case of incomplete or internally inconsistent information, the rologists within the country, the received data should still respondents were contacted to provide further information or be considered as reasonably and not completly reliable clarification; where appropriate, documents were requested to and accurate. In some instances the data are the best esti- support completed questionnaires. mates by the respondents. In spite of this limitation, the Neurology Atlas is the most comprehensive compilation Received data were entered into an electronic database sys- of neurological resources in the world ever attempted. tem using suitable codes and analysed using Stata (special ◆ Because the sources of information in most countries edition) version 8 software. Values for continuous variables were the key persons working in the field of neurology, were grouped into categories based on distribution. Fre- the dataset mainly covers countries where there are neu- quency distributions and measures of central tendency (mean, rologists or other experts with an interest in neurology. It medians and standard deviations) were calculated as appro- is therefore likely that the Neurology Atlas gives an overly priate. Countries were grouped into the six WHO regions positive view of neurological resources in the world. (Africa, the Americas, Eastern Mediterranean, Europe, South- East Asia and Western Pacific) and four World Bank income ◆ While attempts have been made to obtain all the required categories according to 2002 gross national income (GNI) per information from all countries, in some countries it was capita according to the World Bank list of economies, July not available. Hence, the denominator for various themes 2003. The GNI groups were as follows: low-income (US$ 735 is different and this has been indicated with each theme. or less), lower middle-income (US$ 736–2935), upper mid- The most common reason for missing data was the nona- dle-income (US$ 2936–9075) and high-income (US$ 9076 or vailability of the information in the country. 12
  • 14. M ETHO DO LO G Y ◆ The data regarding reported frequency of neurological Data organization and presentation disorders in various settings represents an estimate and has not been collected and calculated using stringent The data included in the Neurology Atlas are organized in epidemiological research methods as for prevalence stud- 15 broad themes. The pages on the right-hand side give a ies. The data were compared with the published evidence graphic presentation of the data and facing pages on the left available from various countries and the results of this lit- provide related text. The graphic displays include maps of the erature review have been incorporated as separate boxes. world with colour codings of country data. Regional maps show aggregate figures by WHO regions. Bar and pie charts ◆ Certain questions, especially in relation to neurological are provided to illustrate frequencies, medians and means resources, were framed in such a way that responses as appropriate. Since the distribution of most of the data could be “yes” or “no”. Although this facilitated a rapid is skewed, the median has been used to depict the central gathering of information, it failed to take account of dif- tendency of the various variables. Atlas pages also contain ferences in coverage and quality. Respondents may have definitions of the terms used in the process of collecting the replied positively to the question of availability of neuro- data. Selected findings from analysis of data are described for logical services in the country even if only a very limited each of the specific themes. No attempt has been made to number of such facilities were available in a few large provide a description of all the possible findings arising out of cities. Also, the response does not provide information data analyses presented. Limitations specific to each theme about distribution across rural or urban settings or across are to be kept in mind when interpreting the data and their different regions within the country. analyses. It should be noted that some implications of the ◆ Itis possible that definitions for various terms vary from findings for further development of resources for neurological country to country. As a result, countries may have had disorders are highlighted. difficulties in interpreting the definitions provided in In addition to the information collected as a part of the Atlas the glossary. The definitions regarding various human project, the Neurology Atlas also provides some data that resources, for example, may need to be amended and were obtained from a review of selected literature under expanded in future. some of the themes. No attempt has been made, however, ◆ While all possible measures have been taken to compile, to provide a comprehensive literature review. This additional code and interpret the information given by countries information is presented in separate boxes and is shown in using uniform definitions and criteria, it is possible that a different colour. Brief review of selected topics related to some errors may have occurred during data handling. neurology by leading experts is also provided in a separate section. 13
  • 15. RESULTS BY THEM E S The following pages present the results of the Neurology Atlas by themes 15
  • 16. 1 N E U R O L OG IC A L D ISOR D ER S IN PRIM ARY CARE R EP O RTED FREQ UENCY Definitions ◆ Primary care in this context refers to the provision of The respondents were asked to provide the five neurological basic preventive and curative health care at the first point disorders that are most frequently encountered in primary of entry into the health-care system. Usually, this means care settings. Ignoring the order of the responses, the pro- that care is provided by a non-specialist who can refer portion of countries that mentioned each of the following complex cases to a higher level. diseases was calculated globally and for each of the regions. Salient findings ◆ Globally, headache (including migraine) is the most com- ◆ Neurological problems caused by vertebral disorders are mon neurological disorder seen in primary care settings among the top five neurological conditions encountered (reported by 73.5% of respondents), followed by epi- in primary care settings as reported by respondents in lepsy and cerebrovascular disease (72.5% and 62.7% of 34.3% of countries. Neuroinfections (26.5% of respond- respondents, respectively). Neuropathies (attributable to ents), Alzheimer’s disease and other dementias (22.6% of diabetes, alcohol, nutritional deficiencies and entrapment) respondents) and Parkinson’s disease (19.6% of respond- are next in order (45.1% of respondents). ents) are the other neurological disorders most frequently encountered in primary care settings. ◆ Epilepsy, cerebrovascular disease and headache are also among the five neurological disorders most frequently ◆ The top ten neurological conditions seen in primary care encountered in primary care settings in all the regions. settings also included symptoms that had not yet led to a diagnosis such as vertigo, syncope and dizziness (17.6% of respondents). Limitations ◆ The frequency of neurological disorders in various set- ◆ Although this information is available from only 102 tings is a rough estimate; data were not collected and cal- countries, the data represent 90% of the global popula- culated using stringent epidemiological research methods tion. Regionally, the data represent more than 80% of the as for prevalence studies. The information is based on the population for all the regions except Africa, where they experience and impression of a key person in a country and represent 52% of the population. not necessarily on actual data from responding countries. Implications ◆ The information regarding the diseases most frequently ◆ Integration of neurological care for common illnesses into seen in primary care settings has implications for mak- primary health care is also essential for extending health ing decisions about resource allocation for health care services to underserved areas in both developed and and prevention, research goals, and education of medical developing countries. undergraduates and general practitioners. ◆ Treatment of common neurological disorders at primary care level would be a cost-effective way of improving the scope and utilization of neurological services. Review of literature Headache, epilepsy and neurological problems caused by vertebral disorders (9% each) also featured among the top five neurological disorders featured most frequently (82%, 64% and 64% of stud- disorders seen in primary care settings in some studies. ies, respectively) among the top five neurological disorders in the Cerebrovascular disorders (100% of studies) followed by epilepsy studies describing the prevalence of neurological disorders encoun- (83%), neuropathies and neuroinfections (67% each) were among tered in primary care settings (7–16). Cerebrovascular disorders the top five admitting diagnoses in the studies concerning the and dizziness or vertigo ranked next (36% each). Neuropathies, neurological content of general hospital admissions (14, 17–21). functional disorders and neuroinfections were also identified The other common reasons for admission included cranial trauma among the top five conditions each seen in primary care in 18% of (33%), dementia including Alzheimer’s disease (33%), tumours of the studies. Parkinson’s disease, cranial trauma and psychiatric the central nervous system (17%) and degenerative and demyeli- nating disorders (17%). 16
  • 17. N EURO LO GICAL DISO RDERS IN PRIM ARY C AR E 1 R EP O RTED FREQ UENCY 73.5% 72.5% st y mo imar rs r rde in p 62.7% iso ted ld r ica po s % ) og ly re trie tries ( ol nt ur e un un 45.1% Ne equ by co by co r e 1.1 f car orted t ep 02R 1 os ary N= 34.3% s m rim er p ord in l dis rted ns ica epo gio %) 26.5% log tly r O re tries ( e uro en H n a ch 22.6% Ne equ in W y cou ad ps y fr re ed b He e 1.2 pil ase 19.6% ca ortp E ise Re lar d ies y scu path rs ps va uro rde ile Ep ase bro Ne dis o ns ise ere ra l tio d e C ec nti a lar da ch teb inf scu a se Ve r u ro e me se va He sea Ne rd ea bro di s e dis ere o n’s at hie d oth n’s C ns ns o rki rop tio an rk ins u c se Pa Ne infe nti a i sea Pa d uro e me rs r’s Ne e rd ord e ime oth ld is he d ra Alz an teb ase Ve r ise sd er’ im he 100% Alz ea n 87.5% 89.5% rr an ite 84.6% ed 31.3% ric as nM ric a me 3 47.4% ter Af 16 76.9% A E as 8 62.5% = 1 1 N N= 73.7% N= 18.8% 68.8% 10.5% 15.4% 53.6% 50% 15.4% 42.1% 38.5% 0% 30.8% 31.3 % 10.5% 21.1% 7.7% 83.3% ia ic As 75% acif st nP e -Ea 75% 87.5% ter rop 66.7% uth es 73.7% Eu 38 So 6 W 8 73.7 % N= 66.7% N= N= 50% 0% 31.6% 66.7% 12.5% 36.8% 50% 50% 7.9% 0% 12.5% 34.2% 47.4% 50% 37.5% 37.5% 17
  • 18. 2 N E U R O L OG IC A L SERV IC ES IN PRIM ARY CARE Definitions ◆ Neurological services in primary care refer to the provi- health-care system. The respondents were asked specifi- sion of basic preventive and curative health care for neu- cally about availability of follow-up treatment and emer- rological disorders at the first point of entry into the gency care in primary care settings. Salient Findings ◆ Follow-up treatment for neurological disorders is available ◆ Emergency care for neurological disorders at primary care in 76% of the responding countries. level is available in 74% of responding countries. ◆ Follow-up treatment facilities for neurological disorders ◆ No emergency care for neurological disorders at primary at primary care level are not available in 33.3% of the care level is available in 34.1% of the responding coun- responding countries in the Western Pacific, 31.2% in tries in Europe, 25% in Africa, 23.5% in the Eastern Africa, 26.8% in Europe, 23.5% in the Eastern Mediter- Mediterranean, 22.2% in the Western Pacific, 16.7% in ranean and 7.7% in the Americas. South-East Asia, and 7.7% in the Americas. Limitations ◆ The question specifically requested information about the in primary care settings. Information on the quality of presence of follow-up treatment and emergency care for services and their availability within each country was also neurological disorders in primary care settings. The avail- not obtained. ability of other basic preventive and curative services was ◆ The percentage of countries in Europe with follow-up not asked for. treatment facilities and emergency care at primary care ◆ In the event of availability of follow-up treatment facilities level is low. It is possible that, in many of these countries, and emergency care for even one neurological disorder the first level of contact as well as follow-up may occur in in primary care settings, it is likely that the question was a specialist rather than a primary care setting. answered positively. Therefore, the above numbers might be an overestimate regarding neurological services provided Implications ◆ Integration of neurological care into primary care is essen- ◆ Many neurological disorders require long-term treatment tial in order to extend services to remote and resource- with drugs and rehabilitation, together with extended poor areas. The availability of neurological services at and regular health-care contact. Provision of neurological primary care level would help in lessening the complica- services at primary care level can reduce the burden of tions and disability, thus decreasing the burden attribut- these conditions and enhance patients’ quality of life. able to neurological disorders. 18
  • 19. NEURO LO GICAL SERVICES IN PRIM ARY C AR E 2 nt ary at me prim orld tre s in e w - up rder d th low iso an fol al d ions 76% for ary rld f ic are rim wo e o log reg y c in p the nc nc se euro WHO ge ers and Pre r n in r me ord s o 2.1 f care 104 o f e l dis gion = 68.8% ce gica O re N orl d en 92.3% W es rolo WH Pr eu in a 76.5% 2.2 n care =104 ric 74% Af s 73.2% N ca eri n 100% Am ea 66.7% er ran p e e dit E uro ia rn M As 75% st ic d ste - Ea cif orl Ea uth Pa 92.3% W So ern 76.5% est ric a W Af 65.9% s ca eri n 83.3% Am ea 77.8% rr an e ite rop t ed Eu i a sen t rn M As st ific Pre bsen Ea ste -Ea ac A uth nP So er est W l nt ica t at me olog eren tre eur diff - up for n e in 58.6% s low re car rie 82.8% fol y ca ary unt f nc o e o e prim of c nc rg se eme rs in ups 81% Pre nd rde gro 2.3 a diso ome 83% inc =104 N w Lo le idd rm we Lo le idd rm g he Hi gh Hi l ica s og g u rol ettin ne re s l 75.9% or ica s t f ry ca og g en a u rol ettin atm prim ne re s tre in for ca 82.8% up rs re y w orde lo is y ca imar fol d nc n pr 81% of rge rs i 60% ce me e sen o f e isord Pre ce d sen Pre 19
  • 20. 3 T H E R A P E U T IC D R U G S IN P R IMARY CARE Definitions ◆ The respondents were asked about the distribution of where the drugs for neurological disorders are reimbursed essential drugs for neurological disorders by the govern- by the government or social health insurance, they are con- ment through the primary care system. In countries sidered to be available in the primary health-care system. Salient Findings ◆ In 22.5% of the responding countries, all standard drugs ◆ There is large variation in the availability of anti-Parkinso- for neurological disorders are available through the pri- nian drugs across different income groups: 17.2% of the mary health care system. low-income countries reported the availability of at least one anti-Parkinsonian drug, while 84.4% of the high- ◆ Regarding the various groups of drugs, at least one anti- income countries reported that at least one anti-Parkin- epileptic drug (mainly phenobarbitone) is available sonian drug is available through the primary health-care through the primary health care system in 84.4% of system. responding countries. In 24.1% of low-income countries, no antiepileptic drugs are available through the primary ◆ The availability of anti-Parkinsonian drugs through the health-care system. primary health-care system also varies widely across regions: 12.5% in Africa, 57.1% in the Americas, 73.7% ◆ Regionally,not even one antiepileptic drug is available in the Eastern Mediterranean, 79.1% in Europe, 33.3% in through the primary health-care system in 6.2% of South-East Asia, and 44.4% in the Western Pacific. responding countries in Africa, 21.4% in the Americas, 10.5% in the Eastern Mediterranean, 18.6% in Europe, ◆ Regarding certain other drugs, immunomodulators such 16.7% in South-East Asia, and 22.2% in the Western as interferons or immunoglobulins for neurological disor- Pacific. ders are available through the primary health-care system in 32.1% of the responding countries. ◆ Anti-Parkinsonian drugs are unavailable at primary care level in 39.4% of responding countries. Limitations ◆ Responses on specific medications were not obtained on ◆ Some of the countries responded that government policy a structured format, so there may be some unreliability in provides for these drugs but financial constraints limit the estimates. For example, some drugs (e.g. aspirin) may their availability in the primary care setting. have been left out. ◆ Availabilityin a country of even one drug in each catego- ◆ Some of the respondents from the European Region ry, e.g. phenobarbitone in the antiepileptic drugs, drew an reported that no drugs are dispensed by the government affirmative response. Thus the results fail to differentiate through the primary health-care system. This could be a between countries where a wide range of medication is possible reason for the nonavailability of even one anti- available (e.g. newer antiepileptics) and those where only epileptic drug through the primary health-care system. one or two conventional antiepileptic drugs are available. ◆ Itis also possible that the availability of the drugs is not uniform across primary care centres in a country as infor- mation regarding quality of services and availability within each country was not obtained. Implications ◆ The nonavailability of drugs in the primary care setting ◆ The inequity in availability of drugs for neurological disor- is one of the many reasons for the treatment gap in epi- ders across regions and income categories and also within lepsy. Because the treatment gap involves much more a country needs to be tackled in order to improve the than the nonavailability of antiepileptic drugs at primary level of primary care for neurological disorders. care level, however, other causes – especially related to access and utilization of health services and the problem of stigma – need to be dealt with to decrease the gap. 20
  • 21. THERAPEUTIC DRUGS IN PRIM ARY C AR E 3 r ld ne ry wo t o rima the as d t le n p an f a rug i ons o d ity tic i bil reg 84.4% a ila pilep HO t Av ntie in W sen t 3.1 a care =109 Pre bsen N A 93.8% d 78.6% orl W a 89.5% ric Af s 81.4% ca eri n 83.3% Am ea er ran e 77.8% dit rop e Eu ia nM As s ter E ast cif ic n nia t Ea th- Pa so eren ou rn in f S est e ark dif W i-P e in tries nt r f a ca oun y o ary of c ilit im ps ab pr ail s in grou Av ug r me 3.3 d inco 109 s = N rie are nt ne ary c cou 83% to f 39% as rim s o a t le in p roup 12% of rug e g 16% bi lity tic d com ila ep in va iepil rent A t n ffe 61% 3.2 a in di 09 1 84% N= 24% 10% 88% 12% 16% 17% 76% w 84% Lo le i dd 90% rm le we idd 88% Lo er m gh gh Hi Hi w Lo n le nia i dd o rm dle ins we mi d ark Lo er Hi gh -P in rld H igh nti are e wo a c f h y o ary d t ilit rim s an 60.6% ab p ion ail in Av ugs reg r 3.4 d WHO 109 = N 12.5% d 57.1% orl W a 73.7% ric Af s 79.1% ca eri n 33.3% Am ne a 44.4% a pe err e dit E uro ia rn M As st ic ste - Ea cif Ea uth Pa So ern es t W 21
  • 22. 4 NEUROLOGICAL DISORDERS IN SPECIALIST CARE R EP O RTED FREQ UENCY Definitions ◆ Information on the neurological disorders encountered ◆ The respondents provided the five most frequently by specialists has implications for health care and teach- encountered neurological disorders in specialist settings. ing. To serve as effective patient advocates, providers of Ignoring the order of the responses, the proportion of neurological care need to understand the local profile and countries that mentioned each of the following diseases effects of neurological disorders to plan resource alloca- was calculated globally and for each of the regions. tion for health care and prevention, neurological care, research goals and medical education. Salient Findings ◆ Globally,epilepsy (92.5%) and cerebrovascular dis- ◆ Epilepsy,cerebrovascular disease and headache (including eases (84%) followed by headache (including migraine) migraine) are also the three top conditions encountered (61.3%) top the list of the diseases most frequently seen by neurologists in all the regions. by a neurologist. ◆ More than one quarter of respondents reported that a ◆ Parkinson’sdisease (46.2%) and neuropathies (35.8%) neurologist’s opinion is sought for Alzheimer’s disease and were the other major diseases encountered in specialist other dementias and in multiple sclerosis. settings. Limitations ◆ The frequency of neurological disorders in various settings ◆ Although this information is available from only 106 is a rough estimate; data were not collected and calcu- countries, the data represent 90% of the world popula- lated using stringent epidemiological research methods as tion. Regionally, the data represent more than 80% of the for prevalence studies. The information is based on the population for all the regions except Africa, where they impression of a key person in a country and not on actual represent 52% of the population. data from countries. Implications ◆ Major inputs in health care and prevention and priorities ◆ The training curriculum of neurologists should concentrate for research should be focused on locally prevalent neuro- on the prevention and management of these disorders. logical disorders. Review of literature Epilepsy, headache and cerebrovascular disorders featured most also featured among the top five neurological disorders seen by frequently (88%, 88% and 76%, respectively) among the top five specialists in some studies. neurological disorders in the studies describing the prevalence of Cerebrovascular disorders and stroke appeared among the five most neurological disorders in specialist settings (22–38). Neuropathies frequent inpatient diagnoses in a study describing the neurological and neurological problems caused by vertebral disorders ranked inpatient services in 14 post-communist central and eastern Euro- next (36% each). Parkinson’s disease and multiple sclerosis were pean countries (39). Epilepsy was the second most common diag- also identified among the top five conditions seen by neurologists nosis to feature in the top five conditions in 85.7% of the countries, in 29% of the studies. Cranial trauma (24%), functional and psy- followed by neuropathies (71.4%), neurological problems caused by chiatric disorders (18% each), dizziness and vertigo, and alcohol- vertebral disorders (57.1%) and multiple sclerosis (42.9%). ism (12% each) and herpes zoster and Down syndrome (6% each) 22
  • 23. NEUROLOGICAL DISORDERS IN SPECIALIST CARE 4 R EP O RTED FREQ UENCY 92.5% t t os ialis 84% r s m pec rde in s iso ted ld r ) ica epo es (% log tly r ntri ntries 61.3% uro en ou ou Ne equ by c by c 4.1 fr are rted t t c epo 6 46.2% os ialis R 10 s m pec N= er s ord in 35.8% l dis rted ons ) ica epo egi (% 27.4% log tly r O r ntries y uro en H ou ile ps 26.4% Ne equ in W by c Ep se 4.2 fr are rted i sea e 26.4% c epo la rd a ch R scu ad ase a He y rov d ise es lep s C erb n’s thi Ep i ase ins o pa ns ise rk uro tio d e Pa Ne ec a lar ch inf nti scu a da se u ro e me sis va He sea Ne rd ero bro di hie s oth e es cl ere n’s t ipl C ns o pa ns a nd ult i ro o P ark eu e cti a e ase M N ro inf e nti s dis eu em sis er’ N er d ero im th scl he do ipl e Alz an ult ase M ise sd er’ im he Alz 100% 100% ea n 93.8% rr an ite s 89.5% ed ca M a 85.7% eri rn 68.8% ric ste Af 16 Am 14 Ea 18 37.5% N= 78.6% N= N= 18.8% 64.3% 57.9% 68.8% 35.7% 35.7% 21.1% 43.8% 50% 26.3% 31.6% 15.8% 12.5% 21.1% 14.3% 6.3% 100% 100% 87.5% ia ic 87.5% t As 88.9% a cif as 77.8% nP e -E ter rop 83.3% uth es Eu 40 So 6 W 9 N= N= N= 66.7% 60% 66.7% 55.6% 55% 55.6% 25% 10% 35% 33.3% 44.4% 47.5% 33.3% 11.1% 11.1% 0% 0% 23
  • 24. 5 N E U R O L OG IC A L B ED S Definitions ◆A neurological bed is defined as a hospital bed main- public or private neurological hospitals, general hospitals, tained only for use by patients with neurological disorders or special hospitals for elderly people or children. on a continuous basis. These beds may be located in Salient Findings ◆A total of 251 455 neurological beds are reported to be the Americas, 0.26 in the Western Pacific, and 1.71 in available in 95 countries. Europe. ◆ The median number of neurological beds in the respond- ◆ The median number of neurological beds per 10 000 ing countries is 0.36 per 10 000 population (interquartile population across different income groups of countries range 0.03–1.35). also varies: 0.03 and 0.24 for low-income and lower mid- dle-income countries, respectively, while the numbers ◆ Almost 70% of the responding countries have access to are 1.83 for higher middle-income countries and 0.73 for less than one neurological bed per 10 000 population. In high-income countries. terms of population coverage, only 8.8% of people have access to more than one neurological bed per 10 000 ◆ The median number of neurological beds per 10 000 population. population is higher for countries with smaller populations (0.63 each for countries in population categories I and ◆ The median number of neurological beds per 10 000 var- II) compared with larger populations (0.10 and 0.20 for ies widely across regions: 0.03 in Africa and South-East countries in population categories III and IV, respectively). Asia, 0.15 in the Eastern Mediterranean, 0.17 in Limitations ◆ In many countries, beds are not earmarked for patients ◆ The lower number of neurological beds in high-income with neurological disorders but are part of the pool for countries compared with higher middle-income countries internal medicine, neuropsychiatry, geriatrics, paediatrics cannot be fully explained. Among the possible reasons or general beds; and these may not have been reported. are that many high-income countries may not have beds earmarked for the care of patients with neurological dis- ◆ Moreover, in many countries patients with various cat- eases, specialized units (stroke units, spinal centres, epi- egories of neurological disease, e.g. cerebrovascular dis- lepsy units) are not defined among the neurological beds ease, meningitis, or status epilepticus, are managed on or there could be other reporting errors. Many of the beds allocated to internal medicine, emergency services higher middle-income countries are in central and eastern or intensive care units, and these may not have been Europe, where neurological services are well developed reported. and where a broader spectrum of diseases is labelled ◆ No information is available on beds available in rehabilita- neurological, e.g. vertebrogenic diseases, and managed in tion, chronic care or centres for the elderly. neurological facilities. Implications ◆ Though not essential for the provision of neurological areas needs to be specifically dealt with. Separate neuro- care, designated beds may be considered to be an indica- logical hospitals with a large number of beds may not be tor of the level of organization of neurological services in desirable, but a neurological facility as a part of a general a country. hospital is necessary for comprehensive management of neurological disorders. ◆ The inequity in neurological services observed across income categories, population categories and geographical Review of literature Very few reports are available (16 countries from the European number of 3.02 (interquartile range 0.4–6.8) neurological beds Region) describing the availability of neurological beds (21, 39, 40). per 10 000 population are present in these countries. In European A median number of 3.5 (interquartile range 0.8–7.1) neurological countries, recommendations are available regarding the required beds per 10 000 population are available in the countries studied. number of neurological beds: these recommendations vary from This figure is congruent with the Atlas data wherein a median 1.5 to 7.3 neurological beds per 10 000 population (21, 41). 24
  • 25. NEURO LO GICAL BE D S 5 0.1 1 0- 1- s f lb ed 0.1 01-5 ro 1. >5 be gica m o ab le WHO 01.171 0 Nu urol 00 n av ail 5.1 ne r 10 latio al ot pe opu gic nn tio p 95 olo n ld ur o or orma N= ne ati Inf of pul he w r po be dt um 000 s an n 0 1.71 an r 1 gio n i e ed e M ds p O r ica l e b WH og in es 5.2 l tri in 95 uro tion coun N= 0.15 ne la of of u 0.17 er pop ups mb 00 gro u 0 0.03 n n 10 me 0.03 e dia per inco M ds ent e a 5.3 b iffer 5 ric 0.26 d =9 Af s N ca eri n 0.36 1.83 Am ea rr an pe ite uro ed E ia nM As r st ic ste -Ea cif Ea th Pa d So u ter n orl es W W l ica 0.24 0.73 log s uro on rie 0.03 f ne lati tego 0.63 r o pu ca m be 0 po tion 0.63 w nu 0 00 pula Lo le ian er 1 t po dd ed mi le M ds p eren ies we r i dd e f 5.4 b n dif untr Lo he rm Hi gh i co Hi g of 5 9 N= 0.1 0.2 tI Ca t II Ca I t II Ca t IV Ca 25
  • 26. 6 S U B -S P E C I A LIZ ED N EU R OLOG ICAL SERVICES Definitions ◆ Paediatric neurology services include any hospital, clinic ◆ Neuroradiology services are concerned with the diagnos- or centre that deals with neurological diseases in children. tic radiology of diseases of the nervous system through the use of X-ray, CT scan, magnetic resonance imaging, ◆ Neurological rehabilitation services are team based and angiography and other diagnostic facilities. comprehensive multidisciplinary programmes designed to improve function, reduce symptoms and improve the ◆ Stroke units provide organized care to stroke patients by well-being of patients with neurological problems and multidisciplinary teams. They are characterized by coordi- their families in their social milieu. These services can be nated multidisciplinary rehabilitation, staff with a special organized as inpatient, outpatient or day-care services. interest in stroke or rehabilitation, routine involvement of carers in the rehabilitation process, and regular pro- grammes of education and training. Salient Findings ◆ Some paediatric neurology service is present in 80.6% of ◆ Some neuroradiology service is present in 77.8% of countries that responded. No paediatric neurology serv- countries that responded. No neuroradiology services are ices are available in 50% of low-income countries. No available in 57.1% of low-income countries. In 81.2% of paediatric neurology services are available in 62.5% of countries in Africa, no neuroradiology services are present. countries in Africa, 33.3% in South-East Asia, and 31.6% ◆ Some kind of stroke unit is present in 62% of respond- in the Eastern Mediterranean. ing countries. In 57.1% of low-income countries, stroke ◆ Some neurological rehabilitation service is present in units are not available and they are also absent in 25% of 73.2% of responding countries. In 60.7% of low-income high-income countries. countries, no neurological rehabilitation service is avail- ◆ In 73.7% of countries in the Eastern Mediterranean able. No neurological rehabilitation service is present in and in 68.7% of countries in Africa, no stroke units are 81.2% of countries in Africa. present and they are also absent in 35.7% of countries in the Americas, 16.7% in Europe, 16.7% in South-East Asia, and 22.2% in the Western Pacific. Limitations ◆ Respondents may have replied positively to the question ◆ Some respondents may have responded in the affirmative of availability of subspecialized neurological services in even if the subspecialized services are a part of the gen- the country even if only a very limited number of such eral services, e.g. neuroradiology as a part of the general facilities are available in a few large cities, as no informa- radiological facilities. tion was obtained on the type, quality and estimated numbers of such facilities. Implications ◆ Subspecialized neurological services are important ◆ For correct diagnosis and subsequent management of because many neurological disorders require highly spe- neurological disorders, neuroradiology services are essen- cialized skills for appropriate diagnosis and management. tial. For example, in the case of head trauma, neuroradi- They also provide the basis for carrying out research and ology can help to delineate the extent of brain injury or training for various neurological disorders. presence of haematoma requiring urgent surgical inter- vention. ◆ The profile of neurological disorders is different in children compared with the general adult population. Special serv- ◆ Substantial evidence shows that organized inpatient care ices are, therefore, needed for them as a group. in a stroke unit decreases mortality and residual disabil- ity, increases the number of independent survivors and ◆A neurological component should be an important part reduces institutionalization, without increasing the cost of of rehabilitation training of community health workers, care. As these units can be established within the existing because community-based, family-centred and culturally medical facilities with minor reorganization of services and responsive care is the best model to help people with neu- training of existing staff without major extra cost to the rological disabilities achieve the highest possible level of health-care system, an effort in this direction is required. function and independence. 26
  • 27. SUB-SPECIALIZED NEURO LO GICAL SERVI CE S 6 y log e uro O orl d 80.6% c n WH he w tri n dia s i dt ae vice s an P er on 6.1 s regi 108 37.5% N= orl d 100% W a 68.4% ric n Af 95.2% tio ca s ita eri n 66.7% a bil Am ea 88.9% reh rld 73.2% rr an e al HO wo ite rop ic W e ed Eu a og th rol s in d i M As ern st ific eu vice s an E ast th -Ea ac N er on S ou er nP 6.2 s regi 108 18.8% est N= d W 78.6% orl W a 73.7% ric Af s 88.1% ca eri n 83.3% Am ea r ran e 77.8% ite rop ed Eu ia M As ern st ic ast -Ea cif E th Pa S ou e rn est W y d og O orl 77.8% iol WH e w ad th ror s in d eu vice s an N er on 6.3 s regi 108 18.8% N= d 92.9% orl W a 84.2% A fric 85.7% s ca eri n 100% Am ea 88.9% er ran e dit rop e Eu ia nM As s ter E ast cif ic HO rld Ea th- Pa 62% S ou e rn i n W e wo est its th W un and e s ok Str gion 8 r e 1 0 31.3% 6.4 N= d 64.3% orl W a 26.3% ric Af s 83.3% ca n eri n 83.3% tio Am ne a 77.8% i lita es err a pe ab tri dit uro lr eh rent oun M e E As ia c ica iffe of ste rn Ea st cif ic l og in d ups Ea uth - Pa uro es ro 88.2% So ern Ne ervic me g 77.4% W est 6.5 s co 8 90.6% in 10 N= 39.3% t sen t Pre bsen A w Lo le m idd er le w idd Lo rm gh g he Hi Hi 27
  • 28. 7 N E U R O L OG IST S Definitions ◆ Inthis context, a neurologist is a medical graduate who uate training in neurology from a recognized teaching has successfully completed at least two years of postgrad- institution. Salient Findings ◆ In total, 85 318 neurologists are reported to be available ◆ In terms of the population covered, 25% have access to in 106 countries. The median number of neurologists in more than one neurologist per 100 000 population. the responding countries is 0.91 per 100 000 population ◆ The median number of neurologist per 100 000 popula- (interquartile range 0.18–4.48). tion across different income groups of countries also var- ◆ The median number of neurologists per 100 000 popula- ies: 0.03 for low-income countries compared with 2.96 tion also varies widely across regions: 0.03 in Africa, 0.07 for high-income countries. Even among high-income in South-East Asia, 0.32 in the Eastern Mediterranean, countries, 24% have access to less than one neurologist 0.77 in the Western Pacific, 0.89 in the Americas, and 4.84 per 100 000 population. in Europe. ◆ The median number of neurologists per 100 000 popula- ◆ Allresponding countries in Africa and South-East Asia, tion is 2.30 for countries in population category I com- 89% in the Eastern Mediterranean, 67% in the Western pared to 0.62 in population category IV. Pacific, 50% in the Americas and 7% in Europe have less than one neurologist per 100 000 population. Limitations ◆ Because the sources of information in most countries The information from these countries might therefore be were key persons working in neurology, the data pertain an underestimate. mainly to countries where there are neurologists or per- ◆ Information about the distribution of neurologists within sons with an interest in neurology. It is therefore possible countries is not available but, as reported by some that the above figures might be overestimated. respondents, the majority are likely to be concentrated in ◆ Insome countries, neurological diseases such as epilepsy urban areas, thus leading to more inequity than is appar- and dementia are also managed by psychiatrists. ent from the above figures. Implications ◆ Neurologists are essential in order to provide comprehen- ◆ The appropriate number of neurologists in the popula- sive neurological care. They are also important for pro- tion depends upon the structure of a country’s health-care viding training, support and supervision to nurses, other system, the way in which primary care is delivered, the paramedical staff and primary health-care providers in role played by specialists, and the geographical distribu- neurological care. tion of the population. In high-income countries with large concentrations of urban population, the specialists ◆ The inequity in the number of neurologists observed primarily act as clinical caregivers; in low-income countries across countries in different income groups, population with large, widely distributed rural populations the most categories and geographical areas needs to be specifically appropriate role for smaller numbers of specialists may be dealt with. in training and education of primary health-care personnel, and in advising on health care planning. Review of literature Reports are available from 67 countries regarding the number of are present in these countries. Recommendations regarding the neurologists (32, 36, 42–49). According to the above reports, a required number of neurologists in a country are available from median number of 2.5 (interquartile range 0.6–4.7) neurologists countries in Europe and the Americas, varying between 1 and 5 per 100 000 population are available in these countries. The figure per 100 000 population. The number of available neurologists in is congruent with the Atlas data wherein median number of 2.4 many of the low-income countries is very much lower than any of (interquartile range 0.5–5.3) neurologists per 100 000 population these recommendations. 28
  • 29. NEURO LO G IS TS 7 of s er ist 0 mb olog 0 00 Nu eur 10 ion 7.1 n per pula t 0.1 1 0- 1- p o 106 0.1 01-5 N= 1. >5 WHO 01.171 le ab ail av ot nn s tio 0 ie 3.19 rma f 00 ntr Info e r o 100 nt c ou s 2.96 mb er re of gis t es nu ts p diffe ories o tri ian ogis in teg rol un ed n eu n in of co n io M urol atio n ca 3.17 of t s ne pul latio er ula up 7.3 po opu 6 u mb pop e gro p 10 2.3 n n 00 om N= e dia 00 0 t inc 0.74 M er 1 ren e 6 7.2 p diff 10 0.03 N= w Lo le idd rm le we idd Lo er m gh 0.57 gh Hi 0.62 Hi tI Ca t II Ca I ts t II gis Ca o t IV tio n rol Ca eu ns p ula f n gio po ld 4.84 ro f 00 wor m be O re o 0 Nu WH er 00 he mb er 1 nd t u p 7.5 i n n n ts ns a e dia logis gio Americas Europe M uro re O 22 370 (N=14) 45 839 (N=43) 7.4 ne WH in 06 0.32 1 N= 0.89 Western 0.03 Pacific 14 293 (N=9) 0.07 a ric Af s 0.77 ca eri WHO 01.182 n 0.91 Am ea rr an e ite rop Africa ed Eu ia M As 423 st ern E ast ific (N=16) Ea th- ac S ou er nP orl d Eastern est W Mediterranean South-East Asia W 1 125 (N=18) 1 118 (N=6) 29
  • 30. 8 N E U R O L OG IC A L N U R SES Definitions ◆ Inthis context, a neurological nurse is a registered nurse successfully completed required additional training in who graduated from a recognized nursing school and neurological nursing. Salient Findings ◆A total of 54 693 neurological nurses are reported to be Pacific, 71.4% in the Eastern Mediterranean, and 41.9% available in 82 countries. The median number of neu- in Europe have less than one neurological nurse per rological nurses in the responding countries is 0.11 per 100 000 population. 100 000 population (interquartile range 0–1.66). ◆ The median number of neurological nurses per 100 000 ◆ The median number of neurological nurses per 100 000 population across different income groups of countries population varies widely across regions. It is 0 in Africa, also varies It is 0 for low-income countries, 5.04 for high- 0.005 in South-East Asia, 0.13 in the Eastern Mediter- er middle-income countries, and 0.38 for high-income ranean, 0.14 in the Americas, 0.32 in the Western Pacific, countries. and 2.43 in Europe. ◆ Even among high-income countries, two thirds have ◆ Of the responding countries, 71% have access to less access to less than one neurological nurse per 100 000 than one neurological nurse per 100 000 population; population. 39% have no neurological nurses. In terms of population ◆ There are more neurologists than neurological nurses in covered, more than one neurological nurse per 100 000 many of the countries (the ratio of neurological nurses population is available for 36.4% of the population. to neurologists is less than one in 73% of the responding ◆ Regionally, all responding countries in Africa and South- countries). East Asia, 90% in the Americas, 87.5% in the Western Limitations ◆ In many countries where no formal training programme neurological nurses as they do not have a separate regis- exists for neurological nursing, many nurses are informally ter for nursing subspecialities. trained in aspects of neurological care. This is not reflect- ◆ Information about the distribution of neurological nurses ed in the data. in countries is not available, but the majority are likely to ◆ Some countries were unable to provide data regarding be concentrated in urban areas. Implications ◆ Neurological nurses are important members of the team ◆ Incountries where no formal training facilities exist for that provides comprehensive neurological care, training neurological nursing, general nurses can be trained to and supervision. provide specific neurological care. ◆ While training for neurologists is being pursued, special- ized neurological nursing training has been neglected even in developed countries. 30
  • 31. NEURO LO GICAL NUR S E S 8 of l er ica mb olog per Nu eur es 0 8.1 n nurs 0 00 atio n 0.1 1 0- 1- 0 pul 1 o 0.1 01-5 p 82 1. >5 WHO 01.171 N= ab le ail av 2.43 ot nn tio orma Inf al gic n s ur olo latio rld rse s ne pu wo e r l nu gion r of 0 po the mb ica re be 00 nd 0.13 nu olog HO n r n um 100 ns a 0.14 dia eu n W o ian er gi f me nd n ion i ed ses p O re 0 M ur n o ts a lat H 8.2 n in W 82 iso ogis popu ar l mp ro 00 d N= ric a 0.005 Co f neu 00 0 orl Af s ca 0.32 8.3 o per 1 the w eri n Am ea nd 82 a = rr an e N ite rop 0.11 ed Eu sia n M A 0.13 4.84 s ter East ific Ea th- ac 0.32 So u nP orl d es ter W 0.14 W 0.89 0 0.03 2.43 f r o al O be ogic WH ric a um rol in N eu es Af 0.07 8.4 n nurs ions as er i c 0.005 reg Am an 0.77 ra ne Americas Europe iter 0.32 5 333 (N=10) 25 985 (N=31) ed pe rn M E uro 0.91 e E ast sia Western s tA - Ea 0.11 Pacific uth c ific 20 335 (N=8) So Pa e rn d est orl W W WHO 01.182 ts Africa gis s rolo urse 28 N eu al n (N=14) ic og Eastern u rol Ne Mediterranean South-East Asia 2 802 (N=14) 175 (N=5) 31
  • 32. 9 N E U R O S U R G EON S Definitions ◆ Inthis context, a neurosurgeon is a medical graduate who has completed at least two years of recognized post- graduate training in neurosurgery. Salient Findings ◆A total of 33 193 neurosurgeons are reported to be avail- population covered, more than one neurosurgeon per able in 103 countries. The median number of neurosur- 100 000 population is available for 20.3% of the popula- geons in the responding countries is 0.56 per 100 000 tion. population (interquartile range 0.07–1.02). ◆ The median number of neurosurgeons per 100 000 ◆ The distribution of neurosurgeons across regions is vari- population across different income groups of countries able. The median number of neurosurgeons per 100 000 varies. It is 0.03 for low-income countries and 0.97 for population is 0.01 in Africa, 0.03 in South-East Asia, 0.37 high-income countries. Half of the high-income group of in the Eastern Mediterranean, 0.39 in the Western Pacific, responding countries have access to less than one neuro- 0.76 in the Americas, and 1.02 in Europe. surgeon per 100 000 population. ◆ Of the responding countries, 26% have access to more ◆ The median number of neurosurgeons per 100 000 popu- than one neurosurgeon per 100 000 population. In terms of lation is 0.94 for countries in population category I, com- pared with 0.49 for countries in population category IV. Limitations ◆ Because the source of information in most countries was ◆ Information about the geographical distribution of neurosur- the professional association, it is possible that neurosur- geons in countries is not available but, as reported by some geons who are not members of these associations were respondents, the majority are concentrated in urban areas. not counted. Implications ◆ Neurosurgeons complement the services provided by ◆ Training of general surgeons in neurosurgical emergencies neurologists, most importantly to provide surgical services is important in settings where it is not possible to have for neurological conditions. They provide expert care at enough neurosurgeons at primary and secondary levels. secondary and tertiary level for neurosurgical emergencies ◆ The inequity in the number of neurosurgeons observed in such as head trauma and haemorrhage and also surgi- countries in different income groups, population catego- cal care for conditions such as space-occupying lesions. ries and geographical areas needs to be specifically stud- In some places, neurosurgeons also provide medical care ied and tackled. for people with neurological disorders. They also provide training, support and supervision to primary health-care providers in care of neurological conditions, especially emergencies. 32
  • 33. NEURO SURGEO N S 9 f ns r o eo be urg 00 m s 0 Nu euro 00 ion 1 1 t 0.0 .1 9.1 n per pula 0- 0 o 103 p = 2- 1-1 N 0.0 0.1 >1 WHO 01.171 le ab ail av s ot on tio nn rge 0.94 a su s 0.97 orm uro n ies on nt nf ne ion i egor rge ffere I f r o at at su i be pul n c uro n d um 0 po latio ne ion i ies 0.94 f n u r o at ntr ian 0 00 pop be opul cou 0.49 ed um 0 p of M er 10 rent tries n s 9.3 p diffe coun ian 00 up 0.77 ed 100 gro M er of =103 me N 9.2 p inco 103 = 0.03 N 0.38 ow 0.49 L le idd rm le we idd Lo rm gh gh e Hi Hi tI Ca t II Ca I t II of s Ca er er e on t IV mb ns p tion rg Ca u su n n geo ula s uro s e dia osur pop ion ne n M eur 00 reg rld of egio 0 O 0.37 er r 9.4 n 100 H wo 1.02 mb O W the 0.76 Nu WH in nd in a =103 9.5 N Americas Europe 8 607 (N=14) 7 321 (N=40) 0.03 0.39 Western 0.01 Pacific 0.56 14 722 (N=9) a ric Af a s e ric WHO 01.182 Am n n ea rra e ite rop Africa ed Eu ia nM As 257 r st ic ste -Ea cif (N=16) Ea uth Pa d So ern orl Eastern est W Mediterranean South-East Asia W 1 163 (N=18) 1 023 (N=6) 33
  • 34. 10 N E U R O PAE DIAT R IC IA N S Definitions ◆A neuropaediatrician is a specialist (neurologist or paedia- trician) who has at least one year of recognized subspe- cialist training in child neurology. Salient Findings ◆A total of 5733 neuropaediatricians are reported to be 23.5% of the responding countries do not have any available in 98 countries. The median number of neuro- neuropediatricians. In terms of population covered, more paediatricians in the responding countries per 100 000 than one neuropaediatrician per 100 000 population is population is 0.10 (interquartile range 0.01–0.42). Since available for only 2.4% of the population. neuropaediatricians are specialists catering only for chil- ◆ The median number of neuropaediatricians per 100 000 dren, the median number of neuropaediatricians in the population across different income groups of countries responding countries per 100 000 under-18 population is also varies. It is 0.002 for low-income countries, com- 0.33 (interquartile range 0.02–1.55). pared to 0.25 for high-income countries. ◆ The median number of neuropaediatricians per 100 000 ◆ Even among high-income countries, only 7.7% of them population varies widely across regions. It is 0 in Africa, have access to more than one neuropaediatrician per 0.003 in South-East Asia, 0.06 in the Eastern Mediter- 100 000 population. ranean, 0.08 in the Western Pacific, 0.12 in the Americas, and 0.47 in Europe. The median number of neuropaedia- ◆ The median number of neuropaediatricians is higher for tricians in the responding countries per 100 000 under-18 countries with smaller populations (0.24 for countries in population is 0 in Africa, 0.007 in South-East Asia, 0.06 in population category I) compared with 0.01 for countries the Eastern Mediterranean, 0.25 in the Americas, 0.26 in in population category IV. the Western Pacific, and 2.07 in Europe. ◆ Of the responding countries, 87.8% have less than one neuropaediatrician per 100 000 population. In fact, Limitations ◆ Inmany countries, neuropaediatrics as a specialty does ◆ Because the source of information in most of the coun- not exist; children with neurological problems are seen tries was the national association of neurologists, it is pos- by neurologists or paediatricians with a special interest in sible that the neuropaediatricians who are not members neurology. This is true not only for developing countries of these associations were not included. but also for some developed ones. ◆ Incountries where neuropaediatricians exist, information ◆ In some countries children with neurological disorders are about their distribution is not available. It is possible that also seen by child psychiatrists, and these are not included. the majority of them are concentrated in urban areas. Implications ◆ Children form a large proportion (40% or more in many ◆ The inequity in the number of neuropaediatricians countries) of the total population. Certain neurological observed across income groups, population categories disorders are also unique to children. Neuropaediatri- and geographical areas needs to be specifically studied cians are therefore required at the tertiary level to provide and tackled. Often the regions with the lowest resources specialist care. They are also needed to provide training, are those with the greatest proportions of children and no support and supervision to primary health-care providers neuropaediatricians. involved in the neurological care of children. ◆ It is also important to build the capacity of paediatricians who have a special interest in neurology so that they can manage neurological diseases more effectively. 34
  • 35. NEURO PAEDIATRICI AN S 10 s ian f ric r o diat e e mb pa 000 Nu euro 00 ion 1 t 10.1 n per pula 1 WHO 01.171 o 98 p = 00 0 0.0 .1 0- 0 N 00 2- 1-1 r1 0.0 0.1 >1 pe of 0.47 le er ans ail ab mb trici HO orld av nu ia W w ot ian ed in e nn ed ropa tion d th ma tio M eu la s an u for 10.2 n pop ion In reg 98 0.06 N= 0.12 0 0.003 a Afric 0.08 s ca eri 0.1 Am e an rran e ite rop ed Eu ia rn M As e st ic E ast th -Ea a cif ou nP orl d S es ter W W 0.24 f n ro s ni of m be cian atio ps er ans tio n 0.23 l nu iatri pu rou 0.56 mb trici pula tion s ian aed 0 po me g n u ia o la rie ed 0 M urop 0 0 inco ian ed 0 p pu nt ed ropa 0 00 t po cou 10.3 ne r 10 ent ies M eu 10 re n of pe iffer untr 10.4 n per diffe ories d co in ateg of =98 c =98 N N 0.25 0.08 0.002 0.05 Lo w tI 0.01 le Ca II idd Ca t rm le t II I we idd Lo rm gh Ca gh e Hi t IV Hi Ca 35
  • 36. 11 N E U R O L OG IC A L T R A IN IN G Definitions ◆ This theme refers to postgraduate specialist training in neurology for medical graduates from a recognized institution. Salient Findings ◆ Postgraduate training facilities in neurology are avail- every year per 100 000 population is 0.04 (interquartile able in 76.2% of the responding countries. No facility range 0–0.19). for postgraduate training in neurology exists in 51.7% of ◆ The number of postgraduate students obtaining a spe- low-income countries. cialist neurology degree per year per 100 000 population ◆ Regionally, facilities for postgraduate training in neurol- varies across different income groups of countries. The ogy are variable. They exist in 31.3% of the responding median number is 0 in low-income countries, while it is countries in Africa and 47.4% in the Eastern Mediterrane- 0.15 in high-income countries. an. The facilities for postgraduate training are present in ◆ Regionally, the median number of postgraduate students 88.9% of the responding countries in the Western Pacific, obtaining a specialist degree in neurology per 100 000 92.9% in the Americas, 93% in Europe, and 100% in population also varies. It is 0 in both Africa and the Eastern South-East Asia. Mediterranean, 0.01 in South-East Asia, 0.04 in the Ameri- ◆ The mean duration of training in neurology is 4.19 years cas, 0.08 in the Western Pacific, and 0.20 in Europe. (Standard Deviation (SD) 1.20). While the mean duration ◆ In 67.9% of the responding countries, students join post- of training in neurology in low-income countries is 3.5 graduate courses in neurology directly after medical grad- years (SD 1.3), it is 5.0 (SD 1.0) in high-income countries. uation; in the rest, they join after a postgraduate course ◆A median number of 12 (interquartile range 5–30) stu- in internal medicine. Even in countries where students join dents obtain a specialist degree in neurology every year in postgraduate courses in neurology directly after medical the responding countries. However, the median number graduation, some training in internal medicine is included of students obtaining a specialist degree in neurology in the neurology course. Limitations ◆ Data regarding the structure of training or the training ◆ Within regions also, specialists trained in one country may curriculum are not available. go and work in other countries. ◆ Many countries send medical personnel abroad for train- ◆ Data regarding the content of neurology courses pro- ing in neurology. Some of these graduates do not return vided in medical undergraduate and internal medicine to their countries of origin. The figures on trained special- postgraduate training curricula was not obtained. ists, therefore, may not reflect the number of specialists who remain available to work in the country. Implications ◆ Education in the field of neurology is important for the number of trained professionals required. All regions, continuous improvement of the delivery of neurological however, should have adequate facilities. care. Although training facilities are available in a large ◆A neurologist trained abroad may find it difficult to work number of countries, the number of postgraduates who in the home country because of differences in the epide- obtain a specialist degree is clearly inadequate. miology of neurological diseases as well as the availability ◆ An important component of neurological training concerns of facilities. Thus there is a need to establish relevant “brain drain”, where graduates sent abroad for training do training centres. not return to practise in their countries of origin. ◆ The training content also varies, with some countries ◆ Postgraduate neurological training facilities may not be offering a greater emphasis on internal medicine as grad- needed in some smaller countries because of the high uates join only after a specialization in internal medicine. cost of establishing training facilities and the small 36
  • 37. NEURO LO GICAL TRAIN IN G 11 of lity ate i u t ab sen t WHO 01.171 ail rad y Pre bsen le Av ostg olog in A ilab r g 11.1 p neu inin orld va tra e w 09 ta no r th =1 N t ion tes pe orm a ua year 0.15 Inf ad er tgr nt os gy p fere f p olo dif es ro r i be neu n in ntr um in atio f cou n g l ian sin pu s o ed ciali 0 po oup 0.07 M pe r 11.2 s 0 00 me g 0.04 10 nco 01 i 1 N= 0 s ate Lo w ra du r le stg pe idd po logy ation orld rm idd le f r o ro ul w we be neu pop the Lo er m gh m in gh Hi nu g 0 d Hi 00 ns an ian sin 0 ed ciali r 10 egio M pe e r rp O tes y 11.3 s yea WH 0.2 ua in =10 1 r ad olog ns stg ur gio N po in ne re of O er ing WH mb ializ r in Nu pec ea y 11.4 s per Americas Europe 0.04 0 715 (N=14) 1 177 (N=39) 0.01 0 0.08 Western Pacific r ica Af a s 284 (N=8) e ric 0.04 Am n ea an pe iterr ro WHO 01.182 ed Eu sia nM A s ter E ast ific Ea th- ac Africa So u nP orl d es ter W 18 W (N=15) Eastern Mediterranean South-East Asia 108 (N=18) 104 (N=6) 37
  • 38. 12 F I N A N C I N G FOR N EU R OLOG IC AL SERVICES Definitions ◆ Budget for neurological care is defined as a separate ◆ Social insurance refers to a fixed percentage of income regular source of money, available in a country’s health that everyone above a certain level of income is required budget allocated for actions directed towards the care of to pay to a government-administered health insurance neurological disorders in the country. fund which, in return, pays for part or all of consumers’ services for neurological care. ◆ Out-of-pocket payments in this context refer to payments made for neurological care by the patient or his or her ◆ Private insurance refers to a premium that health-care family. consumers pay voluntarily to a private insurance company which, in return, pays for part or all of their neurological ◆ Tax-based funding refers to money for health services care. raised by general taxation or through taxes earmarked specifically for neurological services. Salient Findings ◆ Of the responding countries, 10.4% have a separate ing countries), the Western Pacific (50%), the Americas budget within the country’s health budget for care of (42.9%) and South-East Asia (40%). neurological illnesses. ◆ Social insurance is the most important source of financ- ◆ Tax-based funding and social insurance are the primary ing in Europe (58.3% of the responding countries), while methods of financing neurological care in 37.8% and none of the responding countries in Africa use social 35.4% of the responding countries, respectively, followed insurance as the primary method of financing. by out-of-pocket expenses in 25.6%. Private insurance is ◆ Out-of-pocket expenditure is the primary method of the primary method of financing in 1.2% of the respond- financing in 84.2% of low-income countries, while it is ing countries. the primary method of financing in 3.6% of high-income ◆ Out-of-pocket expenses are the most important source of countries. financing in Africa (83.3% of the responding countries) ◆ Tax-based funding and social insurance are primary meth- and South-East Asia (40% of the responding countries). ods of financing in 50% and 42.8% of high-income coun- ◆ Tax-based funding is the most important source of financ- tries, respectively, and primary methods of financing in ing in the Eastern Mediterranean (57.1% of the respond- 10.5% and 5.3% of low-income countries, respectively. Limitations ◆ Thisinformation is based on best estimates by the ◆ Although definitions were provided with the question- respondents and not on a review of actual expenditure or naire, it is possible that they may not have been used budget figures. accurately. Implications ◆ Although a separate budget for neurological services is ◆ In most low-income countries, out-of-pocket payment not essential, when present it assists in earmarking the is the major source of financing. This is likely to result resources and planning the services effectively. In most in further inequity in utilization of neurological services. countries, the budget for care of neurological diseases is Efforts need to be made to introduce some form of public included in somatic medicine. financing to cover these services. 38
  • 39. FINANCING FO R NEURO LO GICAL SERVICE S 12 25.6% ing 37.8% nc fi na HO of n W od are i orld th c me al ew ry ogic nd th a l m a Pri euro ons 14% 14% 1.2% n gi d 12.1 re 82 29% orl 35.4% N= W c as eri 43% 8% 59% Am 33% 17% 83% e rop a Eu 33% Afric 50% 21% 58% ific P ac 17% an ern ne 21% 20% est rra 40% W ite ed r nM ste Ea ia As 40% st -Ea uth So et ck f- po ased e t-o ax-b ranc e Ou T su ranc g l in nsu cin t cia i in an feren s So ate v f f dif trie Pri d o e in oun tho ar f c me cal c ps o 84.2% ry i u ma log ro Pri euro me g 12.2 n inco 82 N= 57.1% 42.8% w Lo le dd mi 10.5% er H igh 0% 5.3% 50% 0% 42.8% 0% 42.8% 38.1% 19.1% le dd gh r mi 3.6% Hi we Lo 3.6% 0% 39
  • 40. 13 D I S A B I L I T Y B EN EFIT S Definitions ◆ Disabilitybenefits in this context are the benefits that are of neurological disorders that cause physical or mental payable as part of legal right from public funds in cases impairment leading to functional limitations. Salient Findings ◆ Of the responding countries, 70.5% reported the avail- ity benefits for neurological disorders, such benefits were ability of some form of disability benefits for patients with available in 66.7% of the responding countries in the neurological disorders. Eastern Mediterranean, 77.8% in the Western Pacific, 85.4% in Europe, and 92.3% in the Americas. ◆ Of the low-income countries, 67.9% reported nonavail- ability of any kind of disability benefit for neurological ◆ Regarding the types of disability benefits reported by disorders, compared with 3.2% of high-income countries. countries, monetary benefits (75.7%) and rehabilitation and health benefits (64.9%) are the most commonly ◆ Availability of disability benefits for neurological disorders reported, followed by other benefits including housing, is also variable across regions. While 25% and 33.3% of transport, education and special discounts (45.9%) and the responding countries in Africa and South-East Asia, benefits at the workplace (37.8%). respectively, reported availability of some form of disabil- Limitations ◆ Information on the exact type of disability benefit for ◆ Data regarding coverage within the countries was not neurological disorders was not obtained on a structured obtained. It is possible that in countries who responded in format. affirmative, disability benefits are available to only a small proportion of the population. Implications ◆ Because of a lack of public information about disability ◆ Efforts should be made to advocate better provision of benefits and the procedure for claiming them, few people disability benefits for neurological disorders. actually receive them in many countries even when ben- ◆ The inequity in the availability of disability benefits efits are available. Sometimes the procedure for availing observed across income groups, geographical areas and themselves of disability benefits is also very complicated. within countries needs to be specifically addressed. 40
  • 41. DISABILITY BENEF ITS 13 s t fit e sen t WHO 04.117 ne opl l Pre bsen le be pe ca ity o gi A ilab bil ble t rolo va sa ila eu ta Di va n rs in no 13.1 a with orde orld at ion orm HO dis e w 5 Inf n Wd th 10 si N= fit orl ne e w be th ity d bil s an 70.5% sa Di gion 03 13.2 re =1 N 25% d 92.3% orl W a 66.7% ric t Af s 85.4% ren eri ca di ffe ies Am a n 33.3% in ntr a ne 77.8% its cou err pe ef f e dit E uro ia en s o M As it y b oup 67.9% ste rn Ea st ific bil e gr 27.6% Ea uth - ac sa nP Di com 05 17.6% So est er 13.3 in =1 W N 3.2% t sen t 32.1% 96.8% Pre bsen A 72.4% 82.4% w Lo le idd rm dd le we mi Lo r gh g he Hi Hi 41
  • 42. 14 NEUROLOGICAL INFORMATION GATHERING SYSTEM Definitions ◆ In this context, health reporting system refers to the ◆ Epidemiological or service data collection system refers preparation of reports, usually yearly, covering health to an organized information-gathering system for serv- service functions related to neurological disorders, includ- ice activity data for neurological disorders. It usually ing the use of allocated funds. incorporates incidence and prevalence rates of diseases, admission and discharge rates, numbers of outpatient and community contacts and other activities. Salient Findings ◆ There is a health reporting system for neurological disor- ◆ Whereas almost two thirds of the responding countries ders in 78.1% of the responding countries. in the Americas and Europe, 41.2% in the Eastern Medi- terranean, and 43.8% in Africa have a data collection ◆A health reporting system for neurological disorders is system for neurological disorders, none of the responding available in 66.7% and 73.3% of the responding coun- countries in South-East Asia and 22.2% in the Western tries in South-East Asia and Africa, respectively, while Pacific have an epidemiological data collection system. such a system is available in 76.9% of the responding countries in the Americas, 77.8% in the Eastern Mediter- ◆ An epidemiological data collection system is available ranean and the Western Pacific, and 83.3% in Europe. in 35.7% of the low-income countries and 73.3% and 51.6% of the higher middle-income and high-income ◆A data collection system for neurological disorders exists countries, respectively. in 48.5% of the responding countries. Limitations ◆ Information about the quality or adequacy of the health ◆ The epidemiological or service data collection system does reporting system for neurological disorders is not avail- not include the epidemiological studies for neurological able. disorders carried out by individual groups in various coun- tries. Implications ◆ An organized health reporting system is essential to ◆ Epidemiological data help to gather information regarding enable health planners to decide how to use various the disease burden and trends and help in identifying the resources. high priority issues. This information is highly useful for planning health services and monitoring trends over time. 42
  • 43. NEUROLOGICAL INFORMATION GATHERING SYSTEM 14 l ica og u rol ne for m ste O rld 78.1% a l sy WH wo g in gic in h e olo e ort rs dt ur ep orde s an ne om R is on f or t inc 14.1 d regi 05 73.3% tem re n N= 1 d ys iffe ries orl s d t 76.9% W ing in oun ort rs c a 77.8% ep orde s of fric 83.3% R is p 14.2 d grou 105 A s ca eri n 66.7% = Am ea 77.8% N 79.3% er ran p e 94.1% e dit E uro ia 71.4% nM As s ter E ast cif ic Ea th- Pa S ou e rn 74.2% est W t sen t Pre bsen w A Lo le idd rm dd le we mi Lo r gh g he Hi Hi for rld em s st er wo sy d the on or d 48.5% cti l dis s an lle ica on co i ta olog reg Da eur HO 14.3 n in W 103 = 43.8% N d 63.6% orl W a 41.2% ric Af as 64.3% e ric 0% Am n ea 22.2% an pe err ro dit Eu M e As ia nt rn st ere ast e -Ea cif ic for diff E uth Pa tem in es 73.3% So e rn ys ers tri est n s sord coun W tio i of ec l d c oll gica ups 44.8% o ata rolo e gr D eu m 35.7% 51.6% 14.4 n inco 103 N = w Lo le m idd er le dd Lo w r mi gh g he Hi Hi 43
  • 44. 15 N E U R O L OG IC A L A SSOC IAT ION S AND NGO 'S Definitions ◆ National neurological association refers to the profes- ◆ Nongovernmental organizations (NGOs) refers to vol- sional association of neurologists or other neurology-allied untary organizations, charitable groups, service-user or sciences; such associations are usually nongovernmental. advocacy groups in the area of neurology. Salient Findings ◆A national neurological association exists in 87% of the ◆ Of the responding countries, 71.7% have at least one responding countries. nongovernmental organization working in the field of neurology. In 10.5% of these countries, the nongovern- ◆ While 43.7% of the responding countries in Africa do not mental organizations are working only in the area of epi- have a national neurological association, 26.3% in the lepsy. Eastern Mediterranean, 11.1% in the Western Pacific and 2.3% in Europe do not have a national neurological asso- ◆ No nongovernmental organizations for neurological disor- ciation. ders exist in 34% of the low-income countries and 29% of the high-income countries. ◆A median number of 192 (interquartile range 46–500) specialists are members of the national neurological asso- ◆ Regionally, no nongovernmental organizations for neuro- ciation in the responding countries. logical disorders exist in 52.9% of the responding coun- tries in the Eastern Mediterranean, 33.3% in the Western ◆ The national neurological associations are involved in Pacific, 23.8% in Europe, 19.7% in Africa, 16.7% in various activities: organizing professional meetings and South-East Asia, and 14.3% in the Americas. conferences (100% of the responding countries), advising government (70.7%), constructing curricula for postgradu- ◆ The nongovernmental organizations are involved in ate training (44.6%), granting a degree of specialization in awareness and advocacy in 92.1% of the responding neurology (31.5%), constructing curricula for undergradu- countries, treatment (69.7%), rehabilitation (65.8%) and ate training (30.4%), accrediting neurology departments prevention (61.8%) activities. for postgraduate training (28.3%) and accrediting neurol- ogy departments for undergraduate training (21.7%). Limitations ◆ Since the sources of information in most countries were ◆ Information regarding the coverage of population by the the key persons working in neurology and possibly mem- activities specified within the countries is not available. bers of a national association, the data pertain mainly to ◆ Information regarding the quality of services is also lacking. countries where neurologists or persons with an interest in neurology exist. Therefore it is possible that the figures ◆ Some of the nongovernmental organizations working in might be an overestimate. the countries are actually international organizations and not local organizations. Implications ◆ Presence of professional associations highlights the com- ◆ Many international nongovernmental organizations are mitment of neurologists to improve the status of care for also involved in various educational and training activities neurological disorders. for neurologists. ◆ The neurological associations should be more involved to ◆ Groups of patients with neurological disorders and their improve the status of patient care and training in neurology. carers need to be established in many more countries, as they can be strong advocates for improvement in the ◆ The participation of both local as well as international quality of services. nongovernmental organizations in the care of neuro- logical disorders is important. Their activities need to be encouraged as they complement the services provided by the public sector. 44
  • 45. NEURO LO GICAL ASSO CIATIO NS AND NG O' S 15 100% 73.7% 97.7% l 100% ica 56.3% ro log HO ld r eu in W wo 88.9% l N ons the a i n tio iat nd 87% Na ssoc ns a 100% o 15.1 A regi 108 = N 70.7% a l ns ric na tio Af as tio ocia eri c Na ss Am n of A an ea ti es ical 44.6% err p e t ivi olog e dit E uro ia Ac eur nM As 2 er st ific 15.2 N =9 31.5% East th -Ea ac N So u nP orl d 30.4% es ter W W 28.3% gs e tin me e nt 21.7% izing rnm g an ov e nin g g rai ree Or ing te t eg ns is ua d g o dv d ing nin ati A tgra t rai ng niz s in d a r p os Gran at et ini org rde orl for u et ra nin g 71.7% rad tal diso he w t n ulum e rg ua t rai rric nd ad me al dt Cu u tgr du ate ern logic s an for gp os a ov ro ion lum in e rgr ng u g u dit nd No r ne re rric cre gu fo HO 6 81.3% Cu Ac itin 15.3 W =10 orl d ed N 85.7% W A ccr a 47.1% A fric 76.2% s ca eri n 83.3% Am ne a 66.7% a pe err dit uro t M e E As ia sen t rn st Pre bsen ste Ea ific Ea - ac A uth nP So er est W 76.7% 66% 75% ns tio ies iza in ntr 71% n s a r c ou org rde of 92.1% n tal diso ups me al gro ern logic ome tal ov of men for rders ng uro inc No r ne rent ies n s o o vit ver on dis 15.5 f diffe 106 69.7% cti ngo izati ical A o = n g 65.8% N 15.4 N orga urolo e 76 n = 61.8% N w Lo le dd r mi le we i dd Lo rm gh g he Hi Hi cy o ca dv t en n da tm n ssa Trea tio ne ita are bil on ha nti Aw Re ve Pre 45
  • 46. BRIEF REVIEW O F SELECTED TO PICS The following pages provide a focus on selected areas in relation to neurology. The specialists who contributed the reviews are listed in the Project Team and Partners. 47
  • 47. EPILEPSY Epilepsy is one of the most common serious Evidence exists that 60–70% of people with epilepsy could disorders of the brain, affecting some 50 million people lead normal lives if properly treated with antiepileptic drugs worldwide. It is unique among these disorders in that its (AEDs) (53). Some of them will need to continue with medi- symptoms can be completely controlled in the majority of cation for life but, for others, the antiepileptic medication affected individuals by inexpensive medications or cost- may eventually be stopped without seizures recurring. For effective surgical procedures, and many forms of epilepsy some patients with intractable epilepsy, neurosurgical treat- can be prevented by appropriate public health interven- ment may be successful. tions. Epilepsy accounts for 1% of the global burden of disease, determined by the number of productive life- Of the burden of epilepsy worldwide, 80% is in the devel- years lost as a result of disability or premature death (50). oping world, where 80% of people with epilepsy receive no treatment at all (52). In most of these regions, misconcep- Among primary disorders of the brain, this burden ranks tions, stigma, and discrimination are greater obstacles to the with depression and other affective disorders, Alzheimer’s well-being of people with epilepsy than lack of adequate disease and other dementias, and substance abuse; among health-care facilities. These problems can be solved rela- all medical conditions, it ranks with breast cancer in women tively inexpensively through education of patients, their and lung cancer in men. families, the general public, health-care providers and gov- Approximately one in 10 people can expect to have at ernment agencies, as well as through improved access to least one epileptic seizure during a normal lifespan, but one effective treatments. A Global Campaign Against Epilepsy, seizure is not epilepsy. Only a third of the people who expe- a joint effort of the International League against Epilepsy rience a seizure have an enduring brain disturbance that (ILAE), the International Bureau for Epilepsy (IBE) and causes recurrent seizures and therefore warrants a diagnosis WHO, is currently in progress in order to reduce the treat- of epilepsy. Despite epilepsy being so common, the reported ment gap for epilepsy and promote acceptance of people figures vary widely. The incidence is generally taken to be with this disorder by bringing epilepsy “out of the shad- between 40 and 70 per 100 000 people per year in indus- ows” (54). The aim of the Campaign is to provide better trialized countries, with estimates of 100–190 per 100 000 information about epilepsy and its consequences and to people per year in developing countries (51, 52). The preva- assist governments and those concerned with epilepsy to lence is between 5 and 40 per 1000 persons (51). Parasitic, reduce the burden of the disorder. viral and bacterial infections have been suggested as impor- Much more basic and clinical research is necessary to devel- tant factors in the cause of epilepsy in developing countries op new approaches for prevention, diagnosis, and treat- (52). Other important causes include brain damage at birth ment, and to devise cost-effective ways to bring currently caused by asphyxia, infections, and brain trauma resulting available approaches to the developing areas of the world from accidents. Some of the public health policies which where limited resources and tropical conditions remain a may help in modifying these risk factors include better peri- major obstacle to adequate health care. natal care, strategies to control head injury, better hygiene to decrease neurocysticercosis, and immunization. In the affluent countries, reduction of stroke by modifying the risk factors may lessen the incidence of epilepsy. 48
  • 48. CEREBRO VASCULAR DISEA S E S Stroke is the second leading cause of death after consumption. This knowledge will allow for institution of ischemic heart disease worldwide, with an estimated 5.5 primary and secondary prevention measures. It is also of million subjects dying from stroke every year. Two thirds of great importance to introduce stroke awareness campaigns these deaths occur in countries with low resources. Approxi- for the public, to promote healthy lifestyles and demon- mately 80% of patients survive the acute phase of stroke: strate the need for risk factor modification. Stroke should be 50–75% of the survivors are left with varying degrees of regarded as one of the preventable cardiovascular diseases, chronic disability, thus making stroke a leading cause of dis- and stroke prevention should be a global effort. ability in adults. Data from the literature shows that organized care in a Hospital care, long-term care, complete or partial working stroke unit is the most effective way of reducing long-term incapacity, and community support – all of these factors case fatality, long-term disability and the need for institu- cause enormous costs for the patients, their families, com- tionalization (57). The benefits of a stroke unit come from munities and the health-care system. There are different its focus on coordinated multidisciplinary care, nursing inte- estimates of costs of management of stroke per patient in gration and early rehabilitation. Specialization of care repre- various regions. In Australia, the European Union and North sented by interest and expertise in stroke rehabilitation, and America, the mean total cost of stroke management for also education and training of staff, patients and caregivers, the first three months is approximately US$ 14 000. The are of great importance. Efforts need to be made to popu- average cost per surviving day is US$ 260 (55). In general, larize and promote stroke unit care, especially in countries more than 70% of costs are directed for covering hospi- with low and medium levels of resources. talization, less than 20% for rehabilitation, and the rest for Important endeavours have been undertaken recently to chronic care facilities. Lifetime costs per stroke patient range improve the knowledge of stroke epidemiology world- approximately between US$ 60 000 and US$ 230 000. wide. The Surveillance and Risk Assessment Division of the These costs should be regarded in the context of the epi- Population and Public Health Branch of Health, Canada – a demiological data, as the number of stroke survivors in a WHO Collaborating Centre for Surveillance of Cardiovas- society translates directly into the actual economic burden cular Diseases – developed a database of worldwide demo- of stroke. graphic data on cardiovascular and cerebrovascular disease Surveys performed before 1990 show that the worldwide mortality and morbidity. Moreover, the World Federation crude prevalence rate of stroke in all age groups ranges of Neurology and the International Stroke Society, in col- from 4 to 20 per 1000 population. More recently published laboration with WHO, have initiated the development of a data from population-based studies show less variability stroke component of the WHO Global Noncommunicable between geographical regions, with the crude prevalence Disease Infobase, which collects information on stroke rate ranging from 5 to 10 per 1000 population (56). prevalence, incidence, mortality and case fatality based on Some gender differences can be observed, as the stroke published data. Another WHO-initiated activity is an inter- prevalence rate is lower in women than in men. Despite national stroke surveillance system: the STEPwise approach, the stable rates, demographic estimates point towards an which will form a framework for surveillance and data col- important increase of the number of strokes in the near lection in order to achieve comparability of data over time future – especially in South America and Asia. and between different countries (58, 59). All these efforts aim to improve prevention and control of stroke and to Based on these simple data one can roughly estimate the facilitate the planning of health services. A joint effort of life-time costs of all strokes as millions of dollars in a medi- health-care professionals, nongovernmental organizations um-sized European country, thus highlighting the impor- and governmental bodies is the key to controlling epidemics tance of stroke as a target for public health campaigns. of stroke. However, stroke-related costs should not be regarded from a perspective of a high-income country. With the increasing burden of stroke in low-income countries the same magni- tude of resources would be required to fulfil the needs of patients and to cover the disability-related loss of productiv- ity. As prevention is more effective than treatment, primary health care is the most appropriate means of preventing stroke and reducing its public health impact. It is crucial to increase awareness among primary care physicians of modifiable stroke risk factors such as hypertension, diabetes mellitus, tobacco smoking, obesity and excessive alcohol 49
  • 49. H E AD A C H E Headache disorders are ubiquitous. Their lifetime year because of migraine alone. A recent United States prevalence in populations in which they have been meas- study measured indirect costs in a managed-care population ured is over 90%. Migraine is most studied, although still at over US$ 4500 per sufferer per year. Tension-type head- not fully in all regions of the world. It mostly affects people ache and chronic daily headache may together cause losses of working age but does trouble children as well. Euro- of similar magnitude. In the 15 European Union countries pean and American studies show that 6–8% of men and prior to enlargement, the annual cost of all headache has 15–18% of women experience migraine every year (60). been estimated at € 10 000-30 000 million. A similar pattern is seen in Central and South America: in Therefore, while headache rarely signals serious underlying Puerto Rico, for example, 6% of men and 17% of women illness, it is high among causes of consulting both general are affected. Major studies are still to be conducted in India, practitioners and neurologists. Over a period of five years, but anecdotal evidence suggests similar levels of migraine one in six patients aged 16–65 years in a large general prac- promoted by Indian lifestyle factors. In Japan it is estimated tice in the United Kingdom consulted because of headache. to affect 8.4% of adults. Migraine appears less prevalent, A survey of neurologists found that up to one third of all but still common, elsewhere in Asia (3% of men and 10% their patients consulted for headache – more than for any of women) and in Africa (3–7% in community-based stud- other single complaint. ies). Again in these areas, major studies have yet to be con- ducted. The higher rates in women everywhere (2–3 times Despite headache being a common occurrence, there is those in men) are hormonally driven. good evidence that large numbers of people troubled by it do not receive effective health care. In many countries, Tension-type headache (TTH) is the most common head- headache conditions are not recognized as diseases but only ache disorder (61). Most is episodic, and this subtype as self-limiting and unimportant symptoms, deserving no affects two-thirds of adult males and over 80% of females allocation at all of resources. A consensus conference organ- in developed countries, although few seriously. In its chronic ized by the American and International Headache Societies subtype, in contrast, it is present on more days than not concluded that migraine is underdiagnosed and undertreat- and is disabling. Chronic tension-type headache overlaps ed throughout the world. with and is sometimes indistinguishable from other forms of chronic daily headache, some of which are unrelentingly Nevertheless there are effective treatments. It is possible present throughout every day. Estimates of the prevalence to alleviate much of the symptom burden of headache and of this group of conditions in Europe and the United States thereby mitigate both the humanitarian and the financial are as high as 1 in 25 of the adult population (62). costs. Crucially, the common headache disorders require no special investigation and their diagnosis and management Not only is headache painful but, depending on its inten- call only for skills generally available to physicians. Most sity and other symptoms that may accompany it, it is also headache can be optimally managed in primary care, if the disabling. Migraine affects people particularly during their following barriers are removed: productive years and, in a survey in the United States, 80% of people with migraine reported disability because of it. ◆ lackof knowledge, among health-care providers, of Extrapolation from migraine prevalence and attack inci- headache disorders and how to treat them; dence data suggests that 3000 migraine attacks occur every ◆ poor awareness among the general public, so that head- day for each million of the general population so it is unsur- aches are often trivialized as a minor annoyance and an prising that, worldwide, migraine is 19th among all causes excuse to avoid responsibility (stigmatization), and among of years of life lost to disability (YLDs) (63). As well as headache sufferers who are unaware that effective treat- suffering directly from its symptoms, people with migraine ments exist; consistently score highly on scales of general physical and mental ill-health. Chronic tension-type headache and other ◆ failureof governments to acknowledge the burden of forms of chronic daily headache are associated with long- headache and to recognize that the costs of treating it term morbidity. are small in comparison with the huge savings that might be made (for example, by reducing lost working days) if Repeated headache attacks, and often the constant fear of resources were allocated to do so appropriately. the next, damage family life, social life and employment. For example, social activity and work capacity are reduced The key to successful health care for headache in most areas in almost all migraine sufferers and in 60% of tension-type of the world is therefore education. This is at the heart of the headache sufferers. The financial cost of headache arises Global Campaign to Reduce the Burden of Headache (64). partly from direct treatment costs but much more from loss of work-time and productivity. In the United Kingdom, for example, 25 million workdays or schooldays are lost every 50
  • 50. PARKINSO N'S DISEAS E Parkinson’s disease occurs worldwide: it affects all For delivery of neurological care to people with Parkinson’s ethnic groups and socioeconomic classes. Besides the disa- disease, adequate human resources and other facilities bling motor symptoms, patients have non-motor symptoms are required. These are regrettably deficient, especially in such as anxiety and depression. The Global Parkinson’s the developing regions. For instance, there are only about disease Survey in six countries demonstrated that depres- 850 neurologists for the care of over 1000 million people sion in Parkinson’s disease is a significant factor affecting in India (1 neurologist for 1.2 million inhabitants). These the health-related quality of life (65). Although there is no neurologists are mainly located in the cities, whereas nearly cure for Parkinson’s disease, there have been advances in two thirds of India’s population reside in rural areas. It is its management through drugs, rehabilitative measures and therefore necessary to seek the help of primary care physi- surgery. To achieve health for all, it is essential that we have cians for the care of patients. Medical education should a true appraisal of the epidemiological aspects of Parkin- be suitably modified so that graduate physicians are able son’s disease and resources available in each region. to recognize primary symptoms of Parkinson’s disease and impart education about this illness to patients and their Most epidemiological studies have shown an estimated inci- families. They should be able to initiate treatment with the dence ranging from 16 to 19 per 100 000 people per year appropriate anti-Parkinsonian drug and refer suitable cases (66), while estimated crude prevalence is 160 per 100 000 to community hospitals in semi-urban areas or to large people per year (67). There are regional variations which urban hospitals. There is also a great need to expand the may, in part, be attributable to different methods of case- support services and to have more nurse specialists, social finding, diagnostic criteria and the age of the population. workers, paramedical staff and rehabilitation centres. Vari- There is clearly a need for well-defined epidemiological ous nongovernmental support organizations are working studies, especially from the developing regions of the world. in this area to increase the awareness of this disease and its Parkinson’s disease poses a significant public health burden, management. which is likely to increase in the coming years. Along with other neurodegenerative diseases such as Alzheimer’s dis- ease, Parkinson’s disease is expected to surpass cancer as the second most common cause of death by the year 2040. The direct and indirect costs for the care of Parkinsonian patients, including cost of drug treatment (about US$ 1100 million worldwide) can be substantial (68). The incidence and prevalence of Parkinson’s disease increase with advanc- ing age, occurring in about 1% of people over the age of 65 years. With increase in life expectancy, future demo- graphic projections predict a larger population over the age of 60 years in the developing regions, with a corresponding increase in the number of Parkinson patients. 51
  • 51. DEMENTIA Dementia is a syndrome characterized by a pro- Primary prevention should probably focus upon risk factors gressive global deterioration in intellectual function. Alzhe- for vascular disease, including hypertension, smoking, type II imer’s disease is the commonest pathology, accounting for diabetes, and hyperlipidaemia. The epidemic of smoking in 50% to 75% of cases. Recent estimates for numbers of developing countries and the high and rising prevalence of people with dementia worldwide suggest that 18–25 mil- type II diabetes in Asia are particular causes of concern. More lion persons were affected in 2000 and that this number work is needed to identify further modifiable risk factors. will double to 32–40 million by 2020 (69, 70). It is largely a disease of older persons: only 2% of cases are under 65 Achieving progress with dementia care has much to do years of age. After this age, the prevalence doubles with with creating the climate for change. Lack of awareness, every five-year increment in age. Prevalence varies very widespread among policy-makers, clinicians and the general little between developed countries: 1% for 60–64 years, public, is a key public health problem with important conse- 1.5% for 65–69 years, 3% for 70–74 years, 6% for 75–79 quences: years, 13% for 80–84 years, 24% for 85–89 years, 34% for ◆ affected persons do not seek help; even if they do, 90–94 years, and 45% for those aged 95 years or over (70). health-care services tend not to meet their needs; Demographic ageing proceeds apace in China, India and ◆ dementia is stigmatized; for example, sufferers can be Latin America. In the 30 years up to 2020, the oldest sector excluded from residential care and denied admission to of the population will have increased by 200% in develop- hospital facilities; ing countries compared with 68% in the developed world ◆ there is no constituency to lobby government or policy- (2). By 2020, two thirds of all people over 60 (and, presum- makers; ably, a similar proportion of all those with dementia) will be ◆ familiesare the main caregivers, but they lack support or living in developing countries (69). In the developing world, however, there is more uncertainty as to the frequency of understanding from others. dementia, with few studies and widely varying estimates Population level interventions are needed. National Alzhe- (71). In general, prevalence and incidence are lower than imer Associations help to raise awareness and create a in the developed countries (71). Early onset cases are again framework for positive engagement between clinicians, rare, though this may be changing in parts of the world researchers, caregivers and people with dementia. where HIV/AIDS is endemic. Primary health-care services have an essential role to play in Dementia is one of the major causes of disability in later prevention, detection and management. Clinic-based serv- life. The consensus estimated disability weight for dementia ices providing acute care do not meet this need. For many applied in the global burden of disease report was higher low-income countries the most cost-effective approach will than that for almost any other condition with the excep- be community primary care services supporting, educating tion of spinal cord injury and terminal cancer. Among older and advising family caregivers, supplemented by subsidized people, dementia was the most burdensome neuropsychi- home nursing or home-care workers. Day care and residen- atric disorder accounting for more than half of all disability- tial respite care are more expensive, but nevertheless basic adjusted life years in this domain of morbidity (2). to a community’s needs, particularly for more advanced People with dementia are heavy consumers of health serv- dementia. Residential care is unlikely to be a government ices, but in developed countries most direct costs arise from priority. Even in some of the poorer countries, however, community and residential care. In the United Kingdom private nursing and residential care homes are opening to these costs amount to US$ 8000 million, or US$ 13 000 meet the new demand (for example, in China and India). If per person with dementia (72). The economic burden is government policies are well formulated, the inevitable shift unevenly distributed; families from the poorest countries are of resource expenditure towards older people can be pre- particularly likely to use expensive private medical services dicted and its consequences mitigated (76). and to be spending more than 10% of per capita GNP on health care (73). Worldwide, family caregivers are the cor- nerstone of support for people with dementia. They experi- ence significant psychological, practical and economic strain (73, 74). Dementia care is particularly time intensive because of the need for close supervision. Many caregivers need to give up or cut back upon work in order to care. When the full costs of their care inputs were calculated, in the United States they amounted to US$ 18 000 million annually (75). 52
  • 52. M ULTIPLE SCLEROS IS Multiple sclerosis is the most common neurologi- As long as the etiology of multiple sclerosis remains cal disorder in younger adults of Caucasian origin. The etiol- unknown, a causal therapy or effective prevention is not ogy is still unknown but pathogenetic steps leading to the possible. Introduction of new disease-modifying therapies characteristic histological findings of perivascular inflamma- such as beta-interferon or glatiramer acetate may alter the tion and focal demyelination, as well as astrocyte scarring disease course, especially in the relapsing-remitting form, by and axonal loss, have become better understood. reducing the number of attacks by about a third and reduc- ing the accumulation of lesions as seen on MRI, and by Clinically the disease course is most often relapsing-remit- influencing the impact of the disease on disability. Rehabili- ting, with exacerbations lasting on average a few weeks to tation still remains the most effective element in the overall a few months. In the long run, over decades, this course management of multiple sclerosis. Clinical as well as basic most often turns (for unknown reasons) into a secondary research are urgently needed in a coordinated fashion in progression. The cases which remain relapsing-remitting are order to find the etiology of this still enigmatic disease, with probably the ones which are benign (10–15%). Another the goal of finding more effective treatments or preventing form of the disease is primary progressive, equally frequent it altogether. in females and males with probably less inflammatory com- ponents. In relapsing-remitting and secondary progressive forms the disease is twice as common in females than in males. The world estimate is 1.11 to 2.5 million cases of multiple sclerosis. High-frequency zones for multiple sclerosis at 50–100 per 100 000 population are Europe, Canada, coun- tries of the former USSR, Israel, northern United States, New Zealand, and south-east Australia. Lowest frequency zones for multiple sclerosis at 5 per 100 000 population are Asia, Africa and South America. In general, multiple sclerosis occurs worldwide with much greater frequency in higher latitudes between 40 and 60 degrees north and south lati- tude (77, 78). 53
  • 53. T R A I N I N G IN N EU R OLOG Y Most care for disorders of the nervous system is these differences spring naturally from local needs, and are provided not by neurologists but by general physicians and not necessarily undesirable. There are wide regional differ- other primary health-care workers, especially in developing ences in the prevalence of various neurological disorders. A countries where neurologists may be few or nonexistent. core curriculum in neurology should be influenced by local Adequate pregraduation training in neurology is needed conditions, particularly for training in neuroepidemiology, everywhere so that general physicians can identify and treat prevention of neurological disorders, changing patterns of disorders of the nervous system, which are major contribu- disease, and the cost-effective use of diagnostic and thera- tors to the global burden of disease. peutic resources. Undergraduate medical curricula should include the epide- The length of training programmes in neurology varies from miology and prevention of the neurological disorders that place to place. Areas of subspecialty training in neurology are most prevalent in the region where graduates will prac- include stroke, movement disorders, epilepsy, neurore- tise. Some of the commonest neurological disorders such habilitation, pain, and clinical neurophysiology, and such as stroke and epilepsy are preventable to some degree, for programmes are generally available only in the wealthiest example by adequate treatment of hypertension in the first countries. They usually require one to two years, but accu- case and by eradication of neurocysticercosis in the other. rate data about the length and content of such programmes The beneficial effects of neurorehabilitation and the careful are lacking. Whether adequate neurology training might be management of chronic neurological diseases should also be done in less time in certain countries or regions would be a included in pregraduate curricula. useful subject for study. Shorter programmes would be less costly and might require fewer faculty members. To keep physicians abreast of changing patterns of neu- rological disorders (such as the increasing incidence of The available data demonstrate that in many low-income cerebrovascular disease and dementia in developing coun- and middle-income countries there may be no neurolo- tries), continuing medical education in neurology should be gists, or as few as one neurologist for every 2 million people readily available to all primary care physicians. Particularly (47). Such countries generally do not have the conventional in countries where neurospecialists are few, and most care academic foundations for postgraduate neurology training of neurological disorders falls to the primary care physician programmes, and their neurologists receive training else- or other health-care professionals, the educational role of where. For small countries, the model of specialty training the neurologist should include providing continuing medical abroad may be suitable, as long as the training corresponds education for primary care doctors (79). Continuing medical to the disease profile and technological milieu of the coun- education for neurologists is widely available in wealthier try where the neurologist will practise. The establishment countries through national and international neurological or improvement of neurology training programmes is desir- societies. For neurologists in developing countries, regional able in larger countries, however, to produce graduates neurological societies can offer educational programmes who will work locally or in the region. The organization and that focus attention on neurological disorders endemic evaluation of new training programmes could be facilitated to the area, and foster connections with neurologists in by international linkages with various nongovernmental wealthier countries. organizations. Neurologists everywhere are recognized by their expertise in In some areas the construction of regional training pro- certain areas such as basic neurosciences, the neurological grammes could avoid duplication of costly resources and history and examination, and diagnosis and management allow pooling of resources. Modern technology would facili- of neurological disorders. Physicians in some countries may tate the use of long-distance teaching, sharing of teach- identify themselves as neurologists after minimal specialty ing materials, and establishment of research ties. In some training, whereas in other countries several years of post- regions it might be desirable to replace or supplement the graduate education, followed by successful completion of a traditional four-year postgraduate neurology programme specialty examination, are necessary. Through their national with a shorter training programme for general physicians professional organizations, neurologists serve as advisers to with a special interest in clinical neurology. national governments in over 70% of countries. Where this is the case, neurology curricula should also include some training in public health and in health-care delivery. There are no recognized international standards for training in the specialty of neurology or for methods of demonstrat- ing competency in the field. Postgraduate neurology curric- ula vary widely, some concentrating on clinical training and others stressing knowledge in basic neurosciences. Many of 54
  • 54. 55
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  • 57. L I S T O F R E SP ON D EN T S Country, Country, territory or area Name territory or area Name Afghanistan M.S. Azimi El Salvador Carlos Antonio Diaz Manzano Albania Jera Kruja Estonia Janika Kõrv Algeria Mahmoud Aït-Kaci-Ahmed Finland Juha Korpelainen Tazir Meriem Jorma Palo Argentina Roberto Sica France Jean-Marc Léger Armenia Vahagn Darbinyan Gambia Kathryn Burton Australia Geoffrey A. Donnan Georgia Shota Bibileishvili George Chakhava Austria Franz Gerstenbrand Germany Michael Strupp Bahrain Adel Al-Jishi Ghana Paul Ayisu Bangladesh Anisul Haque Greece Hellenic Neurological Society Belarus Victor V. Yevstigneyev Guatemala Luis Fernando Salguero Belgium M. Van Zandijcke Honduras Reyna Durón Benin Dismand Houinato Marco Tulio Medina Francisco Ramirez Brazil Marco A. Lana-Peixoto Hungary Imre Szirmai Bulgaria Irena Velcheva Iceland Albert Pall Sigurdsson Burkina Faso Jean Kabore Sigurlavg Sveinbjörnsdottir Canada Morris Freedman India M. Gourie-Devi Donald W. Paty Indonesia Jusuf Misbach Central African Republic Pascal Mbelesso Iraq Sarmed Al-Fahad China Wenzhi Wang Ireland Michael Hutchinson China, Hong Kong Special Administrative Region Richard Kay Israel Oded Abransky Costa Rica Manuel Carvajal Italy Antonio Federico Croatia Slava Podobnik Sarkanji Japan Nobuo Yanagisawa Vesna Vargek Solter Jordan Ashraf Kurdi Cyprus Chris Messis Kazakhstan Abenov Bulat Czech Republic Zdenek Ambler Kenya Renato Ruberti Denmark Troels W. Kjær Lao People’s Djibouti Abdoulkarim Said Democratic Republic Vikham Sengkignavong Dominican Republic Juan R. Santoni Latvia Ministry of Health Egils Vitols Ecuador Fernando Alarcón Lebanon Fouad Anton Egypt Hassan Hassan ElKalla M. Anwar Etribi Libyan Arab Jamahiriya Abduraouf G. Aburkes 58
  • 58. LIST O F RESPO NDE N TS Country, Country, territory or area Name territory or area Name Lithuania Valmantas Budrys South Africa R. Eastman J.A. Temlett Luxembourg Michel Kruger Spain José Luis Molinuevo Guix Madagascar Marcellin Andriantseheno Jordi Matias-Guiu Malawi Gretchen L. Birbeck Sri Lanka J.B. Pieris Mali Moussa Traoré Sudan Daoud Mustafa Mexico Francisco Rubio Donnadieu Sweden Sten-Magnus Aquilonius Mongolia D. Baasanjav Switzerland Julien Bogousslavsky Hans Rudolf Stöckli Morocco Mohamed Yahyaoui Syrian Arab Republic Ahmad Khalifa Myanmar Nyan Tun Tajikstan Sherali Radjabaliev Netherlands Marianne de Visser Thailand Rawiphan Witoonpanich New Zealand Andrew Chancellor Togo Eric Grunitzky Níger Sadio Barry Tunisia Najoua Miladi Nigeria M.A. Danesi Turkey Coskun Ozdemir Norway Johan A. Aarli Ukraine Oleksandr E. Kutikov Oman Pratap Chand United Arab Emirates Jihad Inshasi Pakistan S.S. Naeem-ul-Hamid Gohar Wajid Philippines Amado M. San Luis United Kingdom Colin Mumford Graham Venables Poland Urszula Fiszer S.J. Wroe Portugal José Lopes Lima United States of America Donna C. Bergen Michael F. Finkel Puerto Rico Angel Chinea Donna M. Honeyman Qatar Ahmad Hamad Uruguay José Caamaño Alejandro Scramelli Republic of Korea Seung Min Kim Uzbekistan Karimov Khamid Republic of Moldova Vitalie Lisnic Venezuela, Bolivarian Romania Ovidio Bajenaru Republic of Rolando Haack Russian Federation Michael Piradov Viet Nam Le Duc Hinh Saudi Arabia Saleh M. Al Deeb West Bank and Gaza Strip Mazen I. El-Hindi Fahmi M. Al-Senani Yemen Hesham Awn Senegal Ndiaye Mansour Zambia Gretchen L. Birbeck Serbia and Montenegro Slobodan Apostolski Slovakia Lubomir Lisy Slovenia Antón Mesec 59