Welcome to the WSC 2021 Interactive Program

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Indonesia is one of the biggest developing country in the lower-to middle income zone with gross national income of US$ 3,800 per capita. Stroke is the number one cause of mortality (15.4%) and disability (65%). In addition, the prevalence of stroke is steadily rising based on Baseline Health Research 2018 (7 per 1000 in 2013 and 10.9 per 1000 in 2018).

There are challenges to improve the system of care in Indonesia. This includes onset time to arrival in hospital, human resources, time delays in hospital, lack of imaging facilities and limited national health insurance coverage. The strategies have been developed to improve our stroke systems care. This includes the following: awareness stroke campaign to introduce the FAST (Face, Arms, Speech, Time)signs and symptoms of stroke, continuing medical education for medical staff, workshops and training for clinical practitioners, in house or overseas fellowship training for general neurologists, advanced neuroimaging modalities, standardized acute stroke protocols, integrated multidisciplinary stroke team and tactical engagement with the ministry of health to increase the insurance health coverage for stroke patients.

We hope that the overall effect of the above strategies will further reduce time metrics for reperfusion therapy which decreases morbidity and mortality. We have shown that our stroke centre has successfully reduced door to thrombolysis time. We have also shown that advanced neuroimaging (non-contrast CT brain, CT perfusion, CT angiography) is feasible in Indonesia.

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Sri Lanka is a South Asian country in the lower-middle income category. Noncommunicable diseases account for 71% of all annual deaths, and stroke is a leading cause of death and disability. Current demographic and epidemiological transitions are likely to lead to a large increase in an already high burden of stroke in the community.

Significant gaps exist in the quality of available stroke care. Developments in modern stroke care have been slow due to a lack of human resources and infrastructure facilities. Most patients with acute stroke are treated in state-sector hospitals where facilities for modern stroke care are limited. Neurologists are limited in number, and acute stroke care is largely provided by general physicians. Stroke units, neuroimaging, thrombolysis, mechanical thrombectomy, neurosurgical care and rehabilitation services are all limited in varying degrees across the country, although there are encouraging trends in the development of these. Prehospital stroke care and community support services are virtually nonexistent.

There is a clear need for improving stroke systems of care in Sri Lanka. Clinical audits have demonstrated the capacity of basic stroke units to deliver good acute care despite resource constraints. The National Stroke Association of Sri Lanka is playing a key role in creating public awareness. Sri Lanka, with its high literacy rates, free health care system and excellent primary health care coverage is well positioned to face the challenge of improving stroke systems of care. More research data is needed to guide strategies to minimise the burden of stroke in the country.

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Abstract

Improving Stroke Systems of Care in LMIC: Pakistan

Mohammad Wasay MD FRCP FAAN

Aga Khan University

Karachi, Pakistan

Pakistan is located in southeast Asia with world’s fifth largest population (225 million). It is considered a low middle income country (LMIC) by World Bank ranking with annual per capita GDP 1284 USD. Life expectancy is 67 years (70 years in women). Estimated stroke prevalence is 1200/ 100,000 population. Pakistani stroke population is younger (mean age 55 year) with estimated 30 day mortality upto 40%. There is one neurologist per one million population and one stroke unit for 20 million population.

Primary stroke prevention should be a top priority due to very high risk factors including hypertension, tobacco use and diabetes. Mass awareness, availability of screening facilities for hypertension and diabetes and optimal blood pressure and diabetes control may lead to 20-30% reduction in incidence. Training of general practitioners and medical doctors for stroke prevention, early identification and stroke care is mandatory due to limited availability of neurologists. There are 176 large public hospitals in country. Only two of them have a stroke unit or staff trained in stroke care. Increase in stroke units and stroke rehabilitation facilities specially at district level hospitals is most important infra structure intervention for improving stroke care in pakistan

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The Philippines is an archipelagic nation with 7,100 islands. With over 109 million Filipinos living in the country, only 5% are aged 65 and above. Stroke remains the leading cause of disability and death in the Philippines. Estimates of the true stroke prevalence vary between 0.9% to 2.6% of the population.

The identified barriers to stroke care included lack of health care resources, maldistribution of health facilities, inadequate training on stroke treatment among health care workers, poor stroke awareness, insufficient government support and limited health insurance coverage. Contributing further to this challenge are the geographically isolated and disadvantaged areas limiting access to health facilities.

The Stroke Society of the Philippines (SSP) in cooperation with the Department of Health and the World Stroke Organization launched the nationwide stroke education training to doctors and nurses on acute stroke treatment, setting up Acute Stroke Ready Hospitals and Acute Stroke Units. Thrombolysis training and simulation coupled with adaptation of standard stroke protocols improved the stroke time lines. Identification of stroke referral centers, setting up of stroke registry and the ongoing stroke unit certification will utilize data to assess, monitor and evaluate the effectiveness of the treatment and referral pathways. Stroke awareness and healthy lifestyle campaigns involved the public participation for the prevention and rapid stroke response. The SSP’s strong linkage with the government paved the way to the passage of the National Stroke Policy for prevention, treatment and management of stroke. These consolidate and strengthen the efforts for improving stroke care in the country.