Stroke and Healthcare Facilities in Bangladesh and Other Developing Countries

Abstract

Globally, healthcare systems are struggling to make a healthier citizen by dropping infectious and non-infectious diseases. South-east Asian countries have achieved several Millennium Development Goals (MDG) with the efforts of better health system management. For instance, in the year 2015, the healthcare system of Bangladesh has achieved the MDG-Four in reducing the infant mortality rate and growth rate. Even then, the life-threatening diseases still remain as a major challenge to the healthcare systems in Bangladesh. Among those, non-communicable diseases (NCDs) are the major cause of death, and stroke is the second leading NCD in accordance with causes of death and long-term disability in Bangladesh. The majority as 80% of stroke survivors are living with either minor or major physical, emotional, and cognitive disabilities. They could get back to their functional life through comprehensive rehabilitation services. Nevertheless, information on the availability of rehabilitation services is not visible to all citizens of Bangladesh. That’s why more than half of all stroke survivors are dying on their way to the hospital to seek health care facilities. Therefore, the aim of this literature review was to present a clear vision of the healthcare system and the path of care to all citizens of Bangladesh.

1. Introduction

Stroke is the leading non-communicable disease worldwide and in the Southeast Asia (SEA) region [1]. In Bangladesh, stroke is the second leading non-communicable disease in terms of the cause of death and long-term disability. Those who survived from stroke attack need quality rehabilitation services to maintain their health and prevent them from death due to the second episode of stroke attack [2]. The quality of services can be viewed from many perspectives. However, the patient perspective is now given more importance because it can lead to the effectiveness of healthcare services and better health outcomes. Therefore, this study aims to examine the level of patient expectations and perceptions and the factors relating to the patient expectations and perceptions of outpatient post-stroke rehabilitation services delivery management in Bangladesh.

This chapter includes an overview of Bangladesh, health status and challenges, stroke definition and situation, post-stroke situation and how Bangladesh healthcare service systems respond to the post-stroke, stroke, and post-stroke care pathway and quality of post-stroke rehabilitation services as well as the methodology to examine the quality of post-stroke rehabilitation services and conceptual framework of this research study.

2. Overview of Bangladesh

Bangladesh is one of the smallest and most densely populated countries in the world. It is a developing country and a founding member of the South Asian Association of Regional Cooperation (SAARC) to promote regional connectivity and cooperation. Additionally, it is a member of the Commonwealth of Nations [3].

2.1 Geography

Bangladesh is a country in the South Asia Region [3]. According to the Ministry of Health and Family Welfare [4], geographically it is divided into eight divisions/provinces, and the total land area of this country is 147,570 sq. km. Dhaka division is the central division, and Dhaka city is the capital city of Bangladesh followed by Rajshahi, Barishal, Chittagong, Sylhet, Mymensingh, Khulna, and Rangpur divisions. Bangladesh National Portal [5] reported that the divisions/provinces are divided into 64 districts and 11 metropolises. Under the districts, there are 491 sub-districts. The sub-districts contain 4553 union councils in the rural areas and 323 municipalities in the urban areas. Consequently, a ward is under the municipality and the municipality is under the metropolis. There is no specific number of wards and villages. Figure 1 demonstrates the overall administrative geography of the government of Bangladesh.

Figure 1.

The administrative geography of the Government of Bangladesh. Adopted from: Bangladesh National Portal [5].

3. Socio-demographic and economic

The World Bank [6] reported that approximately 162 million people are living in this country. The World Bank [6] also claimed that in 2016, there are nearly 1253 people per sq. km. However, nearly 35% of the total population are living in urban areas for their employment.

The economic status of the citizens is improving, but still, possibly 25% of the total population are living under the poverty line [7]. In the year 2016, the growth domestic product (GDP) per capita was 1358.78 US$, and in the same year, the annual growth rate was 7.11 US$ [6].

4. Health status and challenges

According to Muhammad et al. [8], the healthcare system of Bangladesh has achieved the Millennium Development Goal Four (MDG-4) by reducing infant mortality rate and growth rate, and maternal and child health improvement. Consequently, life expectancy at birth has increased. As an example, the World Bank [9] reported that in 2005, the life expectancy at birth was 67.94 years and in the year 2015, it reached 72.22 years (i.e. male 70.59 years and female 73.94 years). It is comparatively higher than other state members in SAARC. As evidence, the Bhutanese life expectancy was 69.8 years; Indian was 68.3 years, and Myanmar was 66.3 years in the year 2015 data. However, Ahmed et al. [10] claimed that the health system of Bangladesh had achieved MDG-4 and better life expectancy, though several life-threatening diseases still remain.

The top five causes of death in Bangladesh are heart disease, stroke, Chronic Obstetric Pulmonary Diseases (COPD), lower respiratory infections, and diabetes [11]. The mortality rate of infectious diseases, maternal, prenatal, and nutritional conditions gradually went down from 30.9% in the year 2010 to 25.3% of total death in the year 2015 [12]. Relatively, the mortality rate of non-communicable diseases is now rising and going to be a major health challenge and life-threatening diseases in Bangladesh [8]. NCDs caused almost 67% of the total death [9]. Significantly, stroke caused more than half of the total NCD fatalities in Bangladesh [13]. And due to the shortage of the health workforce and inefficient management, it was difficult to provide proper services for people who had strokes [4]. Table 1 demonstrated all related data by selecting the major geographical, socio-demographic, economic, and health status of the citizens of Bangladesh.

4.1 Stroke definition and situation

According to the American Stroke Association [15], stroke is one of the NCDs which is a medical emergency characterized by a neurological deficit attributed to an acute focal injury of the central nervous system (CNS) by a vascular cause, including cerebral infarction, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) and it is a major cause of disability and death worldwide.

Nearly 4.46 million people have died due to stroke per year; 1.2 million in developed countries and nearly 3.2 million in developing countries [16]. For example, stroke was the 4th leading cause of death for US citizens in the year 2010 [17]. In every 40 seconds, someone was attacked by a stroke, and in every 4 minutes, someone died because of the stroke. It was also the leading cause of long-term disability in the United States. Similarly, in the year 2012 Australia projected that 377,000 people had a stroke sometime in their lives; and in 2013, the estimated deaths due to stroke were 8100 people [18]. Additionally, the stroke prevalence in European countries was also more similar to that in other countries. In 2015, it was found that, in the Netherlands, 0.2% of the total population had suffered from stroke each year [19]. Moreover, in 2008, around 3.7 million Southeast Asian people died from stroke. Islam et al. [20] reported that in Bangladesh, approximately 48,951 people had died due to stroke.

According to mortality, morbidity, and long-term disability rate, stroke is the second leading NCD in Bangladesh [11]. Nearly 113.9 persons per 100,000 had died due to stroke in the year 2013, and the increasing rate per year was 4.9% [21]. A total of 20% stroke patients died immediately in the acute phase, and 80% of the stroke survivors lived with minor or major disabilities [22]. Moreover, Centre for Injury Prevention Health Development and Research Bangladesh (CIPRB) [23] reported that approximately 15 out of 1000 Bangladeshi people were affected by stroke. Additionally, Islam et al. [20] found that the prevalence of stroke is 0.03% and it is snowballing. Nearly 485 out of 10,000 people died suffering from stroke disability [20]. Mamin et al. [24] found that nearly 82.5% Bangladeshi stroke survivors’ age ranged between 41 and 60 years. Consequently, the big proportions of working people have lost their functional ability and it greatly impacts the economy of Bangladesh.

4.2 Stroke impact

The American Stroke Association [25] claimed that the stroke effects depend on the lesion of the area of the brain cell. Different areas of the brain cell are responsible for different activities. Due to the lesion of the brain cell, the stroke effects can be physical paralysis, memory loss, speech loss, emotional, and behavioral problems. Wolfe [26] claimed that the stroke impacts could be explained from the perspectives of the government, society, family, and patient. From there, the socio-economic impact of stroke is more common in developing countries. Similarly, Institute for Health Metrics and Evaluation [11] reported that a stroke is a great economic burden for a developing country like Bangladesh.

According to Mamin et al. [24], nearly 77% of stroke survivors were public or private or self-employed in Bangladesh. Similarly, Global Health Statistics [21] reported that a big proportion of the working-age group and healthy life had been lost due to stroke in Bangladesh. For example, an estimated 1259.1 people at the age range of 30–34, 9102.9 people at the age range of 50–54, and 21695.5 people at the age range of 60–64 were affected by stroke and lost their functional life in the year 2014. Therefore, the government of Bangladesh has lost a big proportion of its workforce, and it greatly impacts the government and the economy.

Besides, Mohammad [22] claimed that the physical limitation of the patients greatly impacted the patients’ participation in the social programs or activities in society. They need long-term hospitalization and rehabilitation services, and the family has to look after them. However, Disability in Bangladesh (2004) reported that it is difficult to bear the whole treatment cost and the health system of Bangladesh has no health insurance package for their citizens. Therefore, it is also an economic burden for their families [11]. According to Mohammad [22], the burden of stroke is not only for their families, but it is also a burden for the patient because of their post-stroke disabilities and impairments.

4.3 Post-stroke

The post-stroke means a group of conditions including physical disability, emotional disturbance, and loss of cognition [27]. At the post-stroke phase, patients suffered from several complications; such as pressure sores, urinary tract infections (UTI), joint contraction, aspiration pneumonia, and recurrent stroke due to lack of proper healthcare services [2]. Consequently, these complications could be a leading reason for readmission and also for excruciating death. Gordon et al. [28] reported that daily activity or daily routine exercise helps the post-stroke patients’ to reduce immobility and make them as functional as possible. Therefore, the post-stroke phase is more crucial. Additionally, Runa [29] found that post-stroke complication is a very common problem in Bangladesh.

Accordingly, Mohammad [22] claimed that better care and rehabilitation services could get them back to their independent life. The better quality of healthcare services means a better patient experience, and it is associated with better health outcomes with a higher level of loyalty to follow preventive and treatment strategies of the hospital personnel [30]. Therefore, the healthcare system needs to ensure better and sustainable healthcare services to reduce post-stroke patients’ complications by increasing the better patient experience and patient participation in healthcare [31].

4.4 Healthcare service delivery systems

The health system is a dynamic and enduring obligation to peoples’ health throughout their lifespan [32]. The primary purpose of the health system is to provide healthcare services to promote, restore or maintain the health of the nation [33]. According to the healthcare policy and Constitution Act 18cited in Ministry of Law [34], the fundamental principle of the health system of Bangladesh is to ensure better healthcare services for their citizens. The healthcare system of Bangladesh has been providing a comprehensive healthcare service by following multilevel healthcare service delivery processes [35]. The comprehensive healthcare service includes curative, rehabilitative, promotive, and preventive services. In accordance with service delivery processes, the three levels of health care services are being considered in the health systems of Bangladesh. Such as tertiary, secondary, and primary care levels of healthcare services.

4.5 Tertiary care level

All the national specialized and medical college hospitals are providing the tertiary level of healthcare services [10]. According to the Ministry of Health and Family Welfare [4], there are numerous condition-based specialized hospitals and 14 medical college hospitals that provide the tertiary level of healthcare services, and these are the highest level of referral hospitals in the health system of Bangladesh. Ahmad [36] reported that this tertiary care concentrated more on curative and intensive healthcare services along with rehabilitative care services and ignored the promotive and preventive care services. Besides, Mamin et al. [24] claimed that the public hospitals also wanted to avoid these rehabilitation services in the health systems of Bangladesh.

In regard to stroke care, all public and private hospitals are serving their in-patient intensive curative care and treatment services [4]. However, only a few of them are providing after-stroke rehabilitation services at the physical rehabilitation department on an out-patient basis [37]. Separately, the non-profit organization as the Centre for the Rehabilitation of the Paralyzed (CRP) is providing after-stroke rehabilitation services in both ways (i.e. in-patient and out-patient basis) [38]. The CRP also extended its branches and services across the six divisions in the health systems of Bangladesh [39].

4.6 Secondary care level

According to the Ministry of Health and Family Welfare [4], secondary care or less intensive care is being provided at the district general hospitals. There are 62 district general hospitals to serve their secondary care services throughout the districts of the country. Secondary care includes curative, promotive, and preventive services. The promotive and preventive care services are being provided only for infectious diseases (i.e. Tuberculosis, Malaria, influenza, etc.) [40]. These secondary care hospitals are the first referral hospital in the health system of Bangladesh, and it does not provide rehabilitation services.

4.7 Primary care level

According to the Ministry of Health and Family Welfare [4], primary care includes curative, promotive, and preventive treatment facilities along with rehabilitative services. The primary care services are being provided at the sub-district or Upazila level, union level, and community level. At this primary care level, the public sector provided the services free of charge. The Upazila health complex and Union sub-centers are committed to providing curative, promotive, and preventive services only. There are 491 Upazila health complex hospitals and 3134 Union Sub-centers at the primary care level to provide in-patient and out-patient services. There are 13,336 community clinics serving maternal and child-related outdoor primary care services with basic medicines. Besides, Biswas et al. [40] reported that the Upazila health complex with the cooperation of NGOs has been running an NCD corner (i.e. fast-track corner) at the primary care level of Bangladesh to prevent the risk factors of NCDs. Consequently, due to the lack of healthcare personnel of the public sector, the NGOs are providing community-based rehabilitation services at this primary care level free of charge.

Table 2 lists all the hospitals and other healthcare facilities beneath the Directorate General of Health Services (DGHS) of the Ministry of Health and Family Welfare of Bangladesh. There is no list of private hospitals; thus, only public hospitals’ information is listed in the table. In this table, the type of hospital services includes inpatient and outpatient types of services.

Subject	Indicators	Value
Area	Total land area (sq. km)	147,570
Population	Total population in the year 2016 (in million); Density in 2016 (per sq. km); Crude birth rate in 2015 (per 1000); Crude death rate in 2015 (per 1000)	162; 1251.84; 19.23; 5.31
Life-expectancy	Male in the year 2016 (at birth); Female in the year 2016 (at birth); Total in the year 2016 (at birth)	70.59; 73.94; 72.22
Economic condition	GDP per capita in 2016 (US $); GDP per capita PPP in 2016 (US $); Annual Growth rate in 2016	1358.78; 3580.70; 7.11
Ethnicity	Muslim (% of total population); Hinduism (% of total population); Others (% of total population)	90; 9; 1
Communicable diseases	Total mortality rate in 2015 (% of total death)	25.3
Non-communicable diseases	Total mortality rate in 2015 (% of total death)	66.9

Table 1.

Major selected geography, socio-demographic, economic, and health status of Bangladesh in the years 2015 and 2016.

Sources: World Bank [6, 9, 12]; Ahmed et al. [10]; and A. Islam [14].

Level of facilities	Type of facilities	Type of services	Total no. of facilities	Bed occupancy
Secondary & Tertiary level hospitals and other facilities under DGHS
District	50-bed hospital; District & General hospital	Hospital; Hospital	2; 65	100; 10,328
Divisional & National level	Chest diseases hospital; Dental college hospital; Hospital for alternative medicine; Infectious disease hospital; Leprosy hospital; Medical college hospital; Other hospitals; Specialized hospital; Specialty post-graduate institute and hospital; Trauma centre; Chittagong skin & hygiene treatment centre; National asthma centre; National centre for control of rheumatoid fever and heart diseases	Hospital; Hospital; Hospital; Hospital; Hospital; Hospital; Hospital; Hospital; Hospital; Hospital; Hospital; Hospital; Hospital	13; 1; 2; 5; 3; 14; 4; 3; 11; 5; 1; 1; 1	866; 200; 200; 180; 130; 12,963; 325; 850; 3184; 100; N/A; N/A; N/A
Total number of hospitals and other facilities			131	29,426
Primary level healthcare facilities
Upazila	Upazila health complex (50 bed); Upazila health complex (31 bed); Upazila health complex (10 bed); Upazila health complex (0 bed); Upazila health office; 31-bed hospital; 30-bed hospital	Hospital; Hospital; Hospital; Hospital; Outdoor; Hospital; Hospital	297; 113; 11; 3; 60; 5; 2	14,850; 3503; 110; 0; ……; 155; 60
Total Upazila level facilities			491	18,678
Union	20-bed hospital; 10-bed hospital; Union sub-center; Union health and family welfare center	Hospital; Hospital; Outdoor; Outdoor	32; 19; 1498; 1585	640; 190; ……; ……
Total union level facilities			3134	830
Word	Community clinic (at present)	Outdoor	13,336	……
Grand total primary level hospitals			482	19,508
Grand total primary level facilities			16,968	19,508
Grand total health facilities under DGHS of Bangladesh			17,099	48,934

Table 2.

The hospitals and other healthcare facilities under the DGHS of Bangladesh.

Source: Ministry of Health and Family Welfare [4].

4.8 Human resources

The Ministry of Health and Family Welfare [41] reported that there were 74,099 physicians, 6,481 dental surgeons, almost 46,000 registered nurses, 775 pharmacists, 6,029 medical technologists, and 66,623 community health workers. The number of physicians and population ratio was 4.5 per 10,000 populations. There was no more data on the rehabilitation professionals, only a little information available about the physical therapist. The Ministry of Health and Family Welfare [4] reported that in the public sector, nearly 117 physiotherapists are working. Separately, World Confederation for Physical Therapy (WCPT) [42] reported that approximately 1,600 physiotherapists are working in the whole Bangladesh healthcare service sectors. According to a 2016 report of the Bangladesh Health Professionals Institute (BHPI), 241 occupational therapists have graduated and are working in various national and international organizations and hospitals in the country and abroad [43]. The Society of Speech and Language Therapists (SSLTs) reports that speech and language therapy is a relatively new profession in comparing with other rehabilitation professions in Bangladesh and as of 2016, there are 104 graduate speech and language therapists those are working in various national and international healthcare organizations in Bangladesh [44]. Approximately, 25 to 30 students from each department of BHPI (the academic institute of CRP) (Occupational Therapy and Speech and Language Therapy) completing their graduate program each year and initiate clinical practices [39]. Table 3 demonstrated the healthcare personnel and population ratio of serving healthcare services healthcare services in Bangladesh. Therefore, the availability of rehabilitation services and the fee for the services are the greatest challenge for the person with rehabilitation service needs.

Healthcare providers and population ratio
Healthcare personnel	Number	Ratio
Physician	74,099	4.5: 10,000 people
Neurologist	60	0.004: 10,000 people
Dental surgeons	6481	0.40: 10,000 people
Registered nurse	46,000	2.84: 10,000 people
Physical therapist	1600	0.1: 10,000 people
Occupational Therapist	241	0.024: 10,000 people
Speech and Language Therapist	104	0.010: 10,000 People
Community health worker	66,623	4.11: 10,000 people

Table 3.

The healthcare professional and population ratio in the years 2015 and 2016.

Source: Ministry of Health and Family Welfare [4, 41], BHPI [43] and SSLTs [44].

4.9 Financial challenges

According to Bangladesh National Health Accounts [45], the total health expenditure was only 3.5% of the total GDP. It is relatively low, and according to per capita, the health expenditure was 27 US$. However, from this expenditure, the government invested only 23%, and the rest of the amount came from out-of-pocket payments. According to Ahmed et al. [10], this out-of-pocket payment was almost 63% of total healthcare cost. Besides, there was no specific budget for stroke and post-stroke patients and their healthcare services. Moreover, the Ministry of Health and Family Welfare [4] reported that they invested only 2714 million BDT taka (32 million US$) for overall NCDs surveillance. This was a very small expenditure compared to the expenditures on communicable and maternal diseases (i.e. 579 million US$) in the healthcare service system of Bangladesh. Therefore, financial challenge is a big challenge to provide NCD-related healthcare programs in the healthcare system of Bangladesh.

4.10 Policy and programs

Since the liberation, the health system of Bangladesh has been concentrating on controlling communicable and maternal and child-related diseases [10]. Global Health Statistics [21] reported that within the last decade the burden of NCDs is snowballing and has become a major health challenge for Bangladeshi citizens. Furthermore, the Ministry of Health and Family Welfare concentrated on this issue, and with the cooperation of NGOs and private organizations, they developed different policies and had been implementing these to strengthen the healthcare system of Bangladesh [40].

There is no specific policy and program for after-stroke disability. All the policies are focused on preventive and promotive health care services to control the risk factors of NCDs including stroke. However, these services are also important to reduce the second episode of stroke attack [46] such as the Health, Nutrition and Population Strategic Investment Plan (HNPSI) for six years (2016–2021) to inter-organization collaborative work and improve healthy lifestyles [4]; The Smoking and Tobacco Products Usages (control) Act, 2013to reduce smoking [5]. Furthermore, the governance, non-governance, and private organizations are working collaboratively to implement these policies and programs [40]. One example is the NCDs intervention corner at the primary care level of Bangladesh.

4.11 Governance and organizations

The health system of Bangladesh has been following a pluralistic healthcare system. The Ministry of Health and Family Welfare is the main government organization of the health system of Bangladesh [4]. This ministry is responsible for providing curative, promotive, and preventive services through tertiary care, secondary care, and primary care organizations. For rehabilitation services, the Ministry of Social Welfare is the responsible government organization, but at present both ministries (i.e. Ministry of Health and Family Welfare and Ministry of Social Welfare) are working collaboratively to serve rehabilitation services at the different levels of healthcare services [47].

The public sector in the health systems of Bangladesh did not concentrate more on rehabilitation services [24]. Thus, the private sectors (for-profit organizations) and NGOs (not-for-profit organizations) extended their healthcare services including rehabilitation services [20]. A few of the private hospitals are providing post-stroke rehabilitation services at tertiary care level hospitals on an inpatient and outpatient basis. Along with the private sectors, several NGOs under the Ministry of Social Welfare have been offering post-stroke rehabilitation services within the community and hospital [40]. These NGOs are the Bangladesh Rehabilitation Assistance Committee (BRAC), Handicap International (HI), International Committee of the Red Cross (ICRC), and the CRP (Handicap International (HI) [48] and Islam et al. [20]). The International Committee of the Red Cross (ICRC) with the collaboration of CRP has been providing rehabilitation services in the community [49]. While only the CRP provides hospital-based stroke rehabilitation services besides community-based rehabilitation services.

The CRP is offering rehabilitation services throughout the six divisions of the administrative geography of Bangladesh [39]. The CRP is also committed to provide Multi-Disciplinary Team (MDT) based rehabilitation services. According to Gresham et al. [50], the rehabilitation services by a multidisciplinary team provide better health outcomes after-stroke disabilities. The MDT approach consists of different specialists or professionals, those working in a team according to the needs of the patient [51]. In this approach, all professionals are offering their highest potential skills to change the patients’ condition as much as possible. Figure 2 demonstrates the overall service structures of the Bangladesh healthcare system.

Figure 2.

Health service systems structure in Bangladesh health systems. Adopted from:Ministry of Health and Family Welfare [4]; Ahmed et al. [10]; Biswas et al. [40].

5. The Centre for the Rehabilitation of the Paralyzed (CRP)

According to CRP [39], the CRP is a not-for-profit NGO to serve rehabilitation services for person with disabilities. CRP’s vision is “to ensure the inclusion of girls and boys, women and men with disabilities into mainstream society.” To achieve this vision, CRP worked with several missions such as “to promote an environment where all girls and boys, women and men with disabilities have equal access to health, rehabilitation, education, employment, the physical environment, and information.” The CRP is coordinated by a committee, and it is committed to serving quality services.

Trust for Rehabilitation of the Paralyzed (TRP) is the central committee and all the decisions such as policy, programs, and implementation are being addressed by the recommendation of this committee. The executive director coordinates all the CRP services throughout the CRP branches. The program manager helps the executive director to coordinate all the programs. The program manager divides all the CRP activities into various programs or services. Every wing is being coordinated by the head of the wing along with several heads of the departments. Additionally, there is the academic wing to provide the skillful rehabilitation professionals to serve the quality services toward the patients. It has ten branches, and the medical service wing is responsible for serving all healthcare services.

In this context, the physical therapy department is responsible for recovering physical functions, the occupational therapy department for recovering daily activities, and the speech and language therapy department for recovering communication and swallowing difficulties. According to CRP policy, all medical professionals have to wear hospital uniform during therapy services. Only the five CRP divisional hospital branches (i.e. Rajshahi, Chittagong, Barisal, Sylhet- Moulvibazar, and Mymensingh branches) along with the main branch of Dhaka division has been providing the out-patient medical services and rehabilitation services. The rest of the branches are responsible for providing Community-Based Rehabilitation (CBR) services and health promotion and prevention activities beneath the rehabilitation wing. CBR is offering these services five full days a week, from 8 am to 5 pm. There are several departments, and the research and evaluation department coordinates all the research-oriented formalities in the CRP. CBR collects donation and undergoes several income-generating activities to enhance the endowment to run the healthcare services (i.e. CRP cafeteria, nursery, woodshop, etc.). Figure 3 demonstrates the CRP management organogram with several services and activities throughout the country.

Figure 3.

The organogram of the CRP activities in Bangladesh. Sources: Adapted from [39].

6. The rehabilitation personnel in the CRP hospital

The CRP (2016) reported that all of 755 dedicated employees are working throughout this organization and its branches. However, there is no exact data for the total number of separate rehabilitation professionals.

7. Stroke and post-stroke care pathways in Bangladesh

The rehabilitation service systems and stroke care depend on the severity of the patients and the episodes of the stroke attack [52]. They have mentioned two phases; the acute phase and the sub-acute phase of stroke care. However, Pitthayapong et al. [2] added the post-stroke phase and it is started at the end of the acute and subacute periods of stroke.

7.1 Acute stroke care

Acute stroke care means care that takes place 24–48 hours after stroke, and during this period they need more intensive comprehensive services including rehabilitation if possible [52]. Particularly, inpatient rehabilitation care units of the hospitals serve the acute stroke care services, and the tertiary/specialized hospitals and divisional general hospitals provide comprehensive stroke care services under the healthcare services structure of Bangladesh ([53]; Bhowmik et al. [7]; & Nessa et al. [37]).

7.2 Subacute stroke care

At the end of the acute period of stroke, the sub-acute period of stroke starts, and the duration of this phase is one week until one month [52]. At this period the neurological condition of the stroke patients is more stabilized than during the acute stroke period, and from this phase, they attend a regular rehabilitation program [54]. The acute and sub-acute stroke patient services are similarly available in the tertiary/specialized hospitals and divisional general hospitals in Bangladesh (Directorate General of Health Services [53]; Bhowmik et al. [7]; Nessa et al. [37]).

7.3 Post-stroke care

Post-stroke care is care that started at the end of the acute and sub-acute phase of stroke patients [55]. However, Habib and Hirschfeld [56] found that the post-stroke care with the integration of rehabilitation services was effective. The limited specialized public and private hospitals at the tertiary level and the CRP hospital provide after-stroke/post-stroke rehabilitation services. The NGOs and Upazila health complex hospitals provide preventive and promotive services for reducing the risk factors of the second episode of stroke attack in the health systems of Bangladesh (Biswas et al. [40] & Ahmed et al. [10]).

The stroke care pathways in the Bangladesh health service system are complex and difficult to control. According to Biswas et al. [40], first, the patient visits the Upazila health complex, and if the responsible health professional notices any signs and symptoms of the stroke risk factors, then they suggest that the patient has to continue the preventive and promotive services from the NCDs corner. Directorate General of Health Services [53] reported that according to the stroke management guideline; if the patient needs emergency services, they are referred to the district hospital for secondary care. Thus, the district hospital takes care of this patient according to their available resources. If the patient’s condition becomes more severe, then the district hospital refers the patient to the tertiary or specialized hospitals for more intensive care and neurological treatment.

According to this stroke management guideline, after completing the acute stage, some of the hospitals send them to the rehabilitation hospital or the rehabilitation unit of the hospitals for early rehabilitation services [53]. Moreover, the rehabilitation professionals are working with those post-stroke patients with a set of standard goals, and after achieving this goal, they send them back to the community or home to continue community-based rehabilitation services by several NGOs [10, 20, 39]. Similarly, they are continuing preventive and promotive services through NCDs corner of the primary care level to reduce the second chance of stroke attack [40]. This study concentrated only on the post-stroke out-patient rehabilitation services system in Bangladesh. According to Ahmed et al. [10], CRP is a rehabilitation center for serving post-stroke rehabilitation services in Bangladesh. It is serving hospital-based inpatient, out-patient, domiciliary, and community-based rehabilitation services. Figure 4 shows the stroke and post-stroke care pathways along with the rehabilitation services in Bangladesh.

Figure 4.

Stroke and post-stroke care pathways along with the rehabilitation services in Bangladesh. Adopted from: Directorate General of Health Services [53]; Ahmed et al. [10]; Nessa et al. [37]; and Bhowmik et al. [7].

8. The CRP post-stroke out-patient rehabilitation services pathways

According to Runa [29], CRP is the biggest rehabilitation hospital in Bangladesh. It provides comprehensive post-stroke rehabilitation services following a Multi-Disciplinary Team (MDT) approach. The MDT team is composed of a physician, physiotherapist, occupational therapist, speech and language therapist, rehabilitation nurse, and patient’s caregiver.

According to the CRP service delivery process [39], at the first contact, the patient comes to the reception (1) to collect the serial token, and after collecting the token, they have to wait in the waiting areas (2) for MDT screening (3). The MDT professionals screen the patient’s condition and consequently recommend the patient for further rehabilitation services. According to the MDT recommendations, the patient goes to the laboratory (4) for the clinical test if recommended and reception (5) for the appointment of outpatient rehabilitation services. There are three departments; physical therapy, occupational therapy, and speech and language therapy for post-stroke rehabilitation services. After collecting the therapists’ appointment from the reception, the patient has to go to the recommended departments (6) to receive the therapy services and wait for therapy timing (7). However, the patient may have to visit several departments based on the patient’s needs. The repetition of the therapy session depends on the patients’ physical stability and availability of the therapy session. The three departments professional demonstrate a health education program (8) at the end of their therapy session. The main purpose of this program is to provide knowledge about stroke risk factors prevention and health promotional activities.

At the end of the session, according to the therapist’s recommendation, the patient may have to go to the pharmacy (9) and the reception (10) again for further appointments. Finally, the patient goes back home (11, 12) and comes again on another day for a laboratory report and the next appointments if needed. Otherwise, the patient and the patient’s caregiver can get help from CRP telemedicine services (13) and CBR services. Using this telecommunications service, they can continue their therapy services at home (Figure 5) [39].

Figure 5.

Demonstrated the overall post-stroke outpatient rehabilitation services pathways in the CRP hospital. Sources and Adopted: From, CRP [39].

9. Post-Stroke healthcare scenario of other underdeveloped and neighbor countries

9.1 India

The Republic of India is a border country of Bangladesh. India is surrounded almost entirely by sharing its’ borders within west, north, and east areas. It has been following a three-tiered model of health care service delivery. These tiered models comprise of primary, secondary, and tertiary level of healthcare services. The primary healthcare centers are particularly focusing on prevention, recognition, and referral for rehabilitation. The secondary level at district hospitals has fortified with medical doctors and other general facilities. At the divisional level, all tertiary care hospitals have equipped with all specialized facilities that are provided by public and private healthcare organizations [57]. There are enormous differences in accessibility and affordability in private and public hospitals for post-stroke healthcare services. For this circumstance, it’s becoming a major challenge for the patients who are seeking quality healthcare facilities for after-stroke patients.

9.2 Myanmar

The Republic of the Union of Myanmar has been sharing its border with the country of Bangladesh. Myanmar has been following pluralistic healthcare system followed by public, private, and NGO sectors. Ministry of Health (MOH) and other professional organizations have been working collaboratively for reducing communicable diseases. While communicable diseases declined, non-communicable diseases have been rising as a major concerning issue in Myanmar. The Department of Health (DOH) is mainly responsible for ensuring healthcare services through rural health centres (RHCs) and sub-rural health centres (Sub-RHCs) in the corresponding the municipality, district, and regional health centers. Preventive, promotive, and rehabilitative services have been providing for all citizens as well as for post-stroke patients to reduce premature deaths. All RHCs, Sub-RHCs are providing primary care services and at the regional level has available emergency and specialized hospital services based on the patients’ need [58].

9.3 Nepal

Nepal is a state of government that has spanned a decade of political disturbance, revolution, and ferocity from the years 1996 to 2006. That particularly affects the development of healthcare sectors in Nepal. In this regard, private sectors have been following a leading role in ensuring healthcare services for the citizens of Nepal. Nepal’s healthcare system is struggling to control infectious diseases and the Ministry of Health and Population (MoHP) has made a significant achievement in reducing infectious diseases. However, due to demographic changes and urbanization, the burden of national diseases has shifted from infectious to non-infectious disease patterns [59]. Wherein, 108 out of every 100,000 deaths in Nepal are occurring by cerebrovascular diseases and almost 543/100,000 persons have led a Disability-Adjusted Life Years (DALY) after their stroke [60]. Public and private sectors have been providing curative and rehabilitative services but, patients have to depend on the private sector for emergency and specialized hospital facilities. The affordability of medical treatment has considered a major role in accessing hospital facilities for all citizens. Besides, out-of-pocket payment is a very common problem in Nepal to receive in-patients hospital services.

9.4 Bhutan

The Royal Government of Bhutan provides free health care services by following the principles of primary healthcare strategy. Bhutan has improved slowly on the way to building a strong health system. However, the Ministry of Health (MoH) has faced several burdens of diseases where the prevalence of non-communicable diseases (NCDs) is aggravated. To fight against the growing trend of NCDs, Bhutan has applied a multisectoral national action plan to prevent health risks of NCDs [61].

9.5 Maldives

The Maldives is a developing country where the government is the head of the country. The Maldives has achieved a distinguished improvement in the health status of all citizens in gaining five out of eight Millennium Development Goals (MDGs) that creates a strong basement in achieving sustainable development goals (SDGs). However, considering the socioeconomic and environmental changes, the country has faced new challenges in controlling non-communicable diseases (NCDs). About 81% of total deaths are caused by NCDs in the Maldives. To address the burden of NCDs, a multisectoral national plan of action has been developed and implemented in focusing on preventive and promotional health interventions to bring changes in lifestyles and reduce health risks of NCDs. The Ministry of Health (MoH) is primarily responsible for ensuring primary health care facilities for all citizens, where, some private hospitals and NGOs provide healthcare in collaboration with the public sector. The government has spent the maximum amount of the total budget in the health sector. For instance, out-of-pocket payments for healthcare services are declining [59, 62].

10. Conclusion

The burden of NCDs as well as stroke is not an issue of a particular country. Globally, it is now a common public health concerning issue. World Health Organization has been working worldwide in dropping down the risk of NCDs. Several countries have adopted a multisectoral collaboration approach to improve health status and work collaboratively with the participation of all individuals in different sectors. In Bangladesh, the Ministry of Health and Family Welfare in cooperation with various NGOs and private organizations has launched NCD corner at the Upazila level for providing preventive, promotional, and rehabilitative services in the community for persons who are having health risks and after-stroke disability. The scarcity of healthcare personnel is also an important barrier for providing such services. At the same time, healthcare financing and lack of infrastructure are the most important hindering factors for maintaining these kinds of services in the community. Therefore, this is the time for the ministry of health and family welfare to work with other ministries and donor agencies for the betterment of all citizens of Bangladesh.

11. The way to meet the challenges

• In order to reduce the bureaucratic problem in adopting any approach related to healthcare in society, the government has to implement a decentralization system.

• The government should increase the annual health care budget for providing low-cost or free treatment facilities. In this case, the government should work with various national and international donor agencies for financial assistance.

• Government and other legislative organizations need to work on primary care practices in both rural and urban areas by increasing the capacity of primary care workers. Similarly, it recommends considering planning environmental changes to make the infrastructure user-friendly and accessible to all.

• Local community leaders, social workers, and general people are needed to be aware of the health risk of NCDs. In this case, a multisectoral collaboration in action approach would be an effective way to work collaboratively as well as initiating telerehabilitation services, remote rehabilitation services, public education, and awareness for early rehabilitation in reducing health risks of affecting NDCs.

• Continuous quality control and monitoring systems are needed for maintaining the quality of the healthcare services as well as strengthening the healthcare service systems of Bangladesh.

Acknowledgments

Ethical approval: Not applicable. Informed consent: Not applicable. Animal Studies: Not applicable. Funding support: We are thankful to the Society of Speech and Language Therapists (SSLTs) in Bangladesh for their overall support to complete this article. Also, thankful to all authors those were sharing their thought and ideas to write this article.

Conflict of interest

The study authors declared that there is no conflict of interest.

Appendices and nomenclature

BRAC

Bangladesh Rehabilitation Assistance Committee

CBR

Community-Based Rehabilitation

CNS

Central Nervous System

COPD

Chronic Obstetric Pulmonary Diseases

CRP

Centre for Rehabilitation of the Paralyzed

DALY

Disability-Adjusted Life Year

DGHS

Directorate General of Health Services

DOH

Department of Health

GDP

Growth Domestic Product

HI

Handicap International

HNPSI

Health, Nutrition and Population Strategic Investment

ICH

Intracerebral Hemorrhage

ICRC

International Committee of the Red Cross

MDG

Millennium Development Goal

MDT

Multi-Disciplinary Team

MoH

Ministry of Health

MoH&FW

Ministry of Health and Family Welfare

MoHP

Ministry of Health and Population

NCD

Non-Communicable Diseases

RHC

Rural Health Centre

SAARC

South Asian Association of Regional Cooperation

SAH

Subarachnoid Hemorrhage

SDGs

Sustainable Development Goals

SEAR

South-East Asia Region

SSLTs

Society of Speech and Language Therapists

TRP

Trust for Rehabilitation of the Paralyzed

UTI

Urinary Tract Infections

WCPT

World Confederation for Physical Therapy