Stroke is the second leading cause of death and the third leading cause of death and disability-adjusted life years (DALYs) combined. While high-income countries (HICs) have been consistently demonstrating a decline in age-standardized rates of stroke incidence, DALYs, and mortality over the last decade, low- and middle-income countries (LMICs) have shown an increase in stroke burden, demonstrating an 86% mortality rate and 89% DALYs. Adoption of primary prevention interventions through risk factor control, advancement in stroke diagnostics and management, and the presence of specialized rehabilitation centers for post-stroke care have contributed to the decline in stroke burden in HICs.
Tanzania, an LMICs, faces many challenges concerning stroke diagnosis, treatment and specialized centers and expertise in post-stroke care. A study conducted at the Muhimbili National Hospital (MNH) reports mortality as high as 40% at one year following a stroke and about 90% of survivors were unable to resume work. With most of stroke incidences occurring in the fourth and fifth decades of life, a population that still serves as the country’s productive force reaps both social and economic repercussions.
While primary prevention for stroke is a key intervention in lowering the incidence of stroke, formalized rehabilitation following stroke is well conceptualized in the World Stroke Organization Road Map. Rehabilitation helps to lower the risk of death and dependency, especially after the acute phase of stroke management. Evidence indicates that early mobilization for people with stroke is associated with lower mortality, fewer medical complications, and shorter length of hospital stay. Similarly, the optimization of quality of life among survivors is highly suggested by the accessibility to rehabilitation programs, while restoration of functional ability among stroke patients to participate in their usual activities is staged out as an important aspect in the improvement of quality of life in post-stroke patients. Stroke rehabilitation includes a combination of medical interventions, physical, occupational, and speech therapies aiming at restoring functional skills lost since stroke, as well as the involvement of psychiatrists, neuropsychologists, nutritionists and community-based social services. The World Health Organization (WHO) recommends community-based rehabilitation as an appropriate method to be used for stroke patients in LMICs, though this is postulated to be necessary given the limited availability of intensive inpatient rehabilitation programs in many LMICs.
Despite the action plans and evidence-based approaches for stroke prevention initiated globally by WHO, the reduction of stroke burden in LMICs has yet to be achieved. Similarly, tertiary intervention approaches including treatment and rehabilitation services for stroke patients are not well established. Low economic status among patients has been reported as a major limiting factor for patients in accessing rehabilitation services. This forces patients to opt for home-based physiotherapy, which is often less effective in the post-acute phase. Furthermore, studies reveal nearly 80% of stroke patients were not in a formal job and hence, lacked sustainable income and were not insured by a national health fund. Moreover, more than 50% of patients had severe disability which significantly determines their inability to be engaged in production activities. The above situation, coupled with the presence of few experts in post-stroke care in sub-Saharan African countries including Tanzania, poses a significant obstacle in providing rehabilitation services. For instance, in Tanzania, there are fewer than 100 physiotherapists, occupational therapists, and speech-language pathologists compared to its total population of over 60 million.
Unified efforts of the government and prominent stakeholders in the healthcare field are highly needed to enable easier accessibility to rehabilitation services among patients in LMICs and subsequently increase their living standards after a stroke. Furthermore, the establishment of practical policies for the provision of health insurance funds for patients to enable earlier access to rehabilitation healthcare, the creation of job opportunities for moderately disabled individuals to improve their livelihood, and setting up a special share in the health national budget for the improvement of rehabilitation services should be emphasized and implemented by policymakers. Additionally, an emphasis on disability-centered and rehabilitation-focused education would aid in training more specialists who can provide rehabilitation services locally. Given the limitations in accessing rehabilitation services in much of the country, particularly for those with limited mobility and financial resources, adopting telemedicine for rehabilitation is a promising solution in increasing the coverage of more patients. Lastly, a call for further research on the rehabilitation of stroke patients in LMICs should be emphasized. Essential holistic approaches including establishing rehabilitation programs that would incorporate cognitive, physical, and social aspects of stroke recovery need to be prioritized in order to meet the needs of many patients with individualized challenges following a stroke.
Innocent Kitandu Paul is in his third year at the Catholic University of Health and Allied Sciences in Tanzania. He is an active member of the Tanzania Medical Students' Association and the Federation of African Medical Students' Associations, serving on the committee of Medical Education and Research. Presently, he is engaged in the Stroke Registry Project at the Weill-Bugando Department of Medicine that was established in 2020 with the goal of enhancing quality care for stroke patients and identifying areas for further research. He possesses a strong passion for driving advancements and progress in healthcare services through his dedicated medical studies.
Joshua Ngimbwa, MD is a Medical Registrar at the Bugando Medical Center in Mwanza, Tanzania. He aspires to work as a physician-scientist conducting clinical and clinical implementation translational research in the region. He is part of the Weill Bugando Stroke Registry Project, which aims at enhancing stroke care and clinical outcomes for its patients.
Sarah Matuja, MD, MMed, MSc Fellow is a Senior Lecturer at the Catholic University of Health and Allied Sciences-Weill Bugando and a clinical Neurology Fellow at the Muhimbili University of Health and Allied Sciences, Tanzania. Her interests are in neurology, particularly in improving stroke care and clinical outcomes. She is currently a scholar for the World Stroke Organization Future Leaders Program and the Training Africans to Lead and Execute Neurological Trials Program, and a former NIH-NINDS Global Health Fogarty Fellow. Her ultimate goal is to conduct collaborative clinical research in Tanzania, sub-Saharan Africa and globally that will improve the health of the masses.
Kaile Eison, DO is an Assistant Professor in the New York-Presbyterian Department of Rehabilitation and Regenerative Medicine at Columbia University Irving Medical Center in New York, NY, USA. She is the department’s Medical Director of Global Health and HIV Rehabilitation and the Associate Director of the CUIMC Inpatient Rehabilitation Unit. She holds particular interests in the comprehensive management of acute rehabilitation needs, individuals recovering from prolonged stays in intensive care units with medically complex needs, individuals with spinal cord injuries, and those living with acute and chronic functional impairments related to HIV.