South-East Asia Region

18 October 2016
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Throughout the large and diverse South-East Asia Region, there have been no data until recently on the prevalence or burden of headache.

In India, headache disorders appear to be highly prevalent, perhaps because of climate and lifestyle. India is itself very large (population 1.2 billion) and diverse. State-based rather than nationwide initiatives offer the best prospects of success. An epidemiological study has been completed in Karnataka State, with logistic support from WHO's South-East Asia Regional Office (SEARO). Extrapolation to all India from an enumerated population of about 12,000 within one State may not be appropriate; another study is therefore planned around Delhi. Similar results from the north of India will be reassuring but still not representative of the country. However, if results from two methodologically sound studies in India are within the worldwide range, no reason will exist for believing they overestimate the problem for health-care planning purposes.

The next stage in India is to propose a model for organisation of headache services.

There are multiple problems:

  •  80% of care is out-of-pocket (in a poor country);
  •  the population is 72% urban, but there is a large urban/rural divide: health-care practitioners (HCPs) are 3.4 versus 0.6 per 1,000 population; hospital beds are 3.0 versus 0.2;
  •  overall there is 1 neurologist per 1.25 million people;
  •  patients may choose at what point they enter the health system, or be referred upwards within the system (there is no formal gatekeeper role);
  •  HCPs are unskilled in headache care;
  •  large variations occur across the country (climate, culture, literacy);
  •  population growth rate is 9%, not accompanied by proportionate increase in social spending.

The National Rural Health Mission provides a good opportunity for change. Its mission is: "to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children." Its goals include "access to integrated comprehensive primary healthcare".

In this context, a proposal for organization on three levels is realistic (although capacity may be inadequate):

  • level one delivered by doctors and, in rural areas, by the new generation of non-medical health-care providers from primary health centres (PHCs) (one per 30,000 population); (there is no tradition of nurse-led services, and pharmacists sell drugs while neither giving advice nor diagnosing);
  • level two delivered from community health centres (one per 100,000 population) and/or Taluk hospitals (one per 5-600,000), the former having some and the latter all specialties;
  • level three in District hospitals (one per 2-2.5 million), which have all specialties and admission facilities; there is a national policy to create academic medical colleges in all District hospitals.

In urban areas there are modifications (urban health centres) and this structure is supplemented by other specialist institutions (such as NIMHANS) and by private centres. Thus an alternative for level three may be community satellite clinics from these specialist institutions.

The way forward is probably through State-based demonstrational projects, supported by State governments, providing for defined populations.

Capacity-building of doctors, especially in PHCs, is a priority: essentially this is a training issue. Public education is a necessary adjunct, but likely to have limited efficacy alone.

In Nepal, a very poor country, a nationwide population-based door-to-door burden-of-headache survey has been completed. This was funded through Samarbeidsorganet, the Liaison Committee between the Central Norway Regional Health Authority and the Norwegian University of Science and Technology (NTNU).

A nationwide population-based door-to-door survey, and a school-based survey of child and adolescent headache, are planned in Sri Lanka.

Indonesia is important because it is a populous country where nothing is known of the burden of headache there. Lifting The Burden is seeking local contacts.

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