The health care workforce for epilepsy in resource-poor settings: What will work? What is realistic?

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In this issue of Epilepsia, two articles highlight the role of nonphysician health care workers in the care of people with epilepsy in resource poor regions (see Kendall-Taylor et al. and Kengne et al.). Given the dearth of physicians in the regions such as Africa (<1/25,000 population) (WHO, 2008) and the even more distressing lack of neurologists (3/10,000,000 population) (WFN, 2004), recognizing the role of other professionals in the care of people with epilepsy (PWE) is critical as we assess the realities of care delivery in such settings and consider feasible options for improving care and decreasing the treatment gap.

In “Traditional healers and epilepsy treatment on the Kenyan coast,” Kendall-Taylor et al. conducted a series of qualitative investigations to explore traditional healers' understanding of epilepsy, approaches to epilepsy care, and interactions and relationships with people with epilepsy. Their findings are consistent with reports from other African countries (Dale & Ben-Tovim, 1984; Rwiza et al., 1993; Preux et al., 2000; Baskind & Birbeck, 2005; Kaboru et al., 2006). Given that the traditional healers are embedded within the community, readily accessible, and provide explanations for seizures that are congruent with the patient and family's existing belief system, patients often seek traditional care before and in parallel with Western-style medicine. Furthermore, Kendall-Taylor et al. found healers' interactions with patients to be very positive and engaged (though no comparison with physician-level care was made). Animosity between healers and physicians exist, but when approached appropriately, healers are often willing to consider collaborative efforts. Some models for physician-traditional healer collaborations exist (Baskind & Birbeck, 2005; Kaboru et al., 2006). As the first access point for care-seeking by people with epilepsy, collaborations with traditional healers may offer one effective means of improving access to antiepileptic agents (AEDs) and other medical treatments for people with epilepsy in resource poor regions.

The efforts described by Kengne et al. in “Nurse led care for epilepsy at primary levels in rural health districts in Cameroon” should be applauded. They report some preliminary success in a program designed to allow nurses to provide epilepsy care services in two rural health centers after the initial diagnosis has been made by physician-level care providers. Neurologists from more developed countries may be uncomfortable with the idea of nurse-led epilepsy clinics, but it is important to recognize that in regions with extreme shortages of physicians, the de facto trained health care providers for virtually all health-related problems are indeed clinical officers and nurses (Birbeck & Kalichi, 2004), who may be almost completely untrained to diagnose or treat epilepsy (Birbeck & Munsat, 2002). Although the most optimal care for people with epilepsy would ideally be that provided by specialist physicians, the best available care for many people in resource poor settings in the foreseeable future will, by necessity, have to be delivered by the nonphysician health care worker.

If we hope to narrow the treatment gap from its present shocking >90% in least developed regions (Meyer & Birbeck, 2006), then we must work within the existing health system resources to identify people with epilepsy who require treatment and find mechanisms to provide services that are accessible and affordable. This will almost certainly require formal collaborations with traditional healers, clinical officers, and nurses. Developing epilepsy care services to be delivered primarily by nonphysician health care workers will require that the appropriate training programs be developed. Furthermore, the outcomes of such care should be rigorously assessed. Clinical officers and nurses in sub-Saharan Africa are already being trained to serve as the primary health care workers in antiretroviral clinics. Given the lack of epilepsy diagnostic capacity in such regions (no EEGs, no neuroimaging) and the fact that the mainstay of epilepsy treatment in most developing regions remains phenobarbitone, it seems reasonable to hypothesize that nurses, clinical officers, and possibly traditional healers could be trained to be first in line to provide the medical management of epilepsy. Other reports from models for such care have been shown to be effective in Bamako (Nimaga et al., 2002) as well as other regions of Africa (Unwin et al., 1999).

Barriers to best available care delivery include the lack of educational tools designed to train nonphysician health care workers in the diagnosis and treatment of epilepsy. Some tools have been developed for use in specific areas (Birbeck, 2001), but may lack generalizability to other regions. Even if nonphysician health care workers are properly trained, national drug policies may need to be revised to allow nonphysicians to prescribe AEDs and/or to provide AEDs to rural and primary clinics staffed by such personnel. This may mean changing and expanding the contents of regularly provided “essential drug boxes” given to primary care clinics. Outcome assessments of epilepsy clinics staffed by nonphysician health care workers should include projections of patient outcomes with this “nonphysician care versus no care,” rather than comparisons to physician- or specialist-level care, because “no care” is the true alternative (i.e., the sad “standard of care”, or rather standard of “no” care) for people with epilepsy in such regions.

As clinical specialists, most clinical educators in Neurology have limited experience training nonphysician health care workers to provide autonomous services for patient care without ready access to physician-level support, but the World Federation of Neurology and the International League Against Epilepsy (ILAE) have some experience in this realm. The recent strategic plan set forth by the U.S. National Institute of Health's Fogarty International Center formally includes priorities in noncommunicable disorders, such as epilepsy, so more investments might be forthcoming from U.S. research resources (Daar et al., 2007). Cross-national collaborations involving such groups, as well as collaborations with appropriate Health Ministries and the few practicing neurologists in such areas, will be needed if efforts to decrease the treatment gap globally are to succeed.

Acknowledgments

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Conflict of interest: I have no conflicts of interest to disclose in relation to this paper.

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