PUBLIC HEALTH POLICIES FOR IMPROVING NEUROREHABILITATION OUTCOMES AFTER STROKE AND TRAUMATIC BRAIN INJURY

Abstract

Background: Stroke and traumatic brain injury (TBI) are leading causes of acquired disability in Pakistan, yet neurorehabilitation remains poorly integrated into national health policy. This study evaluated the impact of public health policies on neurorehabilitation access and functional outcomes following stroke and TBI in Islamabad, Pakistan.

Methods: A convergent parallel mixed-methods design was employed across four tertiary hospitals (two public, two private) in Islamabad. Four hundred twenty adult patients with first-ever stroke or moderate-to-severe TBI were followed for six months using the Modified Rankin Scale (mRS), Functional Independence Measure (FIM), and Fugl-Meyer Assessment. Semi-structured interviews were conducted with 25 key informants, including policymakers, clinicians, and rehabilitation professionals. Data were analyzed using multivariable logistic regression and reflexive thematic analysis.

Results: Significant disparities existed between public and private sectors. Favorable functional outcomes (mRS ≤ 2) at six months were observed in 24.2% of public sector patients versus 62.2% of private sector patients (p < 0.001). Only 18.3% of public sector patients accessed continuous rehabilitation beyond three months, compared to 72.2% in the private sector. The Sehat Sahulat Program excluded outpatient rehabilitation, creating catastrophic out-of-pocket costs. Structured rehabilitation access was the strongest predictor of favorable outcomes (AOR = 4.32, 95% CI [2.85–6.54]). Qualitative analysis identified three critical policy barriers: fragmented continuum of care, financial toxicity due to insurance exclusions, and workforce deficits exacerbated by brain drain.

Conclusion: Neurorehabilitation outcomes in Islamabad are determined primarily by health policy architecture and socioeconomic status rather than clinical severity alone. Urgent reforms, including rehabilitation inclusion in national health insurance, standardized care pathways, workforce investment, and tele-rehabilitation expansion, are essential to achieve equitable post-stroke and post-TBI recovery in Pakistan