Table 1

Metaphor of the ‘car’ and ‘bridge’—thrombolysis in acute stroke17 in LMICs setting*

StakeholdersExpected roles
PopulaceGeneral awareness about stroke to enable immediate recognition of stroke and initiation of appropriate actions.
PatientThe patient/caregiver/neighbour/coworker need to be able to recognise stroke immediately when it occurs and act fast by organising/initiating rapid transfer to a centre where urgent investigations and thrombolytic therapy can be delivered.
ProvidersDoctors/neurologists need to be competent to rapidly investigate, decide on eligibility, administer and monitor thrombolytic therapy in patients with acute ischemic stroke. Pharmacist: To ensure availability of potent thrombolytic therapy (from a genuine source, not expired, appropriately stored and dispensed).
PolicymakersTo make policies that will ensure (a) community level sensitisation about stroke recognition and rapid action, (b) rapid evacuation services for patients who suffered a stroke within the therapeutic time window and (c) availability of proximal certified centres for rapid evaluation and administration of thrombolytic therapies.
PayersHealth insurance companies, the government, drug companies to work together using the antiretroviral therapy model to ensure accessibility of thrombolytic therapy to LMICs using a combination of different mechanisms: discounts, subsidies, supplementation, local manufacture of generic products and donations.
PartnersTo ensure synergistic engagement of all stakeholders listed above to ascertain, evaluate and monitor implementation.
  • *Stroke, the clinical culmination of various cardiovascular risk factors, is the leading cause of cardiovascular death, disability and dementia in LMICs. It often presents in a dramatic acute/hyperacute manner and requires urgent and appropriate action to be taken by all stakeholders. Thrombolysis for acute ischemic stroke is a level A class I recommendation which is proven in HICs.10 While awaiting possible pharmacogenomic drug trials and other new contextual evidence in LMICs, this current evidence may be applied. The ‘car’ is the recommendation ie ‘to administer thrombolytic therapy to all eligible patients with ischemic stroke within the therapeutic time window’. Sections of the bridge are the roles to be played by stakeholders without which the bridge will be impassable and the service cannot be delivered.

  • HICs, high income countries; LMICs, low and middle income countries.