Table 7 Illustrations of how the model might be implemented, with adaptations, in various countries

Abu Dhabi

High

3

Layered, bottom-up

Level-1 services provided by GPs in each State-owned primary health-care centre.

Level-2 services provided either by GPs in selected primary health-care centres, or by hospital-based neurologists.

A single level-3 centre in a specialist neurology department within a hospital-based multidisciplinary health-care facility.

Total population is about 1.5 million. There are 27 State-owned primary health-care centres, but 500 GPs, many in the private sector.

Azerbaijan

Upper-middle

3

Hybrid system, bottom-up

Level-1 services provided in remote rural areas by GPs in primary care, in urban areas by GPs in ambulatory-polyclinic services.

Level-2 services provided either in the same polyclinics, where so-called district therapists/GPs can redirect to a neurologist (or to level 3), or by neurologists working in private clinics or outpatient clinics in private hospitals.

Level-3 services provided in central regional hospitals with neurological beds.

Neurologists at level 2 can provide clinical and educational support to GPs in their locality in a hub-and-spoke arrangement.

Brazil

Upper-middle

3

Layered, bottom-up

Level-1 services provided in the community by GPs in primary care.

Level-2 services provided by neurologists working either in the community or in hospital-based secondary care.

Level-3 services provided by neurological centres, often university-based, in the larger cities.

Total population is 210 million (70% covered by public health services, 25% by supplementary health services, 5% uncovered), served by 35,000 GPs, 5000 neurologists and 500 (uncertified) “headache specialists”. Despite apparently adequate capacity at all levels (albeit unevenly distributed geographically [84]), fewer than 5% of candidates for migraine preventative drugs currently receive them [90].

Bulgaria

Upper-middle

3

Layered, bottom-up

Level-1 services provided in the community by GPs in primary care.

Level-2 services provided by neurologists working either in the community or in hospital-based secondary care.

Level-3 services provided by neurological centres, often university-based, in the larger cities.

Well-developed primary care operating a gatekeeper role, but GPs currently cannot prescribe many drugs without a specialist diagnosis.

China

Upper-middle

3

Hub and spoke, top down

Level-3 services provided by neurologists in provincial or university hospitals.

Level-2 services provided by neurologists in county, district or municipal hospitals.

Level-1 services provided by GPs in community health centres or rural clinics or hospitals.

This system is implemented in parts of the country [91].

Medical facilities at all levels provide either Western or Traditional Chinese medicine.

Colombia

Upper-middle

3

Layered, bottom-up

Level-1 services provided in the community by GPs in primary care.

Level-2 services provided by neurologists in hospital-based secondary care in intermediate and larger cities.

Level-3 services provided by neurological centres, often university-based, in the larger cities

Services are overseen by the State but insurance-based, provided by multiple private or public companies, each with different organizations.

Currently, there is a lack of neurologists, with most located only in larger cities [92, 93]. Neurological conditions in general are not a listed priority for the health-care system [94].

Estonia

High

3

Layered, bottom-up

Level-1 services provided in the community by GPs in primary care.

Level-2 services provided by neurologists working in regional/county hospitals in private or public sectors.

Level-3 services provided by a subspecialty division of a university-based hospital neurology department.

Total population is about 1.3 million. There is only one university-based hospital in the country, which provides all level-3 services.

Ethiopia

Low

2

Layered, bottom-up

Level-1 services provided in the community by community health workers, nurses, clinical officers and GPs in rural health posts, local health centres and primary hospitals.

Level-2 services provided by GPs, internists and neurologists working either in secondary-care general hospitals in district towns or in tertiary-care specialized university-based hospitals in larger cities.

Total population is estimated at 114 million, with the majority still using traditional medicines despite increasing health-service coverage.

The gatekeeper role can be effectively integrated into the existing health-service system by training HCPs in primary care.

Georgia

Upper-middle (recently upgraded from lower-middle)

2

Layered, top down

Level-2 services provided by headache-trained neurologists in private headache clinics in major cities.

Level-1 and some level-2 services provided by GPs or neurologists in urban health-care facilities elsewhere.

A system of interdependent private headache clinics currently operates outside the State system [95]: there is no State-supported alternative, and primary care is poorly developed. Level-3 centres are aspirational.

Greece

High

3

Layered, bottom-up

Level-1 services provided by GPs in private or public health-care sectors.

Level-2 services provided by neurologists in private or public settings.

Level-3 centres provided by headache specialists in neurology departments within hospital-based multidisciplinary health-care facilities.

Many people with headache are currently un- or under-treated. A 2018 national general population survey by the Hellenic Headache Society (HHS) found that one fifth seek professional care, most commonly from private neurologists [65].

Under the umbrella of HHS there are, currently, 14 headache centres in the public sector, three academic (level 3) [96].

Iceland

High

3

Layered, bottom-up

Level-1 services provided by GPs in primary health-care centres.

Level-2 services provided by GPs with a special interest and neurologists in district health-care institutions.

Level-3 services provided by headache specialists in hospitals providing specialist services.

Population is 364,000, served by 12 district health-care institutions and two university or teaching hospitals, both providing general and specialized services.

India (Karnataka State)

Lower-middle

3

Hub and spoke, top down

A single level-3 centre in the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore.

Level-2 services provided by physicians with training in headache in affiliated district or subdistrict hospitals.

Level-1 services provided in urban areas by GPs in health centres and in rural areas by medical officers in community health centres and primary health centres and by health workers in subcentres. Where available, pharmacists may provide level-1 care.

State health care is primary (in community and primary health centres), secondary (in sub-district hospitals) and tertiary (in district hospitals and medical colleges). Many people favour traditional remedies.

The hub-and-spoke top-down system promotes the educational and clinical supportive roles of the level-3 centre to levels below.

Iran

Upper-middle

3

Layered, bottom-up

Level-1 services provided by GPs in the community or in primary-care centres.

Level-2 services provided by neurologists working either in the community or in hospital-based secondary care.

Level-3 services provided by neurological centres, often university-based, in the larger cities.

Services are supported in governmental centres and hospitals, but there are also many private clinics.

Italy

High

3

Layered, bottom-up

Level-1 services provided by GPs in primary care.

Level-2 services provided by hospital- or clinic-based neurologists or other specialists with interest in headache in public or private sectors.

Level-3 services provided in academic hospital-based centres by headache specialists working in multidisciplinary teams.

Italy’s Health Care System is national but also regulated at its 21 regional levels. Its population of 60 million is served by more than 80 headache and migraine centres (public, private but recognized for reimbursement, or fully private).

National legislation [97] recognizes chronic primary headache disorders as disabling and requiring care.

Mali

Low

3

Layered, bottom-up

Level-1 services provided by doctors, nursing assistants and health technicians in community health centres.

Level-2 services provided by GPs and internists, nurses and health technicians in reference health centres at district level or in regional hospitals.

Level-3 services provided by specialists in national hospitals and university hospital centres.

Mali’s health services are built on 4 levels in a pyramid structure: community health centres at level 1 (community); reference health centres at level 2 (district); regional hospitals at level 3; national and university hospitals at level 4.

In Mali, health systems must accommodate simultaneous use of conventional and traditional medicines to respect long-established cultural preferences and practices. Finding the right formula to integrate these remains a challenge in health services generally.

Mongolia

Lower-middle

3

Layered, bottom-up

Level-1 services provided by GPs in primary health-care centres or soum health centres and inter-soum hospitals.

Level-2 services provided by neurologists in aimag- or district-based hospitals.

Level-3 services provided by neurologists in central State hospitals.

Aimags are first-level administrative divisions, soums are second-level. Total population is 3.3 million, with primary care services reaching 70%. Many people favour traditional remedies.

Level 3 currently is largely aspirational because of a lack of headache specialists.

Morocco

Lower-middle

3

Hybrid system in public sector with layered bottom-up and hub-and-spoke top-down elements; top-down in private sector

Level-3 services provided by neurologists in regional and university hospitals or in private hospitals.

Level-2 services provided by neurologists and GPs with special interest in district clinics or provincial hospitals or in private practices.

Level-1 services provided by GPs in public primary health-care centres or private practices, or, in some rural areas, by nurses.

Morocco has a mix of HCPs: public (State-sponsored and free) and private (reimbursed through insurance or paid out-of-pocket). Primary care has a gatekeeper function, which is not always respected, while access to specialists is direct in private care.

Through telemedicine, specialists in Morocco reach and advise patients living far from regional hospitals, a hub-and-spoke system that can also provide clinical and educational support to non-specialists at lower levels.

Nepal (Bagmati Province, Kavre District)

Lower-middle (recently upgraded from low)

3

Hub and spoke, top down

A single level-3 headache centre in Dhulikhel hospital, Kathmandu University Hospital (DH-KUH).

Level-2 services provided by clinical officers and/or physicians in DH-KUH’s outreach health centres.

Level-1 services provided by community health workers in outreach primary care centres or health posts.

Outreach health centres are around 20 in number in and around Kavre and adjoining districts.

Many people favour traditional remedies.

Countrywide, level 3 is currently aspirational in a geographically diverse country with major accessibility challenges [98] but, in a population survey, over half of adults with headache had engaged with HCPs of varying sorts [42], indicating capacity to build on.

Norway

High

3

Layered, bottom up

Level-1 services provided by GPs in primary care.

Level-2 services provided by neurologists (and nurses) working in hospital-based neurological departments, or neurologists or GPs with special interest in headache working outside hospitals.

Level-3 services provided by headache specialists and nurses in academic hospitals, working in multidisciplinary teams.

A process to establish a national system for headache care is commencing now in collaboration with the Norwegian Ministry of Health.

Pakistan

Lower-middle

3

Hub and spoke, top down

Level-3 services provided by headache-trained neurologists in private and public tertiary health centres.

Level-2 services provided by neurologists in private headache clinics in larger cities.

Level-1 and some level-2 services provided by neurologists and GPs in urban, suburban and rural health-care facilities and clinics.

Public health-system infrastructure is fragmented, but both private and public level-3 services exist in larger cities. Most adults seeking headache treatments go first to GPs, but direct access to specialists is available in both public and private sectors. Therefore, level-1 and level-2 services may currently be provided by neurologists or specialists.

A hub-and-spoke top down model, especially with the use of telemedicine, can boost education and support for GPs and remote practice locations, thereby improving service structure and reducing inappropriate demand at level 3.

Perú

Upper-middle

3

Layered, bottom-up in public sector; unstructured in private sector

Level-1 services provided by GPs, nurses, nursing assistants and pharmacists in primary-care health centres.

Level-2 services provided by neurologists in regional hospitals and private clinics.

Level-3 services provided by specialist accredited neurologists (neurology services are subdivided into areas of care, including headache) in hospitals and institutes providing high-complexity care in departmental capital cities.

Perú is multicultural, with 31 million population. Its decentralized health-care system is administered by five entities (Ministry of Health, Social Health Insurance, Armed Forces, National Police and the private sector) and suffers from low investment and lack of horizontal integration.

As in most of Latin America, headache has low priority. Many (doctors and general public) believe only neurologists can resolve it. Structured headache services offer solutions to these challenges, with technological supports (telemedicine can overcome geographic and economic obstacles to transfer of patients).

Portugal

High

3

Layered, bottom up

Level-1 services provided by GPs in primary health-care centres.

Level-2 services provided by neurologists in referral hospitals (community hospitals).

Level-3 services provided by neurologists with specialist training in headache in central and/or academic hospitals.

Well-developed occupational medicine services ally efficiently and helpfully with community health services.

Russia

Upper-middle

3

Layered, bottom up

Level-1 services provided by GPs in primary health-care centres or district-based polyclinics.

Level-2 services provided by neurologists in each regional centre.

Level-3 services provided by neurologists with specialist training in headache in each interregional municipal centre.

Russia has 147 million people, 565,200 physicians, 28,600 neurologists, > 50 tertiary headache centres (mostly private) and about 200 “headache specialists” [99]. Up to half of people with headache consult a physician, most often a neurologist, yet fewer than 1% with migraine use preventative medications [100]. Russia is only slowly divesting itself of arcane traditions in clinical practice, exemplified in headache management by entrenched preferences for vasoactive, nootropic and so-called neuroprotector drugs instead of evidence-based preventative drugs [101].

Ministry of Health recommendations for management of migraine [102] and mandatory inclusion of headache care in under- and postgraduate medical education are addressing care deficiencies nationally, but a headache-service implementation project in Sverdlovsk Oblast (Yekaterinburg) lacks government support [103].

Saudi Arabia (National Guard Health Affairs [NGHA])

High

2/3

Layered, bottom up

Level-1 services provided by GPs in primary health centres.

Levels 2 and 3 are hospital-based, provided by neurologists, sometimes in specialized clinics.

NGHA offers one of Saudi Arabia’s health-care systems, with two medical cities, five hospitals and over 70 primary health-care centres providing full coverage for employees and their dependants. Additionally, it offers services to the general public for certain diseases and for emergencies (providing about 50% of their secondary and tertiary care, to 1.7 million people).

Serbia

Upper-middle

3

Layered, bottom up

Level-1 services provided by GPs in public health centres.

Level-2 services provided by neurologists working either in a polyclinic system within the same public health centres or in local hospitals.

Level-3 services provided by specialists in neurological centres, usually academic, located in the larger cities.

Well-developed primary care with a gatekeeper role but, currently, many medications cannot be prescribed by GPs without diagnosis by a neurologist, and many are not reimbursed.

Turkey

Upper-middle

3

Layered, bottom up

Level-1 services provided by GPs in public health centres.

Level-2 services provided by neurologists in private or government polyclinics.

Level-3 services provided by neurologists with specialist training in headache in private or government university headache centres.

Government-funded Medicaid provides free health insurance to all but is under-resourced. Not all drugs are reimbursed, while GPs in level 1 currently cannot prescribe all medications, and tend to over-prescribe analgesics. The consequence is too many patients in level-2, many with medication-overuse headache.

United Kingdom

High

3

Layered, bottom up

Level-1 services provided by GPs in each practice.

Level-2 services provided by GPs with special interest (GPwSIs), sometimes with support from specialist nurse practitioners, or by neurologists based in or visiting district hospitals.

Level-3 centres staffed by specialists, often supported by nurse practitioners, in neurology departments within selected multidisciplinary hospitals.

The gatekeeper role of primary care is entrenched.

GPwSIs in particular fields are appointed for local areas with the purpose of avoiding unnecessary referrals to specialist care, or by local commissioning groups as local or regional leads, or by larger group practices to take a lead role within the practice [104].

United States of America (Medicaid system)

High

3

Layered, bottom up

Level-1 services provided by primary care physicians.

Level-2 services provided by neurologists.

Level-3 services provided by specialists within neurology departments, typically in university settings.

Medicaid (funded jointly by Federal and State governments but run by each State separately) provides free health insurance to 74 million people whose income and resources are insufficient to pay for health care. Existing Federal adult and childhood quality-of-care measures do not include headache outcome measures. Adding these could educate providers and improve usage of layered headache care, with better outcomes expected.

Telemedicine referrals from rural areas could be employed between levels 1 and 2 in each State, and for follow up.

Zambia

Lower-middle

3

Layered, bottom up

Level-1 services provided in urban areas in district hospitals by clinical officers, with or without a physician, and in rural areas by clinical officers and community health workers in community health centres or rural health posts.

Level-2 services provided by physicians or clinical officers in provincial or general hospitals.

Level-3 services provided by neurologists in the country’s level-3 hospitals (usually university-affiliated).

These levels correspond with the 3 levels of State-provided health care, in which clinical officers substantially outnumber doctors. Level 3 is only recently a possibility with the graduation of Zambia’s first adult and paediatric neurologists. In the near-term, very small numbers of these specialists will severely limit level-3 capacity, increasing dependence on level 2.