The Practice of Sleep Medicine Around The World: Challenges, Knowledge Gaps and Unique Needs

Sleep medicine and its practice in the United States of America (USA) has grown from the first center focusing on sleep disorders established at Stanford University in 1964 to more than 2,500 American Academy of Sleep Medicine (AASM) accredited sleep centers and numerous professional organizations supporting sleep health professionals including board-certified sleep medicine physicians, behavioral sleep specialists, advance practice registered nurses and/or physician assistants and sleep technologists. As sleep medicine continues to grow in the USA, multiple challenges including widening economic inequality, racial/ethnic inequities, and limited healthcare access directly affects the patient setting. Limited sleep medicine education in medical school restricts the ability to educate patients as well as primary care providers on the importance of identifying sleep disorders early on to improve access. The financial burdens of diagnosing and treating sleep disorders, particularly obstructive sleep apnea is seen in an estimated cost of $16 billion annually. Research and data collection includes surveillance surveys conducted by the Sleep and Sleep Disorders Team from the Centers for Disease Control and Prevention (CDC) as well as continuing research in the diagnosis and treatment of obstructive sleep apnea. Additional studies addressing sleep issues and racial disparities in the US are prudent in highlighting this crucial area. Continued efforts in clinical and research knowledge gaps are necessary to support the growing need for sleep medicine providers and services in the USA.

Canada has an expansive, challenging geography with diverse demographics. The country is an industrialized and democratic nation situated at the northern end of the Americas. Canada provides universal healthcare to all residents through a singlepayer system administered by its provinces and territories. Data suggests common sleep disorders are present at similar rates in other industrialized nations, with the exception of a larger number of shift workers and arctic residents subject to circadian disruption. Canada has ‘punched above its weight’ in contributing to the field of sleep medicine, with numerous well-known pioneering specialists in areas ranging from pathophysiology and diagnostic development, to pharmacologic, therapeutic and device treatment. The practice of sleep medicine is provided by trained physicians in neurology, respirology, psychiatry, internal medicine, family practice, otolaryngology, pediatrics, as well as psychology and dentistry amongst other providers. Major challenges to Canadian sleep medicine include limited public healthcare funding, variable funding mechanisms across the nation’s jurisdictions, limited access to diagnostic and therapeutics, and conflicts-of-interest with business. Certain demographic groups are particularly at-risk, including socioeconomically challenged communities, indigenous populations, and other diverse minority groups. Canada’s characteristics and challenges provide it with substantial research opportunities and a chance to lead in such areas as epidemiology, sleep medicine genetics, ethnic and cultural aspects, circadian and shift work considerations, home polysomnography and post-COVID transitions to more virtual sleep medicine care. 

Sleep medicine is a fascinating and still growing field in Mexico. We describe some historical background as well as some clinical and basic research topics that have been studied more recently. We also describe the main characteristics of the clinical practice of sleep medicine, some clinical practice guides for sleep disorders, regulatory bodies for the certification of physicians who practice sleep medicine, and the main types of professional positions in the care of patients with sleep disorders in Mexico. We also detail some of the challenges facing sleep medicine in Mexico, including the limited availability of professional training and human resource specialized in sleep medicine, and the need to implement governmental and public health actions to address sleep disorders in the Mexican population. Finally, we mention the implications of the COVID-19 pandemic in the operation of sleep clinics and the changes that have been implemented in the patient care model.

This chapter explores the current context of sleep medicine in Australia. Detailed descriptions of the providers involved in sleep health care, the services available for the assessment and management of sleep disorders, the professional organisations supporting and advocating for sleep medicine, Australian clinical guidelines, and the barriers limiting the provision of best practice sleep health care are presented within this chapter. Sleep medicine is available within Australia by means of publicly funded specialist-led sleep services such as public hospital outpatient clinics and sleep laboratories, and private referral options including specialist sleep physicians, sleep psychologists and private sleep laboratories. Access to publicly funded sleep services are often limited by long wait times for assessment and management, insufficient numbers of sleep-trained providers and long distances to travel for those individuals located in rural and remote areas. Private sleep services offer shorter waiting times than public sleep services, however the associated costs of accessing private treatment mean that it is limited to those with the financial means to afford it. Subsidies for many treatments for sleep disorders, such as continuous positive airway pressure and mandibular advancement splints, are also restricted to those on government benefits and/or those who hold private health insurance coverage. Research exploring new models of care for sleep health care within the primary care setting is currently being conducted in an effort to improve access to care for the many Australians living with sleep disorders.

Sleep medicine as an independent medical specialty is relatively new in Saudi Arabia. Since its foundation, there has been significant growth and an increase in the number of sleep medicine physicians and technologists to meet the continuous increase in demand among the Saudi population. In response to the expansion of sleep medicine in Saudi Arabia, the Saudi Commission for Health Specialties (SCHS) established clear guidelines for the accreditation of sleep medicine physicians and technologists in 2012. Currently, there are two training programs providing structured training and certification in sleep medicine in Saudi Arabia. Despite this progress, there are still many difficulties hindering sleep medicine growth in Saudi Arabia, including the shortage of trained technicians, and specialists, the lack of financial support, and awareness of sleep disorders and their profound effects on healthcare workers and healthcare authorities. In the future, it is essential to introduce sleep medicine in the medical educational system at all levels to show the importance of early recognition and management of sleep disorders, in addition to developing research that is necessary to build knowledge about the prevalence of many sleep disorders in order to help to plan the number of sleep specialists and sleep facilities needed to meet the increasing demands. This chapter discusses the current practice of sleep medicine, and the challenges it faces in Saudi Arabia, in addition to the available data and research about common sleep disorders among the Saudi population.

Sleep disorders are increasingly being recognized as a major health problem in the UAE. The rising prevalence, potentially modifiable risk factors, and impact on global health outcomes have prompted the growth of sleep medicine. The burden of under-recognized disease has encouraged patient and physician-centric education. Supported by nationalized health insurance plans, the medical fraternity has adopted a multi-disciplinary approach to optimize resources and outcomes, while recognizing that these measures are initial steps in the unique challenges posed.

The development of sleep medicine in Hong Kong has often been driven by clinical needs. The 1980s saw a surge of interest in sleep apnoea and brought multiple specialties together to study the diagnosis and management of sleep-related breathing disorders. Sleep and mood disorders often go hand in hand. With circadian disruption and sleep deprivation impacting the general population, including our paediatric age groups, the lack of quality sleep is a public health concern. Unfortunately, training in sleep medicine has been fragmented from undergraduate curricula to specialty training requirements. Sleep service standardisation is just beginning, although progress has been slow. Due to the lack of a specialty board, the Hong Kong Society of Sleep Medicine is providing a platform for interdisciplinary collaboration especially in training and education for both healthcare professionals and the general public, while the university-affiliated departments will provide the lead for multi-disciplinary research.

As the world's most populous country, China has a high prevalence of sleep disorders, posing a huge public health burden. After 30 years of development, more and more professionals, patients, and public health policymakers are recognizing the importance of sleep. Although sleep problem is recognized in the Traditional Chinese Medicine area, modern sleep medicine starts from the diagnosis and treatment of obstructive sleep apnea. By 2017, about 2,000 sleep centers had been established nationwide which can diagnose and treat OSA, narcolepsy, restless legs syndrome, REM sleep disorder, and other sleep diseases. Research in different sleep fields has emerged in the recent 20 years. However, there are gaps between the sleep service capacity and the demand from patients due to the lack of sleep professionals as well as the medical insurance coverage. Education and training of both physicians and technicians still have a long way to go. Understanding the development and challenges will help us maintain the development of sleep medicine in China.

There are several major universities and medical schools in Lebanon, including the American University of Beirut School of Medicine & Medical Center, Lebanese American University/Medical Center, Lebanese University, Universite Saint Joseph/Hotel Dieu de France, Beirut Arab University, University of Balamand, Saint Georges University/Medical Center, Holy Spirit University of Kaslik and others. Many of these medical centers and schools of medicine offer a solid medical education as well as post-graduate training in various fields of medicine that are related to sleep medicine. These include Pulmonary and Critical Care Medicine, General/Bariatric Surgery, Neurology, Otolaryngology, Head and Neck Surgery, Dentistry, Oral & Maxillofacial Surgery, Orthodontics, Psychiatry, Nutrition/dietetics and other related specialties.

As will be further elaborated in this chapter, there are multiple particularities related to the diagnosis and management of patients who have sleep disorders in Lebanon. Even though the field is developing, there are certainly opportunities for further advancement and development.

Sleep medicine is a young branch of Armenian medicine. In this chapter, we presented the history of sleep medicine development in Armenia. After brief initial information about Armenia as a country, references to sleep and sleep disorders in medieval Armenian folklore and medicine are given. An overview of the current situation with sleep medicine in Armenia is presented. A special attention is given to the spectrum of sleep-related specialists who work(ed) in Armenia, and to the domains of sleep medicine available. Acknowledgement of world sleep experts who helped and contributed to the development of sleep medicine and sleep research in Armenia follows. Also, we discuss different organizations operating in the field of sleep in Armenia, their activities and pursued goals. Importantly, the main results of a sleep disorders prevalence study in Armenia are presented. At the end, we summarize the problems and issues accumulated in the field of sleep medicine in Armenia.

Sleep Medicine is considered a relatively new specialty in medicine. The practice of sleep medicine in Turkey began in the late 20th century. Sleep medicine in Turkey has developed with the opening of several sleep medicine facilities. The Turkish Medical Association and the Ministry of Health oversee the accreditation of sleep centers as well as certify sleep specialists. The diagnosis and proper treatment of obstructive sleep apnea are important when obtaining driver’s licenses and serving in the military. The major hurdles that the sleep medicine community faces in Turkey are financial especially in the current, post COVID-19, and Russian-Ukranian war economic crisis. In addition to these barriers, there are also gaps in knowledge and awareness particularly as it pertains to interethnic differences in sleep disorders’ susceptibility.

Sleep Medicine is a growing discipline in Thailand. The formal 2-year-sleep medicine fellowship was approved by medical council of Thailand and established under four specialties including internal medicine, psychiatry, pediatrics, and otolaryngology in 2018. Thailand has also established formal sleep technologist courses and certification examinations since 2010. Sleep Society of Thailand was established in 2009 and subsequently other sleep societies were also established. All societies contributed to the development and advancement of sleep medicine in Thailand including the development of national clinical practice guidelines. There are limited numbers of sleep laboratories in the country particularly in government settings. Fortunately, polysomnography conducted at a sleep laboratory in a government hospital is covered by most of the health care coverage programs. However, CPAP cost is only covered by the civil service welfare system, limited private health insurance, certain state enterprise or government employees. There has been an increasing number of research in the field of sleep medicine in recent years. However, multicenter, multidisciplinary, longitudinal studies in the field of sleep medicine are still lacking. Internationalization in terms of hosting international conferences and awards by the international sleep society has increased the visibility of Thailand regionally and globally. Collaboration among various disciplines is the key to advancing the field forward.

The Iranian Sleep Medicine (ISM) Society, established in 2005, has worked to increase public knowledge of how important sleep is to maintain health in the community and safety on the roads. The ISM has also had a strong role in the implementation of sleep tests and laboratory standards in collaboration with the Ministry of Health, training sleep specialists to diagnose and treat sleep disorders, certifying sleep labs to ISM standards, and conducting much needed research to improve sleep amongst Iranians. In this chapter, we will first introduce the current healthcare system highlighting the practice of sleep medicine in Iran. Next, we identify three challenges in delivering sleep medicine to millions of Iranians with potential solutions. The challenges are: (1) a limited number of trained sleep medicine specialists unequally distributed across all districts; (2) a limited number of certified sleep labs; (3) the need for insurance to pay for the diagnosis and treatment of sleep disorders such as obstructive sleep apnea, narcolepsy, and insomnia. Lastly, we present future directions for Iranian sleep research including much needed population-based studies to assess the prevalence of sleep disorders. While much progress has been made since 2005 to improve sleep health in Iran, we still have much work to do to reach our goal of significantly reducing disparities and promoting sleep medicine all over Iran toward a healthier future.

The history of sleep medicine dates back to millennia, carrying centuries of wisdom, decades of myths and challenges through the many years of struggle. Having been recognised as a body of knowledge in the last two decades and a formal branch of medicine in modern-day India. The burden of impending clinical practice, research and disproportionate health indices has allowed the tide of sleep medicine to be surfed by multiple specialties. With research interest dating back to 1965, the practice laid its formal beginning with the first sleep lab set up in New Delhi in 1995. The regulatory practices are thin on the ground that impedes the standardization of clinical research, labs or training of personnel in India. Initiatives at the behest of physicians have led to the setup of self-structured regulatory bodies, expanding the network of sleep labs in the country, albeit still very limited in comparison to the size of its populace. Increasing awareness about healthy sleep habits, bridging gaps in research, quality training and standards, improved regulatory frameworks, and translating knowledge from evidence-based medicine will drive the desired public health outcomes as well as the growth of standards and the future of sleep medicine practice in India.

The Federal Democratic Republic of Nepal is one of the most beautiful and stunning Himalayan countries in the world where health care needs of the majority of the population are delivered by a hybrid system of public and private sectors. Public does not perceive sleep disorders to be as critical as other health problems because they remain unaware of the serious consequences of sleep deprivation and sleep disorders. Multiple segments of the Nepalese population are awake across all hours of the 24-hour day because of the large proportions of people working as migrant workforce across the globe in different time zones. Current data reveals a high public health burden of sleep loss and sleep disorders are among them yet these disorders are frequently ignored, readily treatable, and unrecognized health problems in Nepal.

Sleep medicine remains an interdisciplinary field crossing different specialties but in Nepal, it has become almost a subspecialty of pulmonary medicine in the past few years. Nepal does not have sufficient healthcare resources to deliver the appropriate care to patients with sleep-related disorders because of an inadequate number of physicians trained in sleep medicine. Sleep disorders and sleep medicine as a specialty are under-recognized by both the public and health professionals. The government should rethink policies and redesign the programs to address the evolving syndemic of sleep disorders, metabolic syndrome, and tobacco smoking in Nepal and incorporate sleep medicine in undergraduate and postgraduate medical curricula to address the gap in the clinical care of patients with sleep disorders in Nepal.

Although there is no data on the prevalence of sleep disorders in the Syrian population, extrapolating from neighboring countries like Lebanon, Jordan, Iraq, and other Arab and Mediterranean countries, sleep disorders including sleep-disordered breathing are common. Non-Communicable diseases account for two-thirds of deaths. Hypertension, obesity, diabetes, and tobacco smoking are among the highest in the region. There is a strong association between NCDs and sleep-disordered breathing. Most sleep disorders in Syria are undiagnosed and untreated due to the absence of or very low access to sleep specialists and sleep testing, the absence of national policies, and low awareness within the medical community and among the public. The long conflict in Syria, which began in 2011, has resulted in a complex humanitarian emergency, with 6.7 million internally displaced people and 6.5 million refugees out of a total estimated population of 22.5 million. The conflict and the resultant destruction of the health infrastructure have led to a severe public health crisis, which has further impacted the health of the population. There is low access to sleep education, testing, and treatment, mostly in major urban centers, although the demands are increasing. There are ample opportunities to improve the practice of sleep medicine, in spite of the long conflict and war, if local champions, NGOs, national authorities, and medical societies adopted already-available resources, guidelines, and regulations, incorporated creative means and telehealth, and followed the recommendations of the World Health Organization on Sleep and Health.

Sleep is an important physiological function that contributes significantly to the health and well-being of people worldwide. In Nigeria, the most populous country in Africa, sleep problems have been reported across various age groups from childhood to the elderly population. It is therefore noteworthy to access and report the state of sleep medicine practice in Nigeria as well as the strengths, weaknesses, opportunities, and threats to the establishment of a successful sleep medicine program in the country.

Sleep problems appear to be on the rise in the Nigerian population. This may be due to an increase in the prevalence of some risk factors for sleep disorders. It can also be attributed to the growing interest in sleep research and clinical sleep medicine practice by a wide range of specialists. However, the practice of sleep medicine in Nigeria appears to be significantly limited by the poor manpower development, lack of sleep societies/organizations, lack of training programs, lack of equipment and sleep laboratories, limited treatment options, inadequate funding, poor national awareness, and political will. The increasing political unrest and brain drain of health professionals constitute a major threat to the availability of human resources.

The practice of sleep medicine in Nigeria is faced with challenges as well as diverse opportunities. Thus, sleep medicine practice in Nigeria has the potential to grow rapidly and contribute significantly to the global picture if given attention. The growing interest of Nigerian researchers in Sleep medicine, especially in the last decade, as well as the large population of Nigerians, many of whom have risk factors for sleep disorders, suggest that Nigeria may be a significant contributor to the global burden of sleep disorders. Therefore, we suggest concerted and coordinated efforts to enhance the strengths and opportunities highlighted while minimising or eliminating the challenges to improve the practice of sleep medicine in Nigeria.

All through Egyptian history, starting from the pharaohs, passing by the Coptic and Islamic eras up to modern Egypt, there have been different interests in healthy sleep and sleep hygiene. Myths about sleep medicine are common among cultures and in Egypt, lack of public awareness about sleep disorders makes most patients undiagnosed or ignorant about whom to consult about their symptoms. In this chapter, we aim to provide the reader with the current state of the art of sleep medicine in Egypt. We conducted a literature review, furthermore the opinion of sleep experts in Egypt was collected and stated in detail, and additionally Egyptian sleep centers were invited to answer a survey in order to collect information about the equipment and trained personnel presented in this chapter. There are three types of Egyptian medical education streams including, the public, private and Al-Azhar medical schools, in which undergraduate and postgraduate medical students can join and earn their degrees but there are no specialized degrees in sleep medicine yet, exact details about medical education in Egypt are provided below. Egypt has numerous health care system providers or sectors: public, private and financing agents’ parastatal providers. Nevertheless, sleep studies remain expensive for the Egyptian public and most insurance companies do not fund it, which makes the expenses of polysomnography the duty of the patient to pay from his own pocket. Egyptian sleep laboratories are governmental and private labs, the governmental labs usually exist in university hospitals, financial and educational hassles make accreditation of these labs by AASM difficult. We provided statistics describing these labs and the type of equipment they use. We tried to discuss the clinical and research sleep status in Egypt, additionally, we tried to suggest solutions for these challenging issues.

Zambia, a southern African country with a resource-strained healthcare system that for the past three decades has been tailored to fight the HIV pandemic, is grappling with an increasing non-communicable disease burden. The practice of sleep medicine in Zambia, with sleep disorders being a cause of some of the cardiovascular and motor-vehicle-related morbidity and mortality, has long lagged behind the significant HIV-related disease burden. Sleep disorders in Zambia have therefore remained under-researched, and unquantified and thus are not considered a significant clinical problem.

Against a background of scarce specialized sleep practitioners, the absence of a specific regulatory framework for the practice of sleep medicine, and the absolute lack of equipped sleep centers, the diagnosis of sleep disorders is based on the use of validated clinical risk questionnaires. The availability of treatment devices in the country is also scarce. Further, population-wide and practitioner knowledge-gaps have exacerbated the stagnation of the practice of sleep medicine and research. These deficiencies however present an opportunity to finally harness the practice of sleep medicine and the conduct of sleep-related research, and make them a priority.

Sleep Medicine has only recently become a medical specialty in Brazil. There are few qualified professionals in this field, and they are mainly concentrated in metropolitan areas. Access to the diagnosis and treatment of sleep disorders is not yet homogeneous for the entire population. In Brazil, there is a public health system called the Sistema Único de Saúde (SUS) that offers free and universal health access to all. Although it can be difficult and time-consuming to access a sleep assessment, SUS offers free diagnosis and treatment for sleep disorders. However, private clinics and hospitals provide more treatment options and faster access compared to the public sector, but at a high cost. Sleep Medicine is not yet a mandatory discipline in medical training, and most specialized courses and professional development in sleep are not free. With respect to the sleep research being carried out in Brazil, most basic research is concentrated on the effects of sleep deprivation, and clinical research into the health consequences of sleep disorders and possible interventions. Modern society is increasingly subject to sleep restriction and the consequences of sleep disturbances. As a result, sleep has attracted more attention and interest from the media and the general population. Sleep Medicine in Brazil has experienced a significant expansion in knowledge over the last 20 years, and the prospects are positive in relation to future research and the training of specialized professionals.

In this chapter we describe the history, research, education, and practice of sleep medicine in Argentina, pointing out the importance of the role of public policies in the development of sleep medicine grounds. With the drawbacks of a developing or “emerging” country, sleep medicine in Argentina has been growing up in the past decades. This fact allows us to be optimistic despite the unfavorable scenarios that our country usually goes through. Sleep medicine in Argentina is still rather young in the field of medicine and needs much more effort to consolidate as a specialty.

Sleep science and sleep medicine have seen massive growth in the last century in the world, and Portugal is not an exception. In the last 20 years, we have assisted an exponential increase in sleep disorders due to the increase in obesity, lifestyle (24/7 society), massive media utilization, and individual, family, and social commitments. Simultaneously, the scientific community, population, and media have focused on sleep and sleep disorders leading to a progressive need to invest in Sleep Medicine, at the clinical, research, and educational levels.

Despite the increase in diagnostic and treatment capacity of sleep disorders, the National Health Service, and private groups still do not fulfill the real needs. Still, in Portugal, sleep and its disorders are not fully taught in pre-graduated education. Additionally, sleep medicine is not an individual medical specialty and is shared by several medical specialties, such as Pneumology, Pediatrics, Psychiatry, Neurology, Otorhinolaryngology, Maxillofacial surgeons, and Dentistry, among others. Training programs of the different clinical specialties do not offer sleep medicine even as an option being mandatory only in the pulmonology curriculum.

Considering the importance of sleep for physical, mental, and social health, the growth of sleep disorders and their individual, familiar, social, and economic impact, sleep medicine should be one of the focuses of health development and investment in this century.

This chapter focuses on the historical insights and current development of Portuguese Sleep Science and Sleep Medicine fields.

Austria has had a long tradition of sleep and dream science since Sigmund Freund published his psychoanalytic theory of personality at the turn of the twentieth century. Sleep medicine today, however, is a multidisciplinary specialization and training in Austria lasts about 18 months. Exploring the impact of sleep on daily activity, Austrian scientists are especially interested in the role of sleep disorders as an independent risk factor for neurological, psychiatric, and vascular diseases and their therapeutic management.

When the Austrian Sleep Research Association (ASRA) was founded in 1991, CPAP therapy for sleep apnea had already celebrated its 10th birthday and had become a standard therapy covered by all public health insurance. Quite in contrast, in the field of insomnia, cognitive behavioral therapy for insomnia (CBT-I) has been established in international therapy guidelines, but for sleep-disturbed patients, affordable rapid access to this therapeutic option is still a challenge in our country.

Since 1998, the ASRA has been offering voluntary accreditation based on a quality check process to sleep centers. More recently, a sleep training plan was introduced to obtain a sleep physician diploma by the Austrian Medical Chamber.

The practice of sleep medicine in the UK has made considerable progress over the past 3 decades. This has been driven by the invention of CPAP and the development of OSA services, but other factors related to National Health Service innovations and healthcare professional developments have also been important. Key challenges remain in service provision, education and research, and in resolving regional equalities in access to care.

The practice of sleep medicine within Iceland has been shaped by its position as a sub-arctic Nordic nation with a small population and a strong tradition of sleep research.

The major facility providing clinical diagnostic and therapeutic sleep services is the Landspitali - The National University Hospital of Iceland. Sleep studies are mainly conducted as home sleep apnoea testing with video hook-up instructions and electronic questionnaires. In the context of the COVID-19 pandemic, the majority of positive airway pressure therapy initiation took place at the home of the patient with auto settings and remote follow-up.

Sleep medicine service challenges include inferior access for rural areas, funding limitations, the COVID-19 pandemic and low sleep education at a national level for both the general population and specifically healthcare staff.

The unique clinical and research knowledge gap of Iceland requires studies on the health effects of living at such a northern latitude. The high hypnotic and antidepressant use of Icelanders as well as the high prevalence of restless legs syndrome symptoms may be at least in part contributed by latitude. The 1-1.5 hour discrepancy between the solar clock and the local clock may also cause social jet lag in Icelanders but this needs to be studied further. Finally, social factors such as the high energy drink consumption of Icelandic teenagers and the high screen time made possible by the 99% internet penetration and a mobile connection percentage that exceeds the total population level may contribute to the short sleep length found in Icelandic teenagers.

Lithuania is a small country with a relatively short (31 year) history of independence in the modern era. Complicated history and geopolitical situation determined gaps in many socioeconomic spheres compared to other western European countries 30 years ago. Nevertheless, the country's ambitious goals and direction towards democratic values resulted in high recent socioeconomic ratings and acknowledgment among other European Union, NATO and Organisation for Economic Co-operation and Development members. The chapter presents short Lithuania’s geopolitical and healthcare system data, the current practice of sleep medicine, the practitioners involved, the availability of diagnostic tools and medications to treat common sleep disorders. It discusses challenges to the practice of sleep medicine: patient access to care, resource limitations and financial hardships, clinical and research knowledge gaps.

Prof. Bedrich Roth founded sleep medicine in our country 70 years ago. However, the inter- and multidisciplinary nature of sleep medicine developed several decades later, in the early 1990s, with the cooperation of pulmonologists, neurologists and psychiatrists. This led to the foundation of the Czech Sleep Research and Sleep Medicine Society (short title Czech Sleep Society) in 2001. At present, the Society includes 215 members and plays a leading role in the current practice of sleep medicine in the entire country. Activities include accreditation/certification procedures, educational programs, annual national meetings, the development of guidelines and recommendations for different sleep disorders, promoting research and many other endeavors. The society also collaborates with other medical societies in discussions with state health care authorities and health insurance companies. Health insurance companies cover sleep medicine care by means of a DRG system for hospitalizations, and a point system for outpatient care. The majority of sleep medicine care is centralized, and medications are largely covered (e.g. modafinil and natrium oxybate are available to patients free of charge). Positive airway pressure devices are lent to patients by health insurance companies if treatment criteria for sleep breathing disorders are met and compliance is fulfilled. The absence of acknowledged specialization or sub- specialization in sleep medicine by the Czech Ministry of Health is the main challenge to be overcome.

Somnology in Russia is a competency area for medical doctors from different disciplines. Most of them are cardiologists involved in private clinics located in the central and western parts of the country in the major cities. Some factors limit the development of somnology: differences between the regions, absence of legislative and regulatory absence of documents, lack of sleep-related services in the medical standards of health care, no insurance reimbursement, undergraduate sleep-related programs, and high cost of diagnostic and treatment equipment. Several professional societies focus on the development of different fields - clinical, fundamental, pediatric somnology, chronobiology and dream research. The postgraduate activities for medical doctors include different lectures online, web-based interactive educational modules on sleep disorders within the continuing medical education system, regular seminars in the major medical centers; certified (within other medical specialties) short training courses on sleep-disordered breathing and non-invasive ventilation and longer 36-72 hours courses in sleep medicine. The members of sleep-related societies perform various public activities all year round and in relation to the World Sleep Day. Diagnostic features of sleep practice include the unique use of rheopneumogram in Holter monitoring for very rough screening of apneas during sleep. Initiation of noninvasive ventilation therapy is more often started at home with the use of auto-CPAP machines. Various instrumental methods developed in Russia for insomnia treatment lack strong evidence. Support of the governmental institutions would help to solve present issues with regulatory standards in education and treatment in sleep medicine.