Rehabilitation Global Needs

Original Editors - Naomi O'Reilly , Vidya Acharya and ReLAB-HS

Top Contributors - Naomi O'Reilly, Kim Jackson, Vidya Acharya, Jess Bell, Oyemi Sillo, Tarina van der Stockt, Lucinda hampton, Ashmita Patrao and Ewa Jaraczewska      

Introduction

Rehabilitation is the care needed when a person is experiencing or is likely to experience limitations in everyday functioning due to ageing or a health condition, including chronic diseases or disorders, injuries, or trauma. According to the World Health Organization (WHO), rehabilitation is defined as a set of interventions designed to optimise functioning and reduce disability in individuals with health conditions interacting with their environment. Moreover, rehabilitation is now considered an urgent and growing global issue. The world's population is ageing, and the number of people living with non-communicable diseases is increasing. There are also more people living with injuries and injury-related consequences because of conflict, rapid urbanisation, and motorisation. The current demographic and health shifts are contributing to a rapid global increase in the number of people experiencing impairment or a decline in functioning for substantially larger periods of their lives, which results in enormous unmet rehabilitation needs. Much of these unmet needs are concentrated amongst the poorest and most vulnerable populations in low- and middle-income countries and conflict-affected settings, which are often ill equipped to cope with increasing demand for rehabilitation services

Rehabilitation is a critical health strategy to optimise everyday functioning and ensure the highest possible standard of health and well-being. It can include exercise, balance training, home modification, sensory integration, community activities, mobility aids, prosthetics/Introduction to Orthotics and many other interventions. Rehabilitation interventions optimise function and well-being by addressing impairments, limitations, and restrictions in many areas (mobility, vision, and cognition) while considering personal and environmental factors.

The need for rehabilitation depends on the timing, aetiology and severity of the person’s health condition, the prognosis, the way in which illness affects the person’s ability to function in their environment, as well as the individual’s identified personal goals. Rehabilitation services may be required throughout the lifespan of persons with health conditions. Yet despite its benefits for the individual and society, rehabilitation has not been prioritised in many countries and it is under-resourced.

Growing Demand for Rehabilitation Services

In the 21st century, rapid population ageing, accompanied by a rise in chronic conditions, trauma/injury survival and non-communicable diseases (NCD), as well as global conflict, rapid urbanisation and motorisation are leading to a rapid shift in health care needs. Moreover, rehabilitation needs will further increase in the years to come, which is a considerable challenge for health and social systems.

Reliable data about unmet needs for rehabilitation and assistive technology are scarce, but useful estimates can be drawn from information like the global burden of disease profiles and age statistics. According to the 2019 Global Burden of Disease Study, 2.41 billion individuals, which equates to approximately 1 in 3 people, had conditions that would benefit from rehabilitation. This contributes to 310 million years of life lived with disability (YLDs). However, estimates of current demand and supply are unclear, especially in low-to-middle-income countries (LMIC).

The total number of people who would benefit at some point from rehabilitation services has increased by 63% from 1990 to 2019, although age-standardised prevalence and YLDs rates showed modest declines since 1990, indicating that the large increase in cases is due to population growth and more specifically population ageing. Excluding acute and remitting conditions associated with mild disability, 74% of YLDs globally are a result of health conditions for which rehabilitation would be beneficial, while severe levels of disability (where rehabilitation is a fundamental health intervention to optimise function) account for 15% of all YLDs.

Gender Considerations

If we consider this in terms of gender, the prevalence of a condition with rehabilitation needs was almost equal in men (1.19 billion) and women (1.22 billion). However, women present with more YLDs (163 million) than men (146 million). A study by Ott et al. demonstrated the presence of sex and/or gender inequities in rehabilitation participation and outcomes, including access to assistive technologies and caregiving.

Age Considerations

According to the world data published in 2019, life expectancy has continued to increase globally with a 6-year increase seen between 2000 and 2019; from 66.8 years in 2000 to 73.4 years in 2019. Generally, people can now expect to live more than twice as long as our ancestors, and this progress is seen in every world region. According to WHO, the number of people over 60 years of age is predicted to double by 2050, with more people living with chronic conditions such as diabetes, cardiovascular disease, stroke, and cancer.

Figure.1 Disease categories of prevalent conditions that would benefit from rehabilitation globally, by three age groups, 2019

As expected, if we consider rehabilitation needs in relation to an ageing population, the age where we see the greatest need both in terms of prevalence and YLDs is in people aged 50-70 years, while we see the lowest need for rehabilitation services in those aged 95 years and older.

Musculoskeletal disorders, neurological disorders, sensory impairments, and chronic respiratory diseases were the largest contributors for those aged >65 years, while mental disorders and musculoskeletal disorders accounted for a smaller proportion when compared to adults aged less than 65 years. Widespread availability of rehabilitation services is essential for health systems to be able to respond effectively to the needs of an ageing population. Evidence suggests that access to primary care services and community-based rehabilitation increases the safety and independence of older people, reduces the risk of falls, and decreases the need for hospital and nursing home admissions. With ageing populations, the need for long-term care is going to increase, especially in low-resource settings where a large part of the world's ageing population already lives. Thus, integration of rehabilitation into long-term care is an essential strategy, as one of its main goals is to improve limitations in everyday functioning due to ageing or underlying health conditions.

In 2019, for those aged 15-64 years, 1600 million had a condition that would benefit from rehabilitation, with musculoskeletal disorders contributing to approximately two-thirds of this number.

Yet the potential benefits of rehabilitation services are not restricted to the adult and ageing populations. There are approximately 150 million children and adolescents who experience disabilities. Moreover, injuries for people of all ages are becoming more frequent due to conflict, rapid urbanisation and motorisation. Children constitute a significant and important portion of users of rehabilitation services. According to WHO, while child mortality rates are declining, not all who survive thrive. Early interventions that optimise developmental outcomes for children with various health conditions and injuries (including congenital, acquired, neurological, orthopaedic, musculoskeletal and cognitive impairments) can positively affect participation rates in education, community activities, and future capacity to work. If we consider children younger than 15 years, sensory impairments, mental disorders, and musculoskeletal disorders accounted for 91% of the 162·3 million prevalent cases of children who have rehabilitation needs.

For further information in relation to age and rehabilitation implications, causal distribution of the need for rehabilitation by age group can be found at: Global Burden of Disease Supplementary Appendix

Regional Considerations

The highest needs for rehabilitation services were seen in the Western Pacific Region, with 610 million people, which accounts for 83 million YLDs, followed closely by the Southeast Asia Region at 593 million people and 77 million YLDs. The highest age-standardised prevalence of 34% and YLDs rate of 0·040 per person was in the European Region, while the Western Pacific region had the lowest prevalence of 26% and the Americas had the lowest YLDs rate of 0·034 per person.

Further information on region-specific and country-specific results and considerations and causal distribution of the need for rehabilitation by WHO Region can be found at: Global Burden of Disease Supplementary Appendix.

Condition Considerations

Musculoskeletal disorders, with 1.71 billion people globally and 149 million YLDs, accounts for the greatest contribution to prevalence. These are the largest contributor to the need for rehabilitation services among children and they account for approximately two-thirds of cases in those aged 15-64 years. Low back pain is the main reason for a premature exit from the workforce and it has the highest burden globally, with 568 million people affected and 64 million YLDs. It is the leading health condition contributing to the need for rehabilitation services in 134 of the 204 countries analysed. Evidence suggests that these numbers will increase in the future, and even more rapidly in low-income and middle-income countries.

Figure. 2 Map of leading health conditions requiring rehabilitation in each country, 2019

Sensory impairment is the second largest disease area in terms of the number of people affected, with 677 million people at 45 million YLDs. Sensory impairment is split between vision loss (329 million people and 21 million YLDs) and hearing loss (403 million people and 24 million YLDs). Children aged under 15 and older adults are the largest contributors to this category. This may be attributed to a growth in the number of school-aged children presenting with conditions like myopia, and an increase in the number of older adults with age-related conditions (eg, presbyopia, glaucoma, age-related macular degeneration, and age-related hearing loss) due to global population growth and ageing.

Neurological disorders are the third largest disease area at 255 million people with 51 million YLDs. Stroke represents the highest overall need for rehabilitation within this group of diseases with 86 million people affected and 18 million YLDs.

The incidence of traumatic injury (such as burns), the occurrence of natural disasters (earthquakes/floods), disease outbreaks, and human-induced hazards (conflict, terrorism, or industrial accidents) can also create overwhelming rehabilitation needs due to injury or illness. YLDs from injuries are largest in individuals aged between 20 and 69 years, which encompasses the working age population. This highlights the importance of investing in rehabilitation to gain individual and societal benefits. Traumatic injuries affect existing services and significantly impact the most vulnerable populations and the weakest health systems. Almost 1 billion people globally live with the consequences of fractures, amputations, spinal cord injury, traumatic brain injury, or other traumatic injuries, and rehabilitation is vital for many of these individuals, especially those living with the long-term consequences of an injury.

Non-communicable diseases (NCDs), also known as chronic diseases, may differ significantly from acute conditions and require a different approach due to the disease's complexity and frequent requirements for continuing care. Since chronic diseases are long-lasting conditions that can have a compounding and sustained effect on the social, physical, psychological and economic state of both the individual and broader society. Chronic diseases cost billions of dollars in direct healthcare costs and also in productivity losses. Poverty is also very closely associated with NCDs. Lack of access to health care and screening for conditions and also lack of disease-prevention efforts put people in low-income countries at higher risk of mortality from non-communicable disease. Non-communicable disease threatens progress towards the 2030 Agenda for Sustainable Development, which includes a target of reducing premature deaths from NCDs by one-third by 2030.

Conclusion

As we have shown, evidence suggests that rehabilitation is needed by 2.41 billion people globally. These people present with a wide variety of health conditions and rehabilitation needs that cross the lifespan. These changing health and demographic trends are contributing to rapid global increases in the number of people experiencing decline in functioning, resulting in enormous unmet rehabilitation needs. Much of these unmet needs are concentrated amongst the poorest and most vulnerable populations in low- and middle-income countries and conflict-affected settings, which are often ill-equipped to cope with these increasing needs for rehabilitation services.

There is also emerging evidence that many of the people affected by the COVID-19 pandemic also have long-term consequences regardless of their initial disease severity or length of hospitalisation. This has increased the global demand for rehabilitation services even further since the Global Burden of Disease Study in 2019. It is evident that to meet rehabilitation needs, rehabilitation services need to be integrated into health systems and, specifically, rehabilitation services need to be strengthened at the primary care level, where people will benefit from rehabilitation close to home. A strong primary care system, where the diagnosis of most health conditions, identification of problems in functioning, referral to specialised service delivery platforms, and adherence to treatment plans is key to overcoming some of the gaps in the provision of rehabilitation services, especially in many low-income and middle-income countries. Promoting these functions of primary care will ensure that a life-course and integrated perspective on care is achieved, thus improving the functioning and quality of life of the population.

Rehabilitation is a key strategy for universal health coverage in the 21st century, with evidence suggesting that the common view, that rehabilitation is an optional service that is only needed by a minority of the population, is untrue. The findings of the Global Burden of Disease Study 2019 indicate an urgent need to scale up rehabilitation, particularly at primary health care level, to ensure services reach those who need them most. With a global ageing population who live longer as a result of advances in preventive strategies and medical interventions, but often with more disability, rehabilitation and access to rehabilitation services need urgent attention globally.

Resources

Health Metrics and Evaluation (IHME) Rehabilitation Needs Estimator