Strengthening Rehabilitation in Low-Resource Settings

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Top Contributors - Stacy Schiurring, Tarina van der Stockt, Kim Jackson, Jess Bell and Ewa Jaraczewska  

Introduction

Rehabilitation has a role in health systems but it requires partnership and collaboration on a global scale to strengthen its availability in low-resource settings.  How this can be done involves attainable goal-setting, redesign of how rehabilitation fits into health systems, and providing support and infrastructure to rehabilitation education and professional development in low- and middle- resource areas.

United Nations Sustainable Development Goals

Topical Specialist Cliona O’Sullivan quotes Horton and Lo from their 2013 Lancet article saying “sustainable development is about all of us, not just some of us.  And it’s about taking the health of future generations as seriously as we take our own.”

The United Nations (UN) created the 2030 Agenda for Sustainable Development as an action plan for “people, planet, and prosperity. (15)”  It creates global partnership by laying out 16 Sustainable Development Goals (SDG) to address a wide range of issues from ending poverty, spurring economic growth, improving health and education, and tackling climate change (5).

Sustainable development goal three, or the health goal, aims to “ensure healthy lives and promote well-being for all ages.” (5)  The targets and indicators for the SDG all point toward rehabilitation being a critical component to meeting of the outlined targets due to the professions focus on optimizing function (3) and health promotion (1,2).  For example, SDG target 3.8 discusses universal health coverage, of which rehabilitation is a key part.  

Health Systems overview

According to the World Health Organisation (WHO), the primary purpose of a health system is to improve health by delivering preventive, promotive, curative and rehabilitative interventions in a way that is responsive, financially equitable, and treats all people with respect (9).

The WHO Building Blocks Framework for health system describes six components of a health system:

1. service delivery
2. health workforce
3. health information systems
4. access to essential medicines
5. financing
6. leadership/governance

According to the WHO handbook, the leadership/governance component provides the basis for overall policy and the regulation of the other health system blocks (9).  

How Rehabilitation Fits within Health Systems

There has been renewed focus on rehabilitation as part of global health systems, as exemplified by the WHO’s Rehabilitation 2030 initiatives (10).  The initiatives shine a light on the profound need of rehabilitation across the globe, highlight the part rehabilitation has to play in the UN’s SDG, and to strengthen the role of rehabilitation in health systems (6,8) to respond to global trends in health and aging.  There is a great need for rehabilitation, especially as the number of people living with chronic disease continues to climb globally.  This is most hard felt in low- and middle-income countries where more than 50% of people do not receive needed care because of underdeveloped rehabilitation services (8, 10).  Global burden disease data for 2019 suggests that 2.4 billion people worldwide would have benefited from rehabilitation that year alone (7, 10) and that one in three people are currently living with a health condition that could benefit from skilled rehabilitation (8, 10).  

The Way Forward

Key Areas of Growth

Using SDGs and the WHO rehabilitation competency framework (12) as a guide, rehabilitation must grow and develop in key areas within health systems (10):

1. Leadership: there is a need for leadership at all levels of organizations within the rehabilitation professions to advocate for both patients and the profession.  There needs to be an improved awareness of what services rehabilitation provides, that it is not a luxury service but rather a basic component of healthcare that optimizes function and is health-focused.  Leadership education and mentorship should be a facet of rehabilitation training programs in both entry-level training and at the workplace (10).
2. Cross-sectional collaboration: there is a need for the creation of networks between professional bodies, between NGO’s, and educational institutions to support growth of rehabilitation in health systems (10).  An example of this was the SUDA project, whose aim was to improve the capacity of PT professional organisations and improve the PT standards of education in three African countries by assessing and enriching established physiotherapy programs, and providing the skills and training to continue development once the project was completed (10, 11).  The project also created a network of more than 150 physiotherapists from 12 French-speaking African countries using WhatsApp to exchange information and support (10, 11).  For more information on this collaboration, please see: https://world.physio/what-we-do/projects/suda
3. Increase the rehab workforce: perhaps the greatest challenge to strengthening rehabilitation within health systems is the lack of trained rehabilitation professionals in low-resource countries.  To illustrate this, topic specialist Cliona O’Sullivan states that in Niger West Africa with a total population of 20 million people, 48 are registered physiotherapists; in Ethiopia, with a population of 100 million people, only approximately 200 are trained physiotherapists (10).  As the need for rehabilitation increases, the need to expand workforce training, strengthen and adapt regulation and quality assurance measures become more urgent, especially in low-resources regions (12). In order to expand the rehabilitation workforce in low-resource health systems, rehabilitation needs to be supported by local and international governments and professional organizations (10) to improve:

• • • Education: establishing and supporting strong physiotherapy schools in low-resource regions; developing partnerships with physiotherapy schools in high-income countries to create a global society for learning and resource development to the mutual benefit of both parties (10).
    • Professional support and development: developing NGO and university partnerships to support mid-level rehabilitation therapist training programmes (10).
    • Job availability: a commitment is needed to employ graduates through governmental bodies such as the Ministry of Health or the Ministry of Education (10).
    • Competency framework: Created by the WHO, the rehabilitation competency framework outlines key competences and activities for rehabilitation works in five domains: practice, professionalism, learning and development, management and leadership, and research (10). Competency frameworks are valuable tools for aligning a workforce with the needs of a population by supporting competency-based education and training, regulatory standards, and developing tools for performance review.  The framework can be adapted to the rehabilitation needs of a population (10, 12).

1. Rehab service delivery: The AAAQ framework is often used to describe health service delivery, we will use this model to look at rehabilitation in health systems (10).

• Availability: in low-resource countries, there is often little or no rehabilitation services available.  Where it is available, rehabilitation is often concentrated in urban centers or is delivered by NGO’s which means the services are not integrated into the local health service system (10).
• Accessibility: access can be limited by expense or need to pay out-of-pocket or long wait times to be scheduled (10).  Topic Specialist Cliona O’Sullivan cites a study which looked at access for people with amputation in conflict environments and found that the delay between amputation and ability to access rehabilitation services was 8.2 years for people with traumatic amputation and three years for people with amputation due to non-traumatic causes (10, 13).
• Acceptability: rehabilitation services must be ethically and culturally appropriate to the populations it serves (10).  Topic Specialist Cliona O’Sullivan cites a study which looked at 30 years of data of more than 280,000 service users and found that fewer women and girls attended for rehabilitation across all health conditions.  Further research is indicated to understand the exclusion of women and girls from rehabilitation services as it affects their potential and has a negative impact on their families and greater communities (10, 13).
• Quality: Underpinning quality of rehabilitation services is evidenced-based practice.  Unfortunately, there is a mismatch between where rehabilitation research is conducted, with relatively little being done in low-resource contexts (10).  Topic Specialist Cliona O’Sullivan cites a study cites a systematic review of interventions for persons with stroke from low- and middle-income countries, and found only 62 studies, 44 of which were conducted in India (10, 14). This exemplifies the lack of rehabilitation research carried out in low- and middle-income contexts.  Another limiting factor of quality of rehabilitation is inability to access meaningful research due to lack of relevancy to the context or it is blocked by a paywall or there is a language barrier in terms of reading the research and translating knowledge (10).

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