Access to Rehabilitation

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Introduction[edit | edit source]

Affordable and high-quality services should be available to all those in need. This is the main premise behind Universal Health Coverage (UHC), which is defined as, “ensuring all people have access to needed promotive, preventive, curative, rehabilitative, and palliative services they need, of sufficient quality to be effective, while ensuring that the use of these services does not expose the user to financial hardship”.[1] While this principle that everyone has the right to timely access to affordable, preventive and curative health care is recognised in many countries globally, there remain large gaps in access to health care which have been further exacerbated in the wake of the COVID-19 pandemic.

People with a disability or those with chronic conditions often experience poorer levels of health than people without with evidence from a range of settings, both high-income and low-income settings, they face a multitude of barriers to accessing healthcare services.[2] [3] Access to healthcare is a complex concept. If services are available and there is an adequate supply of services, then the opportunity to obtain health care exists, and a population may 'have access' to services, but the services available must be relevant and effective if the population is to 'gain access to satisfactory health outcomes'. [4]

Evidence on access to rehabilitation services is limited; however, what research is available suggests that there is expected to be very limited capacity to meet the demand for rehabilitation services in low resource settings, with estimates that there are less than ten skilled rehabilitation practitioners per 1 million population within these contexts.[2][5] The extent to which a population 'gains access to healthcare' depends on a wide range of factors including financial, organisational and social or cultural barriers that limit the utilisation of services. Thus access measured in terms of utilisation is dependent on the affordability, physical accessibility and acceptability of services and not merely adequacy of supply. If we consider these aspects, then access to health care means having timely use of personal health services to achieve the best possible health outcomes and comprises of the following four key components; [4]

Coverage[edit | edit source]

Healthcare coverage facilitates entry into the health care system. Disparities in health have been shown to have a strong socio-economic component. Those individuals with lower income or uninsured people are less likely to be able to access and receive medical care, generally being more likely to have poor health status.[6][7] Differences in health outcomes by the level of income may be due to a range of factors, for example, behavioural aspects, exposure to risk factors, stress, quality of housing, employment. The higher prevalence of ill health in groups with lower socioeconomic status may also to some extent and in some cases be explained by problems in access to healthcare and inadequate use of healthcare services. [8]

Services[edit | edit source]

Having a usual source of care and / or usual health care provider has been shown to lead to better health outcomes, fewer disparities in healthcare access, and lower costs[7]. While people with a usual place of care and a usual provider are more likely to receive preventive services and recommended screenings than people with no usual source of care.[6][9]

Timeliness[edit | edit source]

The ability to provide health care when the need is recognised is focused on the health system’s capacity to provide care quickly after a need is recognised[7]. Timely delivery of appropriate care can help reduce mortality and morbidity for chronic conditions, such as kidney disease.[6][10]

Workforce[edit | edit source]

A Health Service with capable, qualified, culturally competent providers. Ensuring well-coordinated, high-quality health care requires the establishment of a supportive health system infrastructure[11]. Key elements include a Well-distributed capable and qualified workforce. Organisational capacity to support culturally competent services and ongoing improvement efforts. Health care safety net for hospital admissions of vulnerable populations. [6]

Right to Health[edit | edit source]

The right to health contains four elements:

Availability

Functioning public health and health care facilities, goods and services, as well as programmes in sufficient quantity.

Accessibility

Health facilities, goods and services are accessible to everyone, within the jurisdiction of the State party. Accessibility has four overlapping dimensions: non-discrimination; physical accessibility; economical accessibility (affordability); and information accessibility.

Acceptability

All health facilities, goods and services must be respectful of medical ethics and culturally appropriate as well as sensitive to gender and life-cycle requirements.

Quality

Health facilities, goods and services must be scientifically and medically appropriate and of good quality.

Barriers to Health[edit | edit source]

Commonly reported barriers to health and more specifically rehabilitation include logistical factors (distance to service, lack or cost of transport), affordability (of services, treatment, lack of insurance), and knowledge and attitudinal factors (including perceived need, fear, and lack of awareness about the service). However, some barriers identified in the research are particular barriers that are disability-related, which include discrimination from the health provider, provider lacking skills, and communication barriers, or potentially enhanced among people with disabilities (e.g., lack of affordability). The following examines some of the wide range of barriers that can prevent individuals from receiving high-quality health care. 

Personal

The first step in the process of accessing health services generally revolve around an individuals recognition of their need and their decision to seek access to health care. The likelihood of an individual accessing health care is influenced by a balance between the perceptions of their needs and their attitudes, beliefs and more importantly their previous experiences with health services and are generally subject to social and cultural influences as well as environmental constraints.[12]

Financial

Access to and utilisation of health care services are often limited as a result of financial barriers. Even in systems where access is essentially free at the initial point of use, there are often some services that still require payment or top-up fee, or alternatively costs as a result of time lost from work or in travelling to and from a clinic or costs of child care in order to attend appointments. The impact of user charges and other associated costs of accessing care affect different socio-economic groups in different ways, for some groups their access is not affected, while our others these costs may represent a significant deterrent. As such equal costs for health care services do not necessarily give equal access and financial incentives can influence the availability of services and the types of service available. [12]

Organisational

Long waiting lists and waiting times may sometimes be indicative of organisational barriers to access which may result from inefficient use of existing capacity or a failure to design services around the needs of patients. Systematic variations in referral practices also act as barriers to accessing care, especially referral from primary to secondary care. Redesign of the way clinical services are delivered, such as the replacement of waiting lists with booking systems, might do much to reduce organisational barriers to access.[12] Policies or standards that systematically disadvantage those in need of rehabilitation services e.g. at a health care facility people may need to stand in a long line before receiving services, which can be a barrier for individuals who have balance problems or a hospital administrator who does not allocate needed resources for rehabilitation services. )

Governmental

Laws or policies that do not consider rehabilitation needs of the population e.g. rehabilitation services and assistive products not covered under a nation’s Health Care Plan

Service Delivery

Negative attitudes, presumptions, prejudices, or misconceptions e.g. low prioritisation of coordination of care by rehabilitation professionals leading to a lack of appropriate referrals for the needed continuum of care.  

Environmental

Barriers in the built or natural environment e.g. no ramp to enter the health facility or no public transportation that accommodates wheelchairs or those with mobility impairments.

Informational

Not offering the same health information to all people e.g. lack of data and research on which treatment interventions for specific impairments are most effective.

Facilitators to Access[edit | edit source]

Facilitators to rehabilitation for individuals with an impairment or chronic condition identified in the research include the provision of information, doctors having good skills, easy access to doctors and rehabilitation professionals, a good understanding of rehabilitation services, confidence in the value of rehabilitation services, meaningful assistance from health and rehabilitation professionals, having therapeutic relationships with health and rehabilitation professionals, and being assertive and independent in rehabilitation and easily accessible rehabilitation services. [13][14][15]When we look at access to rehabilitation within health systems, some of the key facilitators include;

  • reforming policies, laws, and delivery systems, including development or revision of national rehabilitation plans;
  • developing funding mechanisms to address barriers related to the financing of rehabilitation;
  • increasing human resources for rehabilitation, including training and retention of rehabilitation personnel;
  • expanding and decentralising service delivery;
  • increasing the use and affordability of technology and assistive devices;
  • expanding research programmes, including improving information and access to good practice guidelines.

Conclusion[edit | edit source]

In much of the research health professionals’ attitude towards the individual has been identified as both a facilitator and a barrier to accessing rehabilitation and health services. Respect and empathy were highlighted as key facilitators, while a focus on their impairment and not their health was identified as a key barrier. On the whole, a person-centred approach is vital to improve access to rehabilitation services, which emphasise autonomy and acknowledgement as individuals as important aspects of the rehabilitation process.

References [edit | edit source]

  1. World Health Organization Universal Health Coverage and Health Financing. [(accessed on 13 April 2018)];2018 Available online: http://www.who.int/health_financing/universal_coverage_definition/en/
  2. 2.0 2.1 Bright T, Wallace S, Kuper H. A systematic review of access to rehabilitation for people with disabilities in low-and middle-income countries. International journal of environmental research and public health. 2018 Oct;15(10):2165.
  3. Mlenzana NB, Frantz JM, Rhoda AJ, Eide AH. Barriers to and facilitators of rehabilitation services for people with physical disabilities: A systematic review. African Journal of Disability. 2013 Jan 1;2(1):1-6.
  4. 4.0 4.1 Gulliford M, Figueroa-Munoz J, Morgan M, Hughes D, Gibson B, Beech R, Hudson M. What does 'access to health care' mean? J Health Serv Res Policy. 2002 Jul;7(3):186-8. doi: 10.1258/135581902760082517. PMID: 12171751.
  5. World Health Organization Rehabilitation 2030: A Call for Action. [(accessed on 24 April 2018)];2017 Available online: http://www.who.int/disabilities/care/rehab-2030/en/
  6. 6.0 6.1 6.2 6.3 Agency for Healthcare Research and Quality, Rockville, MD. Elements of Access to Health Care. Available from https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/access/elements.html (accessed on 20 June 2021)
  7. 7.0 7.1 7.2 Healthy People 2020. Access to Health Services. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. http://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services. (accessed April 14, 2021).
  8. Health and Food Safety. IMPROVING ACCESS TO HEALTHCARE THROUGH MORE POWERFUL MEASUREMENT TOOLS: An overview of current approaches and opportunities for improvement. 2021
  9. Blewett LA, Johnson PJ, Lee B, et al. When a usual source of care and usual provider matter: adult prevention and screening services. J Gen Intern Med 2008 Sep;23(9):1354-60. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518015/. (access April 14, 2021.
  10. Smart NA, Titus TT. Outcomes of early versus late nephrology referral in chronic kidney disease: a systematic review. Am J Med 2011 Nov;124(11):1073-80e2. http://www.sciencedirect.com/science/article/pii/S0002934311004128 . (accessed April 14, 2021)
  11. Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Washington, DC: National Academy Press; 1993. https://www.ncbi.nlm.nih.gov/books/NBK235882/ (accessed 21 June 2021)
  12. 12.0 12.1 12.2 Gulliford M, Figueroa-Munoz J, Morgan M, Hughes D, Gibson B, Beech R, Hudson M. What does' access to health care' mean?. Journal of health services research & policy. 2002 Jul 1;7(3):186-8.
  13. Vincent C., Deaudelin I., Robichaud L., Rousseau J., Viscogliosi C., Talbot L.R. et al. ., 2007, ‘Rehabilitation needs for older adults with stroke living at home: Perceptions of four populations’, BMC Geriatrics 7(20). http://www.dx.doi.org/10.1186/1471-2318-7-20, PMid:, PMCid: [PMC free article] [PubMed] [Google Scholar]
  14. Kroll T., Jones G.C., Kehn M. & Neri M.T., 2006, ‘Barriers and strategies affecting the utilisation of primary preventive services for people with physical disabilities: A qualitative inquiry’, Health and Social Care in the Community 14(4), 284–293. http://dx.doi.org/10.1111/j.1365-2524.2006.00613.x, PMid: [PubMed] [Google Scholar]
  15. Crisp R., 2000, ‘A qualitative study of the perceptions of individuals with disabilities concerning health and rehabilitation professionals’, Disability and Society 15(2), 355–367. http://dx.doi.org/10.1080/09687590025720 [Google Scholar]