Strengthening Rehabilitation in Low-Resource Settings

Original Editor - Stacy Schiurring based on the course by [Cliona O'Sullivan]
Top Contributors - Stacy Schiurring, Tarina van der Stockt, Kim Jackson, Jess Bell and Ewa Jaraczewska

Introduction[edit | edit source]

Rehabilitation has a role in health systems, but it will need partnership and collaboration on a global scale to strengthen its availability in low-resource settings.[1]  How this can be achieved will involve setting attainable goals, recategorising how rehabilitation fits into health systems, and providing support and infrastructure to rehabilitation education and professional development in low- and middle- resource areas.[1]

United Nations Sustainable Development Goals[edit | edit source]

UN Sustainable Development Goals

Horton and Lo from their 2013 Lancet article state “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." [1][2]

The United Nations (UN) created the 2030 Agenda for Sustainable Development as an action plan for “people, planet, and prosperity."[3]  It strives to create global partnership by laying out 17 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.[4]

Sustainable development goal three, or the health goal, aims to “ensure healthy lives and promote well-being for all ages."[4] The targets and indicators for the SDG all point toward rehabilitation as a critical component to meeting the outlined targets due to the profession's focus on optimising function[5] and health promotion.[6] [7]  For example, SDG target 3.8 discusses universal health coverage, of which rehabilitation is a key part.[1]  


Health Systems Overview[edit | edit source]

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]

WHO Building Blocks Framework

The WHO Building Blocks Framework for health system describes six components of a health system:[10]

  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[edit | edit source]

There has been renewed focus on rehabilitation as part of global health systems, as exemplified by the WHO’s Rehabilitation 2030 initiatives.[1]  The initiatives shine a light on the profound need for rehabilitation across the globe. They also highlight the part rehabilitation has to play in the UN’s SDG, and the need to strengthen the role of rehabilitation in health systems[11][12] 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.[1][12]  Global burden disease data for 2019 suggests that 2.4 billion people worldwide would have benefited from rehabilitation that year alone[1][13] and that one in three people are currently living with a health condition that could benefit from skilled rehabilitation.[1][12]


The Way Forward[edit | edit source]

Key areas of growth[edit | edit source]

Using SDGs and the WHO Rehabilitation Competency Framework[15] as a guide, rehabilitation must grow and develop in key areas within health systems:[1]

Leadership[edit | edit source]

There is a need for leadership at all levels of rehabilitation professional organisations 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 optimises function and is health-focused.  Leadership education and mentorship should be a facet of rehabilitation training programmes in both entry-level training and in the workplace.[1]

Cross-sectional collaboration[edit | edit source]

There is a need for the creation of networks between professional bodies, NGOs, and educational institutions to support the growth of rehabilitation in health systems.[1]  An example of this was the SUDA project, whose aim was to improve the capacity of physiotherapy professional organisations and improve the physiotherapy standards of education in three African countries by assessing and enriching established physiotherapy programmes, and providing the skills and training to continue development once the project was completed.[1][16]  The project also created a network of more than 150 physiotherapists from 12 French-speaking African countries using WhatsApp to exchange information and support.[1][16] 

Increase the rehabilitation workforce[edit | edit source]

Perhaps the greatest challenge to strengthening rehabilitation within health systems is the lack of trained rehabilitation professionals in low-resource countries.  Niger West Africa, for example, has a total population of 20 million people, but only 48 registered physiotherapists; in Ethiopia, with a population of 100 million people, only approximately 200 are trained physiotherapists.[1]  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.[15] In order to expand the rehabilitation workforce in low-resource health systems, rehabilitation needs to be supported by local and international governments and professional organisations[1] to improve:

  1. 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.[1]
  2. Professional support and development: developing NGO and university partnerships to support mid-level rehabilitation therapist training programmes.[1]
  3. Job availability: a commitment is needed to employ graduates through governmental bodies such as the Ministry of Health or the Ministry of Education.[1]
  4. Competency framework: Created by the WHO, the rehabilitation competency framework outlines key competencies and activities for rehabilitation works in five domains: (1) practice, (2) professionalism, (3) learning and development, (4) management and leadership, and (5) research.[1] Competency frameworks are valuable tools for aligning a workforce with the needs of the population it serves 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 the served population.[1][15]
Rehabilitation service delivery:[edit | edit source]

The AAAQ framework is often used to describe health service delivery and we will use this model to look at rehabilitation in health systems.[1]

  1. Availability: in low-resource countries, there are often little or no rehabilitation services available.  Where it is available, rehabilitation is often concentrated in urban centres or is delivered by NGOs which means the services are not integrated into the local health service system.[1]
  2. Accessibility: access can be limited by expense, the need to pay out-of-pocket or long wait times.[1]  Topic Specialist Cliona O’Sullivan cites a study that 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.[1][17]
  3. Acceptability: rehabilitation services must be ethically and culturally appropriate to the populations they serve.[1]  Topic Specialist Cliona O’Sullivan cites a study that looked at 30 years of data of more than 280,000 service users and found that fewer women and girls attended 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.[1][17]
  4. Quality: Underpinning the 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.[1]  A 2020 systematic review of interventions for persons with stroke from low- and middle-income countries found only 62 studies, 44 of which were conducted in India.[1][18] This exemplifies the lack of rehabilitation research carried out in low- and middle-income contexts.  Another factor limiting the quality of rehabilitation is the inability to access meaningful research. This may be due to a lack of relevancy to the context, articles/research may be blocked by a paywall or there may be a language barrier in terms of reading the research and translating knowledge.[1]

Conclusion[edit | edit source]

It is an exciting time to be a rehabilitation professional, as there is renewed focus to strengthen and promote rehabilitation worldwide within health systems.  Rehabilitation professionals, specifically physiotherapists, should be healthcare leaders in noninvasive interventions for prevention, wellness, health education, and physical maintenance against the leading causes of premature death globally.[1][6]  The nature of physiotherapy practice is cost-effective, highly ethical, and evidence-based.  These traits further place this profession in a position to positively affect the outcomes of these conditions.  Entry-level physiotherapy education should align with these trends to prepare new therapists to make global change collectively through local actions.[6] A global physiotherapy action plan should include health promotion and wellness in physiotherapy practice.  Health-focused practice should be a priority and developed into a clinical competency.[6] [7]  Optimising function is a global health goal, and physiotherapy is especially suited to address this need.[5]

By focusing on the SDG and using the WHO framework it is possible to ensure good health and promote wellbeing for all.[1]  Further research is needed to fully understand the interplay of cultural and social factors to allow full access of all people to rehabilitation within health systems.[17]

Resources[edit | edit source]

Related Articles:

Further reading and resources from the Topic Specialist:

Additional Viewing:


References[edit | edit source]

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 O’Sullivan C, Partnership and Collaboration to Strengthen Rehabilitation in Low-resources Settings. Strengthening Rehabilitation in Low-Resource Settings. Plus. 2021.
  2. Horton R, Lo S. Investing in health: why, what, and three reflections. The Lancet. 2013;382(9908):1859-1861.
  3. United Nations.Transforming our world: the 2030 Agenda for Sustainable Development. 2015 [cited 2021.11.01]; Available from:
  4. 4.0 4.1 United Nations. Sustainable Development Goal 3. 2017 [cited 2021.10.29]; Available from:
  5. 5.0 5.1 Heinemann AW, Feuerstein M, Frontera WR, Gard SA, Kaminsky LA, Negrini S, Richards LG, Vallée C. Rehabilitation Is a Global Health Priority. Arch Phys Med Rehabil. 2020 Apr;101(4):728-729.
  6. 6.0 6.1 6.2 6.3 Dean E, Al-Obaidi S, De Andrade AD, Gosselink R, Umerah G, Al-Abdelwahab S, Anthony J, Bhise AR, Bruno S, Butcher S, Fagevik-Olsén M, Frownfelter D, Gappmaier E, Gylfadóttir S, Habibi M, Hanekom S, Hasson S, Jones A, LaPier T, Lomi C, Mackay L, Mathur S, O'Donoghue G, Playford K, Ravindra S, Sangroula K, Scherer S, Skinner M, Wong WP. The First Physical Therapy Summit on Global Health: implications and recommendations for the 21st century. Physiother Theory Pract. 2011 Nov;27(8):531-47.
  7. 7.0 7.1 Dean E, de Andrade AD, O'Donoghue G, Skinner M, Umereh G, Beenen P, Cleaver S, Afzalzada D, Delaune MF, Footer C, Gannotti M, Gappmaier E, Figl-Hertlein A, Henderson B, Hudson MK, Spiteri K, King J, Klug JL, Laakso EL, LaPier T, Lomi C, Maart S, Matereke N, Meyer ER, M'kumbuzi VR, Mostert-Wentzel K, Myezwa H, Olsén MF, Peterson C, Pétursdóttir U, Robinson J, Sangroula K, Stensdotter AK, Tan BY, Tschoepe BA, Bruno S, Mathur S, Wong WP. The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases. Physiother Theory Pract. 2014 May;30(4):261-75.
  8. Hi Air. How rehabilitation contributes to realising SDG 3. Available from: [last accessed 02/11/2021]
  9. 9.0 9.1 World Health Organization. Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and their Measurement Strategies. 2010 [cited 2021.10.30]; Available from:
  10. Stockton DA, Fowler C, Debono D, Travaglia J. World Health Organization building blocks in rural community health services: An integrative review. Health Sci Rep. 2021 Mar 9;4(2):e254.
  11. Gimigliano F and Negrini S.  The World Health Organization “Rehabilitation 2030 -- a Call for Action.  European Journal of Physical and Rehabilitation Medicine 2017 April.
  12. 12.0 12.1 12.2 World Health Organization. Rehabilitation 2030. 2017 [cited 2021.10.30]; Available from:
  13. Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2021 Dec 19;396(10267):2006-2017.
  14. WHO. WHO: Rehabilitation: Key for health in the 21st century. Available from: [last accessed 02/11/2021]
  15. 15.0 15.1 15.2 World Health Organization. Rehabilitation Competency Framework. 2021 [cited 2021.10.31]; Available from:
  16. 16.0 16.1 World Physiotherapy. SUDA Project. 2016 [cited 2021.10.30]; Available from:
  17. 17.0 17.1 17.2 Barth CA, Wladis, A, Blake C, Bhandarkar P, O’Sullivan C, (2020) Users of rehabilitation services in 14 countries and territories affected by conflict, 1988-2018. Bulletin of the World Health Organisation. 2020 September 98:599-614
  18. Dee M, Lennon O, O'Sullivan C. A systematic review of physical rehabilitation interventions for stroke in low and lower-middle income countries. Disabil Rehabil. 2020 Feb;42(4):473-501.
  19. TED Talk. The global goals we've made progress on -- and the ones we haven't | Michael Green. Available from: [last accessed 02/11/2021]