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The Role of Rehabilitation Within Low Resource Settings

Original Editor - Robin Tacchetti based on the course by Cornelia Barth
Top Contributors - Robin Tacchetti, Robin Leigh Tacchetti, Wanda van Niekerk, Tarina van der Stockt, Kim Jackson, Jess Bell, Ewa Jaraczewska and Stacy Schiurring

Introduction

"Physiotherapists in low-resource settings cannot simply be physiotherapists. They need a whole array of skills and understanding in order to fulfil the many roles their profession requires in [low resource] settings." -Cornelia Barth, Physiotherapist

Recent estimates by the World Health Organization state that over 2.4 billion people[1] need rehabilitation services. 80% of these individuals are from low- and middle-income countries. Poverty breeds disability, and disability breeds poverty - the two are inherently linked.[2] Malnutrition, non-potable water, unsanitary conditions and inadequate shelter compound the impact of poverty.[3] Attaining healthcare services can be even more challenging in areas that are also grappling with political uncertainty, corruption, volatile security, lack of professional healthcare training, dysfunctional and/or overwhelmed health systems and insufficient roads to access services.[4]

Purple=Advanced Blue=In Transit Orange=Less Developed Red= Least Developed


Health Inequalities in Low Resource Settings

"The problem rehabilitation currently has in low-resource settings is that very often, it is actually not part of the health system. Rehabilitation is often married to disability in the minds of policymakers. And fair enough, persons with disabilities do need rehabilitation, but that excludes the sector from being an equal component within health systems, from being presented within health ministries, rather than ministries of social affairs or other ministries, having a place on the table and access to health resources, access to certain research funding, to education models and all that within the network of health professions." -Cornelia Barth, Physiotherapist

Migration in Low Resource Setting

Poor people living in low-income settings tend to be the least healthy and benefit the most from healthcare. Social determinants of health, such as education, income level, gender, ethnicity, place of residence and employment status, directly correlate with the rate of illness, with lower-income countries bearing a higher burden of disease or illness.[5]

Access to Care

Accessibility of healthcare services is a crucial problem. When discussing access to care, we must consider if the services are available, affordable and well-accepted.[6]  

Availability

If healthcare services are provided within these settings, it is often of poor quality. Substandard or ineffective care tends to lead to mistrust in healthcare and a decrease in demand for these services. This, in turn, impacts whether or not individuals seek future care and generates mistrust of providers.[6]

Affordability

When healthcare services are obtainable, are they affordable?[6] [7]

Acceptability

People living in low-resource settings may have educational and cultural differences that may prevent them from pursuing healthcare services and/or they may not appreciate the potential health benefits of available services.[8][6]

Rehabilitation Specific

The need for rehabilitation services is high and increasing in low-resource settings.[9] [10] However, there are low resources and low supply (in terms of quantity and quality). Fewer than 50% of people in low- and middle-income countries who need rehabilitation services are able to receive the care they require. [11] These countries have less than ten skilled rehabilitation providers per 1 million population.[9][12]

"... it helps to understand that rehabilitation is the same everywhere. In the last years, we have seen huge developments in terms of definition of rehabilitation, of competencies, of education frameworks. Developed for a global world and not only high-resource settings. So rehabilitation, its core, its purpose, its concept is the same everywhere. It's the implementation that may vary greatly from one context to the other." -Cornelia Barth, Physiotherapist

The demand for rehabilitation services continues to increase as the world manages global warming, droughts, floods, natural disasters, war and conflict, epidemics and migration and displacement.[13] [14] This video by the World Health Organization explains why rehabilitation services are so important in low-income countries.

[15]

Future Course for Rehabilitation Professionals

"There's a huge diversity and complexity and the situation is very challenging. Then why does it matter? Because there's high needs that are met with low supply, human resources, infrastructure, and with low demand and low awareness and understandings, it's like a vicious circle. How do you make it work? Teamwork and partnerships. Different conditions but same purpose, learn from each other and strengthen each other." -Cornelia Barth, Physiotherapist

Knowledge

When working in low-income settings, rehabilitation professionals must investigate the region's local political, economic, cultural and social circumstances. Interventions from high-income countries should be adapted to the cultural norms of local settings. Additionally, when donating equipment and medication, it is necessary to consider the needs of the community to which they are being sent.[16] Learning about the culture will prevent the misuse of donations, as in the real-life examples below:

  1. Hip prosthesis provisions were distributed to a country where people were used to squatting[16]  
  2. Lice shampoo was dispensed to people who could not read and who viewed shampoo as a luxury that should be shared with others[16]

Advocate

In low-resource settings, there is minimal recognition of rehabilitation services. This prevents the rehabilitation sector from gaining an equal footing in local health systems. Advocating for rehabilitation services to become a division within the Ministries of Health would allow rehabilitation professionals to access education models, health resources and research funding. Rehabilitation professionals should promote their services to health policymakers, local health authorities, and the people living within these areas.[13][17]

Listen

Utilising high-income country interventions, even when they are evidence-based, may not be applicable in low-resource settings. Services must be determined by the people living in the region and reflect the situation of these diverse settings. The most effective way to initiate care is to listen to experts on the ground. These experts can identify available resources within that particular setting and any cultural beliefs that must be considered.[13]

Partnerships

Rehabilitation professionals from higher-resource settings can assist low-resource healthcare professionals via education and professional development. Non-governmental organisations should move from short-term to long-term partnerships with local authorities to improve health care over time.[16]

Resources

References

  1. ↑ World Health Organization. 2019. Available from: https://www.who.int/teams/noncommunicable-diseases/sensory-functions-disability-and-rehabilitation/global-estimates-of-the-need-for-rehabilitation#:~:text=According%20to%20this%20landmark%20global,billion%20to%202.41%20billion%20people.
  2. ↑ 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. ↑ Orach D, Garimoi C. Health equity: challenges in low income countries. African health sciences. 2009 Oct 1;9(s2):S49-51.
  4. ↑ Barth CA. Meeting the needs of people with physical disabilities in crisis settings. Bulletin of the World Health Organization. 2019 Dec 1;97(12):790.
  5. ↑ WHO. Health inequities and their causes. Available from https://www.who.int/news-room/facts-in-pictures/detail/health-inequities-and-their-causes (accessed 15/11/2021)
  6. ↑ 6.0 6.1 6.2 6.3 Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Hafizur Rahman M. Poverty and access to health care in developing countries. Annals of the new York Academy of Sciences. 2008 Jun;1136(1):161-71.
  7. ↑ Bhuiyan MI, Haque A. Role of NGOs in providing available and affordable health care services to the slum people in Dhaka. Clinical Epidemiology and Global Health. 2024 Jan 1;25:101478.
  8. ↑ Sarikhani Y, Najibi SM, Razavi Z. Key barriers to the provision and utilization of maternal health services in low-and lower-middle-income countries; a scoping review. BMC women's health. 2024 Jun 5;24(1):325.
  9. ↑ 9.0 9.1 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.
  10. ↑ Heine M, Derman W, Hanekom S. Towards a framework for the scale-up of rehabilitation for patients with non-communicable disease in low-resource settings. medRxiv. 2022 Jan 1.
  11. ↑ Charumbira MY, Kaseke F, Conradie T, Berner K, Louw QA. A qualitative study on rehabilitation services at primary health care: insights from primary health care stakeholders in low-resource contexts. BMC Health Services Research. 2024 Oct 23;24(1):1272.
  12. ↑ Ohnmar HT, Yuliawiratman BS, Tannor AY, Asikin MZ, Elaine SO, De Groote W, Naicker MS, Naicker AS. Barriers and facilitators for increased accessibility to quality rehabilitation services in low-and middle-income countries: a systematic review. European Journal of Physical and Rehabilitation Medicine. 2024 Mar 29;60(3):514.
  13. ↑ 13.0 13.1 13.2 Barth, C. The Role of Rehabiliation in Low Resource Settings. Course. Plus. 2021
  14. ↑ Jesus TS, Landry MD, Hoenig H. Global need for physical rehabilitation: systematic analysis from the Global Burden of Disease Study 2017. International journal of environmental research and public health. 2019 Jan;16(6):980.
  15. ↑ WHO: Rehabilitation: Key for health in the 21st century. Available from https://www.youtube.com/watch?v=a8uaRziXruc (last accessed 15 November 2021)
  16. ↑ 16.0 16.1 16.2 16.3 Bauer I. More harm than good? The questionable ethics of medical volunteering and international student placements. Tropical diseases, travel medicine and vaccines. 2017 Dec;3(1):1-2.
  17. ↑ Msomi NL, Ross AJ. Community service rehabilitation therapists’ understanding of social accountability. African Journal of Primary Health Care & Family Medicine. 2024 Jun 6;16(1):4473.
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