Rehabilitation, Sustainable Development Goals and Inclusion

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Introduction

Rehabilitation is a set of interventions designed to optimize the physical, social, and mental functioning of individuals in interaction with their environment. Today 2.4 billion people of all ages are in need of rehabilitation services, encompassing assistive technologies and a wide range of interventions (exercises, training, education, support and counselling, and adaptation of the environment) offered by rehabilitation professionals in diverse rehabilitation settings like homes, communities, hospitals, and rehabilitation centers. Everyone might need rehabilitation at some point in their life, due to congenital and acquired disorders, chronic diseases, injuries, trauma, degenerative conditions, and other health conditions and disabilities that can limit the capacity to function in everyday life. An ageing population, increasing prevalence of non-communicable diseases and injuries have generated higher demand for rehabilitation services. The number of people in need of rehabilitation had increased by 63% from 1990 to 2019. Rehabilitation needs will continue to increase in the years to come.

This is a clear indication of current health trends: we live longer, but with more limitations in functioning.

Recently, rehabilitation has also proved to be a crucial health measure for COVID-19 patients in the acute phase (when receiving ventilator support), in the sub-acute phase (when hospitalized) and long-term phases (following discharge), shortening the duration of hospitalization, relieving pressure on acute care and facilitating recovery, even for cases of the so-called ‘long COVID’.

Although rehabilitation is essential to respond to the health challenges of the 21st century, health systems worldwide are still focused on reducing mortality and morbidity. Functioning, the third health indicator, often remains a neglected aspect of health care - and so do rehabilitation services.

Indeed, rehabilitation services are very often under-developed and under-resourced. As such, they are unavailable or unaffordable for the vast majority of the population who live in poverty, in rural areas, and in particular in low and middle-income countries.

In addition, social-determinants of health considerably impact the identification of rehabilitation needs; access to quality rehabilitation services and assistive technology, for all ages; as well as motivation and participation in rehabilitation programs and their follow-up.

As a result, the unmet needs for rehabilitation are immense. More than 50% of persons who need rehabilitation cannot access or know how to access the services they require. In some low and middle-income countries, barriers for persons with disabilities are so significant that only 3-5% are able to access the rehabilitation services they need.

Rehabilitation and Sustainable Development Goals

Although rehabilitation is not explicitly mentioned in the 2030 Agenda and its 17 Sustainable Development Goals, rehabilitation is clearly a matter of global health and well-being, as well as of global development. By improving physical, mental, and social functioning, rehabilitation enables individuals to live, learn, work, and thrive at their full potential. Indeed, the ultimate goal of rehabilitation is the full participation and inclusion in society.

By intervening mainly on health-related aspects, rehabilitation primarily contributes to the realization of the right to health and to SDG3 on health and well-being. However, an individual who can enjoy good standard of health is more able to fully participate economically, culturally, politically on equal basis with others, with the impact going beyond the individual and reaching the whole society. Therefore, increasing access to quality rehabilitation services can significantly improve population health outcomes and foster inclusive, sustainable development.

The commitment to ‘leave no one behind’ is a recurring objective enshrined in the 2030 Agenda, and requires all actors involved in the implementation of the SDGs to address the inequalities affecting vulnerable people, including persons with disabilities (who are disproportionately represented in low- and middle-income countries). Rehabilitation can benefit a large number of individuals, especially the most vulnerable and marginalised, by providing them with concrete opportunities for empowerment, independence, and participation in society. Thus, rehabilitation is a fundamental element to translate the “leave no-one behind” commitment into reality.

In relation to SDG 8 (decent employment) and SDG 1 (zero poverty) -  By improving individual functioning, rehabilitation increases human capacity, thus strengthening the work-force, enabling participation and economic productivity. Rehabilitation enables access or return to the labour market, reduces the number of days off work, prevents illness, increases wellbeing. This results in increased productivity, participation and income, thus leading to sustainable poverty reduction. Improving the health-outcomes of the person can foster their autonomy, providing caregivers with additional time to resume or begin activities that they had to drop.

In relation to SDG 4 (education) - For example, the provision of a prosthetic leg or functional rehabilitation may enable a child to access school and participate in classes. Rehabilitation optimizes child development, with the largest gains registered when rehabilitation services are provided to children with traumatic injuries. Providing rehabilitation and AT, adapting the learning environment, can boost inclusive education and enable all children to learn together.

Rehabilitation interventions tend to be cost-effective or showed cost-saving in a variety of health conditions. In addition, rehabilitation generates further economic benefits as it accelerates hospital discharge and prevents readmission. This means that health-related costs for the individual and the family will be lower on the long-term.

A recent report from ATScale shows that investment in the provision of four assistive products – hearing aids, prostheses, eyeglasses, and wheelchairs – will result in a return on investment of 9:1'. For example, for 'a child in a low- or middle-income country, access to AT can make a difference of $100,000 in lifetime income.

Let’s focus for a moment on a specific SDG target, SDG 3.8, which sets to achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.

Universal health coverage means that all people have access to the health services they need, when and where they need them, without financial hardship. Rehabilitation, together with promotion, prevention, treatment, and palliative care, is an essential part of Universal Health Coverage – as it is set in the Declaration of Astana on Primary Health Care (2018) and in the UN Political Declaration on UHC (2019).

However, this is far from being reality: in particular in low-income countries, access to rehabilitation services is in general limited because it is unavailable and, if available, it’s unaffordable for the most marginalized populations. Their financial coverage is highly variable, absent or often provided by non-governmental organisations. Rehabilitation often represents catastrophic health expenditures in low- and middle-income countries, thus exacerbating poverty and marginalization. SDG target 3.8 on UHC can only be achieved if rehabilitation is strengthened and fully integrated in financial protection mechanisms.

Future

Examples of good policies and practices demonstrate that when rehabilitation is integrated in health systems, access to services improves. With adequate leadership and political will, resources can be mobilized, coverage can be expanded, the rehabilitation workforce can be strengthened, and more persons in need of rehabilitation can improve their functioning and participation. There is need to promote an integrated, people-centred approach to rehabilitation, which relies on innovations, such as telerehabilitation, to maximize its impact and reach-out to people in need.

International cooperation and humanitarian actors have a role to play. Since mobilization of domestic resources remains challenging in certain contexts, assistance conveyed via bilateral, regional and multilateral channels is critical.

Civil society organisations are also part of the solution. They act as providers of rehabilitation services, especially in fragile contexts and in times of crisis, and they accompany governments in the development and implementation of rehabilitation policies and programming (with an important role to play in particular at the community level).

Summary

Sustainable Development Goal 3 “Ensure healthy lives and promote well-being for all at all ages” can be achieved only if health leaders adopt a comprehensive approach to health and well-being. Improving the health status of a population not only means reducing the number of deaths and of people affected by diseases, but also ensuring that people live, function, and participate at their best potential, allowing them to productively contribute to society. Thus, the performance of health systems should be monitored and evaluated based on the complete set of health indicators: mortality, morbidity, and functioning, keeping in mind that “health and well-being for all” is often a pre-condition to achieve many other SDGs.