Rehabilitation in Health Systems: Achieving Equitable Global Policy
According to the World Health Organization (WHO), rehabilitation is “a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments”.[1] More recently, ‘Rehabilitation 2030’ (further discussed below) states “Rehabilitation is a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment”.[2] Although definitions of rehabilitation vary slightly in wording, a key similarity is the focus on achieving an optimal outcome for the individual affected, also known as having a person-centred focus. Having a person-centred focus is ideal when working on global rehabilitation projects. This is the key to the success and continuity of rehabilitation projects existing around the globe. Rehabilitation is also characterized by interventions that address impairments, activity limitations, and participation restrictions, as well as personal and environmental factors that have an impact on functioning. Within the health sector, rehabilitation has been found beneficial in reducing length-of-stay in hospital, decreasing readmissions, and preventing costly and potentially fatal complications, thus helping to mitigate the negative social and health risks associated with prolonged hospital stay and health complications. Additionally, rehabilitation improves a person’s independence and prevents caregiver burnout. With a rapidly aging population, rise in communicable diseases, and a growing demand for rehab, it is urgent to discuss rehabilitation initiatives and their efficacy.
Despite the critical role rehabilitation plays in optimizing one’s functional ability and minimizing the impact of health conditions on the health, social and economic domains, the unmet rehabilitation need is profound and ever-increasing.[3] In many parts of the world (particularly in low- and middle-income countries), the capacity to provide rehabilitation services is limited or non-existent, failing to adequately address the needs of the population.[3] For example, evidence shows that only 26% of people in South Africa receive the rehabilitation services they need.[4-6] There are several factors behind the lack of rehabilitation infrastructure worldwide, including but not limited to:
A long history of undervaluing rehabilitation within the primary healthcare system, leading to its under-prioritization by government amongst other competing priorities;[2,3]
An absence of rehabilitation policies;[2]
A dearth of robust evidence on rehabilitation needs;[2]
An insufficient number of rehabilitation professionals, facilities and equipment;[2]
A lack of integration of rehabilitation services into health systems;[2]
The magnitude and scope of unmet rehabilitation needs has been highlighted in the following seminal global literature:
the WHO’s World Report on Disability (2011) calls for Member States to “develop, implement, and monitor policies, regulatory mechanisms, and standards for rehabilitation services, as well as promoting access to those services”1 (p. 122);
the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) calls on Member States to take appropriate measures to organize, strengthen and extend rehabilitation services and programmes7 (Article 26); and
WHO Global Disability Action Plan 2014-2021 urges all states “to strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation”8 (p. 3).
In 2017, WHO launched ‘Rehabilitation 2030’, a call for action to scale up rehabilitation so that countries can be prepared to address the increasing rehabilitation needs of the global population by the year 2030.[2] ‘Rehabilitation 2030’ presents a global commitment and sustainable action plan to the global calls to strengthen rehabilitation services in Member States. The action plan includes the following: drawing attention to the increased needs for rehabilitation; improving rehabilitation governance and investment;[10] expanding a high-quality rehabilitation workforce[10]; and enhancing rehabilitation data collection.[9,10] The Rehabilitation 2030 community’s commitment to strengthen health systems to provide rehabilitation services will give an opportunity for millions of people to not only live longer and ‘survive’, but also to live well and ‘thrive’.[10]
With its objective of optimizing functioning, rehabilitation supports those with health conditions to remain as independent as possible, to participate in education, to be economically productive, and fulfil meaningful life roles. Evidently, the importance of available and accessible rehabilitation services extends beyond simply ‘health’ as we typically know it. It bridges being able to fulfil activities of daily life with broader compassion and humanity. In understanding rehabilitation services in this way, it pushes providing basic rehabilitation services to become a moral obligation in ensuring that individuals’ basic needs are met. However, ensuring a basic level of rehabilitation services for all to improve health equity is met by various challenges in our global environment. With a long tradition of investing in the health services that directly reduce mortality and morbidity, rehabilitation goals of improving functioning and overall well-being have been under-prioritized and misinterpreted as a luxury health service. With this view, these services can be vastly ignored in the face of competing healthcare demands, leaving the rehabilitation services underdeveloped, under-resourced, and undervalued.[3] Even if governments were to take action today, data limitations pose a challenge in assessing rehabilitation needs. These two factors ultimately restrict the government’s ability to implement policy, as a lack of knowledge around the status quo and limited desire to prioritize the issue result in inaction on rehabilitation. This is furthered by both an insufficient number of rehabilitation resources (professionals, facilities, and equipment) and a lack of integration of rehabilitation services into health systems.
A change in mindset by global policy-makers is urgently needed. A general shift in the perception of the role of rehabilitation is needed to ensure the prioritization of this issue (i.e. to highlight the importance of rehabilitation in improving the health of citizens and its ability to boost economic productivity). Further to this, is ensuring that rehabilitation services are provided in a more equitable manner. This builds on current global action on Universal Health Coverage (UHC) by the WHO. “UHC means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care”.[11] In measuring progress on UHC, the WHO identifies “16 essential health services”[11] which fall into the categories of: “reproductive, maternal, newborn and child health”, “infectious diseases”, “noncommunicable diseases”, and “service capacity and access”. However, none of these standard categories of indicators explicitly measure rehabilitation. Given the overarching role of rehabilitation in improving quality of life and ability to carry out daily activities of living, it may be in the best interests of the government to focus some efforts on rehabilitation services and include indicators to measure progress in this domain. In fact, because countries are unique, additional indicators can be added by countries to refine the focus of their UHC efforts and to measure them appropriately. Ultimately, this aids in contributing to the knowledge gap around rehabilitation services and may contribute to the development of more robust rehabilitation policy in the future.
The work undertaken at the global level to improve the availability of accessible and affordable rehabilitation, and more broadly, UHC, plays a fundamental role in achieving Sustainable Development Goal (SDG) 3: “ensure healthy lives and promote well-being for all at all ages”.[12] Rehabilitation, along with prevention, promotion, treatment and support, is a key health strategy to address the full health needs and promote both living longer and living better as stated in SDG 3. Therefore, action undertaken to improve the availability of accessible and affordable rehabilitation not only improves human lives, but contributes to global goals of well-being for all.
References
The World Bank & World Health Organization. World Report on Disability. <https://www.who.int/disabilities/world_report/2011/report.pdf>. (2011).
World Health Organization. Rehabilitation 2030 – A Call for Action: February 6-7 2017 Meeting Report. 77 <https://www.who.int/disabilities/care/Rehab2030MeetingReport_plain_text_version.pdf>. (2017).
World Health Organization. Rehabilitation: key for health in the 21st century. <https://www.who.int/disabilities/care/KeyForHealth21stCentury.pdf?ua=1>. (n.d.).
Yusman Kamaleri & Arne H. Eide. Living conditions among people with disabilities in Lesotho. A national representative study. p. 98 (SINTEF Technology and Society, Global Health and Welfare, Oslo, Norway, 2011).
Arne H. Eide & Yusman Kamaleri. Living conditions among people with disabilities in Mozambique: A national representative study. (SINTEF Rapport, Oslo, Norway, 2009).
Loeb M & Arne H. Eide. Living conditions among people with activity limitations in Malawi: A national representative study. (SINTEF Rapport, Oslo, Norway, 2004).
United Nations Department of Economic and Social Affairs. Article 26 – Habilitation and rehabilitation, <https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities/article-26-habilitation-and-rehabilitation.html> (n.d.).
World Health Organization. WHO Global Disability Global Action Plan 2014-2021. <https://apps.who.int/iris/bitstream/handle/10665/199544/9789241509619_eng.pdf?sequence=1>. (Geneva, Switzerland, 2015).
World Health Organization. Rehabilitation 2030 – A Call for Action: February 6–7 2017 Meeting Report. 56 <https://www.who.int/disabilities/care/Rehab2030MeetingReport2.pdf?ua=1>. (2017).
Krug, E. & Cieza, A. Strengthening Health Systems to Provide Rehabilitation Services. American journal of physical medicine & rehabilitation 96, 438-439, doi:10.1097/PHM.0000000000000753 (2017).
World Health Organization. Universal health coverage (UHC), <https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)> (2018).
World Health Organization. SDG 3: Ensure healthy lives and promote wellbeing for all at all ages, <https://www.who.int/sdg/targets/en/> (n.d.).
Handi-Care Intl. Amar Seva Sangam, <http://www.handicareintl.org/> (n.d.).