How can we overcome barriers to accessing rehabilitation for persons with disabilities in LMIC?

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Question & problem

Rehabilitation is described as a set of measures to optimise the functioning of individuals, and is important for wellbeing, participation and quality of life. Rehabilitation includes diagnosis, treatments, surgeries, assistive devices and therapies. Not all people who need rehabilitation are people with disabilities, and not all people with disabilities need rehabilitation. The World Health Organisation (WHO) recently estimated that 1 in 3 people globally (2.41 billion people) would benefit from rehabilitation: this number has increased nearly two thirds since 1990, due to population growth and increase in Non-Communicable Diseases (NCDs). In contrast, there are estimated to be less than 10 skilled rehabilitation practitioners per million population in Low and Middle Income Countries (LMICs), and only 5 – 15% of people in need of assistive devices are thought to have received them.

Quote

“Governance, political will and a common understanding of disability and rehabilitation are crucial for implementation of the recommendations in the [WHO] rehabilitation guideline”
- [Furlan et al, 2018]

Recommendations

Use updated WHO guidance to strengthen and better integrate rehabilitation services into health systems

Key recommendation

Use the WHO Rehabilitation in Health Systems Guide for Action to strengthen and better integrate rehabilitation services into health systems, increasing access and availability for all

Action

Follow new WHO guidance to aggregate fragmented services into a coherent delivery system, following key recommendations on how to integrate rehabilitation services into primary, secondary and tertiary levels of health systems. This includes development of standardised referral pathways and mechanisms between health system levels to coordinate individuals’ continuum of care, and strengthening both in hospital and community-based services.

Build the capacity of an indigenous rehabilitation workforce to better meet population rehabilitation needs

Key recommendation

Build the capacity of an indigenous rehabilitation workforce to meet population rehabilitation needs

Action

Use the new WHO Rehabilitation Competency Framework guidance to identify population needs, collecting population data and in consultation with user groups.  Develop competency-based education and training programmes, and develop regulatory standards to build a local, knowledgeable, multidisciplinary rehabilitation workforce aligned to these needs

Identify context-relevant approaches to tackle key barriers to accessing rehabilitation among people with disabilities in LMICs

Key recommendation

Identify context-relevant approaches to tackle the two key barriers to accessing rehabilitation among people with disabilities in LMICs: affordability and availability

Action

Review how services are currently managed and ways that they can be made more affordable or readily available. Potential interventions include building rehabilitation into health insurance, ensuring availability of services at the community level and support for traveling longer distances to specialist care

Collect, strengthen and share evidence on what works to improve access to rehabilitation for people with disabilities

Key recommendation

Collect and share evidence on what works to improve access to rehabilitation for people with disabilities

Action

There is a lack of evidence on what works to improve access to rehabilitation for people with disabilities globally. Contribute to this evidence base by investing in collaborating with researchers to collect process data, monitor and evaluate the outcomes of interventions and capture and respond to context-specific requirements for people with disabilities.

Challenges

Challenge #1: People with disabilities experience barriers to accessing rehabilitation that are varied and multi-layered

  • A 2018 systematic review of access to rehabilitation among people with disabilities in LMICs identified 77 studies across 64 countries. The diverse range of outcome measures limited comparability or generalisability from findings. The review concluded that generally, access to rehabilitation among people with disabilities in LMICs was low. No clear patterns of access by equity measures, such as socio-economic position, age, or locality, emerged, possibly due to limited evidence.
  • Most common barriers included accessibility (distance to services, transport issues, not having someone to accompany the person), affordability (cost of service or treatment, lack of insurance), acceptability (have not heard of service, unaware of value of service, fear), availability (waiting times, unavailable medicines) and quality (discrimination, provider skills, communication barriers)
  • A separate review on access to assistive technology for persons with intellectual disabilities identified the cost of assistive products, a lack of awareness and inadequate assessment protocols as key barriers

Challenge #2: Rehabilitation services are not tailored to the population’s needs

  • Historically rehabilitation has been described as “fragmented”, lacking a unified approach across various professional rehabilitation groups. Rehabilitation interventions have previously been sponsored by international organizations and  managed independently of local health services, limiting sustainability and the long term availability of appropriate services and products
  • A 2012 review of prosthetic and orthotic services in LMICs recommended the need for an indigenous workforce for sustainability of services, to address contextual factors (social, economic, cultural, psychological and climate-related) that affected supply and demand, and to capitalise on available technology and resources.
  • Community-Based Rehabilitation (CBR) has been developed as an alternative rehabilitation model in many LMICs, but evidence on its effectiveness is limited, and coverage is sparce

Challenge #3: There is little evidence on “what works” to overcome barriers to rehabilitation for people with disabilities in LMICs

  • Few studies have evaluated interventions to improve access to rehabilitation for people with disabilities in LMICs. Magnusson et al. (2019) identified 38 studies globally evaluating rehabilitation interventions for children with disabilities. Sample sizes were low and interventions were diverse, limiting generalisability. There was some evidence that task shifting (caregiver or community worker led support) supported children with disabilities’ rehabilitation needs.
  • Iemmi et al. (2016) reviewed the literature on CBR and found some evidence that interventions improved clinical outcomes, enhanced functioning and increased quality of life. In contrast, Gelaw et al (2020) found mixed evidence of the impact of home-based rehabilitation versus in-hospital rehabilitation for people with stroke or physical disabilities
  • Several demand-side facilitators for improving access to rehabilitation have been identified, but from small-scale studies and with limited generalisability. These included: increased knowledge and awareness of assistive products increased demand for assistive technology among people with intellectual impairments; and information and easy access to medics and confidence in the value of services increased demand for rehabilitation among people with physical disabilities.

Challenge #4: Guidance on how to strengthen rehabilitation services has historically been lacking

  • In part related to the breadth of different services that constitute rehabilitation, guidance on strengthening rehabilitation services and their availability has historically been lacking
  • In 2017, the WHO launched the Rehab 2030 Call for Action, to improve rehabilitation governance and investment, expand a high-quality rehabilitation workforce, enhance data collection on rehabilitation and support its incorporation into Universal Health Care. Further guidelines on health-related rehabilitation are under development, and a new population needs estimator has been built to provide data for all regions and countries globally. Additionally, the Rehabilitation Competency Framework was launched in 2021, providing guidance on aligning population rehabilitation needs with the required workforce, including establishing regulatory standards, mechanisms for performance appraisal and gap analysis.

Finding the answers

This evidence brief is based on the findings of one overview of systematic reviews, five systematic reviews, two meta-analyses and one scoping review. It also includes data and recommendations recently released by the WHO. The literature that contributed to this brief was either global, global with a focus on LMICs, or focused on LMICs only. 

Recommendations & actions

Use updated WHO guidance to strengthen and better integrate rehabilitation services into health systems

Key recommendation

Use the WHO Rehabilitation in Health Systems Guide for Action to strengthen and better integrate rehabilitation services into health systems, increasing access and availability for all

Action

Follow new WHO guidance to aggregate fragmented services into a coherent delivery system, following key recommendations on how to integrate rehabilitation services into primary, secondary and tertiary levels of health systems. This includes development of standardised referral pathways and mechanisms between health system levels to coordinate individuals’ continuum of care, and strengthening both in hospital and community-based services.

Build the capacity of an indigenous rehabilitation workforce to better meet population rehabilitation needs

Key recommendation

Build the capacity of an indigenous rehabilitation workforce to meet population rehabilitation needs

Action

Use the new WHO Rehabilitation Competency Framework guidance to identify population needs, collecting population data and in consultation with user groups.  Develop competency-based education and training programmes, and develop regulatory standards to build a local, knowledgeable, multidisciplinary rehabilitation workforce aligned to these needs

Identify context-relevant approaches to tackle key barriers to accessing rehabilitation among people with disabilities in LMICs

Key recommendation

Identify context-relevant approaches to tackle the two key barriers to accessing rehabilitation among people with disabilities in LMICs: affordability and availability

Action

Review how services are currently managed and ways that they can be made more affordable or readily available. Potential interventions include building rehabilitation into health insurance, ensuring availability of services at the community level and support for traveling longer distances to specialist care

Collect, strengthen and share evidence on what works to improve access to rehabilitation for people with disabilities

Key recommendation

Collect and share evidence on what works to improve access to rehabilitation for people with disabilities

Action

There is a lack of evidence on what works to improve access to rehabilitation for people with disabilities globally. Contribute to this evidence base by investing in collaborating with researchers to collect process data, monitor and evaluate the outcomes of interventions and capture and respond to context-specific requirements for people with disabilities.

Policy priorities

Several reviews described a gap between international and national legislation on access to rehabilitation, and the reality in many contexts. The WHO recommends that financing and procurement policies should stipulate availability of assistive products to all who need them, with adequate training on how to use them. Integration of rehabilitation services into the health system is strongly recommended, usually with governance by the Ministry of Health and strong ties to related sectors such as social welfare, education and labour.

Conclusion

Rehabilitation is a crucial resource for supporting the wellbeing, functioning and quality of life of many people with and without disabilities in LMICs. Access to rehabilitation among people with disabilities has historically been low, and there is limited robust evidence on interventions to overcome this. However, new guidance on improving rehabilitation service systems is now available which, alongside evidence on barriers to access experienced by people with disabilities, may contribute towards strengthening service provision and utility among people with disabilities in LMICs.

Gaps & research needs

More large-scale studies evaluating what works, both in terms of rehabilitation outcomes, and in terms of increasing access to services, is needed. Given the breadth of service provision that falls under the umbrella of rehabilitation, and the breadth of different service needs different user types may have (depending on impairment or health condition, age or location etc.), much more evidence is required to support optimum allocation of scarce resources to support population need.

Acknowledgements

Peer Review: This brief was reviewed by Onaiza Qureshi, Knowledge Exchange Officer at Disability Evidence Portal and Tom Shakespeare, Co-director of the International Centre for Evidence in Disability at LSHTM.

Publication details: © London School of Hygiene & Tropical Medicine, April 2021.

Suggested citation: Islay Mactaggart. Evidence Brief: How can we overcome barriers to accessing rehabilitation for persons with disabilities in LMICs? Disability Evidence Portal, 2021.

Disclaimer: The views expressed in this publication are those of the author/s and should not be attributed to Disability Evidence Portal and/or its funders.