Rehabilitation Governance

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Original Editors - Add your name/s here if you are the original editor/s of this page.  Vidya Acharya

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Introduction[edit | edit source]

Rehabilitation is the care given when an individual experiences limitations in everyday functioning due to aging or a health condition, including chronic diseases or disorders, injuries, or traumas.[1] According to the World Health Organization (WHO), rehabilitation is defined as a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions interacting with their environment. The interventions optimize well-being by addressing impairments, limitations, and restrictions in many areas (mobility, vision, and cognition) and considering personal and environmental factors.[2]  These services may be required  throughout their lifespan by persons with health conditions. Also, the need for rehabilitation depends on timing, type of intervention that a rehabilitation provider selects, aetiology and severity of the person’s health condition, the prognosis, the way in which illness affects the person’s ability to function in the environment, as well as the individual’s identified personal goals.[2]

Growing Demand for Rehabilitation Services[edit | edit source]

The rapid increase in numbers of people experiencing a decline in functioning seen worldwide is due to the changing health and demographic trends of the increasing prevalence of non-communicable diseases and population aging. Hence, rehabilitation needs will further increase in the years to come, which is a considerable challenge for health and social systems in addressing those needs.[1]

Non-communicable Diseases[edit | edit source]

Noncommunicable diseases (NCDs), also known as chronic diseases differ significantly from acute conditions and require a different approach to the disease's complexity and frequent requirements for continuing care. The World Health Organization estimates that 50% of the global disease burden is due to chronic illness.  Since chronic diseases are long-lasting, conditions do have compounding and sustained effects on the individual and broader society's social, physical, psychological, and economic levels. Chronic diseases cost billions of dollars in direct healthcare costs and also in productivity losses. [3]

Aging Population[edit | edit source]

According to the world data published in 2013, life expectancy has increased globally from less than 30 years to over 72 years. After two centuries of progress, people can expect to live much more than twice as long as our ancestors, and this progress is seen in every world region, with people today can expect to live more than twice as long.[4] According to WHO, the number of people over 60 years of age is predicted to double by 2050, with more people living with chronic diseases such as diabetes, stroke, and cancer. [5]

Childhood Related Issues[edit | edit source]

Children constitute a significant and important portion of users of rehabilitation services. The potential benefits of rehabilitation services are not restricted to aging and adult populations. According to WHO, while the child mortality rates are declining, not all who survive thrive. Early interventions that optimize developmental outcomes for children with various health conditions (including neurological, congenital, and intellectual impairments), and injuries, can positively affect participation rates in education, community activities, and future capacity to work.

Other Health Conditions[edit | edit source]

The ongoing incidence of injury (such as burns), the occurrence of natural calamities (earthquakes/floods), disease outbreaks, human-induced hazards (conflict, terrorism, or industrial accidents) can create overwhelming rehabilitation needs due to injury or illness. They affect existing services and significantly impact the most vulnerable populations and the weakest health systems.[5]

Socioeconomic Impact of Poverty[edit | edit source]

Poverty is closely associated with NCDs. Lack of access to health care and screening for conditions and also lack of disease-prevention efforts put people in low-income countries at higher risk of dying from non-communicable disease as well as infectious disease.[6][7]

The non-communicable disease threatens progress towards the 2030 Agenda for Sustainable Development, which includes a target of reducing premature deaths from NCDs by one-third by 2030.[6] Widespread availability of rehabilitation services is essential for health systems to be able to respond effectively to the needs of older populations. Numerous studies have concluded that community-based rehabilitation increases the safety and independence of older people, reduces the risk of falls, and decreases the need for hospital and nursing home admissions. [2]

Rehabilitation Governance[edit | edit source]

Governance of health systems comprises the actions adopted by society to organize itself to promote the health of its population. Good governance results in the effective delivery of health services and improves health outcomes. As health services and service providers often disorganised in various poor setting resources, it hampers their access. This results in the provision of poor quality services, inefficient use of resources, duplication of services, and decreased service-user satisfaction.[8]

In recent years, governance has transitioned to the fore of the international development agenda, shifting from micro-level, project-specific objectives to macro-level issues of policy-making.[8] There is a need for the policymakers in less-resourced settings to know how to most adequately strengthen the performance of health systems.

The complexities of leadership and governance can be addressed through a participative, transparent, well-defined, and structured framework. To promote good governance and leadership of health systems, coherent and flexible policies, which incorporate health-related human rights and opportunities together are essential.

Leadership and Governance[edit | edit source]

The leadership and governance of health systems [9], also called stewardship, are the most complex and critical building block of any health system. It is about the role of the government in health and its relation to other actors whose activities impact health. It involves overseeing and guiding the whole health system, private as well as public, to protect the public interest. This needs both political and technical action with increased attention to corruption and calls for a more human rights based approach to health. [9]

All governments are faced with the challenge of defining their role in health concerning other actors. Any approach to leadership and governance must be contingent on national circumstances. WHO helps governments as follows: [9]

  • Develop health sector policies and frameworks
  • Regulatory framework: Design, implement and monitor health-related laws, regulations, and standards; regulation of medical products, vaccines, and technologies; regulation concerning occupational health and workplace safety
  • Accountability on monitoring health system performance as discussed earlier in the building blocks.
  • Generate and interpret intelligence and research on policy options
  • Build coalitions across government ministries, with the private sector and with communities: to act on key determinants of health; to protect workers’ health; to ensure the health needs of the most vulnerable are properly addressed; to anticipate and address the health impact of public and commercial investments.
  • Work with external partners to promote greater harmonization and alignment with national health policies.

Package of Rehabilitation Interventions (PRI) is developed to support ministries of health in planning, budgeting and integrating rehabilitation interventions into health systems.[10]

Governance Framework[edit | edit source]

According to the WHO (2007) model of the Health system, the governance framework is based on major independent building blocks that overlap each other.[11]

  1. Service delivery acts as the output or is perceived as the quality of the Health System,
  2. Human Resources, Medical Technologies, Information/Data collection, and Financing form the health system inputs,
  3. And People, as the governance includes overseeing the entire health system, it permeates with all other building blocks and is driven by People and Actors in the system.

Strategic vision & policy design and participation & consensus orientation can be viewed more conventionally as governance inputs; these are all interlinked within the governance building block  and are dynamic and interchangeable. [11]

  • Strategic vision using transparent information by the stewards are important factors for good health system governance.
  • A well-designed system should increase integration and reduce fragmentation and duplication, and encourage the participation of all relevant stakeholders, both state and non-state (such as citizen groups, pharmaceutical companies, insurance firms) in designing policies. Literature suggests a need for meaningful participation of the person with disabilities in the policymaking process. The participation can be strengthened by supporting access to research, statistical information, training for people with disabilities. Governance in health can be assessed by estimating the Determinants of Governance which measures whether the procedure or regulation or policy or law exists. Governance Performance Indicator which assesses to what degree rules or policies are followed or enforced. This can be done by surveys such as Public Expenditure Tracking Surveys, Exit Interviews.
  • Consensus should be sought when the voices of numerous stakeholders may not always be homogenous.

Addressing corruption, being transparent, and being accountable are governance processes.[11]

  • To ensure that the systems' rules are followed, a good health system governance should involve accountability. It includes holding public officials/service providers answerable for processes and outcomes, and imposing sanctions if the specified outcome is not delivered.
  • Clear goals should be based on the participation of relevant stakeholders especially from disadvantaged groups or those with less power in order  to influence policies, design transparent policies, and promote accountability thereby reducing the risk of corruption.

Political Priority[edit | edit source]

To increase demand for rehabilitation, rehabilitation must become a political priority. Initiatives are more likely to attract political support if they share certain features in each category: the power of actors, the influence of ideas, the nature of political contexts, and characteristics of the issue itself. These form the foundation of our framework on the determinants of political priority for global initiatives.Representatives of different rehabilitation stakeholder groups need to come together and discuss their contributions in making rehabilitation a political party. Global political priority depends on: [12]

Actor Power[edit | edit source]

Policy communities are the network of individuals or organizations’ that operate at global levels and are linked by central concern for issues.[13] For example, prominent NGO leaders, government officials, UN Agency members. Policy communities help to bring the attention of political leaders in order to solve problems. The emergence of respected leaders embraced by the community facilitates coalescence and gives direction to the initiative. It is important to have strong guiding institutions - organizations or coordinating mechanisms with a mandate to lead the initiative. Initiatives are more likely to gather political support if they are linked to grassroot organization in civil society for pushing global attention to issues rather than remaining confined to select members of global policy.[13] Strong stakeholder cohesion and leadership within rehabilitation are critical. It involves different professions and sub-specialties, and as a result rehabilitation governance is considerably disintegrated. To strengthen the rehabilitation sector as a whole, it is important to embrace our diversity, create a culture of cohesion and create a common rehabilitation identity.[12]

Ideas[edit | edit source]

Ideas shape political support for initiatives. It is the way in which actors understand and portray the issue and depends on the degree to which the policy community agrees on the definition of, causes of, and solutions to the problem and the public portrayals of the issue in ways that resonate with external audiences, especially the political leaders who control resources.[13] Ideas Rehabilitation requires a cohesive unified narrative, both within the rehabilitation community and with external partners. Despite the profession, setting or sub-specialty,  all rehabilitation stakeholders have a common goal – to optimise functioning.[12]

Political Contexts[edit | edit source]

Political context is the environments in which actors operate. Political moments are when global conditions align favorably for an issue, presenting opportunities for advocates to influence decision-makers. The global rehabilitation community needs to seek political windows, identifying enablers in the system of which advantage can be taken. Rehabilitation is already an integral part of  Universal Health Coverage and thus the broader Sustainable Development Goal 3, and is key to ensuring healthy lives and well-being for all at all ages. Rehabilitation is therefore well-positioned within the broader health and development agenda, and this political window needs to be leveraged. [12][13]

Topic Characteristics[edit | edit source]

It refers to the features of rehabilitation, and its relevance in the global health context. To raise awareness and advocate for the importance of rehabilitation, the rehabilitation field as a whole requires a strong evidence base. This involves relevant and credible rehabilitation indicators, data on functioning, integration of rehabilitation in the broader health information system, evidence on effective rehabilitation interventions, and a strong economic case for investment.[12]

Current Health Priorities[edit | edit source]

The Health 2020 policy is based on four priority areas for policy action:[14]

  • investing in health through a life-course approach and empowering people;
  • tackling the Region’s major health challenges of non-communicable and communicable diseases;
  • strengthening people-centered health systems, public health capacity and emergency preparedness, surveillance and response; and
  • creating resilient communities and supportive environments.

Health 2020 recognizes that successful governments can achieve real improvements in health if they work across government to fulfill two linked strategic objectives:

  1. improving health for all and reducing health inequalities,
  2. improving leadership and participatory governance for health [9]

However the global rehabilitation needs continue to be unmet due to multiple factors, including:[5]

  • Lack of prioritization, funding, policies and plans for rehabilitation at a national level.
  • Lack of available rehabilitation services outside urban areas, and long waiting times.
  • High out-of-pocket expenses and non-existent or inadequate means of funding.
  • Lack of trained rehabilitation professionals, with less than 10 skilled practitioners per 1 million population in many low- and middle-income settings.
  • Lack of resources, including assistive technology, equipment and consumables.
  • The need for more research and data on rehabilitation.
  • Ineffective and under-utilized referral pathways to rehabilitation.

There is an increasing need for rehabilitation worldwide; more than half of people living in some low and middle-income countries requiring rehabilitation services do not have access to it. The COVID-19 pandemic has led to a new increase in rehabilitation needs as well as causing severe disruption to existing rehabilitation services in 60-70% of countries worldwide.[5]

Rehabilitation Policies and Plans[edit | edit source]

WHO Global Disability Action Plan 2014–2021.& Sustainable Development Goals (SDG) - 3[edit | edit source]

Rehabilitation is a key objective in the WHO Global Disability Action Plan 2014 - 2021. Rehabilitation services are necessary for the achievement of Sustainable Development Goals (SDG) 3 - Ensure healthy lives and promote well-being for all at all ages.

[IMAGE:https://en.wikipedia.org/wiki/Sustainable_Development_Goals_and_Nigeria#/media/File:Sustainable_Development_Goals.svg]

Rehabilitation 2030[edit | edit source]

Rehabilitation 2030 [15] is a call for action to scale up rehabilitation so that countries can be prepared to address the evolving needs of populations up to 2030 was launched in February 2017.[16] The initiative draws attention to the profound unmet need for rehabilitation worldwide and highlights the importance of strengthening health systems to provide rehabilitation. According to WHO’s definition, rehabilitation is one of the quality health services that should be included in Universal Health Coverage so all individuals would be able to access quality rehabilitation services without fear of financial hardship. It focuses on coordinated action from all stakeholders to improve rehabilitation leadership, political support, and investment; integrate rehabilitation within health systems and emergency preparedness; expand high-quality rehabilitation workforces and services; build stronger partnerships, and improve rehabilitation data collection and research capacity. Since the initial call, WHO has supported approximately 20 countries to strengthen health systems to better provide rehabilitation services. Following are the recommendation for strengthening in Rehabilitation in Health System: [17]

To integrate rehabilitation into the health system:[edit | edit source]

  • Effectively integration of rehabilitation needs clear designation and strong governance. In most situations, the ministry of health will be the most appropriate agency for governing rehabilitation, with strong links to other relevant sectors, such as social welfare, education, and labor.

To integrate rehabilitation services into and between primary, secondary, and tertiary levels of health systems[edit | edit source]

  • For the identification of needs and an effective continuum of care throughout a person’s recovery, rehabilitation is required at all levels. Standardized referral pathways and other coordination mechanisms between levels help to ensure a good transition of care for optimal outcomes.

To ensure hospitals include specialised rehabilitation units for inpatients with complex needs[edit | edit source]

  • Specialized rehabilitation wards can provide intensive, highly specialised interventions for restoring functioning to patients with complex rehabilitation needs - in cases with lower-limb amputation, spinal cord injury, stroke, and in the care of older people. The establishment or extension of specialised rehabilitation units should be based on the context of the health system, specifically the availability of rehabilitation workforce and funding.

To ensure both community and hospital rehabilitation services are available[edit | edit source]

  • Rehabilitation in both hospital and community settings is necessary to ensure timely intervention and access to services. Rehabilitation in hospital settings enables early intervention speeding the recovery, optimizing the outcomes, and facilitating smooth, timely discharge. Many people require rehabilitation well beyond discharge from the hospital, while other users may require services solely in the community. People with developmental, sensory, or cognitive impairment may benefit from long-term interventions that are often best delivered at home, school, or in the workplace

To ensure the availability of a multi-disciplinary rehabilitation workforce[edit | edit source]

  • A multi-disciplinary workforce would ensure that the rehabilitation needs within the population can be met. These interventions are effective in the management of many chronic, complex, or severe conditions that may significantly impact multiple domains of functioning (vision, communication, mobility, and cognition). As rehabilitation disciplines need distinct skills, a multidisciplinary workforce can significantly improve the quality of care and improve health outcomes. Long-term investment in the education, development, and retention of a multidisciplinary rehabilitation workforce should thus be factored in health sector planning and budgets.

To ensure financial resources are allocated to rehabilitation services[edit | edit source]

  • The service delivery gets significantly influenced by the way health systems allocate financial resources so there is a need to allocate specific budgets for rehabilitation services. Allocation of resources for rehabilitation can increase both the availability and the quality of rehabilitation services and minimize out-of-pocket expenses, which is a significant barrier to service utilization.

To ensure rehabilitation services to be covered under health insurance[edit | edit source]

  • Access to rehabilitation services increases, when health insurance includes rehabilitation. Because health insurance protects only a minority of the population in many parts of the world, this mechanism of financial protection should be part of broader initiatives to improve the affordability of rehabilitation services.

To implement financing and procurement policies that ensure assistive products are available to everyone who needs them[edit | edit source]

  • Assistive products, such as mobility devices, hearing aids, and white canes, play an important role in improving functioning and increasing independence and participation.

The study shows that there are many barriers to both accessing and providing amputee rehabilitation services in the Western Area, Sierra Leone, and recommends a revised effort by the government to implement the progressive policies on disability which will aid the improvement of amputee rehabilitation services. Increased funding and local training programmes are needed to improve service delivery.[18]

Second Global Rehabilitation 2030[edit | edit source]

Two years after the launch of Rehabilitation 2030, the Second Global Rehabilitation 2030, held in July 2019, at WHO headquarters in Geneva to take stock of progress and collectively plan the next steps to continue advancing the global rehabilitation agenda.[12] Over 260 rehabilitation stakeholders from 65 countries, including the Member States, United Nations agencies, civil society, professional organizations, academia, rehabilitation experts, and user groups attended the event and shared personal stories and functioning data.

The objectives of the meeting are to: [12]

  1. review actions undertaken to date by WHO, its partners and Member States for the Rehabilitation 2030 initiative,
  2. agree on concrete actions for rehabilitation in countries to advance the implementation of the WHO’s Thirteenth General Programme of Work 2019 - 2023, and
  3. identify enablers and barriers for moving the global rehabilitation agenda forward.

The meeting emphasized: [12]

  • the importance of ‘functioning’ as WHO’s third health indicator alongside mortality and morbidity, highlighting the central role that rehabilitation plays in optimising functioning.
  • acknowledged the need for strengthening health systems in general and primary health care, in particular, to reach all people in need. Efforts should be directed towards strengthening the health system as a whole.
  • integrating rehabilitation into universal health coverage for rehabilitation to reach its full potential as it recognized universal health coverage as the vehicle for making sure that everyone who needs rehabilitation gets quality services to optimize and maintain their functioning in everyday life.
  • advancing health financing mechanisms and packages of care, health workforce capacity, and health information systems in countries
  • accelerating action at country level by Key WHO resources
  • the launch of the Rehabilitation in health systems: guide for action – a tool that supports countries to identify priorities and develop a strategic plan to increase quality, accessible and effective rehabilitation services. It has a four-phase process: assessment of the situation, developing rehabilitation and strategic plan, establishing rehabilitation monitoring and review process, and implementation of rehabilitation plan.
  • Showcased progress to date, using examples from Solomon Islands, Lao People’s Democratic Republic, Pakistan, Tajikistan, Spain, Eswatini, the Philippines, Russian Federation, Malaysia, Malta and Myanmar.

Conclusion[edit | edit source]

To increase rehabilitation services globally, rehabilitation community must focus on: [12] Consistent collection of information on functioning  so that health policies can be planned. Researchers, journal editors and experts from WHO Collaborating Centres need to promote data collection on functioning and move towards research in health systems.

Political commitment and investment in rehabilitation and rehabilitation stakeholders play a role in advancing the rehabilitation agenda. The responsibility is now on Member States and key rehabilitation stakeholders to ensure that rehabilitation is firmly positioned within the main health agenda and becomes a priority in their respective countries and regions. The Rehabilitation 2030 agenda has paved the way for this process.

Strengthening of Health systems  and integration of rehabilitation at all service levels is critical, particularly at the primary care level.

Rehabilitation professionals to strengthen their collaboration and join efforts for rehabilitation as a unified professional field. Organizations delivering services and organizations of specific medical specialties need to promote health system strengthening for rehabilitation.

Resources[edit | edit source]

Rehab 2030[edit | edit source]

  1. WHO Rehabilitation 2030
  2. WHO Rehabilitation in Health Systems Guide for Action
  3. Negrini S. The possibilities and challenges of "Rehabilitation 2030: a call for action" by the World Health Organization: a unique opportunity not to be missed. European Journal of Physical and Rehabilitation Medicine. 2017;53(2):169-72.

Other[edit | edit source]

  1. Cieza A. Rehabilitation the health strategy of the 21st century, really?. Archives of physical medicine and rehabilitation. 2019 Nov 1;100(11):2212-4.
  2. Heinemann AW, Feuerstein M, Frontera WR, Gard SA, Kaminsky LA, Negrini S, Richards LG, Vallée C. Rehabilitation is a global health priority.
  3. McVeigh J, MacLachlan M, Gilmore B, McClean C, Eide AH, Mannan H, Geiser P, Duttine A, Mji G, McAuliffe E, Sprunt B. Promoting good policy for leadership and governance of health related rehabilitation: a realist synthesis. Globalization and Health. 2016 Dec 1;12(1):49.
  4. Implementation of Clinical Governance in Rehabilitation Medicine
  5. Gilson L, Agyepong IA. Strengthening health system leadership for better governance: what does it take?.
  6. Bamford‐Wade AN, Moss C. Transformational leadership and shared governance: an action study. Journal of nursing management. 2010 Oct;18(7):815-21.
  7. Kirigia JM, Kirigia DG. The essence of governance in health development. International Archives of Medicine. 2011 Dec 1;4(1):11.

References[edit | edit source]

  1. 1.0 1.1 Cieza A. Rehabilitation the health strategy of the 21st century, really?. Archives of physical medicine and rehabilitation. 2019 Nov 1;100(11):2212-4.
  2. 2.0 2.1 2.2 Mills JA, Marks E, Reynolds T, Cieza A. Rehabilitation: essential along the continuum of care
  3. MacIntosh E, Rajakulendran N, Khayat Z, Wise A. Transforming health: Shifting from reactive to proactive and predictive care. Toronto: MaRS Discovery District. Accessed: Jul. 15, 2018.
  4. Roser M, Ortiz-Ospina E, Ritchie H. Life expectancy. Our World in Data. 2013 May 23.
  5. 5.0 5.1 5.2 5.3 World Health Organisation. Rehabilitation. Available from: https://www.who.int/news-room/fact-sheets/detail/rehabilitation (accessed on 12 Jan 2021)
  6. 6.0 6.1 World Health Organisation. Noncommunicable Diseases. Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases (accessed 21 Jan 2021)
  7. Patrick Smith A Vicious Circle: Poverty and Noncommunicable Diseases
  8. 8.0 8.1 McVeigh J, MacLachlan M, Gilmore B, McClean C, Eide AH, Mannan H, Geiser P, Duttine A, Mji G, McAuliffe E, Sprunt B. Promoting good policy for leadership and governance of health related rehabilitation: a realist synthesis. Globalization and Health. 2016 Dec;12(1):1-8.
  9. 9.0 9.1 9.2 9.3 EVERYBODY’S BUSINESS  Strengthening Health systems to improve Health Outcomes WHO’s Frame Work for Action
  10. Rauch A, Negrini S, Cieza A. Toward strengthening rehabilitation in health systems: methods used to develop a WHO package of rehabilitation interventions. Archives of physical medicine and rehabilitation. 2019 Nov 1;100(11):2205-11.
  11. 11.0 11.1 11.2 Mikkelsen-Lopez I, Wyss K, de Savigny D. An approach to addressing governance from a health system framework perspective. BMC international health and human rights. 2011 Dec;11(1):1-1.
  12. 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 World Health Organisation. Rehabilitation 2030 Meeting Report 8 - 9 July 2019. Available from: https://www.who.int/docs/default-source/documents/health-topics/rehabilitation/2nd-rehab2030-meeting/rehab2030-2ndmeeting-report.pdf?sfvrsn=bc6402fb_5 (accessed 2 Feb 2021).
  13. 13.0 13.1 13.2 13.3 Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. The lancet. 2007 Oct 13;370(9595):1370-9.
  14. Health 2020: a European policy framework supporting action across government and society for health and well-being. Copenhagen: World Health Organization Regional Officie for Europe. 2012 Sep
  15. World Health Organisation. Rehabilitation 2030 Initiative. Available from: https://www.who.int/initiatives/rehabilitation-2030 (accessed 2 Feb 2021).
  16. World Health Organisation. Rehabilitation 2030 A Call for Action Meeting Report Feb 6 - 7 2017. Available from: https://www.who.int/disabilities/care/Rehab2030MeetingReport2.pdf?ua=1 (accessed 2 Feb 2021).
  17. World Health Organisation. Rehabilitation in Health Systems Booklet. Available from:https://www.who.int/disabilities/brochure_EN_2.pdf?ua=1 (accessed 2 Jan 2021).
  18. Allen AP, Bolton WS, Jalloh MB, Halpin SJ, Jayne DG, Scott JD. Barriers to accessing and providing rehabilitation after a lower limb amputation in Sierra Leone–a multidisciplinary patient and service provider perspective. Disability and Rehabilitation. 2020 Nov 11:1-8.