A meeting between stakeholders

By Katherine Dobson and Sarah Magoba for ReLAB-HS

There is a widening gap between available rehabilitation services and the needs of the global population, at least 2.4 billion of whom experience a condition that could benefit from rehabilitation.  In Uganda, where we are collaborating on the USAID-funded Learning, Acting, and Building for Rehabilitation in Health Systems (ReLAB-HS) activity, a recent Systematic Assessment of Rehabilitation Situation (STARS) assessed rehabilitation in Uganda’s health system and identified both current strengths, and what needs to be prioritized.

Clearly, closing the gap between needs and current services is a hugely complex and urgent challenge. Emerging normative frameworks and tools increasingly set broad targets for what rehabilitation and assistive technology (AT) services should look like, provide a means to critically assess current performance, and develop comprehensive plans to respond.

But the scarcity of rehabilitation and AT services is not the only challenge. Our emphasis on integration recognizes that rehabilitation and AT are often present in health systems, but poorly coordinated with—and connected to—other health services, which accounts for much of the enormous unmet need for rehabilitation and AT.

While the agenda is increasingly clear, and commitment from national governments is growing stronger, examples of local implementation of programs that turn national strategies into local realities are scarce. A major focus of our work is generating practical, scalable methods to integrate rehabilitation and AT in local health systems.

What did we do?

In March, we worked with 50 rehabilitation and health system stakeholders from Northern and Eastern Uganda for three days to consider and discuss a series of integration goals and establish priorities for action.

We have developed a practical and adaptable tool that national and sub-national actors can use to assess the extent to which rehabilitation services are integrated with health systems and to track how performance changes over time.

The structure of our tool built on the work of ReLAB-HS partner, Humanity & Inclusions (HI), on measuring and actioning improvements in service delivery quality. Using a goal-based, structured reflection process can help reveal and support understanding around challenging conditions in which professionals are working and use local expertise and knowledge about the most effective and feasible responses.

The content of our tool builds on both:

  • Existing measurement frameworks and data collection methods focused on rehabilitation in health systems, including the World Health Organization’s Systematic Assessment of Rehabilitation Situation and accompanying Template for Rehabilitation Information Collection, and Rehabilitation Indicator Menu; and
  • ReLAB-HS’s integration consensus workshops and two forthcoming scoping reviews: Neill, Zia, and colleagues’ work exploring the approaches used to date to measure integration across sectors in low- and middle- income countries and Waterworth, Marella, Smith, and colleagues’ review identifying examples of how rehabilitation services are integrated in and between primary, secondary, and tertiary levels of health care.

We used this integration tool in a workshop with 50 rehabilitation and health system stakeholders from the Ugandan districts of Gulu, Lira, Iganga, and Mayuge, including health personnel from all levels, consumer representatives, and senior management.

To understand current performance of rehabilitation and AT service provision, stakeholders from the four districts reviewed 55 integration goals and 35 quality goals. Priority goals were developed through an adapted nominal group technique.

What do stakeholders have now?

After three days of discussion and deliberations—as well as all the work to build relationships, establish buy-in, and understand needs prior to that—stakeholders agreed on 21 priority goals for integrating rehabilitation and AT in the Ugandan health system and improving quality of rehabilitation and AT.

What next?

In Uganda, ReLAB-HS has convened and supported technical committees in Gulu, Lira, Iganga, and Mayuge to implement practical measures to improve performance on priority goals. Each quarter, stakeholders will reflect on what they have done so far to progress each goal (and with what outcomes) and plan what actions come next.

In Pakistan, we’ve built on experiences in Uganda and used the integration module to assess rehabilitation and AT in the districts of Swat and Thatta.

ReLAB-HS will continue to refine how this approach and tool can be used to implement national plans, focus efforts, and demonstrate progress and impact.