By Valentina Pomatto for ReLAB-HS
By Valentina Pomatto for ReLAB-HS
*This post is part of a two-part article illustrating the importance of including rehabilitation and assistive technology services as part of Universal Health Coverage. (Part 1 – Rehabilitation in Universal Health Coverage: The need for assistive technology)
One year ago, the United Nations (UN) High-Level Meeting on Universal Health Coverage (UHC) adopted a new Political Declaration. This Political Declaration reaffirms that rehabilitation and assistive technology (AT) are essential components of UHC and emphasizes the role of primary health care in expanding coverage, improving access, and achieving health for all.
Another pivotal international instrument adopted in 2023, the World Health Assembly’s Resolution on Strengthening Rehabilitation in Health Systems, calls on World Health Organization (WHO) Member States to establish appropriate financing mechanisms for rehabilitation services and the provision of AT, including integrating them into essential care
packages.
However, the path to integrating rehabilitation into UHC efforts is not easy. Often, rehabilitation is still perceived as a luxury service rather than an essential component of the continuum of care. Despite limited resources and competing health priorities, rehabilitation is a smart investment in population health and well-being, social inclusion, and economic outcomes. It prepares health systems to respond to changing population health needs that accompany increased life expectancy, such as chronic conditions, health issues related to aging, and injuries.
Learning, Acting, and Building for Rehabilitation in Health Systems (ReLAB-HS) is committed to strengthening rehabilitation and AT services within health systems to support equitable access to quality services. To shed light on this critical need, we asked two people with different backgrounds from Uganda and Pakistan (where ReLAB-HS is currently being implemented) to share their perspectives on the coverage, availability, access, and quality of rehabilitation and AT services.
Dr. Nisar Uddin, rehabilitation professional in Pakistan
Dr. Nisar Uddin is a qualified physiatrist and the Head of the Department of Physical Medicine and Rehabilitation at the Swat Medical College in Pakistan. He also serves as a mentor to the primary health care providers in the facilities in Swat where ReLAB-HS is implementing interventions. He shares his unique perspective as a clinician on the gaps that need to be bridged for the rehabilitation professions in his country.
Have you witnessed development in the rehabilitation professions, in your country, in the past years?
Provincial health workforce strategic plans are being developed, but progress towards adoption and implementation is very slow and results are not (yet) visible. Trained rehabilitation professionals, such as physiotherapists, occupational therapists, speech therapists, orthotists, prosthetists, and physiatrists are not present at all levels of the health system, particularly in primary care facilities.
What are the main challenges for the development of rehabilitation professions in your country?
There is a lack of public awareness of the importance of rehabilitation, which affects the demand for and subsequent availability of professionals in this field.
Pakistan has few rehabilitation institutions that offer specialized training in rehabilitation professions. Curricula need to be up-to-date and meet international standards, which is essential to ensure a well-qualified rehabilitation workforce.
Limited funding for rehabilitation results in limited positions for health professionals in the public health system and difficulties in retention. Many professionals are not motivated to remain in [their] post due to unattractive salary conditions, inadequate facilities and equipment, and lack of clear pathways for career advancement.
In your experience, what are the main barriers that users face in accessing and maintaining rehabilitation?
In my experience as a clinician in the Malakand Division (Khyber Pakhtunkhwa province), I have found that users face logistical, financial, cultural, and systemic barriers.
Rehabilitation services can be expensive, and many users in the Malakand Division do not have the financial means to afford them. This includes the cost of therapy sessions, assistive devices, and transportation to and from rehabilitation centers.
The Malakand Division is a mountainous region, and many areas are remote and difficult to reach. Limited transport infrastructure can make it difficult for users to travel to the few rehabilitation centers that exist in the region.
There is often a social stigma associated with disability and rehabilitation, leading to a reluctance to seek help. Gender norms restrict women’s access to rehabilitation services: women may not be allowed to travel alone or may require male accompaniment, which adds another layer of difficulty.
Finally, general health care providers are often not well informed about rehabilitation options or may not refer patients appropriately.
It is crucial to recognize rehabilitation and AT professions as essential to the continuum of care. Increasing the investment in rehabilitation education and training is needed to grow the workforce and improve the distribution of qualified health workers throughout different levels of the health system, improving the availability of and access to quality services.
In collaboration with key stakeholders in Pakistan, ReLAB-HS identified opportunities to develop and expand the rehabilitation workforce. At the national level, ReLAB-HS is supporting professional associations and training institutions to use the International Rehabilitation and Education Training Toolkit (IRETT) to align professional regulation, academic and training programs, and continuing professional development (CPD) with international standards. As part of this, ReLAB-HS has developed and delivered interprofessional clinical skills training programs to rehabilitation professionals in the Sindh and Khyber Pakhtunkhwa provinces to enhance their ability to manage complex cases and integrate services within their communities. To sustain opportunities for clinical skills development and CPD for rehabilitation professionals, ReLAB-HS is developing a training-of-trainers program to establish a pool of qualified instructors capable of teaching clinical skills to other rehabilitation professionals and mentoring them to become future trainers.
At the district level, ReLAB-HS is engaging existing health workers to expand the reach and increase the availability of rehabilitation and AT services. ReLAB-HS has strengthened the capacity of Lady Health Workers (Pakistan’s community health workers) to identify individuals with rehabilitation and AT needs and refer them to appropriate services, bridging the gap between the community and essential health care. In tandem, to meet the increased demand for services, ReLAB-HS has leveraged WHO resources to expand the rehabilitation workforce at the primary care level by training primary care providers at district-level health facilities to provide basic rehabilitation and AT services. ReLAB-HS has also engaged rehabilitation professionals from higher-level facilities to mentor these primary care providers, prioritizing quality, coordination of care, and sustainability. These interventions have supported the integration of rehabilitation and AT services at the primary care level, improving the availability of and access to quality services.