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By Gilliane McShane for ReLAB-HS

Despite the growing need, rehabilitation and assistive technology (AT) services continue to be under-prioritized, and services in low- and middle-income countries are hampered by persistent challenges, speakers at a Learning, Acting, and Building for Rehabilitation in Health Systems (ReLAB-HS) webinar told attendees.

Challenges include a shortage of a trained workforce, accessibility barriers (physical, economic, social), and poor quality of services and products. These problems are exacerbated when situated in contexts of instability and/or conflict, where needs increase and put additional burden on the system which is overwhelmed, damaged, destroyed, or significantly under-staffed. As such, the provision of rehabilitation and AT services requires reliable leadership and resilient health systems.

On September 26, ReLAB-HS hosted the webinar, “Leadership for Rehabilitation: Addressing the Needs in Fragile and Conflict-affected Settings,” in which speakers shared personal experiences of using rehabilitation and AT services, called for more effective leadership, and highlighted the World Health Organization’s (WHO) newly formed World Rehabilitation Alliance.

Persistent challenges

Alex Munyambabazi, founder of Amputee Self Help Network in Uganda, shared his experience navigating the Ugandan health system as a user of rehabilitation and AT services. He described services as being largely provided by private facilities in city centers, making it difficult for people to access due to the logistical challenges of physically getting there and the added burden of transportation costs. Another financial barrier is the high cost of assistive technology devices, making them unaffordable to many. Consequently, people who greatly need rehabilitation services forego getting them.

Munyambabazi emphasized, “We need to plan to ensure … people get affordable and quality services.”

In Burma, availability of rehabilitation and AT services was already a significant challenge, but due to the change in government, Myat Thu Winn, founder of the Shwe Minn Tha Foundation, explained that the country has experienced a large reduction in its workforce. General health care services are hard to access due to limited availability and high costs, and this is felt even more for rehabilitation and AT services. Access to and availability of AT is especially challenging; the stock of devices in Burma is very low, and importing devices is quite difficult and costly. Nongovernmental organizations are filling the gap where possible—services are largely delivered through the informal health system, operationalized through organizations for persons with disabilities and community-based organizations—however, gaps remain.

In Ukraine, strides to address challenges around rehabilitation and AT services have been hampered by the war with Russia. ReLAB-HS Ukraine Country Coordinator Sergii Khomchenko’s overview of the situation in Ukraine emphasized the challenges faced by an already fragile health system in responding to rapidly increasing needs for rehabilitation and AT services. He shared that since the start of the conflict in February, modest estimates by the United Nations Office for the Coordination of Humanitarian Affairs show that 8,000 people have been injured, and WHO statistics estimate that 14.5 million people need some type of health assistance.

“Over a quarter of the people living in villages in Ukraine don’t have access to operational medical facilities,” Khomchenko said.

The need to respond is further complicated by direct attacks on Ukraine’s health system and infrastructure (workforce, facilities, transport vehicles, supplies), exacerbating obstacles to the provision of care; displacement of the rehabilitation workforce, while those that remain are not trained to treat war-related injuries; and a lack of adequate AT services due to an ongoing shortage of devices. These conditions severely limit early rehabilitation interventions in affected areas where they are greatly needed, he said.

Rehabilitation demands responsive and adaptive leadership

“Rehabilitation needs leadership today,” said Chiara Retis, Global Coordinator for Humanity & Inclusion with ReLAB-HS.

Retis conveyed that the poor provision of rehabilitation and AT services demands urgent and effective leadership. Within health systems, she characterized leadership as the ability to identify priorities and provide technical guidance for policy development. As an extension of that, effective leadership relies on the ability to provide strategic direction to multiple actors and to inspire their commitment and action to address priorities. These qualities of leadership are bolstered by mechanisms of governance that track performance of services and promote accountability.

Retis highlighted the ReLAB-HS Global Rehabilitation Leadership Institute as a sound method to inspire “a new generation of rehabilitation leaders,” as it will develop leadership skills among a diverse group of stakeholders, intending to strengthen health systems at all levels.

Leadership in health systems was further discussed by Professor Cyrus Engineer of the Johns Hopkins Bloomberg School of Public Health, who explained that in fragile and conflict-affected settings, effective leadership builds resiliency—the ability to withstand shocks—in health systems. He elaborated that this is achieved when leaders embrace systems thinking (that is, examining both the parts of a system and how they interrelate, as well as the system as a whole) and adopt an intersectoral approach to problem-solving. In conflict-affected settings, good leadership requires a thorough understanding of the nature of the conflict and relies on the ability to be adaptive and agile, adept at change management, while maintaining a vision and motivating others to work towards it.

Strengthening leadership for rehabilitation through collaborative governance

ReLAB-HS is committed to nurturing and reinforcing leadership in health systems and facilitating advocacy through collaborative governance—the practice of cross-sector collaboration. This concept upholds the belief that leadership is demonstrated by actors in various sectors from the grassroots level up to the decision-making level.

In her remarks, Retis explained that “leadership is stimulated and held accountable when formal and informal networks of rehabilitation stakeholders exist.” In conflict-affected settings, operating at the intersection of development, humanitarian, and peace-keeping efforts requires collaboration and cooperation between different sectors, and successful interventions rely on the inclusion of affected communities.

This approach to oversight and support for rehabilitation in health systems is embedded in the WHO’s World Rehabilitation Alliance (WRA), an advocacy network of rehabilitation organizations committed to the implementation of the Rehabilitation 2030 agenda. Peter Skelton, Rehabilitation in Emergencies focal point for the WHO, addressed the surging rehabilitation needs in emergency settings, highlighting that the WRA’s advocacy efforts are focused on strengthening weak health systems. By raising awareness among leaders, advocating for the inclusion of rehabilitation in early response, and encouraging intersectoral collaboration, the WRA seeks to strengthen leadership and the integration of rehabilitation in health systems.

Providing care, offering hope

ReLAB-HS is committed to continued collective advocacy for integration of rehabilitation and AT services into health systems, while supporting leaders in the field who share the goal of ensuring accessibility and improving quality of care, even in the most challenging settings.

In reflecting on his own experience, Munyambabazi encouraged webinar attendees to view rehabilitation as a restorative form of health care, stating, “I have learned that you should look at rehabilitation…as something bringing back someone to life.”

ReLAB-HS is made possible by the generous support of the American people through the United States Agency for International Development.