By Gerald Okello and Zehra Zaidi for ReLAB-HS
Uganda is experiencing an urgent need for rehabilitation services inclusive of assistive technology (AT). It is estimated that one-sixth (6.8 million)[1] of the country’s population experiences a health condition that could benefit from rehabilitation. However, the majority of the population’s rehabilitation needs remain unmet.
In Uganda, the absence of or unequal geographical distribution of services, lack of transportation, and unaffordability of rehabilitation and AT services exacerbate the unmet need. For example, rehabilitation services are largely limited at secondary and tertiary health care facilities (national and regional referral hospitals, private hospitals) located in urban settings, complicating access for many.
In response to the growing unmet needs for rehabilitation and AT, Learning, Acting, and Building for Rehabilitation in Health Systems (ReLAB-HS) is strengthening rehabilitation services in the health system by supporting the Ministry of Health to improve service access. With a focus on integrating rehabilitation and AT services at the primary care level, ReLAB-HS is testing innovative interventions in collaboration with the World Health Organization (WHO) and the Ministry of Health at regional and district levels.
Using the WHO’s Basic Rehabilitation Package Clinical Resource (BRP-CR), ReLAB-HS trained 60 primary health care (PHC) providers (medical doctors, clinical officers, and nurses) and 17 rehabilitation professionals (physiotherapists, occupational therapists, and orthopedic officers), who were trained as mentors. The BRP-CR is designed to develop the capacity of PHC providers to assess, manage, and monitor basic rehabilitation needs at the primary care level and to strengthen the coordination of care across different levels of the health system. Comprised of tools to support screening, assessment, follow-up, and referral of patients accessing rehabilitation services, the BRP-CR guides PHC providers and supports the delivery of quality services.
To improve efficiency and facilitate the collection of accurate and real-time data on patients accessing rehabilitation and AT services at the PHC level, ReLAB-HS digitized the paper-based BRP-CR by developing a mobile application (“app”), RehabConnect. ReLAB-HS built the app using CommCare, an open-source platform that supports case management of patients and streamlines data collection in low-resource settings.
In December 2023, ReLAB-HS trained a first cohort of PHC providers to use RehabConnect to screen patients for rehabilitation needs, conduct rehabilitation assessments, set rehabilitation goals, follow up with patients, refer them to rehabilitation professionals, and discharge them. In tandem, ReLAB-HS trained rehabilitation professionals to use RehabConnect to access the patients referred to their facilities, treat and follow up with them, and discharge them to lower-level facilities for follow-up. Upon completion of the training, the trained PHC providers and rehabilitation professionals were equipped with tablets and internet modems to support the utilization of the digital platform for the provision of quality rehabilitation and AT services.
The PHC providers observed many improvements with the introduction of RehabConnect. One provider welcomed the digitization of the BRP-CR as a time-saving measure that will improve care. “The system makes the assessment easy, thus reducing the assessment time, which has been a major challenge with paper-based assessment. We see so many patients and the system is going to help in easing the assessment,” said the provider.
Similarly, the automation of the app gave providers confidence that their ability to provide quality care would be supported. “The system is automatic. If you miss a domain in the assessment, the system will remind you. Also when there is a red flag, the system will automatically refer the patient,” one provider shared.
Another provider saw the potential to improve case management. “I was worried about continuity, however, with this system the data is synchronized, such that when the patient comes back for follow-up and I am not on duty, my colleague will be able login and access the data and follow-up [with] the patients, hence enabling treatment continuity.”
The app not only equips health care workers with essential tools but also acts as a guide, helping identify cases that require referral to higher-level facilities. Once a referral is made, the app ensures a streamlined process, directing patients to the appropriate secondary or tertiary care facility. Moreover, tertiary care facilities can discharge patients directly through the app, or, when suitable, refer them back to the primary care facility for basic rehabilitation.
Importantly, RehabConnect works offline, “so lack of internet cannot stop me from assessing the patient,” shared one of the rehabilitation professionals.
On a broader level, providers using the app has important implications for data management. Using the tablets will organize data and ensure that it is secure. Additionally, the systematic collection of data by facilities will inform decision-makers at the district level about the use of rehabilitation and AT services, capturing the need and promoting continued efforts to strengthen services.
The emerging impact of the app is evident in the reduction of the average distance traveled by patients to access rehabilitation services, both in terms of distance in kilometers and out-of-pocket expenses. Patients who previously faced significant obstacles in accessing rehabilitation care can now receive the necessary support within their community.
[1] “Uganda key findings, 2019,” WHO Rehabilitation Need Estimator, Institute for Health and Metrics Evaluation, available from http://ihmeuw.org/62×9