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Rehabilitation in health systems. Geneva: World Health Organization; 2017.

Cover of Rehabilitation in health systems

Rehabilitation in health systems.

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3Recommendations and good practice statements

These recommendations describe the foundations for strengthening rehabilitation in health systems. They are based on the rigorous prescribed system of evidence collection, review and assessment described above and in Annex 1, which underpinned the decisions of the researchers and the Guidelines Development Group about the direction, strength and quality of the evidence for each recommendation. The good practice statements did not undergo this process, as the Group had sufficient confidence in their benefits that the process of evidence collection and appraisal would have been unproductive and a poor use of resources. Their confidence stemmed from the underlying value of ensuring equitable service delivery and the availability of assistive products, as expressed in the Sustainable Development Goals, specifically target 3.8, and objective 2 of the WHO global disability action plan 2014–2021; and the large body of indirect evidence for the net benefit of the course of action stated (19,30).

Each recommendation, which is based on the best available evidence, was prescribed a strength (how unequivocally it can be suggested that the recommendation be implemented) and assessment of the quality of the evidence. The strength of the recommendation and the assessment of the quality of the evidence are not necessarily correlated.

3.1. Strength of recommendations and quality of evidence

The strength of the recommendations and the ratings of the quality of evidence were determined according to processes defined by the WHO Guidelines Review Committee (5). This process is designed to ensure transparent, systematic, evidence-based decision-making; importantly, it allows the strength of a recommendation to be based on factors beyond the quality of the available evidence. It is critical that users of this document not assume that a recommendation based on low- or very low-quality evidence is weaker or less important than those based on moderate- or high-quality evidence. Use of evidence identified in the systematic literature reviews to determine the quality of the evidence for each recommendation is further explained below.

3.1.1. Determining the strength of a recommendation

The strength of a recommendation was decided by the Guideline Development Group after consideration of the balance of benefits versus harm and burden, the degree of variation in the values and preferences of different stakeholders, resource implications and the quality of the evidence. On the basis of these factors, the recommendation were deemed strong or conditional (5, p. 129).

Strong: The desirable effects of adherence to the recommendation outweigh the undesirable effects. Thus, in most situations, the recommendation can be adopted as policy.

Conditional: There is uncertainty about the factors listed above, OR local adaptation should account for greater variation in values and preferences, OR resource requirements make the intervention suitable for some but not for other locations. Therefore, substantial debate and involvement of stakeholders will be required before this recommendation can be adopted as policy.

3.1.2. Assessing the certainty of the evidence

In the WHO guideline development process, the GRADE approach is used to assess the certainty of evidence identified in systematic literature reviews. This approach is based primarily on the level of certainty of the estimated effects of the intervention (5, p. 113). The ratings are:

High: The Guideline Development Group is very confident that the true effect lies close to the estimated effect. Further research is unlikely to change the confidence in the estimated effect.

Moderate: The Guideline Development Group is moderately confident in the effect estimate. The true effect is likely to be close to the estimate, but there is a possibility that it is substantially different. Further research is likely to have an important impact on the confidence in the estimate of effect and may change the estimate.

Low: Confidence in the effect estimate is limited. The true effect may be substantially different from the estimated true effect. Further research is very likely to have an important impact on the confidence in the estimate of effect and is likely to change the estimate.

Very low: The Group has very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimated effect. Any estimate of effect is highly uncertain.

Of the various types of study, randomized controlled trials generally provide the most certain estimated effects. This type of study is not, however, suitable for all types of intervention. For example, when assessing a systems-level intervention and comparison, randomization is neither feasible nor meaningful. For these types of intervention, case studies or observational and longitudinal studies more adequately capture what and how environmental factors impact implementation of interventions in different contexts (51).

The decision-making process used by the Guideline Development Group for each recommendation in this guideline is documented in the evidence-to-decision tables in Annex 2. Annex The GRADE tables used to rate the quality of the evidence are available online1, while the references for key indirect evidence underlying the recommendations are listed after each evidence-to-decision table.

3.2. Recommendations and good practice statements

The model of rehabilitation service delivery used in a health system have significant clinical and economic implications; the way in which service delivery is planned, financed and implemented affects who can access services, the quality of the services that can be delivered in different settings and the resources, both human and fiscal, required (52). The essential aim of a model of service delivery should be to ensure that “effective, safe and quality personal and non-personal health interventions… are provided to those in need and where needed (including infrastructure), with minimal waste of resources” (53, p. vi). As service delivery is one of the six elements of a health system, achieving a strong service delivery model is fundamental to strengthening and extending rehabilitation. The following recommendations address some of the key policy strategies that countries should formulate, with careful consideration of their context.

The evidence-to-decision tables on which the recommendations are based are shown in Annex 2.

A. Should rehabilitation services be integrated into the health system2 or into the social or welfare system or equivalent?

Background

While rehabilitation is delivered in the context of a health condition, usually in conjunction with other health services, it is currently not effectively integrated into the health system in many parts of the world. This has been attributed in part to how and by whom rehabilitation is administered (6,7). Responsibility for rehabilitation should be clearly designated for effective integration into the health system. This is becoming more important in view of the anticipated increase in the demand for rehabilitation services (1,2) and the multiplicity of actors involved in providing rehabilitation. Although rehabilitation addresses the needs of people with any health condition or impairment, whether temporary or long-term, it is commonly associated with disability and is often administered in the same ministry (usually a ministry for social welfare). In some countries, rehabilitation governance is shared between the ministries of health and of social welfare (6,7). Determination of whether rehabilitation should be integrated into the health system or into the social welfare system includes issues of rehabilitation governance and the impact on how rehabilitation is integrated into services.

Summary of research evidence

No published literature directly related to this question was identified. The direction of the recommendation was thus based on the consensus of the Guideline Development Group, which considered:

  • the anticipated benefits of integration of rehabilitation into the health system with regard to improved coordination with medical and other health services, improved accountability and quality assurance and sustainability; and
  • previous challenges associated with integrating rehabilitation into health services when it is administered by the social welfare system.

While the extent of these effects could not be determined, the overall assessment of benefits and harm led the Group to conclude that rehabilitation should be integrated into health systems.

ARehabilitation services should be integrated into health systems

Strength of recommendation: Conditional | Quality of evidence: Very low

Remarks:

  • Clear designation of responsibility for rehabilitation governance is necessary for effective integration of rehabilitation services into health systems. In most situations, the ministry of health will be the most appropriate agency for rehabilitation governance.
  • Strong links between the ministry of health and other relevant sectors such as social welfare, education and labour are important to promote efficient person-centred rehabilitation service delivery.
  • When a considerable shift in governance is required to integrate rehabilitation into a health system, careful consideration should be given to the capacity of the health system and its ministry to govern, invest in and coordinate services. A phase of transition between ministries may be required.

Rationale

In recommending that rehabilitation should be integrated into health systems, the Guidelines Development Group considered the anticipated benefits with regard to improved coordination with medical and other health services, accountability, quality assurance and sustainability. Given previous challenges in integrating rehabilitation into health services when it is administered by a ministry for social welfare or equivalent, the Guidelines Development Group suggested that rehabilitation should be governed by the ministry of health. This suggested was grounded in the understanding that:

  • Rehabilitation is a health strategy, with promotion, prevention, treatment and palliation, and rehabilitation interventions are delivered in the context of health conditions or impairments (49,50).
  • Rehabilitation services are usually provided in conjunction with other health services and share common resources (such as financing, technology, infrastructure and human resources).
  • Planning and policy-making for rehabilitation should be based on information captured and organized by health information systems.

B. Should rehabilitation services be integrated into and between primary, secondary and tertiary levels of the health system or only into selected levels?

Background

In many parts of the world, rehabilitation services are often provided only at selected levels of the health system.3 The reasons include underdevelopment of the rehabilitation sector and insufficient human resources and investment, which limit distribution of services among levels. Several long-standing misconceptions about rehabilitation have also determined at which level it is available. One pervasive misconception is that rehabilitation services are needed only by people with disabilities.4 When rehabilitation is considered to consist of interventions for a specific (minority) group of people rather than as an important aspect of health care for all, it may be under-prioritized and under-funded. This is compounded by another common misconception of rehabilitation as a luxury non-essential health service. Furthermore, when the role of rehabilitation in acute and post-acute care is not recognized, its integration into secondary and tertiary levels of the health system can be neglected. This question is a reflection of the situation of rehabilitation provision in many countries, and seeks to bring clarity to the levels of the health system at which rehabilitation should be available.

Summary of research evidence

Published research directly on the availability of rehabilitation at different levels of the health system was limited. Studies on values and preferences (54–57), acceptability (58) and feasibility (58–60) nevertheless support integration of rehabilitation in and between primary as well as secondary and tertiary levels of the health system.

BRehabilitation services should be integrated into and between primary, secondary and tertiary levels of health system

Strength of recommendation: Strong | Quality of evidence: Very low

Remarks:

  • Coordination mechanisms, including standardized referral pathways, in and between the different levels of the health system are essential for facilitating a smooth continuum of care for people who require multiple services or prolonged care.
  • Integration of rehabilitation into and between different levels of the health systems calls for a capable workforce, and consideration should be given to the capacity of the workforce to function at primary, secondary and tertiary levels, including the number of rehabilitation personnel available, their distribution, skills and competence. Where the capacity of the rehabilitation workforce is limited, task-shifting may be effective for increasing access to rehabilitation care. Such mechanisms should be used with caution, however, with consideration of limitations to specialization or to the extent of interventions if the workforce has not had specific professional training.
  • Effective integration of rehabilitation into and among all levels of the health systems is the responsibility not only of dedicated rehabilitation professionals but of all health workers. Promoting understanding among health workers of the principles of rehabilitation and its role in different contexts is imperative for high-quality care, appropriate referral and optimal use of services.
  • While the initial investment required to implement rehabilitation in and among the different levels of the health system may be considerable (particularly if existing services are limited), the associated long-term savings can mitigate any strain on the health system in the context of limited revenue for health care.

Rationale

In light of limited evidence directly addressing the research question, the Guidelines Development Group carefully considered the implications of integration of rehabilitation services across all levels of care and found that there is potential for moderate benefits and trivial risk of harms. Depending on their needs and the interventions available to address them, people will require different types and intensities of rehabilitation at different levels of the health system, as they may move between primary, secondary and tertiary levels during their care. Fragmentation among different levels of the health system is a recurrent issue in many countries, and can compromise health outcomes. The recommendations for rehabilitation in the World report on disability called for better coordination among levels of care and sectors to maximize the efficiency of services and to optimize health outcomes (6). Integration of rehabilitation services at all levels can facilitate the provision of person-centred care, a concept in which health services are organized to respond to the needs of people rather than health conditions (52). For this reason, health systems should ensure the availability of rehabilitation services at each level, with established coordination mechanisms, so that rehabilitation can follow the continuum of care as required.

C. Should a multi-disciplinary or a single-disciplinary rehabilitation workforce be available?

Background

Multi-disciplinary rehabilitation (provided by two or more disciplines) is common in many health care settings when a person’s needs require a broader scope of specializations than can be met by any one discipline. It is commonly used in chronic, severe or complex injuries or illnesses, such as traumatic injury or stroke. For example, a physiotherapist may deal with musculoskeletal and mobilization concerns while a speech pathologist will assist with language and swallowing, and an occupational therapists will work to restore independence in daily living. In many low- and middle-income settings, however, the rehabilitation workforce comprises a single discipline, often physiotherapy, resulting in wide gaps in rehabilitation services. These are either not addressed or are addressed by other health personnel, who may be inadequately trained or specialized, with ensuing impacts on the quality of care.

Summary of research evidence

Eight systematic reviews related to the PICO question were retrieved. Several studies that addressed the effectiveness of multi-disciplinary rehabilitation in older populations found that it can improve functional status, including activities of daily living, and reduce admissions to nursing homes and mortality (15, 61). Handoll et al. found a tendency towards better overall results of multi-disciplinary rehabilitation among older people with hip fracture, but the findings were not statistically significant (9). Two systematic reviews were conducted of the effect of multi-disciplinary rehabilitation for adults with back pain and one for adults with neck-and-shoulder pain (8,62,63). Kamper et al. found that people who received multi-disciplinary rehabilitation experienced less pain and disability and there was a positive influence on work status (8). Karjalainen et al. found moderate evidence for the effectiveness of multi-disciplinary rehabilitation in helping people return to work faster, take shorter sick leave and have subjective disability (62). In an earlier study, the authors found little scientific evidence for an effect on neck-and-shoulder pain (63). In a systematic review, Ng et al. found evidence to suggest that multi-disciplinary rehabilitation improved the quality of life and reduced the length of hospitalization; high-intensity multi-disciplinary rehabilitation reduced disability (64). The effectiveness of multi-disciplinary rehabilitation has also been shown in adults with acquired brain injury (65). Four studies were identified in the systematic review of the values, preferences and acceptability of multi-disciplinary rehabilitation. Three found that users value and prefer multi-disciplinary rehabilitation for stroke and mental health (66–68). In a qualitative study, Gage et al. found that multi-disciplinary rehabilitation was well accepted by a sample of people with Parkinson disease (69).

CA multi-disciplinary rehabilitation workforce should be available

Strength of recommendation: Strong | Quality of evidence: High

Remarks:

  • The demand for multi-disciplinary rehabilitation interventions depends on the health condition being addressed, its severity and other factors such as age and rehabilitation goals. It is important, therefore, that multi-disciplinary rehabilitation be based on a needs assessment.
  • Provision of multi-disciplinary rehabilitation depends on the availability of skilled personnel. As described in the World report on disability, these professions include occupational therapy, physiotherapy (sometimes referred to as physical therapy), physical and rehabilitation medicine, prosthetics and orthotics, psychology, social work and speech and language therapy (6, pp. 97 and 100).
  • Planning the establishment or formation of a multi-disciplinary rehabilitation workforce should include consideration of the scope and specialization of the competence required to address the needs of the population; in certain settings and contexts, including where a professional rehabilitation workforce has not been fully established, trans-disciplinary approaches1 may be appropriate.
  • Implementing rehabilitation as a multi-disciplinary health service in the health system therefore requires:
    –

    collaboration with the ministry for higher education to ensure that institutions provide qualification of various rehabilitation professionals (6);

    –

    ensuring that mechanisms for retaining and further developing the rehabilitation workforce are available, such as by supporting professional organizations (6,70);

    –

    ensuring that the rehabilitation workforce is distributed appropriately, so that multi-disciplinary rehabilitation services are also available in rural and remote communities and to people living in poverty (6); and

    –

    investing adequate funding into relevant facilities and programmes to support the provision of multi-disciplinary rehabilitation, such as hospitals and community services (6).

1

Trans-disciplinary approaches” refers to the practice of crossing disciplinary boundaries to provide a broader scope of practice. Here, it is advised only in contexts in which there is an insufficient professional rehabilitation workforce to address the needs of the population adequately.

Rationale

The availability of a multi-disciplinary rehabilitation workforce in a health system helps to ensure that all the rehabilitation needs of the population are met. The needs are diverse, and providing high-quality rehabilitation for a range of health conditions requires the skills of various, multiple rehabilitation disciplines. For example, the skills required to rehabilitate an adult with an orthopaedic condition differ from those required to rehabilitate a child with cerebral palsy. As different rehabilitation professionals have different specialities, a multi-disciplinary rehabilitation workforce can significantly improve the quality of care a country can provide to its population. Furthermore, joint interventions by people in multiple rehabilitation disciplines, all of which may not be necessary, have been shown to be effective in the management of many conditions, including stroke, hip fracture and chronic back pain (8–10). The benefits of multi-disciplinary rehabilitation are demonstrated in health outcomes and in indicators such as reduced hospital admission rates and greater patient satisfaction (6,66,69). An example of the scaling-up of the rehabilitation workforce is given in Box 1.

Box 1Scaling up the rehabilitation workforce in Guyana to provide multi-disciplinary rehabilitation

The scarcity of qualified, skilled health workers in Guyana is a major challenge for rehabilitation service delivery. Most rehabilitation professional shave been trained internationally and many do not return, attracted to higher wages in their country of training. As a result, Guyana has only 12 physiotherapists, no occupational or speech and language therapists and 45 rehabilitation assistants to provide services for a population of 800 000 people, the majority of whom live in rural areas.

The Ministry of Public Health, in collaboration with the Guyana Public Hospital Cooperation, is forming a multi-disciplinary workforce by expanding and strengthening training opportunities in the country and establishing a tiered model of a rehabilitation workforce. The University of Guyana offers professional degrees in occupational therapy, speech pathology and physiotherapy, with the support of international lecturers. The number of rehabilitation assistants is being increased through an 18-month course that provides basic training in the main areas of rehabilitation, and a 1-week course that is offered to community workers who will provide basic services and identify people in need of referral to more skilled personnel.

A growing number of graduates in rehabilitation in the coming years will increase the provision of professional multi-disciplinary rehabilitation services. Initially, the services will be available predominantly in the urban capital, Georgetown; however, as the numbers build, professional multi-disciplinary services will become available in rural areas. In the meantime, rehabilitation assistants and community workers help to ensure that people living in rural and remote areas can access basic services and be referred to professional care.

D. Should rehabilitation services be available in both community and hospital settings or only in community or only in hospital settings?

Background

Depending on factors such as the development of the rehabilitation sector and understanding and prioritization of the role and application of rehabilitation, these services are available in either the community, hospitals or both. Community rehabilitation services include services provided in a person’s house, school or workplace, while hospital rehabilitation constitutes inpatient and outpatient services for people undergoing a surgical or non-surgical intervention for a health condition or impairment. The setting in which rehabilitation is provided has implications not only for access but also factors such as efficiency, cost–effectiveness and patient satisfaction. In addressing this question, the Guideline Development Group analysed studies on the identification and needs of different users, the continuum of care and contextual factors such as geography and infrastructure.

Summary of research evidence

The evidence suggests that the cost–effectiveness and outcomes of rehabilitation in hospitals or in the community depend on the health condition being addressed and its severity. In the context of stroke, the evidence indicated the effectiveness of inpatient rehabilitation in stroke units with rehabilitation in the community after discharge (71–74). A Cochrane review by Taylor et al. (75) indicated that home-based and centre-based cardiac rehabilitation were equally effective in improving clinical and health-related quality of life. Cardiac rehabilitation in both home and community settings were effective in reducing hospital admissions, increasing quality of life and reducing mortality (76–78). There is evidence to suggest that community rehabilitation for mental health increases health-related quality of life and physical activity, reduces risk factors for homelessness and shifts use from hospitals to primary health care (79). In a systematic review, Burns et al. also found that people with psychotic disorders were more satisfied overall with treatment at home (80). Among older people, rehabilitation provided in hospital with early discharge and multi-disciplinary outreach was associated with a lower risk for delirium, greater patient satisfaction and lower cost (81). Another study found that complex community interventions can help older people live safely and independently (82).

Overall, rehabilitation provided at home is the preferred, more highly valued option for users (83–89). Two studies of cardiac rehabilitation showed that users preferred hospital services, and Court et al. found no difference in patient satisfaction with hospital and community services (90).

DBoth community and hospital rehabilitation services should be available

Strength of recommendation: Strong | Quality of evidence: Moderate

Remarks:

  • Well-distributed community rehabilitation services take into account factors such as geography, transport, cultural and social attitudes and demographics.
  • People who provide rehabilitation services in the community may encounter challenges that are unique or beyond those experienced in a hospital; they may feel isolated from their peers, lack professional support and have poor access to the equipment and infrastructure they require. Establishing or strengthening support for people providing rehabilitation in the community is important in ensuring high-quality services, in staff retention and in service sustainability. Monitoring of requirements for rehabilitation equipment and infrastructure and effective systems of provision and maintenance ensure that people providing rehabilitation in the community are adequately equipped.

Rationale

Rehabilitation should be provided in both hospitals and communities to ensure timely intervention and access to services. Article 26 of the Convention on the Rights of Persons with Disabilities calls on Member States to make rehabilitation available at the earliest possible stage and make rehabilitation services available as close as possible to people’s communities, including in rural areas (44). For many health conditions, including injury, rehabilitation is beneficial along the continuum of care. The presence of rehabilitation services in hospitals ensures that interventions commence at the earliest possible stage, which has been found to accelerate recovery, optimize outcomes and facilitate smooth, timely discharge (6,11). Moreover, providing rehabilitation during the acute phase of care can increase the likelihood of appropriate referral to follow-up services in the community (12). These outcomes are not only beneficial for the person receiving care but may also confer considerable financial advantages on the health system. When rehabilitation services are lacking or insufficient in a hospital, people may develop complications, such as skin breakdown or muscle contractures, be inappropriately discharged, deteriorate, sustain further injury or require a prolonged hospital stay (6). In addition, many people who are admitted to hospital require rehabilitation services after discharge.

Rehabilitation is appropriate not only for people with injuries or health conditions, such as a fracture or stroke but also for the prevention of injury or functional deterioration and for developing or maintaining functioning in the context of developmental, sensory, and cognitive impairments. Thus, many people who require rehabilitation may receive their treatment solely in the community. For example, children with developmental disability may require long-term interventions in settings such as community clinics, the home and school. For certain health conditions, such as sensory impairment (hearing or vision loss), it is especially important that interventions are provided in the settings in which a person lives, works or studies (91). Furthermore, people with some conditions, such as diabetes and cardiovascular disease, may not require hospital admission but require rehabilitation.

An example of how rehabilitation services can be provided both in the hospital and in the community in the context of a highly dispersed country is provided in Box 2.

Box 2Providing rehabilitation services to a highly dispersed population in the Solomon Islands

The Solomon Islands consists of some 900 mountainous islands in the South Pacific. The country is experiencing growing urbanization, yet much of the population is widely dispersed, approximately 80% living in remote communities. A decentralized model of health service delivery reflects the distribution of the population. Thus, primary health care is delivered largely by local nurse aides, and secondary and tertiary care are provided in a 300-400-bed national referral hospital in the country’s capital, Honiara.

Rehabilitation service delivery in the Solomon Islands, like other health services, faces the challenges of reaching a scattered population with limited resources. The Ministry of Health and Medical Services, however, provides strong leadership, funding and coordination to facilitate access to services for people even in remote communities. The system of service delivery includes community and hospital services connected through an official referral system that is also accessed by doctors, nurses, family members and care providers.

In the population of 595 000, community rehabilitation services are delivered by 24 widely dispersed community rehabilitation field officers and 11 rehabilitation officers. They are locally trained to identify people in need of rehabilitation, provide basic services, promote community awareness and link people with professional rehabilitation services when indicated. The officers are supported by more senior provincial coordinators and directors. The national referral hospital has physiotherapy, occupational therapy and speech and language therapy services. Many of the rehabilitation professionals who deliver these services are international volunteers, although some physiotherapists are locally trained.

Accessing rehabilitation and identifying people who require rehabilitation are difficult, given the geography of the Solomon Islands. The Ministry therefore funds transport between health services via the official referral system, and the distribution of community rehabilitation officers means that basic services and links to professional services are available even in many remote communities.

E. Should rehabilitation services for people with complex needs5 be provided in specialized rehabilitation units or only in general wards or non-specialized units?

Background

The provision of inpatient rehabilitation in specialized units is a model of service delivery for people with complex needs in many parts of the world, while some countries provide rehabilitation only in general wards or other non-specialized units. “Specialized rehabilitation units” are understood to be dedicated areas (facilities or wards) that provide rehabilitation assessment, treatment and management. Services are delivered by a multi-disciplinary team with recognized qualifications that prepare them to provide specialist rehabilitation. Specialized units for rehabilitation may care for people with specific health conditions or in specific age groups (such as older people) or people with complex rehabilitation needs more generally. The aim of this question was to determine the effectiveness of specialized rehabilitation units as compared with other models of service delivery for people with complex needs in order to guide service delivery planning and development.

Summary of research evidence

The evidence on outcomes of specialized rehabilitation was limited but did include high-quality systematic reviews and a meta-analysis. A Cochrane review by the Stroke Trialists’ Collaboration found that designated stroke units providing multi-disciplinary care were more effective in reducing mortality, increasing independence and keeping people at home (one year after stroke) than the provision of rehabilitation in general wards (10). No difference in length of stay was observed. A “narrative review” found that specialized rehabilitation units improved the health outcomes of people with spinal cord injury as compared with general non-specialized wards (92). Similarly, a randomized controlled trial of the outcomes of people with lower extremity amputation who received rehabilitation in specialized units or in general wards found a 33% greater improvement in physical functioning at discharge among those treated in specialized units. They were also more likely to be discharged and receive the assistive products they required (13). Another systematic review and meta-analysis found that multi-disciplinary rehabilitation provided in a specialized unit specifically designed for older people could improve functional outcomes, reduce admissions to nursing homes and reduce mortality (15).

EHospitals should include specialized rehabilitation units for inpatients with complex needs

Strength of recommendation: Strong | Quality of evidence: High

Remarks:

  • The establishment or extension of specialized rehabilitation units should be based on the context of the health system, specifically:
    –

    the availability or development of a multi-disciplinary rehabilitation workforce with adequate specialization to work effectively in these settings, or, where the rehabilitation workforce is underdeveloped, international recruitment as an interim measure; and

    –

    allocation of funding for the necessary equipment and consumables for effective rehabilitation.

  • Specialized rehabilitation units cannot replace rehabilitation in general wards and in the community.
  • Hospitals should endeavor to apply a system of needs assessment tin order to ensure the best use of specialized rehabilitation units.
  • Establishment or extension of specialized rehabilitation units should be accompanied by promotion of internal and external referral mechanisms.

Rationale

Evidence indicates that rehabilitation provided in specialized units results in better outcomes than that provided in general wards (10,14,15). Examples of situations in which specialized rehabilitation units may be particularly beneficial are:

  • management of health conditions that require prolonged, specialized rehabilitation, such as for people with stroke, brain injury, spinal cord injury and complex fractures;
  • after a prolonged hospital stay, when people, particularly older people, may be deconditioned and require customized rehabilitation before returning home in order to be sufficiently safe and independent; and
  • management of chronic conditions that require intermittent rehabilitation so that people can maintain or improve their functioning.

It is likely that the benefits associated with positive outcomes of rehabilitation in specialized units are associated with their focus on restoring functioning, the intensity of rehabilitation and the degree of specialization of providers in these settings.

F. Should financial resources be allocated to rehabilitation?

Background

In many parts of the world, no specific funding is allocated to rehabilitation services. A study of 114 countries in 2005 found that one third did not have a specific budget for these services (16). Rather, resources are drawn from other areas of health, competing for often limited resources. Furthermore, external barriers, such as macroeconomic crises, corruption, political instability or lack of political will for reform can hinder adequate financial investment in rehabilitation services (93).

Target 3.8 of the Sustainable Development Goals calls for Member States to achieve universal health coverage. As countries move towards this target, well-planned, carefully implemented financing strategies are needed to ensure that rehabilitation services are included in essential packages of care and covered by financial risk protection mechanisms (94). The aim of this question was to ascertain whether countries should allocate dedicated financial resources to support and sustain quality rehabilitation services.

Summary of research evidence

No direct comparisons of allocating and not allocating financial resources for rehabilitation were identified; therefore, studies on the outcomes of decisions on resource allocation with respect to rehabilitation use and cost-effectiveness were analysed. One study indicated that rehabilitation use is based on numerous factors, including the severity of the impairment and co-morbid conditions, so that it is difficult to make firm predictions about rehabilitation use (95). A systematic review and meta-analysis found that different models of rehabilitation service provision are cost-effective for different patient groups and situations; inpatient rehabilitation is the most cost-effective method for some and community-based services for others (96). A systematic review of the economic outcomes of rehabilitation showed that rehabilitation interventions are cost-effective or result in cost-saving in a variety of conditions (42).

FFinancial resources should be allocated to rehabilitation services to implement and sustain the recommendations on service delivery

Strength of recommendation: Strong | Quality of evidence: Very low

Remarks:

  • The financial resources invested for implementing the recommendations for rehabilitation service delivery should be sufficient to ensure equitable access to services, including for people living in poverty.
  • The amount of the financial investment into rehabilitation services should reflect their benefits and not be based on crude statistics on disability, which can result in considerable underestimates of the true rehabilitation needs of a population.
  • Rehabilitation services can be delivered by public, private or not-for profit providers, and many countries rely on a mix. Countries are encouraged to use the type and range of service providers that best ensure equitable access to affordable, high-quality rehabilitation services for everyone who needs them (93). Added advantages of this approach are the benefit of different sources of funding, reduced competition for scarce resources and extended reach of services in the population.
  • Equitable financing for rehabilitation services can be based on mechanisms such as pooling and redistributing funds to subsidize people who cannot afford to pay for them (97).
  • The distribution of investments in rehabilitation services should ensure that the same quality and access to services are achieved for all people. Due consideration should also be given to the indirect costs associated with accessing services, such as transport (6, p. 114).

Rationale

While evidence to answer the question is limited, the Guideline Development Group found that the balance of benefits and harm is strongly in favour of allocating financial resources for rehabilitation and that failure to do so is potentially more harmful and costly than allocating resources.

Experience shows that allocation of funding by health systems significantly affects service provision and equity (97). Allocation of resources has been identified as a key mechanism for strengthening and improving access to rehabilitation services (6, p. 122). While allocation of designated financial resource for rehabilitation may be perceived as placing additional demands on often strained financial resources for health, it is important that policy-makers acknowledge that investing in rehabilitation is an investment in human capital and has broad economic implications for various sectors, as it is associated with increased participation in labour markets and education, longer independent living and fewer or shorter hospital admissions (15,30,34,36,98).

G. When health insurance exists, should it cover rehabilitation services?

Background

While direct user fees are the simplest form of transaction for health services and can sustain health systems by generating revenue, they can result in a considerable decrease in service use when applied universally in a population, and people living in poverty may be the most adversely affected (93). People with significant disability, who are more likely to require rehabilitation services intensively and/or over a long period, are also 50% more likely to experience catastrophic health expenditure (6). The Sustainable Development Goals strongly emphasize equity. Therefore, financing models should address the needs of people living in poverty, those who are geographically isolated and those who are marginalized, to ensure that “no one is left behind” (19).

Financial barriers to health services are well documented, and health insurance, either public or private, is a common mechanism used to remove them. Rehabilitation, however, is covered by insurance to varying degrees. Because of the role insurance plays in achieving equitable access to and optimal use of health services, the aim of this question was to determine whether rehabilitation should be included in insurance coverage.

Summary of research evidence

No research directly related to insurance coverage of rehabilitation and its impact was identified. Several studies explored the impact of health insurance on service access and use of health services, however, and showed that people without insurance had substantially more unmet health needs and recommended health services were underused. The findings pertained to both adults and children (99-103). One study showed that the effect of not having insurance was amplified for people with a disability, while in another caregivers reported insufficient coverage of services by insurance providers (100-104).

GWhere health insurance exists or is to become available, it should cover rehabilitation services

Strength of recommendation: Conditional | Quality of evidence: Very low

Remarks:

  • Health insurance is one of numerous mechanisms for increasing access to and use of health services and for protecting people from burdensome expenses (105). This recommendation does not endorse any particular method or arrangement of health insurance but indicates that, where it is used, rehabilitation should be covered.
  • In accordance with Article 28.2.A of the Convention on the Rights of Persons with Disabilities and in alignment with target 3.8 of the Sustainable Development Goals, people living in poverty should not incur out-of-pocket expenses for rehabilitation services (44). Insurance is a financial protection mechanism that can substitute for direct user fees. In many settings, particularly low- and middle-income countries, however, health insurance protects only a minority of the population (17, pp. 41-42). It is therefore important that this mechanism be applied as part of broader initiatives to improve the affordability of rehabilitation services.

Rationale

This recommendation is based not only on evidence of the positive effects of insurance on health outcomes but also on the principle that rehabilitation is an important aspect of health care and should thus be covered by health insurance (6,99-101,103,105). Furthermore, the considerable number of people, especially those with disability, who face financial barriers to rehabilitation services and suffer financial hardship as a result means that every effort should be made to reduce out-of-pocket expenses.

Good practice statements for assistive products

Background

Prescription of and training in the use of assistive products are important in rehabilitation for many people in order to improve functioning and to increase independence and participation. The Guideline Development Group decided that it was important to provide “good practice statements” on the provision of assistive products and appropriate training in their use. These statements are based on the importance of equitable, high-quality service delivery and the underlying certainty that they have more benefits than harm for the population.

Accessing appropriate assistive products can be challenging throughout the world but especially in low-income countries, where as little as 5–15% of the population have access to the products they need6 (18). The Global Cooperation on Assistive Technology (GATE) initiative is working to improve the availability and affordability of assistive products (106). It is equally important that provision of these products be accompanied by the necessary training, so that they can be used effectively and safely and be maintained over time (Box 3). Rehabilitation providers are well positioned to support training in the use of many products, such as prostheses, hearing aids and wheelchairs. Involvement of appropriate rehabilitation professionals, especially for users with complex needs, can help ensure that the products are suitable for the person and the environment in which they will be used, that the products are adapted or changed as the needs of the user evolve and that they are maintained to ensure safety and effectiveness over time (6).

Good practice statements for assistive products

Financing and procurement policies should be implemented to ensure that assistive products are available to everyone who needs them.

Adequate training should be offered to the user, and care provider when appropriate, when assistive products are provided.

Box 3Provision of appropriate assistive products and training in their use

Access to appropriate assistive products is limited in western Uganda, as are the rehabilitation services that provide them and the necessary training in their use. The vast geographical spread of districts, inadequate infrastructure and low family incomes further hinder acquisition of the products and the required training. Without appropriate assistive products, such as wheelchairs, children with significantly restricted mobility may be unable to participate in their communities and schools and find themselves dependent on their family or carers for basic needs. Some children, such as those with severe cerebral palsy, have more complex needs and require specialized seating to obtain the support and stability they require. The Motivation Charitable Trust, with the Ministry of Health and several wheelchair service centres in Uganda, provide basic services consistent with WHO’s Guidelines on the provision of manual wheelchairs in less resourced settings (107). The Trust provides services for children with cerebral palsy and their parents or carers, which consist not only of appropriate wheelchairs but also the knowledge and skills to maximize their impact. The right training can facilitate function, enable better communication and improve behaviour, all of which can make it easier for the children to be included and to participate in meaningful activities.

Masika’s story

Masika is an 11-year-old girl with cerebral palsy who lives in Kasese, Uganda. She relies on a wheelchair both to move and for postural support, as her condition makes it difficult for her to sit comfortably and breathe properly. For six years, Masika had been using a donated adult wheelchair. As it fitted her poorly, she developed sores and would often slip down and cough as she struggled to breathe. It would take Masika’s mother over two hours to push the wheelchair over rough terrain to a parent support group, and, even when at home, her daughter frequently required repositioning, disrupting her work. Masika was provided with a new, rough-terrain wheelchair by the Motivation Charitable Trust in 2014. The new chair accommodates her complex postural needs, making her happier and safer and allowing her mother to reach the parental support group in a quarter of the time.

Footnotes

1
2

In the context of this recommendation, integration in the health system involves the management and delivery of rehabilitation in conjunction with other health services so that people receive timely, comprehensive and well-coordinated care, according to their needs and across different levels of the health system. Adapted from Integrated health Services - what and why? Technical Brief No. 1. World Health Organization, 2008. http://www​.who.int/healthsystems​/service​_delivery_techbrief1.pdf

3

Primary services are usually the first point of contact within a health system and may be provided by general health care workers; they represent a link to more specialized care. Primary services are usually provided locally in a range of settings (typically communities). Secondary services include health care provided by medical specialists and other health professionals. They are usually based at the district or regional level and provided in a range of settings (typically hospitals and institutions). Tertiary services include specialized consultative health care, usually based at national level and provided in hospitals on an inpatient basis (based on definitions in the health component of the community-based rehabilitation guidelines (18)).

4

In the Convention on the Rights of Persons with Disabilities (44), people with disabilities are defined as “those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others.”

5

Complex needs are understood in the context of this recommendation to be needs that arise from having significant or multiple health conditions that impact various domains of functioning (such as vision, communication, cognition, and mobility).

6

A conservative estimate based on data on the prevalence of disability, which do not fully capture the needs for assistive products by the older population.

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