https://orcid.org/0000-0001-5887-5852
Figures
Abstract
Background and objective
The need for rehabilitation is growing due to health and demographic trends, especially the rise of non-communicable diseases and the rapid ageing of the global population. However, the extent to which rehabilitation is integrated into health systems is mostly unclear. Our objective is to describe and compare the nature and extent of integration of rehabilitation within health systems across nine middle-income countries using available Systematic Assessment of Rehabilitation Situation (STARS) reports.
Methods
Cross-country comparative study with variable-oriented design using available rehabilitation health system assessment reports from nine middle income countries.
Findings
The integration of rehabilitation into health systems is limited across countries. Governance and financing for rehabilitation are mostly established within health ministries but weakly so, while health information systems are characterized by no available data or data that is insufficient or not routinely generated. The overall numbers of rehabilitation workforce per capita are low, with frequent reports of workforce challenges. In most countries the availability of longer-stay, high-intensity rehabilitation is extremely low, the availability of rehabilitation in tertiary hospitals is modest and in government supported primary care its almost non-existent. Multiple concerns about rehabilitation quality arose but the lack of empirical data hinders formal appraisal.
Conclusion
The study sheds light on the limited integration of rehabilitation in health systems and common areas of difficulty and challenge across nine middle income countries. All countries were found to have a basis on which to strengthen rehabilitation and there were often multiple areas within each health system building block that required action in order to improve the situation. Findings can inform governments, regional and global agencies to support future efforts to strengthen rehabilitation. Additionally, our study demonstrates the value of STARS reports for health policy and systems research and can serve as a model for further comparative studies.
Citation: Kleinitz P, Sabariego C, Llewellyn G, Taloafiri E, Mangar A, Baskota R, et al. (2024) Integrating rehabilitation into health systems: A comparative study of nine middle-income countries using WHO’s Systematic Assessment of Rehabilitation Situation (STARS). PLoS ONE 19(2): e0297109. https://doi.org/10.1371/journal.pone.0297109
Editor: Samir Garg, State Health Resource Center, Chhattisgarh, INDIA
Received: August 1, 2022; Accepted: December 28, 2023; Published: February 5, 2024
Copyright: © 2024 Kleinitz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All key data is included in the manuscript and full STARS reports can be made available on request.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Rehabilitation is a key health strategy that optimizes population functioning [1], and contributes to better health and wellbeing of populations [2]. The need for rehabilitation is growing, associated with health and demographic trends, especially the increase of non-communicable diseases (NCD) and rapidly ageing populations. Data from the 2019 Global Burden of Disease (GBD) study indicates 2.4 billion people are living with health conditions that could benefit from rehabilitation [3]. People with unmet rehabilitation needs frequently experience greater difficulties moving, communicating, caring for themselves and being productive, including people with disabilities who experience discrimination, social exclusion and humans rights abuses [4]. Nevertheless, in many low and middle income countries (LMICs) rehabilitation provision is very limited and much of the population needs go unmet [5]. In many LMICs, rehabilitation is often an under-developed and under-valued area of health care [6], and the COVID-19 pandemic also unveiled its weakness as rehabilitation was one of most highly disrupted services [7]. To address the many challenges faced by rehabilitation, especially in LMICs, WHO launched the Rehabilitation2030 initiative in 2017 [8] and is developing guidance documents and tools to support countries strengthening rehabilitation in their health systems.
From its outset, the Rehabilitation2030 initiative emphasised the need to integrate rehabilitation at all levels of health care within health systems to ensure a continuum of care that is in line with people’s needs across the life course [9]. Building sustainable rehabilitation services at all levels of care necessitates its integration across the many components of a health system, for example its planning, financing, workforce and information systems [10]. Evidence on the nature and the extent to which rehabilitation is included in health systems is scarce. This knowledge, however, is important for understanding how to organise national and international efforts to strengthen rehabilitation. For WHO and other development partners this can inform the development of programmes and projects, as well as guidance and resources for country support.
Acknowledging the need for evidence and that strengthening efforts for rehabilitation need to be tailored to national needs and priorities, WHO developed a health system assessment (HSA) tool [11], the Systematic Assessment of Rehabilitation Situation (STARS). STARS generates standardised and structured assessments [12] and is part of the WHO Rehabilitation Guide for Action [11], an online available resource that guides rehabilitation strategic planning. STARS allows for cross-country comparative studies, a type of health policy and systems research (HPSR) [13], about the nature and extent to which rehabilitation is integrated in health systems at national, regional and global levels. Such studies provide information about the current situation and areas for improvement [14]. Additionally, governments can learn from countries with similar experiences in developing rehabilitation in health systems.
The objective of this paper is therefore to describe and compare rehabilitation status across nine middle-income countries using available STARS reports, exploring the policy and programme implications of the findings. Our paper contributes to filling the lack of evidence relevant to governments, regional and global agencies to support future efforts to strengthen rehabilitation in health systems and serves as a model for future HPSR research on rehabilitation.
Methods
Cross-country comparisons can be categorised into case-oriented or variable-oriented studies [15]. We used a broad variable-oriented design, which is a form of HPSR [13] that supports generation of hypotheses and can be used to identify the differences across countries.
STARS
STARS was developed between 2016–2019 by WHO. The development of STARS, and its assessment components, has been described elsewhere [16], and the product itself, including the definitions and descriptions of all the assessment components and how to use STARS is part of the WHO Guide for Action and available online [11]. STARS is an HSA tailored to rehabilitation. It is made up of three components; a Manual which guides the assessment process and preparation of reports; a Template for Rehabilitation Information Collection (TRIC) which guides the initial collection of data and information from countries; and a Rehabilitation Maturity Model (RMM) which defines 50 components for assessment and describes these on a 4-level maturity continuum. STARS utilises a logic model to its structure whereby the health system comprises building blocks (HSBBs) which cover areas of inputs (governance, financing, information, medicines and health products, workforce) and outputs (services). Assessment of services considers what is available at all levels of tertiary to primary healthcare (PHC) and in the community, as well as its quality, such as effectiveness and person-centred characteristics. The logic model prompts descriptions of service outcomes (at individual and population levels) and the extent of attributes of a well-functioning health system such as equity, efficiency and sustainability that are present. STARS generates a tailored report that is primarily designed to inform national stakeholders and make recommendations on how to strengthen rehabilitation in national health systems.
Countries
The 10 countries from the six WHO regions that were ‘early adopters’ implementing WHO STARS between August 2019 and February 2021 were eligible to participate. Their WHO STARS implementations resulted in final reports endorsed by government and publicly available in English. A request to use the information within STARS reports for this study was sent to the rehabilitation focal points of the ministries of health (MOH), all of whom had engaged in drafting of the original STARS report. After obtaining their written permission, the data was extracted from reports and included in the study. Approval for the field testing of STARS in these countries was received from the WHO Ethics Committee.
Data extraction
The first author (PK) initially mapped the common assessment components within STARS reports to the six HSBBs. All items that had either a quantifiable (e.g., workforce numbers) or empirical/observable feature (e.g., rehabilitation plan), and were similarly defined, measured or described across STARS reports were selected. Outcomes and attributes components were initially considered but not included because they lacked the quantifiable and empirical data: an example are measures for effective coverage which were not available in all countries.
The extracted data for each country was then sent to the rehabilitation focal points of the MOH and corresponding country co-author(s), who reviewed it for accuracy and precision, edited any inaccurate or imprecise information and added further or missing details. This step served as validation of the extracted information, noting that an earlier validation had also occurred during drafting and country review of the original STARS report. Where countries lacked the required information in their STARS report it was noted as ‘not available’.
Data analyses
Country data was compiled into a common Microsoft Excel file. For qualitative items, data is presented in tables. For quantitative items, numbers or percentages (as required) were included and descriptive statistics (mean, median and range) were derived whenever possible. Where needed, quantitative data were standardised relative to population size. Analyses were conducted to 1). Identify differences across countries; and 2). Identify similarities and differences between countries accordingly to income categorisation grouping (either lower middle income or upper middle-income). The policy and programme implications of the findings are included in the discussion.
Results
Nine middle income countries (Table 1) agreed to participate, one from each WHO region: three upper middle-income countries namely Georgia, Guyana and Jordan; and, six lower middle-income countries namely Nepal, Myanmar, Solomon Islands, Sri Lanka, Tanzania and Zambia. No low-income countries were ‘early adopters’ of the WHO STARS and therefore not included in the study.
Current Health expenditure per capita and GDP per capita in current international $. Income status: lower or upper middle income.
Altogether 49 STARs items were selected for the comparison. A small number of items, such as expenditure, had limited available or comparable information across countries but were included due to their relevance for scaling up rehabilitation.
Rehabilitation governance (Tables 2 and 3)
In all nine countries, MOH was primarily responsible for rehabilitation, however in Georgia the social affairs section of the joint health and welfare ministry led rehabilitation and in Jordan multiple agencies contributed and MOH was not the primary agency (Table 2). Only Nepal, Tanzania and Zambia had a regular leadership and coordination mechanism convened by MOH. Georgia, Guyana, Nepal, Solomon Islands, Sri Lanka, Tanzania and Zambia had rehabilitation focal points within the MOH with responsibility for rehabilitation; Jordan and Myanmar MOHs relied on rehabilitation professionals located within health services for governance of rehabilitation. Six countries had addressed rehabilitation in their National Health Strategic Plan and all countries had included rehabilitation in at least one other health plan, most frequently in the health plan for NCDs. All countries reported that rehabilitation was included in their existing health policy and/or legislation although not always explicitly mentioned; additionally, 5 countries explicitly addressed rehabilitation in their disability legislation (Table 3). Annual routine reporting on availability of rehabilitation services in government healthcare occurred in two countries. Leadership, coordination and planning for assistive technology (AT) was generally characterised as limited and fragmented. Nepal had a government convened multi-stakeholder AT working group, and Nepal and Sri Lanka had developed national Assistive Product Priority Lists (APPL). No observable distinction in leadership and governance occurred between the upper and lower middle-income countries.
Rehabilitation financing (Tables 4 and 5)
All countries financed rehabilitation using multiple sources, typically a combination of government tax-based public health or social health insurance schemes (as well as other insurance schemes in some instances), individuals’ out of pocket (private) contributions and development partners. Eight countries included rehabilitation in their major tax-based public health financing scheme in which the MOH is main funder and provider; Georgia which was the exception included rehabilitation in their financing scheme for services for people with disabilities (Table 4). Five countries described having a basic or essential package of health services (typically financing for services in primary care and lower end of secondary care), that is, Georgia, Guyana, Myanmar, Nepal and Sri Lanka; of these only Guyana and Sri Lanka included rehabilitation in this package of health services. Rehabilitation expenditure data was mostly not available or incomplete, hence expenditure on rehabilitation as proportion of total health expenditure was not available for comparative analysis (Table 5). Where expenditure on rehabilitation data existed, it was lowest at 0.2% (Nepal) and highest at 1.2% (Guyana). Out of pocket expenditure (OOPE) appeared to be a significant contribution to financing rehabilitation but detailed data was not available. The combination of government tax-based public health or social health insurance schemes financing rehabilitation suggested that the level of population coverage was high however access to services was low because of scarcity and concentration of rehabilitation in major urban centres. Across all countries, Assistive Products (AP) financing was limited and OOPE for AP was considered substantial, typically more than for other rehabilitation services. Fees-for-service (a form of OOPE that the provider is reimbursed for with each service provided) existed for government funded rehabilitation in most countries: in Guyana, Myanmar, Solomon Islands, Sri Lanka and Zambia these fees were characterised as minimal.
Rehabilitation information (Tables 6 and 7)
Information on rehabilitation from MOH administrative sources was limited. Specifically, workforce data was available in the MOH workforce accounts in Guyana, Solomon Islands and Sri Lanka; these countries also routinely collated information on availability of services, however the six other countries did not (Table 6). Expenditure data was incomplete or not available in all nine country’s national health accounts. Generally, health facilities in all countries collected service utilization data, however, in seven countries this was neither standardised or collated and reported at district or national levels, although this did occur in Guyana and Solomon Islands. No country routinely collected and reported service outcomes, population need or coverage of rehabilitation services (Table 7). Guyana and Solomon Islands, the two smallest countries by population, had the most comprehensive rehabilitation information available.
Rehabilitation workforce (Tables 8–10)
Rehabilitation workforce information included national workers from government and private sectors as well as international workers and volunteers. All lower middle-income countries had five or less rehabilitation workers per 100,000 population, whereas upper middle income ranged from 12–22 per 100,000, reflecting a difference between country income levels (Table 8). Regarding total numbers of workforce, Jordan could not produce reliable data in their STARS report. The number of rehabilitation professions was lowest with four in Myanmar and Zambia and highest with seven in Nepal, international volunteers increased this in smaller countries such as Guyana and Solomon Islands. The median number of cadres for the upper middle-income countries was 6, and for lower middle-income countries it was 5. Physiotherapists, occupational therapists and prosthetists and orthotists were available in all countries and all countries had at least one training course for rehabilitation cadres with two of the upper middle-income countries having three or more post-graduate courses compared with none in four of the lower middle income (Table 9). Centralised workforce planning to allocate rehabilitation workers to government healthcare occurred in seven countries. Supervision practices of rehabilitation workers in government healthcare was characterised as basic with few systematic processes in place. Multiple common workforce challenges were reported across all countries (Table 10), regardless of income category, and these included; limited professional development opportunities (eight countries); lack of rehabilitation professions available (six countries); difficulty in attracting and retaining workers outside major urban areas (six countries); limited opportunity for career progression (five countries); low profile of rehabilitation professions; rehabilitation not being a popular career choice (three countries) and rehabilitation workers not feeling valued by other healthcare professionals (three countries).
Assistive products, and rehabilitation infrastructure and equipment (Table 11)
Eight MOHs intermittently undertook centralised procurement of AP. MOH procurement was driven by rehabilitation focal points in collaboration with medical equipment departments however this generally occurred in the absence of national guidance and specifications. Infrastructure and equipment typically varied across facilities (Table 11). No country had a comprehensive inventory or report on rehabilitation infrastructure and equipment, hence conclusions regarding availability across level of healthcare are cautious, however, typically, where high intensity, longer-stay rehabilitation facilities existed these had adequate levels of equipment and treatment spaces; similarly large tertiary hospitals had adequate equipment but often limited treatment spaces; secondary hospitals often had treatment spaces but inadequate equipment; government supported primary care rarely had rehabilitation infrastructure or equipment. The STARS reports from Guyana, Solomon Islands and Sri Lanka explicitly mentioned lack of infrastructure, equipment and componentry for prosthetics and orthotics.
Rehabilitation services (Tables 12–14)
High intensity, longer stay rehabilitation, required for people with complex needs was very limited across all countries with rehabilitation beds per capita ranging from 1 per 43,000 Sri Lanka to 1 bed per 2.4 million in Tanzania; country income category did not align with rehabilitation bed per capita. Rehabilitation services were mostly available in tertiary level government hospitals, with 100% availability in tertiary hospitals in Guyana, Nepal, Solomon Islands and Zambia, a percentage value was not available for Jordan and Georgia. Physiotherapy services were most frequently available across all countries. Availability of rehabilitation reduced considerably in secondary care, with upper middle-income countries reporting a slightly higher mean rehabilitation availability at this level than that in lower middle-income countries. Availability of rehabilitation in government supported primary care was almost non-existent with only Myanmar and Solomon Islands reporting limited availability (Table 12). All countries had significantly less rehabilitation services outside major urban areas. Early identification and referral of children in need of rehabilitation was mostly characterised as emerging or in need of establishment in all countries. Integration of rehabilitation into mental health care was established but limited to psychology and occupational therapy services in specialist mental health facilities. Integration of rehabilitation into eye care and hearing care was assessed by availability of low vision services and audiology services that provided hearing aids, respectively (Table 13). Rehabilitation for eye care was very limited in four countries (only in 1–2 sites), whereas Sri Lanka reported access across multiple government sites and Georgia reported many private providers of eye care; rehabilitation for hearing care was very limited in five countries, with the private sector providing hearing aids in seven countries. All countries had non-government organizations (NGOs) delivering some rehabilitation for people with disabilities in community settings, these services also commonly provided social supports, education and livelihood focused programmes; in all countries, the extent to which these services were available across the entire country was estimated to be low. The provision of AP was dominated by mobility with some vision and hearing products available, AP targeting people’s communication and cognition was particularly low with four countries not providing any such AP (Table 14).
Quality of rehabilitation was difficult to assess at a national level as few empirical or measurable items were collated across facilities, also variation between facilities in countries can be high. The minimal comparable information reported in STARS included; existence of national clinical practice guidelines; wide-spread utilisation of documented outcomes measures; and nationally documented referral pathways. Of these, no country had all three and seven countries had none. Country reports also included other concerns regarding quality of services, including; regular utilization of non-evidence-based rehabilitation interventions; limited scope of rehabilitation with little specialisation of rehabilitation workers; low rehabilitation dose and intensity with limited follow-up, particularly when client discharged from hospital back to community; delays in receiving rehabilitation, particularly when client coming from community settings and especially for children with disabilities and developmental delays; limited availability of multidisciplinary, coordinated rehabilitation, which was mostly limited to specialised rehabilitation settings; and, limited use of person centred care in rehabilitation services.
Discussion
In line with available evidence [17–19], our variable-oriented comparative study confirms and expand the evidence pointing out to a limited integration of rehabilitation into health systems in middle income countries. Some but not large distinctions between upper and lower middle-income country groups were observed, including for instance much lower numbers of rehabilitation workers per 100,000 population and slightly lower rehabilitation availability in secondary care in the latter. Governance and financing are mostly established but weak while integration of rehabilitation data in health information systems (HIS) is emerging and very weak. Rehabilitation workforce per capita is low, with considerable differences between countries and frequent reports of workforce challenges. Most countries experience extremely low availability for high-intensity rehabilitation, modest availability in tertiary hospitals, and low availability at the secondary, primary care and community level. Services outside of major urban areas are sparse. Provision of AP is limited with low levels of financing and high OOPE in all countries, and inadequate rehabilitation infrastructure is frequently experienced. As many of these findings and the challenges experienced in countries are relevant for other LMICs, these are now discussed in light of relevant literature and considering policy and practice implications which may be used to inform governments, and regional and global agencies about ways forward to strengthen rehabilitation in health systems.
Governance
Governance weaknesses are not uncommon in health systems [20]. However, the limited national leadership, planning, coordination mechanisms, administrative capacity and accountability for rehabilitation observed across all countries is concerning. Contributing factors to this situation in LMICs include the historical focus on preventive and curative care [21], misperceptions of rehabilitation as a ‘disability service’ only [1], lack of recognition of what is rehabilitation because it is frequently called something else (e.g. physiotherapy) [22], and the often under-valued and fragmented workforce lacking critical mass and cohesion [23, 24]. Even in countries where planning for rehabilitation existed, this did not necessarily mean these plans were well-conceived and/or implemented. Appreciating that effective leadership and governance for rehabilitation is crucial in driving change, development partners and governments must focus on equipping relevant rehabilitation stakeholders within countries for this role. A practical way forward includes expanding rehabilitation leadership and administrative capacity at national and sub-national levels and developing multi-stakeholder national coordination mechanisms and sectoral networks, both good practice approaches [25]. Additionally, an important step in countries has been to undertake national rehabilitation strategic planning based on accurate insights into the country situation. While rehabilitation strategic planning may seem an unnecessarily ‘vertical planning approach’ for a health service that should be highly integrated into a wide range of healthcare, the process of bringing stakeholders together, discussing priorities, creating a shared vision, identifying objectives and then sequencing actions has been crucial for the sector’s efforts to advocate, coordinate, collaborate and importantly integrate rehabilitation across other relevant areas of health policy and planning [26].
The success of many efforts to strengthen rehabilitation will be underpinned by the ability to generate adequate rehabilitation data. For example, governance cannot be effective without information that informs decision making and enables accountability; and integrating rehabilitation into health benefit packages requires data to measure needs, utilization and outcomes. As reported previously [27], the current study shows that rehabilitation is not well integrated into health information systems, that generation of information is generally very limited and standardisation of rehabilitation data within and across countries is particularly low. Arguably some of the more politically influential data for decision making is where the greatest gaps exist, for example the financial expenditure for rehabilitation, utilisation rates, service outcomes and effective population coverage.
Health information systems
There is an urgent need to address these challenges, especially considering that health decision making is occurring in an environment of increasingly competing needs for constrained resources. Fortunately, the integration of rehabilitation into HISs can be well guided by the opportunities and practices that already exist for other areas of healthcare. Ways forward for rehabilitation include using the WHO International Classification of Functioning, Disability and Health as a common language framework, as well as inclusion of rehabilitation information in MOH administrative data, such as the national health accounts and national workforce accounts; inclusion of rehabilitation data in routine health management information systems; and inclusion of rehabilitation into population surveys for monitoring effective service coverage. The WHO is already working on initiatives and products that address these areas, such as WHO’s Guidance on the Analysis and Use of Routine Health Information System, Rehabilitation Module [20] which provides a standardised data set for clinical facility use. Another example is the Rehabilitation Needs Estimator which harnesses GBD data for understanding rehabilitation needs, rather than promoting costly dedicated surveys [3]. In the health sector and other sectors, there is a frequently quoted saying—‘what gets measured gets done’, the findings from this study serve as a wakeup call to governments to begin measuring rehabilitation as a critical step in the process of strengthening rehabilitation in health systems.
Rehabilitation services
Making rehabilitation services available in LMICs will also require further integration of rehabilitation into health financing schemes and health benefit packages. However, to achieve this several underlying challenges need attention. One challenge already mentioned is data, as countries increasingly move towards priority setting of health benefit packages that is more systematic, evidence-based and transparent [28], the need for better rehabilitation data increases. Another challenge, evident in this study, was that decisions to expand financing for any health service are generally informed by the existing availability of that service, which for example can be a barrier to the financing for rehabilitation in primary care, where it is particularly limited in LMICs [9]. Of the five countries with essential health benefit packages, rehabilitation was not included in three because it was not a service already available at this level. While this approach may seem understandable, it creates a chicken and egg situation that will require targeted efforts to address. This is being tackled in Myanmar, for example, where the rehabilitation workforce and services in primary care in one geographic location are being expanded with the explicit intention to demonstrate how in future, rehabilitation in primary care can become part of the country’s essential heath benefit package [29].
Workforce
Responsive health systems rely on a well-trained workforce available at sufficient scale. The findings from this study in upper and low middle income countries align with studies of workforce density that have illustrated large differences across HICs and LMICs [28]. A large number of challenges existed for the rehabilitation workforce in countries in the present study, some of which were experienced more intensely by this workforce than others, for example, feeling misunderstood and under-valued by other health workers [24]. Typically, strengthening workforce means expanding trained workers, establishing new rehabilitation professions (e.g., speech and language therapists) and ensuring training is aligned with international standards and population needs. The findings suggest that training efforts should also include expanding rehabilitation in medical and nursing training, as the lack of this likely contributes to low levels of understanding and valuing of rehabilitation in health systems. Improving regulation is also an important lever for increasing recognition of the workforce and improving and monitoring quality. To assist countries, WHO has developed the Rehabilitation Competency Framework [30] and is currently piloting the WHO Guidance of Rehabilitation and Workforce and Evaluation [31], a tool to support a deep dive analysis into rehabilitation workforce within countries to inform more detailed workforce planning.
Rehabilitation and primary care
While significant gaps in rehabilitation services exist across all levels of healthcare in many LMICs, expanding availability in primary care has the most potential to transform access for the population. Primary care is provided close to where people live and work, it reduces significant barriers to access such as transportation costs and time to service [28, 31, 32]. The renewed, global focus on PHC [33–35], the appreciation of its role in achieving Universal Health Coverage [36], and the investment occurring [37], make it a clear target of rehabilitation strengthening efforts. This is not without significant challenges because in LMICs there is limited availability of workforce and funding for the services. To address this, task-sharing approaches used in other areas of health care may be usefully employed [38, 39]. Currently, WHO is investing in the development of a resource that supports delivery of a limited set of rehabilitation interventions by existing primary care workers using a task-sharing approach, its purpose is to build capacity of existing primary care workers to identify rehabilitation needs, provide basic rehabilitation care and referral as needed. In an environment of constrained resources, decisions to expand services in one level may come at the cost of another, difficult decisions are required but should consider the potential primary care has at transforming access and subsequently achieve better population health and functioning outcomes [9].
Assistive products
Assistive products primarily target human functioning [40]. Providing APs is one type of rehabilitation intervention in services characterised as physical, vision, hearing, cognitive or mental health rehabilitation services [41]. The limited inclusion of APs in financing mechanisms and resultant poor availability requires urgent attention. Substantial OOPE was reported by countries, and this hindered access and can trigger catastrophic health expenditure putting a strain on persons in need and their families. WHO, along with other development partners is working to address key challenges, including synthesising evidence through development of a Global Report on Assistive Technology [42], promoting streamlined and standards-based procurement [43] and supporting global partnerships to address assistive technology such as the AT scale Global Partnership.
The study had several limitations. First, the nine countries were all middle-income countries and had a MOH that had sought WHO support for strengthening rehabilitation in their health systems. The findings therefore cannot be generalised to all middle or low-income countries. Additionally, the relatively small number of upper middle-income countries in the study makes the findings about any distinction between upper and lower middle incomes countries tentative. Limited completeness of information by some countries also meant comparisons were descriptive rather than numerical in some instances. Nevertheless, this study is one of the first using a standardised assessment of rehabilitation using health policy and systems research and as such shines a light on gaps and challenges faced by middle-income countries.
Conclusion
This variable oriented HSPR comparative study adds to the literature by providing for the first-time comprehensive information about rehabilitation across nine middle income countries, shedding light on the limited integration of rehabilitation in health systems and common areas of difficulty and challenge. It found that all countries had a basis on which rehabilitation strengthening efforts could be built, and that systematic analysis, as it is done in STARS, provides a good starting point from which to identify actions that need to be taken at national levels, as well as inform development of regional or global programmes and projects and policy and practice guidance. Additionally, our study can serve as a model for future studies, and by June 2022 a total of 26 countries have commenced STARS highlighting the potential for a larger cross-country comparative study including low-income countries.
Acknowledgments
We thank the consultants who undertook the rehabilitation situation assessments in countries.
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