Health Systems Approach to Strengthen Rehabilitation

Abstract

Rehabilitation has been identified by the World Health Organization (WHO) as one of the key components in achieving Sustainable Development Goal (SDG) 3: “Ensure healthy lives and promote well-being for all at all ages”. Universal health coverage, as the main strategy to attain SDG 3, entails the provision of promotive, preventive, curative, rehabilitative, and palliative services across the continuum of care. With the passage of the Philippine’s Universal Health Care (UHC) bill into law as Republic Act 11223 in 2019, rehabilitation is now included in the essential packages of primary to tertiary level health care services. Hence, we are experiencing and we are expecting an increase in demand for rehabilitation in the country.

“Rehabilitation in Health Systems: Guide for Action” was published by the WHO in 2019 to help countries and their respective governments utilize health system strengthening practices to address the unmet needs for rehabilitation. The recommended 4-phase process includes: (1) situation assessment; (2) strategic planning; (3) development of monitoring, evaluation, and review processes; and (4) implementation of the strategic plan. Throughout these four stages, WHO’s Health Systems Building Blocks Framework will be used to navigate the different components of rehabilitation. These six building blocks are health workforce, service delivery, medicine and technology, health information systems, health financing, and leadership and governance.

Where are we now? Beginning with the first step–situation assessment–a brief review of the articles published in the Rehabilitation Medicine Issues of Acta Medica Philippina since 2010 can give us a glimpse of the status of rehabilitation in each of the building blocks.

Health Workforce

Anticipating the increased necessity for rehabilitation, capacity building of healthcare workers is paramount to strengthen the health system. Innovations in training on Rehabilitation Medicine are being implemented across the spectrum of medical and postgraduate education in the University of the Philippines (UP) College of Medicine and Philippine General Hospital (PGH). Undergraduate medical students were equipped with skills in musculoskeletal medicine, a core competency in rehabilitation, through strategies such as the Gait, Arms, Legs and Spine (GALS) Locomotor Screen Teaching-Learning Package. Virtual learning approach to residency training has also been explored among PGH Rehabilitation Medicine residents and faculty in response to the restrictions brought by the pandemic. Finally, in light of the demands for specialized rehabilitation services, a Fellowship Program in Musculoskeletal Rehabilitation Medicine has been developed, the first of its kind in the country.

Wellness among health professionals, both physical and mental, was also a recurring theme in the publications. A healthcare workforce that can deliver quality services needs to be a healthy workforce. The pandemic brought mental health to the forefront. A survey among the rehabilitation medical and paramedical staff during the pandemic found that majority used functional coping strategies and had relatively high job satisfaction despite the health risks at that time. In this 2024 Rehabilitation Medicine issue, focus has been shifted to a more preventive perspective of physical wellness with two studies describing the levels of physical activity among staff of the PGH community and how these findings can be applied to create a healthier work environment.

Service Delivery

Telerehabilitation as a means of service delivery has been the highlight of recent articles. In 2022, the application of telehealth as an alternative method for patient consultation during the COVID-19 pandemic was examined. The PGH medical community had very good telemedicine readiness and acceptance. Similarly, a case series of PGH patients who transitioned from in-person rehabilitation to telemedicine showed good satisfaction with the program’s implementation and outcomes. The utility of telerehabilitation as a means to improve access to healthcare beyond the pandemic and beyond the community of PGH will be elaborated in this issue. The acceptance and willingness to use telemedicine were surveyed among populations with special needs like Doctors to the Barrios, who serve municipalities in remote areas, and caregivers of pediatric patients and children with disabilities.

Creative strategies for rehabilitation interventions have also been developed through collaboration with other disciplines. In partnership with the UP College of Music, the “G.T.A.R.A. (Grip/Grasp Training with Active Range of Motion Activities using Guitar)” project tested guitar exercises as a means to restore hand function among patients with unilateral hand impairment.

Challenges in service delivery can be properly identified and resolved through operational research. The Division of Physical Therapy recognized the need to revisit their operations to improve human resource allocation and prioritization of deliverables while maintaining the quality of rehabilitation treatment. They initiated a time and motion study to objectively assess the hospital’s current processes.

Medicine and Technology

Assistive technology is one of the foundations of rehabilitation. The “Walking Free” Program aimed to ensure sustainable delivery of quality prosthesis to indigent Filipino amputees. It cited “inclusion of prosthetic devices in the reimbursement package by the Philippine Health Insurance Commission” as one of the critical factors towards successful implementation. Fourteen years after its publication in 2010, we are reaping the benefits of the program with Philhealth packages now readily available for Filipino amputees.

Health Information Systems

Information on rehabilitation needs to be collected using validated and appropriate tools in order to be inclusive and to have a better representation of Filipinos. In this issue, the process of translating and testing the reliability of the Filipino Gross Motor Functional Classification System (GMFCS) for cerebral palsy has been described. This translated tool will be beneficial locally as services for Children with Disabilities are being prioritized at the community level.

Financing

Financial risk protection is essential in universal health coverage. In preparation for UHC implementation, the “Functionbased Rehabilitation Model” was created. The framework emphasized the differences between disease and impairment, and how a single disease entity such as stroke, can manifest with different impaired functions across individuals. They have identified four major disability categories based on function: mobility, self-care, cognitive/behavioral, and communication. These recommendations would serve as guides in the development of comprehensive rehabilitation benefit packages and in the implementation of an expanded insurance coverage.

Leadership and Governance

Government leadership and commitment is integral in the success of strengthening rehabilitation. Among the six building blocks, leadership and governance have not been explored in any of the Acta Medica Rehabilitation Medicine issues. Reviews on legislations relevant to rehabilitation and evaluation of their implementation can be future topics of interest. Studies focusing on disability should also be considered to guide leaders in creating policies that promote inclusive development.

The WHO defined rehabilitation as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment.” The combination of increasing proportion of elderly population and increasing prevalence of non-communicable diseases will further magnify the unmet needs of rehabilitation. There are efforts to address these demands for services in the country as seen through the articles mentioned. However, there are gaps that limit their impact to the community. More often, rehabilitation services and assistive technology are available, but the target population have limited access and could not afford them. Similarly, policies are enacted, but the infrastructures and human resources for rehabilitation service delivery are ill-prepared for their implementation. A harmonized health systems approach, anchored in good leadership and political support, will ensure sustainability of these initiatives and will maximize their effects to strengthen rehabilitation.