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 Table of Contents  
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 51-60

Implementation of rehabilitation innovations: A global priority for a healthier society

Department of Rehabilitation Medicine, Royal Melbourne Hospital; Australian Rehabilitation Research Centre, Royal Melbourne Hospital; Department of Medicine, Royal Melbourne Hospital, The University of Melbourne; Peter MacCallum Cancer Centre, Parkville, Victoria, Australia

Date of Submission17-Feb-2022
Date of Decision20-Mar-2022
Date of Acceptance25-Apr-2022
Date of Web Publication07-Jun-2022

Correspondence Address:
Dr. Bhasker Amatya
Department of Rehabilitation Medicine, Royal Melbourne Hospital, 34-54 Poplar Road, Melbourne, Parkville 3052, Victoria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisprm.JISPRM-000160

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With improved global survival rates, there is an increased demand for health-care needs for persons with noncommunicable diseases, chronic illnesses, and disaster survivors (including pandemics). Many countries struggle to meet the existing demand for health care, including rehabilitation services. Further, many persons with disability still experience socioeconomic inequity/disparities in accessing rehabilitation services. Despite increased demand for rehabilitation, many countries globally struggle to meet existing demand due to economic, social, and other barriers. The World Health Organization (WHO) initiative “Rehabilitation 2030: A Call for Action” promotes universal access to rehabilitation and prioritizes the scaling-up and strengthening of rehabilitation services and strong governance of global health partnerships and coordination between the authorities and public. The WHO launched a conceptual framework “WHO Rehabilitation in Health Systems: Guide for Action” for the development and implementation of an effective rehabilitation program within the health-care system. This pivotal resource provides detailed steps to lead governments through rehabilitation system strengthening practice specifically in low- and middle-income countries, organized in four key phases: (i) assessment of the situation; (ii) development of a rehabilitation strategic plan; (iii) establishment of the monitoring, evaluation, and review processes; and (iv) implementation of the strategic plan. The goal is to shift health trajectories onto the rehabilitation-inclusive system in a sustainable and equitable path. The article aims to provide an overview of key global initiatives in disability and rehabilitation, exclusively highlighting the WHO framework and other innovative care models for consideration.

Keywords: Disability, functioning, global health, rehabilitation

How to cite this article:
Amatya B, Khan F. Implementation of rehabilitation innovations: A global priority for a healthier society. J Int Soc Phys Rehabil Med 2022;5:51-60

How to cite this URL:
Amatya B, Khan F. Implementation of rehabilitation innovations: A global priority for a healthier society. J Int Soc Phys Rehabil Med [serial online] 2022 [cited 2023 May 28];5:51-60. Available from: https://www.jisprm.org/text.asp?2022/5/2/51/346840

  Introduction Top

Global health is in transition in many contexts. The Global Burden of Disease report suggests four key epidemiological demographic transitional points: disease transition, i.e., communicable diseases that have long occupied international health initiatives are now replaced with noncommunicable diseases (NCDs) such as cancer, cardiovascular disease, diabetes, and others (constituting 80% of disability burden); disability transition, i.e., many of these NCDs are in younger populations with worse outcomes; health risk transition, i.e., shift in disease risk factors from poverty-related issues to lifestyle-related risk factors due to global financial improvement (such as obesity and environmental changes/pollution); and demographic transitions, i.e., increase in the aging population with a significant increase in life expectancy and decline in birth rates.[1],[2] Compared with 1950, in 2017, the average life expectancy for males and females increased from 48 to 71 years and 53 to 76 years, respectively.[1],[2]

The global prevalence of disability is escalating, potentially due to the aforementioned global health transitions, increased natural/man-made disasters, and pandemics.[3],[4],[5] There are an estimated one billion people in the world with some form of disability, equating to 15% of the world population or 1 in 7 people.[4] Of these, 11%–19% have significant difficulties, such as inability to walk, perform self-care, communicate, or participate in education or employment.[4] The prevalence of health conditions associated with severe disability such as epilepsy, multiple sclerosis, and cancer has increased by nearly 23% since 2005.[6] Further, the majority of persons with disability (PwD) (approximately 80%) live in low- and middle-income countries (LMICs).[4],[7] Although disability poses significant economic and social costs, there are no inclusive data estimates for the overall cost of disability.[4] It is estimated that 15% of all years lived with disability (YLDs) are caused by health conditions associated with severe levels of disability.[6] Disability-related cost is around 10% of public social expenditure across the Organisation for Economic Co-operation and Development (up to 25% in some countries).[4],[8] Studies estimating the extra costs of disability from different countries report varied numbers, e.g., in the United Kingdom (UK), the estimate ranged from 11% to 69% of income, in Australia, it was 29%–37%, and in Vietnam, the estimated extra costs were only 9%.[4] Further, wide-ranging indirect economic and noneconomic disability-related costs such as loss of productivity, social isolation, and psychological impairments are substantial, but difficult to quantify.[4]

There is evidence that PwD experiences poorer health outcomes than their able-bodied counterparts, and many do not receive basic health-care needs. They face more frequent socioeconomic inequity, with a higher rate of poverty and lower rates for education and employment.[4],[7] These social disparities are strong determinants of health inequities, including restricted access to health services and poorer health outcomes.[4],[7],[9] Further, in addition to general health-care needs, many PwD may require a range of complex services, including rehabilitation.[4] Despite high variability regarding access to rehabilitation services for PwD globally, overall, it was generally low.[10],[11] In many LMICs, most rehabilitation services are not fully developed, and where existing, either they are institutional-based and/or run by outreach services. In many LMICs, rehabilitation services are only available in major metropolitan cities and not covered under the government health-care scheme; hence, they are not affordable to all people who need them. Many PwD get limited access, specifically due to geographical distance, costs, knowledge, and culture and language barriers. Further, various natural disasters and pandemics present considerable challenges to PwD and who are more vulnerable to poorer health outcomes.[3] Many Other factors/barriers and socioeconomic determinants of health exist which impact PwD accessing timely healthcare.[4],[7],[10],[11] [Figure 1] provides an example of factors (health system and social determinants) influencing PwD accessing rehabilitation services, which is structured based on various published reports. These factors impede the right of PwD to achieve the highest attainable standard of physical and mental health, affecting substantial activity, participation, and QoL.
Figure 1: Potential factors impacting access to rehabilitation for persons with disability

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This article presents an overview of key global initiatives in disability and rehabilitation, exclusively highlighting the WHO “Rehabilitation Implementation Framework” and innovative care models for consideration.

  Rehabilitation Service Provision in the Global Context Top

The World Health Organization's (WHO) International Classification of Functioning, Disability, and Health (ICF) identifies “functioning” as a crucial health indicator after morbidity and mortality.[5] This signifies rehabilitation as an essential component across all levels of the health-care system and a pillar for sustainable development, contributing to health, economic, and social development.[12] The WHO defines rehabilitation as, “A set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment.”[13] It is a process to enable people to reach and maintain optimal physical, sensory, intellectual, and psychological functions to enhance participation. Rehabilitation needs have been growing significantly worldwide. Current global health and demographic trends indicate that a higher proportion of the world population will live with limitations in function, and likely experience disability, therefore the increase in global demand for rehabilitation.[5] In 2019, an estimated 2.41 billion (95% uncertainty interval [UI]: 2.34–2.50) individuals worldwide had conditions that would benefit from rehabilitation, contributing to 310 million (95% UI: 235–392) YLDs.[14] This equates to at least one in every three people requiring rehabilitation at some point during their disease or injury course.[14] This equates to a 63% increase in estimated YLDs germane to physical rehabilitation from 1990.[14] This signifies the urgent need for global scaling-up and strengthening of rehabilitation services (infrastructure, workforce, resources, etc.), for timely delivery of affordable services.[15] However, the availability of rehabilitation services varies across settings, and the overall global unmet needs of rehabilitation is profound, specifically in LMICs.[6] Cieza et al. analyzing the evolving trends in physical rehabilitation needs, using data on YLDs, from the Global Burden of Disease Study 2019 reported that the Western Pacific region had the highest need of rehabilitation services (610 million people, 83 million YLDs), followed by the Southeast Asia region (593 million people, 77 million YLDs).[14] Further, the highest contributor to the prevalence of estimated rehabilitation needs was musculoskeletal disorders (1.71 billion people, 149 million YLDs), followed by sensory impairments (677 million people, 45 million YLDs) and neurological disorders (255 million people, 51 million YLDs).[14]

The access to and timely delivery of rehabilitation services is challenging in many countries.[13] In LMICs, the density of skilled health-care professionals (physicians, nurses, and midwives) is suboptimal: an estimated 890 per million population in Africa, 1900 per million in South-East Asia, and 2210 per million population in the Eastern Mediterranean regions.[6],[12] The data on rehabilitation services and trained rehabilitation professionals are often fragmented.[4],[12] The unmet need for rehabilitation is across every area of specialized rehabilitation services such as rehabilitation medicine, physiotherapy, occupational therapy, prosthetics, and orthotics.[6] The number of skilled rehabilitation practitioners in many LMICs is estimated to be below 10 per 1 million population.[6] The data available from the Eastern Mediterranean and South-East Asia regions show that the density of rehabilitation physicians is below 1 per 1 million population.[6],[13]

There is evidence to support rehabilitation as an integral component of the health-care process (including disasters) for the physical, mental, social, and vocational abilities of survivors.[3],[16],[17],[18] The current evidence on coronavirus disease 2019 (COVID-19) survivors reports a range of functional and psychological impairments, resulting in disabilities, in both acute and subacute stages of recovery, and most are amenable to rehabilitation.[19],[20] The COVID-19 pandemic is an unprecedented challenge for the health-care sector, including rehabilitation and has tested the resilience of health systems of even developed countries,[19] and many LMICs are struggling to contain and manage this pandemic, with devastating effects on their health-care system and economy.[21] Further, during this pandemic, a widespread disruption of health-care services is reported, with disruption of rehabilitation services noted in an estimated two-thirds (63%) of the countries worldwide.[22] To date, more focus has been on acute care and public health measures, while rehabilitation has been a lesser priority.[21],[22] A need for a comprehensive biopsychosocial model, as opposed to the medical model, is fully expressed.[23] Therefore, inventive approaches with a global coordinated, collaborative effort with the involvement of key governing organizations, governments, nongovernmental organizations, PwD and local community, are now needed for an effective response to deliver evidence-based rehabilitation-inclusive care to survivors.

  Key Global Initiatives Top

In 1978, the Alma-Ata Declaration accepted that health is not just “absence of disease and infirmity” but a “state of complete physical, mental, and social well-being,” and recognized rehabilitation as a core health strategy to maintain population health.[5],[24] This definition is further conceptualized in the ICF (body function and structure; activities and participation),[25],[26] with disability as the interaction between the PwD and their environment.[4],[25],[27] The UN Convention on the Rights of Persons with Disabilities (CRPD) (2006) secured equal rights for PwD for an inclusive society, with core human values of dignity and autonomy.[28] Further, rehabilitation is considered a fundamental health strategy to achieve the goals of universal health care (along with health promotion, prevention, and palliation).[29] The 2030 Agenda for Sustainable Development at the global level in its Goal 3 (SDG 3-Health) calls for healthy lives and well-being for all, implicitly establishing the goal for PwD and developing disability-inclusive health-care development. The Global Disability Action Plan 2014–2021: Better Health for All People with Disability aligns with the principles of universal health coverage and proposes to strengthen the disability-specific services related to rehabilitation, habilitation, assistive products, and community-based rehabilitation (CBR). The “Rehabilitation 2030: A Call for Action” proposes practical actions to strengthen rehabilitation in health-care systems with the inclusion of various strategies, such as rehabilitation awareness programs, engagement and participation of stakeholders, development of policies, and implementation of innovative programs. The International Society of Physical and Rehabilitation Medicine (ISPRM) has a crucial role with key organizations such as the WHO, UN, and regional, local rehabilitation authorities and international nongovernmental organizations.[30] Its potential role in disasters, including pandemics, is detailed in earlier publications.[31] It supports the whole-of-society approaches that many countries have taken in coordination with the Global Health Community to respond to unforeseen disasters such as the COVID-19 pandemic.

In the last two decades, significant developments in international and national collaboration and management capacity in rehabilitation have occurred. Some key global initiatives and developments in disability and rehabilitation are listed in [Table 1].
Table 1: Some of the key global disability and rehabilitation initiatives

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  Structured Framework for Rehabilitation Program Implementation Top

A “model of care” is a multifaceted concept, which broadly defines how health care is delivered including the values and principles; the roles and structures; and the care management and follow-up and referral processes.[36] Managing and coordinating care for PwD is inherently complex due to multiple long-term needs and depends strongly on social dynamics at various levels of the health systems. Designing and implementing models of care for efficient management of PwD throughout their disease trajectory requires an integrated care approach with the involvement of various stakeholders.[36] Evidence suggests that integrated health-care model should incorporate four key types of integrations: organizational (bringing together several organizations through coordinated provider networks), functional (integration of nonclinical support), service (integration of different clinical services at an organizational level), and clinical (integration of clinical care delivered by different health-care providers through shared protocols or evidence-based guidelines).[36] The rehabilitation model of care elements should be evidence based, emphasizing patient education and self-management empowering and preparing patients to manage their needs. It should embrace longitudinal, community-based, and integrated approaches placing patients at the center to enhance access to services and decrease variations in the quality of care.

Rehabilitation services vary across countries and are based on local disability trends and patterns.[6] Largely, rehabilitation need is growing significantly globally and across countries of varying income levels, specifically in the LMICs (111.5% growth),[37] where rehabilitation service provision and infrastructure is limited and/or health systems do not yet have the capacity to meet the demand for rehabilitation.[6],[12],[37],[38] One key reason is the fragmented and poorly integrated health system, which undermines the ability to provide universal, equitable, and high-quality sustainable health care.[39] From the perspective of the health-care system, the need for specific rehabilitation services is relevant in relation to efficacy, patient-care quality, resource investment, and overall health of the population.[5],[40],[41] Despite the availability of various theoretical frameworks for the implementation and evaluation of healthcare programs/interventions, the information on specific rehabilitation programs is limited.[42],[43] A necessity for innovative solutions toward developing and implementing locally suitable unevenly distributed rehabilitation programs is a prerequisite to providing timely and high-quality rehabilitation to those in need. Therefore, evaluation and mapping of the existing services, through which to view the gaps in service and care provision for PwD, is the first step in changing the treatment paradigms currently used to manage this population. Disability itself is a unique clinical entity, different from medical conditions and comorbidities.[44],[45]

The WHO in collaboration with the ISPRM is developing “National Disability Health and Rehabilitation Plan,” for individual countries.[25],[46] This health system approach is based on strengthening rehabilitation services and building the capacity of the rehabilitation workforce, based on the rehabilitation needs at a population level. This framework provides a matrix for checklists to map existing rehabilitation services to identify gaps in service provision. This is achieved by the establishment of Rehabilitation Advisory Teams, comprising experts in global and regional health systems for guidance to local governments.[25],[46] The “Framework on integrated people-centered care,” endorsed in the 69th World Health Assembly 2016, emphasizes the need for an integrated, people-centered approach to responding to emerging and varied global health challenges.[39] This framework sets a vision of equitable and timely access to quality health services that are comprehensive, safe, effective, and coordinated across the continuum of care. It proposes five interdependent strategies for primary health care, which are also applicable to rehabilitation services, which include empowerment and engagement of people and communities; strengthening governance and accountability; reorienting the model of care; coordinated services within and across sectors; and creation of an enabling environment.[39]

Although rehabilitation strategies may differ across countries and needs, commitment from all actors in the area is vital for a sustainable economic trajectory and an inclusive society. Rehabilitation strategies must consider local needs and contexts, existing resources and service delivery systems, rules and regulations, potential barriers, and cultural/social values.[25],[39] These require a coordinated multistakeholder engagement plan for effective implementation and improved advocacy, which is adaptable in routine clinical practice. Successful implementation of rehabilitation programs/interventions requires planning, collective engagement, monitoring and evaluation, effective communication, and transparency and accountability.[39] Further, various factors need to be considered for the successful implementation of a rehabilitation program [Box 1].[12],[25],[46],[47]

Rehabilitation services play an integral role within the health-care continuum and integration of rehabilitation into the health system, and strengthening rehabilitation services at all levels is key to scaling-up rehabilitation to reach all those in need.[48],[49] The development of an efficient, effective program and its successful implementation requires a structured framework. This is more prominent for rehabilitation, as rehabilitation requires a multidimensional approach with the involvement of multidisciplinary team. Various general conceptual framework has been developed, which include the Reach, Effectiveness, Adoption, Implementation, and Maintenance Framework,[50] Theoretical Framework of Innovation Process in Healthcare (developed by Fleuren et al.),[42] generic implementation framework,[51] and others. These implementation frameworks address important aspects in process evaluation and implementation of health-care programs into practice (such as rehabilitation) and plan program to be realistic for adoption in a relevant clinical setting (inpatient, ambulatory, and community).[42],[50],[51] The focus is on the innovation to be implemented (rehabilitation program) and describes key stages in the innovative process (introduction of new interventions or programs in health-care settings), with related categories of determinants/factors that may influence the process.[47],[50],[51] These frameworks were developed through rigorous processes and are applicable and widely used in different health-care settings, including rehabilitation settings.[51],[52],[53]

Recently, the WHO's “Rehabilitation 2030: A Call for Action” launched the”Rehabilitation in Health Systems: A guide for Action,” as a practical guide for governments to strengthen rehabilitation within countries.[49] This pivotal resource provides detailed steps to lead governments through rehabilitation system strengthening practice, organized in four key phases: (i) assessment of the situation; (ii) development of a rehabilitation strategic plan; (iii) establishment of the monitoring, evaluation, and review processes; and (iv) implementation of the strategic plan [Figure 2].[49] The cyclical nature of this four-phase process evolves over multiple years and should be used flexibly and tailored to the local situation. It recommends that completion of the four phases will take approximately 12 months with the implementation of the strategic plan (Phase 4) being an ongoing process and includes an annual “plan, do, and evaluate” cycle that is carried out repeatedly over many years. Further, phases 1–3 should be carried out periodically (for example, once every 5 years). This guide focuses on strengthening national planning for rehabilitation, specifically in LMICs and recommends governments for strong leadership, readiness, and commitment.[49] It uses common health system strengthening practices concentrating on the WHO's health system building blocks (leadership and governance, financing, health workforce, service delivery, medicine and technology, and health information system).[49]
Figure 2: The WHO four-phase process of rehabilitation strategy implementation.[49] WHO: World Health Organization

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The proposed WHO conceptual framework [Figure 2] exclusively adapts the principles of key health-care program implementation strategy. The interrelated steps within the framework are essential for the successful implementation and sustainability of any rehabilitation program. Various determinants that may influence each stage and during the transition from one stage to another needs to be considered,[42] such as characteristics of the program (complexity, up-to-date evidence, feasibility, costs associated, etc.); organizational characteristics (organizational structure, processes for decision-making, policies and legislation, governance structures, communication and collaboration, etc.); operational characteristics (infrastructure, workforce, patient characteristics, education/training, monitoring process, attitudes in the society, culture, etc.); and personal characteristics (knowledge, skills and attitudes of the service providers, awareness, motivation, etc.). The framework recognizes the need to understand the local health systems; identify the specific needs and goals of the service, capacity building, and target gaps/barriers; monitor changes; and enhance the research community. The aim is to provide comprehensive rehabilitation across the population, reflecting on the local needs and capabilities, strengthening community involvement in decision-making, improving communication, and enhancing the better use of the resources. The proposed framework can be used as a memory aid, to ensure that all core concepts during the rehabilitation program implementation process are considered. It can be applied also for the development of new implementation programs, and new setting-specific variables can be modified or added accordingly to each block (as required). Therefore, incorporating all sectors within the health-care system is an integral precursor for comprehensive patient care to consolidate current fragmented health-care systems, reduce medical jargon, and improve patient outcomes.[44]

  The Way Forward Top

Health-care authorities acknowledge that rehabilitation should be considered within the context of the overarching health system, evolving context of population health (including pandemics/disasters), and changing needs of patients. Many have taken initiatives in prioritizing different aspects on inclusivity of rehabilitation in the health system, specifically in LMICs. However, ratification of CRPD by many LMICs has yet to bring significant changes to ensure equitable and high-quality rehabilitation services for PwD. Various barriers and gaps still exist, which stem from poor awareness, financial constraints, limited political will, limited skilled workforce and infrastructures, etc. The current COVID-19 pandemic has created a range of additional challenges testing the resilience of many health-care systems and vulnerabilities at all levels (acute, subacute, community, and individuals) on the global stage. This brought numerous operational and organizational challenges to the rehabilitation services, specifically on inpatient caseload management, signifying the need for new patient care models and reshaping of services to deliver comprehensive care effectively.[21] Rehabilitation services are moving toward patient-centered care approach with the collaboration of treating interdisciplinary teams and patients/families to provide the most convenient and effective care delivery and reduce the burden on health-care systems. The current advancement in information technology provides an opportunity for the development of innovative interventions and various alternative methods of service delivery including, telerehabilitation, rehabilitation at home, and community rehabilitation. Due to inadequate health information technology and communication systems strategies in many LMICs, implementation of many of these programs is still challenging, however can be considered in the future. Rehabilitation professionals are in the best position to develop new sets of skills and lead these technologically advanced efforts to provide an effective and financially viable clinical care continuum.

  E-Health Top

The e-health landscape is emerging with the introduction of new applications for efficient patient care, data, and communication across settings and providers. For example, telerehabilitation is replacing the traditional face-to-face consultations extending rehabilitative care beyond the hospital to a convenient location and environment for the patients (typically their home or in the community). This method provides the prospect for appropriate, efficient, and timely access to rehabilitation care to geographically isolated and physically and economically disadvantaged patients. Telerehabilitation can enhance patients' adherence and compliance to the prescribed therapies by providing interactive tasks with feedback, prerecorded sessions, online rehabilitation guidelines/protocols, patient-therapist web-interface platforms, etc. Teleconsultations using videoconferencing and social media platforms are becoming increasingly more feasible for efficient service delivery and to monitor patients' needs and progress. Further, various technology-based interventions are emerging to enhance rehabilitation efforts, such as interactive and stimulating settings via virtual reality, wearable sensors, and robotic assistive devices.

  Rehabilitation at Home Top

“Rehabilitation at home” - a model designed to provide rehabilitation in the patients' home setting is another widely embraced care delivery model in the current pandemic environment. It is a bed-substitution model of service delivery, providing evidence-based rehabilitation practice in the comfort of a person's own home or other suitable environments. Standard care is delivered at home to patients who are medically stable enough to be at home and therefore do not require frequent monitoring. Patients receive similar comprehensive treatment that they would have received had they been in an inpatient hospital bed. Family members as the primary caregivers are actively involved to provide care needs and social and moral support to the patient throughout the recovery process.

  Community-based Rehabilitation Top

CBR and mobile rehabilitation services have gained significant attraction due to their efficacy, cost-effectiveness, and reliability in enhancing social inclusion and adjustment of PwD. The CBR strategy, developed by the WHO in 1979 following the Alma-Ata Declaration, aimed at the equalization of opportunities, improving access to services, poverty alleviation, and social integration, especially of PwD.[54] The 2006 United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) established a CBR matrix, which provided a structured overview of thematic areas: health, education, livelihood, social integration, and empowerment.[54],[55] CBR aims to maximize a person's physical and mental ability and support access to regular and timely services. It promotes active patient participation by enabling access to services in the patients' proximities and convenience.

  Learning Health System Top

Enhancing research and data collection is imperative to build an evidence-based practice and to assist services to understand and meet their operational and strategic objectives. There is a need to develop robust data collection and research processes that can be used to effectively support and improve rehabilitation care and service delivery across the continuum of care. Research and collecting appropriate data enable to evaluate the effectiveness and outcomes of rehabilitation programs and to monitor patient activities (judge improvement/deterioration for agreed goals/priorities), decision-making for appropriate interventions, and resource allocation. Currently, there is a substantial interest in using health information technology and digital strategies to systematically evaluate patients' outcomes in clinical settings for an improved health-care system. Learning health-care systems (LHSs) are emerging globally to leverage advancement in health information technology for health-care practice and quality improvement at lower costs.[56] The key features of the LHS include using data to generate new knowledge (D2K), using knowledge to inform clinical practice (K2P), and evaluating changes in clinical practice (P2D) [Figure 3].[56],[57],[58] In this model, patient care data from clinical practice and research are captured and analyzed in a planned and strategic manner to enable the treating clinicians for an evidence-based clinical decision support system in real time. This clinical information obtained provides insights into gaps and barriers, a better understanding of patient needs, which is subsequently used for the implementation of continuous innovation and quality improvement in clinical practice. Further, service delivery models should be evaluated for efficacy with timely feedback for changes/modifications in clinical practice as required [Figure 3].
Figure 3: The LHS model.[56],[57],[58] LHS: Learning health systems

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  Conclusion Top

Rehabilitation is a core health service for anyone with an acute/chronic health condition or physical impairments that limit functioning and should be available for anyone who needs it. There is an increased demand for rehabilitation due to an aging population, economic transitions, rising NCDs, and other health-care needs of the population. These require an accessible rehabilitation-inclusive health-care system,[48] within universal health coverage,[25] and include strengthening national rehabilitation systems. Despite the existence of various initiatives and policies, there is still a wide gap between the health status of PwD and their able counterparts, particularly in LMICs. The WHO “Rehabilitation 2030: A Call for Action” sets out a practical guide to strengthening rehabilitation processes, specifically in LMICs, where rehabilitation services are still inadequate. Time to “closing the gap in rehabilitation service delivery” through capacity building, advocating awareness, and funding is more evident than ever before. The WHO framework for the implementation of rehabilitation programs outlines shifting health trajectories onto the rehabilitation-inclusive system in a sustainable equitable path. Strong partnerships and coordination between the governing bodies (such as WHO, UN) and other actors in the field (including local governmental bodies, NGOs, disability organisations, etc.) are needed to identify necessities and priorities. There is a need for strengthening capacity building and fostering an environment of empowerment of local service providers. Further, research in LMICs, particularly from the rehabilitation perspective, is scarce. Iterative research processes need to be firmly embedded within new and existing systems to improve the quality of evidence and monitor and evaluate different rehabilitation interventions. Despite the availability of a range of resources in literature to support researchers, conducting research in LMICs can be complex and challenging largely due to logistic, financial, and resource (skilled workforce, infrastructure, etc.) issues. An international coordination center is crucial to build up academic collaboration/partnership to enhance rehabilitation research efforts, provide required resources and support researchers, specifically in LMICs. In the future, the development of the integrated approach of rehabilitation-inclusive health care should consider reshaping/redesigning evidence-based service delivery models using advanced technologies, which are flexible to meet local needs and contemplate both current and future service demand and capacity, care quality, and cost.


We acknowledge the International Society of Physical and Rehabilitation Medicine and Rehabilitation Medicine Society of Australia and New Zealand for their support. The views expressed in this article are of the authors only.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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