Rehabilitation in the Fragile Health Systems of Low-Resource and Conflict-Affected Settings

The World Health Organization’s Rehabilitation 2030 initiative and call for action to integrate rehabilitation within health systems has led to increased collaborations, research projects and awareness since its launch in 2017. However, a large number of people with disabilities do not benefit from these developments as they live in countries of protracted conflict with health systems too fragile to prioritise rehabilitation. Research on rehabilitation in such contexts is still extremely rare and has not yet been conducted on a cross-national scale. Therefore, the aim of this PhD is to understand rehabilitation in the fragile health systems of low-resource and conflict-affected contexts to identify priorities for the development of rehabilitation services there and for future research. A mixed methods approach was employed. Two retrospective observational studies analysed the demographic and clinical characteristics of 287,274 rehabilitation users in 14 countries and the demographic and amputation characteristics of 28,446 rehabilitation users with amputation in five countries, using descriptive statistics. Data originate from an ICRC-developed database of routinely collected data on persons accessing ICRC-supported rehabilitation structures. Two qualitative focus group studies identified the perspectives of 35 ICRC-employed or -partner physiotherapists from 18 countries about barriers and facilitators of rehabilitation service development and about measuring rehabilitation outcomes in such contexts, using reflexive thematic analysis in an inductive and deductive approach to data analysis, respectively. To discuss study findings, the Rehabilitation in Conflict (RiC) framework was developed. It consists of the four components Context, Systems, Population and Services. Key findings were the diversity and complexity of context, which affects rehabilitation needs and how they are addressed. Indicators of weak health systems were found in all studies, as well as fragmented education, economic, and other systems. Rehabilitation users were characterised by low female representation, young age and disabilities caused by conflict and system challenges. Rehabilitation services were marked by a lack of recognition and health systems integration and a strong but insufficient workforce of mainly physiotherapists who lack appropriate outcome measures to reliably demonstrate impact. It is recommended that rehabilitation strengthening in such contexts starts on services level to drive change on systems level. This requires simple, reliable data collections, training, and service provision that pilots feasible, contextualised rehabilitation outcome measurement and models of care. Future research should explore disability prevalence, rehabilitation needs and outcomes including the perspectives of users, access barriers for women and possibly other neglected populations, using participatory approaches. Finally, implementation research is advised to investigate the development of rehabilitation in the most fragile contexts worldwide.2023-09-08 JG: Author's hand signature removed from PD