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Retis C.1, Pryor W.2, Lippolis G.3
1Handicap International, Rehabilitation Unit, Phnom Penh, Cambodia, 2Nossal Institute for Global Health University of Melbourne, Melbourne, Australia, 3Handicap International, Rehabilitation Unit, Brussels, Belgium
Background: There is an unmet need for quality rehabilitation care in emerging health systems. Even with recent policy push factors such as World Health Assembly resolutions calling for better support for rehabilitation, enormous challenges remain, including a lack of simple means to monitor compliance with recognized standards of practice. As an attempt to fill this gap, we developed and implemented a scoring system, based on a balanced scorecard approach, in 19 rehabilitation centers supported by Handicap International in 8 countries.
Purpose: We report on compliance of recognised standards of practice in a cross section of rehabilitation services in low and middle income countries and on the experience of rehabilitation teams, including physiotherapists, in implementing them.
Methods: Standards for services were derived from a consensus-based list of guidelines for rehabilitation and were operationalised into ordinal scores between 0 (critical issues) and 3 (exceeds the standard) with simple descriptors for each score. Standards cover domains related to the building blocks of the WHO health system strengthening framework. Scoring was performed in collaboration with management at the rehabilitation centres. Overall compliance with standards, frequency of compliance within the different scoring areas and simple descriptive information of high and low performing centres were determined from 15 centers. Information on experience in implementation of standards was gathered through an online survey.
Results: Overall, 36% of standards were met or exceeded. Compliance within each scoring domain was between 27% (finances) and 56% (user-focused approach). Scoring domains with relatively infrequent compliance were: implementation of evidence based practice, workplace safety, cost calculation and recovery, and in routine service evaluations. Strongly performing areas were: understanding the client experience, budgeting and financial accountability and general governance practices. Reported difficulties in implementing scoring were for standards related to evidence based practice, community based rehabilitation, monitoring and evaluation, finance and human resources management. Reasons behind those difficulties included limited knowledge on references and evidence, limited management skills and resources, language barriers.
Conclusion(s): In a cross section of rehabilitation services in low and middle income countries, compliance with consensus-based standards is modest. More research to understand reasons for poor uptake of guidelines is required, along with the identification of determinants of good compliance and research to develop simple but reliable management solutions. A minimum set of indicators or a process of systematic prioritisation for use of these practices in small services with limited human and financial resources is needed.
Implications: Current investment in guidelines for rehabilitation practice should be matched with efforts to ensure they are simple to implement, monitor and improve performance, taking into account sustainability issues and outcomes for service users. Relative weaknesses could be addressed through targeted technical, management and financial support to complement service delivery. Review of existing standards of practice using participatory, consensus-based techniques is required to include new evidence and good practice.
Funding acknowledgements: This study was funded and implemented by Handicap International in collaboration with Nossal Institute of Global Health, Melbourne.
Topic: Globalisation: health systems, policies & strategies
Ethics approval: Ethics approval for the use of data was obtained from the University of Melbourne. Rehabilitation centre managers gave written consent.
All authors, affiliations and abstracts have been published as submitted.
