Rehabilitation in low-resource health systems (FS-06)

Introduction video



C Barth1, L Bernhard2O Robert Kanyara1, AL Rodrigues1, B Alsakkaf2
1International Committee of the Red Cross, Physical Rehabilitation, Geneva, Switzerland, 2International Committe of the Red Cross, Physical Rehabilitation, Bangui, Central African Republic
Learning objectives:
  1. Understand the complexity of protracted crisis contexts (PCC) and the challenges of strengthening rehabilitation in such settings.
  2. Know specific strategies implemented by the International Committee of the Red Cross (ICRC) rehabilitation programme in a selection of contexts (Centralafrican Republic, South Sudan, Syria, Yemen), their impact and limitations.
  3. Identify requirements to tackle rehabilitation\nneeds in these contexts in the future.

Description: The important Rehabilitation 2030 initiative launched by the World Health Organization (WHO) in 2017 aims to advance the global rehabilitation agenda in low- and middle- income countries (LMICs) (2). However, the initiative starts at a level of systems organization that does not or no longer exist in most protracted crisis contexts (PCC). At the same time, these countries present the most complex and urgent rehabilitation needs (3). Many are simultaneously struggling with challenges typical for high income countries (HIC) (ageing populations, NCDs and other chronic conditions), LMICs (lack of quality healthcare and rehabilitation workforce), and conflict settings (polytrauma, complex injuries, restricted access) (4).

Rehabilitation for persons with permanent impairment and disability (PwD) is demanding in any given context, because it involves long-term programming that requires financial and human resources with specialized skills and a sustainable presence (5). In protracted crises, however, rehabilitation is exceptionally complicated (3). The overall situation in a country may be characterized by political uncertainty, poverty and corruption. The infrastructure may be destroyed or degraded, affecting access to and for the population, buildings and routes, and procurement of rehabilitation products and communications. The economy may be collapsed. The security situation will be volatile and unpredictable. The education system may be weak, perhaps barely existing, complicating post-school professional training. The social system may be fragile due to lack of funds and perspective, and the impact of long-term conflict on a society. The health system may be overwhelmed, dysfunctional, the interlocutors at ministerial level may be lacking, have other priorities and high turnover. The needs for rehabilitation will be increased, urgent and complex. In consequence, the clinical presentations requiring rehabilitation will be pre-existing conditions that were deteriorating or further developing plus physical and psychological traumata accumulated at different points in time. Cultural concepts and beliefs around disability may be stigmatising, hindering the development of rehabilitation policies. Accordingly, the most vulnerable may get further marginalized, exploited and exposed to violence. Persons in need of rehabilitation services may have faced forced displacement and separation from their families whilst living in unfamiliar and unsafe households. Rehabilitation professionals, if existent, may have left the country, even got threatened or killed (6), those still present will be insufficient in numbers and qualifications.

The ICRC's rehabilitation programme\nis active in over 40 countries, many of them PCC and provides services to over\n480,000 PwD per year (4,7,8). Its four strategic objectives are increased and\nenhanced access, quality, sustainability and societal integration to work\ntowards timely, appropriate and affordable rehabilitation services. Despite the\nICRC's universal approach each PCC offers distinct solutions, success stories,\nchallenges and limitations. This diversity will be presented by examples from\nICRC rehabilitation programmes in four PCC addressing the following questions:

How can access to rehabilitation services be improved in the Central African Republic where a lack of workforce, public awareness, financing and infrastructure result in a limited understanding of PwDs' needs?
What defines sustainability in rehabilitation service provision in South Sudan, a country marked by ongoing civil war, natural hazards and poverty?
What strategies help to meet rehabilitation needs in Syria where a previously functioning, collapsed health system is met with complex health conditions typical for LMICs and for conflict?
How can fluctuating levels of international funds be channeled to serve an underdeveloped rehabilitation sector in war-ridden Yemen?

The symposium concludes with an elaboration of sixstrategies and enabling actions proposed to tackle future challenges in PCC:
1. Increase awareness beyond the aid community and foster global exchange of rehabilitation professionals
2. Provide perspectives for PwD and fight stigma by social reintegration measures
3. Work towards sustainability by ongoing capacity building on a technical and managerial level, by 'substituting' systems in absence of those and by strengthening PwD and professional associations
4. Create PCC-adapted guidelines beyond restoring mobility that include participation and reintegration measures
5. Promote collaboration with international actors such as WCPT and WHO
6. Advance and finance data management and research\non prevalence, needs, rehabilitation impact and programming including qualitative\nresearch with PwD and service providers.

Implications/conclusions: This symposium elaborates how rehabilitation needs are being and will have to be\naddressed to work towards achieving SDG 3 in the world's most challenging and\ncomplex contexts of protracted crisis.

1. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Global humanitarian overview 2020 [Internet]. 2019 [cited 2020 Jan 27]. Available from:
2. World Health Organization. Rehabilitation 2030 - a call for action. WHO [Internet]. 2017 [cited 2019 Jul 15]; Available from:
3. Barth CA. Meeting the needs of people with physical disabilities in crisis settings. Bull World Health Organ [Internet]. 2019 Dec 1;97(12):790-790A. Available from:
4. International Committee of the Red Cross. Protracted conflict and humanitarian action: some recent ICRC experiences [Internet]. Geneva; 2016 [cited 2019 Jul 10]. Available from:
5. World Health Organization. Rehabilitation [Internet]. [cited 2020 Jan 27]. Available from:
6. Debarre A. Hard to Reach: Providing Healthcare in Armed Conflict [Internet]. 2018 [cited 2019 Apr 5]. Available from:
7. International Committee of the Red Cross. Physical Rehabilitation Programme. Annual Report 2018. [Internet]. Geneva; 2019 [cited 2019 Sep 16]. Available from:
8. International Committee of the Red Cross. Special Appeal 2018 Disability and Mine Action. 2018.
Key-words: 1. Crisis 2. Rehabilitation 3. Health systems

Funding acknowledgements:We thank the ICRC for funding congress attendance of chair and presenters

All authors, affiliations and abstracts have been published as submitted.

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