Disability & rural health: proofing what for whom?

Disability & rural health:

proofing what for whom?

Kate SherryRHAP Rural-Proofing Program Stakeholders’ Forum

26th November 2013

Rural Rehab South Africa• Founded September 2011• Physio, Occupational Therapy, Speech Therapy, Audiology• 2-fold purpose:

- Policy input (NDOH, NDOE)- Promoting rural careers for therapists, including:

- Training institution input- Rural therapists’ support network- Development of best practice

So what is “rehab”?

Disability in context

Poverty

RuralityDisability

Disability as a development issue• Links with poverty:Disabled people = 20% of poorest people

(World Bank in Yeo 2003)• Links with rurality: 80% of chronically poor households = rural

(Aliber 2001)• Links with MDG’s: Cannot eradicate poverty unless PWD’s are

included in development efforts (Lee 1999)

• Population estimates: 4-10%, depending on source and definitions

Population at risk of/affected by disability• Quadruple burden of disease:

- HIV/AIDS & TB –> neurological, developmental, and other impairments- NCD’s –> stroke, amputation, loss of eyesight, loss of vital capacity,

MENTAL HEALTH- Maternal & child care –> birth trauma leading to neurological and

developmental impairments, birth defects, intrauterine impairment (e.g. FAS)- Trauma & violence -> SCI, TBI, orthopaedic, mental health sequelae MAJORITY of health-care users are at risk (NB prevention)Most households will have a disabled member at some point

Role of environment in determining level of participation restriction

So what do therapists do?

Ways of thinking about disability• “Medical model”:

- Individual, problem-centred focusIntervention response: “Fix what is broken”Services: technical, institution-centred, individual-focusedBlind spot: impairments that cannot be “fixed”

Ways of thinking about disability (2)• “Welfare model”

- Individual (sometimes family), basic needs & maintenancefocusIntervention response: “care”Services: traditionally institution-basedBlind spots: long-term sustainability, isolation

Ways of thinking about disability (3)• “Social model”

- Focus on barriers in society, aim at full participation Intervention response: create environments that aim at

inclusion- “community-based rehabilitation” (CBR)Services: integrated, community-based, multisectoralBlind spot: value of technical rehabilitation

So what?• Each model dictates different service emphasis, different service

delivery platform• Current international thinking most strongly influenced by

International Classification of Functioning (ICF) (WHO,2001)System of describing functioning of person with a health

condition (replacing “disability and handicap”)Attempts balance between need for individual/technical

rehab and community-level interventions• Global “best practice WHO Guidelines on Community-Based

Rehabilitation (2010)

CBR: what does it mean?• Rehab belongs to every sector, not just health

• “Rehabilitation” used in 2 senses – the whole picture, AND the technical service offered under health cluster

• Shares principles with PHC: accessibility, affordability, sustainability, community participation, etc

In South Africa:• Strong disability movement during 1980’s and 1990’s – relatively

progressive policy put in place by post-1994 administration• Integrated National Disability Strategy (1997)• Policies based on CBR exist in Health (National Rehab Policy, 2009),

Education (White Paper 6 on Inclusive Education, 2001) and Social Development (DSD Policy on Disability, 2010), amongst others• Health has been the most proactive sector, employs the majority of

rehab therapists• Nonetheless, implementation of the NRP has not really been realised

Key policies for rehab in South Africa• Constitution of South Africa (1996)• Integrated National Disability Strategy (1997)• Norms & Standards for a Comprehensive PHC Package (2000 & 2010) • National Rehabilitation Policy (2000)• Community Service for Rehab Professionals (2003)• Assistive Devices Policy (2003)• Uniform Patient Fees System (annual)• Free Health Care for PWD’s (2003)• UN Convention on the Rights of PWD’s (2006, ratified by SA 2007)

A picture of the sector• Split between disability movement and (mainstream) professionals• Fragmentation within disability movement• Professional territorialism and lack of unity• Tertiary, institution-focused, and private sector weighting• Mid-level worker debate• Lack of national and provincial leadership in public sector

Recent progress• Public sector professional forums move for joint meeting• Professional organisations desire to increase public sector

membership• Training institutions: increased PHC focus• Rural community service placements • SA ratifies UNCRPD• National Rehabilitation Task Team • Role of RuReSA

Rehab in health sector context• Competition of priorities: underrated by managers and officials

• Rehab/disability is a stigmatised and overlooked issue Impact on institutional placement and power

Impact on HR: recruitment and retention

• Policy as PROCESS (Walt & Gilson 1994): e.g. research in Umzimvubu subdistrict, Sherry & Watson 2010

Rehab as a “silo” is ineffective

Disability needs to be integrated in every program, at every level – if it is to be addressed at all

A major attitude shift is needed

Health policies need to be disability-proofed, as well as rural-

proofed

3 aspects to rural rehab policy work• Getting basic disability/rehab policies in place• Making sure these are rural-friendly• Making sure all health policies are disability-friendly

Getting basic rehab policies in place• Historical lack of clear service level agreements – provincially

dependent, no benchmarks

• E.g. NHI Rehab Task Team – service delivery platform & basic service package, staffing allocations

Rural issues in rehab• ACCESS ACCESS ACCESS• Terrain and infrastructure• Economic implications• HR challenges• Sustained engagement with service

Service model: home & clinic based- OUTREACHbroad scopemid-level worker cadrecontinuity of care, record-keeping & tracingtime allocations

Ensuring rehab policies are rural-friendlyExamples:• Mid-level worker debate: generic vs profession-specific• Staffing structure e.g. KZN 2013

Ensuring health policies are rehab-friendlyExamples:• CCG level 1 training (2012): presence of a disabled person signifies a

vulnerable household• All standard treatment guidelines: need to include referral to rehab

– audit implications• Access to services (DPW, other): include sign-language interpreters,

large-print/braille text, multiple media, strategies for reaching a hard-to-reach population, physical access, signage, security/assistance

Backing other rural-rehab-friendly policies • E.g. PHC re-engineering:Shift to household-levelStrengthen CHW networksPrevention and health promotion

• We add:Outreach budgeted and planned forDistrict hospital as hubMid-level rehab workers at clinic levelRole of therapists in schools addressed

Where to from here?• Need for baseline data• Rural-friendly basic rehab package • Commitment to HR and budget• Translation at provincial level• Integration across programs within health• Unite disability sector for stronger voice• Tackle other sectors…

Thank you!Questions?