Learning, Acting, and Building for Rehabilitation in Health Systems

Our vision is a world where quality rehabilitation services across the lifespan, integrated into strong health systems, are available and accessible to all.

Launched in late 2020, ReLAB-HS was a comprehensive five-year program, funded by the USAID, that responded to the escalating need for physical rehabilitation and AT services in low- and middle-income countries. We worked across all levels of the health system, building technical, policy and research capacity; increasing political commitment; and inspiring leadership.

A commitment to generating evidence and sharing learning was at the heart of ReLAB-HS. Our approach was participatory, involving end users, including people with reduced functioning, disabilities, and those who have sustained injuries in conflict-affected settings.

There are significant barriers to individuals’ access to rehabilitation and AT services. An insufficient rehabilitation workforce combined with the lack of appropriate equipment and limited logistical and financial resources prevent the delivery of services needed to support the timely identification of conditions that would benefit from rehabilitation. Furthermore, a lack of referral systems, poor case management, and both the limited supply of assistive products and their high cost prevent many from accessing services and products that would support improved functioning.

Working with a focus on service delivery, workforce, and leadership and governance, we partnered with stakeholders to demonstrate models for integration of quality rehabilitation and AT services into health systems that were sustainable and created local demand for rehabilitation and AT. We documented this in a way that the process could be replicated in other contexts by local stakeholders.

Publications include toolkits for strengthening local health systems (R-FIT), developing the rehabilitation workforce (IRETT), and creating strong leadership and governance (GRLI). The toolkits contain resources that guide anyone to repeat the process in a way that is adapted to their context.

We also developed a group of rehabilitation and AT champions who can assist in the implementation of these toolkits for other projects and at scale.

ReLAB-HS implemented co-designed interventions with the goal of strengthening the integration of rehabilitation and AT into health systems and is committed to supporting local solutions to integrate quality rehabilitation and AT services into primary care.

ReLAB-HS implemented activities at the district level through Networks of Care, which consisted of both public and private health providers ranging from community health workers to specialist rehabilitation service providers at regional referral or specialty hospitals. In each Network of Care, an improved service delivery model that integrated rehabilitation and AT was co-developed with local stakeholders. The service model included details on how to operationalize services, such as administrative, technical, and clinical processes needed to ensure that consistent, appropriate service can be maintained. Other elements included defining community outreach and clinical roles and responsibilities, establishing referral pathways, improving data collection, and strengthening the supply chain to secure the availability of assistive products as close to the community as possible.

Training was delivered to community health workers, primary care providers, and rehabilitation professionals to ensure that they have the skills to recognize client needs, refer clients to higher levels of care, and/or provide rehabilitation and AT services, according to their respective roles. Quality and integration measures were being used to support the quality improvement process.

In addition, ReLAB-HS tested innovative solutions like the use of a mobile application to assist primary health workers with assessing and providing care for clients with basic rehabilitation needs, advising on AT, referring them to tertiary services as needed, and tracking completed referrals and counter-referrals.

This approach supported coordination among different stakeholders and health service providers from the community level to the regional level to increase access to rehabilitation and AT services. 

Limitations in the rehabilitation workforce capacity represent one of the greatest challenges impacting health systems globally. To support workforce capacity, ReLAB-HS developed globally relevant tools and digital platforms to support the implementation of workforce development activities.

The IRETT contains tools that support:

• Professional regulation of the rehabilitation professions and continuing professional development.
• Academic capacity of education institutions to deliver programs that meet international standards.
• Clinical skills training programs for the development of improved knowledge and skills.
• Advocacy activities to raise awareness and understanding of rehabilitation.

The IRETT tools can be adopted and adapted to local contexts and are focused on creating opportunities for sustainability and scale.

Supporting digital resources include the Rehabilitation Resource Repository, which provides an accessible way to find rehabilitation-related resources; the ReLAB-HS portfolio of online courses hosted on Plus; and the Rehabilitation Community Platform, which provides opportunities for networking, collaboration, and coordination of rehabilitation initiatives.

In addition, ReLAB-HS tested innovative training modules, like the Basic Rehabilitation Package Clinical Resource (BRP-CR), a newly developed resource from the World Health Organization (WHO). The WHO developed the BRP-CR for primary health care providers to support the delivery of “low-cost, high-impact, evidence-based interventions for rehabilitation.” With this training, ReLAB-HS partnered with the WHO to expand the skill sets of primary care providers in Pakistan and Uganda to improve the availability of and access to rehabilitation services.

ReLAB-HS was a uniquely talented international consortium made up of five partner organizations. Led by the Johns Hopkins International Injury Research Unit at the Johns Hopkins Bloomberg School of Public Health, together, they have considerable expertise in health systems, innovation in rehabilitation service delivery, and implementation science, gained from working in over 70 countries.

• Johns Hopkins International Injury Research Unit
• Humanity & Inclusion
• Momentum
• Physiopedia
• The University of Melbourne

Key strategies for integrating rehabilitation and AT in health systems include generating demand, building leadership, strengthening the workforce, and strengthening local service arrangements.

As countries build evidence for unmet needs and develop strategic plans to address them, health planners and other stakeholders need practical guidance on what works, what steps to take, and how to target limited resources in the most effective ways. It is also essential that new interventions are systematically adjusted to suit local contexts, while recognizing that conditions in local health services may also require adjustment for new interventions to be introduced, successful, and sustained.

The R-FIT offers practical steps and tools to guide the integration of rehabilitation and assistive technology in health systems, emphasizing local adaptation and coordination mechanisms.

The R-FIT guides local actors with key steps and tools to support them in selecting and adapting interventions based on recent evidence and good practices that are relevant to local conditions. The R-FIT was developed to complement and draw on findings from analyses and guides, such as the WHO's Rehabilitation in Health Systems: Guide for Action, focusing on how to implement solutions to deliver on strategic plans and solve priority challenges.

The R-FIT guides stakeholders in setting up local arrangements and assessing readiness, including access to necessary information, such as findings from relevant analyses. The aim was to generate buy-in and establish coordination mechanisms necessary to decide on and implement local actions.

Key steps in choosing options for integration after assessing local rehabilitation performance and integration were outlined in the R-FIT, including a menu of existing standards and goals to select from, along with relevant actions and examples of evidence-based interventions to address them. This included guidance and tools for describing and revising local service arrangements to make progress toward priority goals and introduce priority interventions. This aimed to provide a method for systematically describing how rehabilitation and AT intersect with other health services and to identify necessary short- and long-term changes.

The R-FIT also includes steps and guidance to adapt and introduce specific interventions, including introducing training and service changes for primary health care workers (such as the WHO’s Basic Rehabilitation Package Clinical Resource), assistive product procurement, assistive product training, and local governance mechanisms.

The R-FIT was developed in consultation with ReLAB-HS collaborators to identify the most useful guidance at each key implementation step and by drawing on current evidence. Its development was supported by an advisory group comprised of ReLAB-HS partners, local collaborators, and external groups who are potential implementers of rehabilitation and AT interventions at local levels and might benefit from guidance and tools.

R-FIT planned modules

1. Set up: Establish preliminary arrangements locally and assess readiness
2. Assess local rehabilitation quality and integration and establish priority local actions
3. Review progress
4. Making local service changes

Key challenges for the rehabilitation workforce include having well-regulated professions, academic programs that meet international standards, and finding sufficient opportunities for continued professional development. The International Rehabilitation Education and Training Toolkit (IRETT) contains tools that aim to contribute to efforts in overcoming these challenges.

The Academic Program Reflection Tool (APRT) guides training institutions to create or critically review and update their rehabilitation programs; the Professional Regulation Reflection Tool (PRRT) assists professional associations in developing effective strategies for the regulation of rehabilitation professions; and the Clinical Skills Training Tool (CSTT) supports stakeholders to develop and deliver training activities for the development of improved knowledge and skills among service providers. These tools make up the IRETT.

Each of the three tools contains comprehensive workbooks to guide the process with accompanying worksheets that are centered around a common “Plan,” “Do,” “Assess,” “Adjust” reflective process. The tools can be used independently or with support from an IRETT mentor.

A defining feature of the IRETT tools is that they can be adopted by anyone, adapted to any context, and are focused on creating opportunities for sustainability and scale. These tools are expected to help strengthen rehabilitation education, training, and regulation, which in turn should help to strengthen rehabilitation service quality and therefore client outcomes.

Digital resources available to support the use of the IRETT include the Rehabilitation Resource Repository, which provides an accessible way to find rehabilitation-related resources and the ReLAB-HS portfolio of online courses hosted on Plus.

The IRETT offers comprehensive tools for addressing workforce challenges, promoting reflective processes in academic programs, enhancing professional regulation, and developing clinical skills training.

• Academic Program Reflection Tool (APRT) - This is a structured guide to support the review of academic programs for rehabilitation professions. The purpose of the tool is to use a reflective review process to identify opportunities to create meaningful change to strengthen academic programs. It is targeted at academic institutions that are developing new entry-level rehabilitation programs, as well as existing academic programs that are driven to strengthen their programs.
• Professional Regulation Reflection Tool (PRRT) - This tool helps to identify gaps in policy documents for the regulation of a profession. The aim is to support professional associations and regulatory bodies to develop new policy for regulation, as well as review existing strategy in a structured process. It is suitable for use by associations and regulatory bodies for strengthening the regulation of their profession. This tool can also be used interprofessionally when different associations decide to pursue a shared vision.
• Clinical Skills Training Tool (CSTT) - This is a set of resources that can be used to create training programs for developing clinical knowledge and skills. The purpose of the tool is to guide the development and delivery of continuing education and professional development activities. It can be used by clinics to deliver in-service training, professional associations to provide professional development programs, or individuals to share their knowledge and train other professionals.

This site was developed to collate open publications and resources that are relevant to rehabilitation professionals and other rehabilitation-related health systems stakeholders across the globe. With these resources accessible in one place, it is easy to discover and share information to support the integration of rehabilitation into health systems.

Explore the repository

The ReLAB-HS portfolio of online courses has been specifically developed to respond to the needs of rehabilitation professionals in low- and middle-income countries. Courses can be used to fill gaps in academic teaching capacity, for continued professional development activities, and for in-service training of staff. Hosted on Plus, they are available for free to all in low- and middle-income countries.

Explore the courses