Funding uncertainty: a slippery slope for evidence-based rehabilitation in Africa
There is an increasing demand for rehabilitation services in Africa to help restore and improve patients’ quality of life. This demand is driven by various physical, cognitive, sensory and communicative impairments resulting from both avoidable and natural causes, including injuries, diseases, accidents, and congenital conditions.
Several external factors are responsible for this rise in demand across Africa. Firstly, there has been a dramatic increase in non-communicable diseases, including the high prevalence and early incidence of stroke, diabetes, and heart disease. This has been driven by the adoption of Western diets and lifestyles and other lifestyle risk factors. Secondly, there is the increased national burden of chronic conditions since prevalent diseases like HIV, and recently COVID-19, were reclassified with demonstrable indicators of chronic conditions. Thirdly, the already high burden of acute and chronic diseases is inflated by high rates of injuries and trauma due to wars, violent crime, motor vehicle accidents and work-related injuries. Finally, the alarming disparity between the public and private sectors across healthcare in the region persists. This leads to inequitable access to healthcare, as those who can afford private care can access some of the best available care globally, while the poor only access primary (and often inadequate) care.
Severe lack of trained rehabilitation specialists in Africa
There is a gap between the requirements in this sector and the care currently being provided in Africa. This is due to the lack of qualified rehabilitation professionals, the lack of priority given to government rehabilitation services, and the poor use of evidence in decision-making and clinical practice. This is further characterised and sustained by the absence of investment in, and funding of, rehabilitation issues on the continent.
In Africa, only an estimated 1% to 2% of people needing rehabilitation gain access to these services. On average, many African countries have fewer than 0.5 rehabilitation professionals per 10,000 people. This is due to the lack of interest and investment in training rehabilitation professionals locally. Many countries lack training programs and infrastructure for rehabilitation health practitioner training, and many existing programs are substandard, with no policies in place to grow and train expert physicians, medical specialists or rehabilitation health professionals.
This lack of will and commitment has led to low prioritisation of rehabilitation issues, which makes it difficult for healthcare professionals to make a decent living teaching, training and carrying out rehabilitation activities. This is a problem of monumental magnitude as there is no substitute for locally trained, permanently employed specialists.
While it can be expensive to train rehabilitation specialists, many African governments can afford this cost. Yet, they choose not to support services due to a lack of political will to invest and prioritise rehabilitation issues. One of the biggest drivers for this is the absence of, or poor use of, evidence in decision-making across public and private healthcare sectors in Africa. This has led to inadequate identification of priority healthcare areas and potential solutions to problems across the region. If governments and local authorities were to invest in research to inform their decisions and policies, this could be resolved. To effectively change this narrative, it is necessary to examine the depth and breadth of our healthcare problems, evaluating and monitoring progress, and prioritising and generating local solutions to contextual problems.
Collaboration and research: keys to success
Effective collaboration can help address these problems. This collaboration between stakeholders, within the African continent and beyond, should aim at sustaining high-quality rehabilitation services. Collaboration with the Global North should be encouraged at the partnership level, where experiences and skills are shared, rather than being donor-recipient in nature. A partnership of this type should consider the relevant priorities of local and national issues, as well as the sustainability of efforts for the longer term. Efforts leading to the development of local infrastructure and policies on rehabilitation issues should be strongly encouraged. Free wheelchairs and other assistive technologies make good photo opportunities, but without sustainable rehabilitation, these efforts are insufficient interventions.
Africa’s efforts in rehabilitation and beyond could be enhanced by research that evaluates what works locally. Yet, the lack of public funding for research in Africa is well documented and reflects the meagre growth in diverse disciplines, including health and care. In 2006, all member countries of the African Union committed to investing 1% of their GDP to research and development. Still, disappointingly, on average, in 2019, Africa’s funding and investment was only 0.42%, in sharp contrast to the 1.7% global average. With inadequate research and funding, the identification and prioritisation of major healthcare concerns becomes challenging. This makes effective collaboration nearly impossible.
Adequate rehabilitation funding is an investment in human capital, contributing to health, economic and social development. People with compromised capacity often cannot study or work; consequently, they cannot contribute optimally to their families, communities or the country. With the rising incidence of non-communicable diseases, especially in younger populations, relative to global demographics, it is becoming increasingly important that African states and authorities prioritise research and funding to build and strengthen rehabilitation capacity in Africa.
Rehabilitation services must be tailored to African needs
Rehabilitation is an essential component of healthcare services. It has been shown to improve the lives of people with various health conditions and disabilities by optimising their functional independence. Despite the plethora of benefits of rehabilitation services and interventions, the best outcomes are obtained when these services and interventions are evidence-based and, importantly, context-specific. This, therefore, implies that evidence-based rehabilitation interventions developed in high-income countries may not be suitable for application in an African context. Beyond transferability issues, there is a need for more context-relevant research and investment to develop human capacity to translate the evidence to the African context to optimise rehabilitation efforts.
Despite the compelling need for attention, rehabilitation services have not been prioritised and developed in many African countries, and are heavily under-resourced. The situation is unsurprising, as rehabilitation interventions and services are often seen as a fallback strategy when curative interventions fail. They are viewed as a disability-specific service for a few individuals. Furthermore, rehabilitation has been incorrectly perceived as an expensive clinical and specialised service, predominantly at secondary- and tertiary-care levels.
African Rehabilitation Network: improving research and evidence in rehabilitation services
Some African countries have national rehabilitation policies with strategic goals, such as better integration of rehabilitation services and uptake of specific monitoring and evaluation frameworks. Reports suggest there has been little progress in meeting the current demands for rehabilitation services across the continent. The gap between demand and rehabilitation capacity in Africa will continue to grow and be difficult to close as the capacity to meet rehabilitation needs is slow. Rehabilitation issues may continue to slip further down policymakers’ list of national priorities unless there is committed, unified action to change this narrative.
I have been an African Rehabilitation Network (ARN) coordinator since 2020. ARN is a community of practice for rehabilitation professionals practising in Africa. It evolved from a group focused on COVID-19 to one centred around rehabilitation. It comprises diverse professionals, predominantly physiotherapists, occupational therapists, and speech and language therapists. The ARN is committed to improving research and evidence for rehabilitation in Africa. Despite members from over 24 countries being aware of the evidence supporting the development and strengthening of rehabilitation services and capacity in Africa, there is increasing evidence that investment into rehabilitation issues and research is inadequate.
In this era of evidence-based healthcare, for African states to equal the rest of the globe, there is a compelling need to consider prioritising, investing and building capacity in rehabilitation research. If health services are not strengthened and the health workforce is not developed, the demand for services will surpass rehabilitation capacity. Irregular and sporadic funding programs from global funders cannot address or sustain community issues for the populace until local funding is made accessible. With the gloomy uncertainty for funding, evidence-based rehabilitation is still on a slippery slope .
Disclaimer
The views expressed in this World EBHC Day Blog, as well as any errors or omissions, are the sole responsibility of the author and do not represent the views of the World EBHC Day Steering Committee, Official Partners or Sponsors; nor does it imply endorsement by the aforementioned parties.
