Integrating Rehabilitation Services at Primary Healthcare Level in Johannesburg, South Africa

Abstract

Rehabilitation is an essential component of attaining true Health for all in South Africa. The National Health Insurance Bill of 2019 specifies primary healthcare (PHC) reengineering as one of the action plans. Similarly, the National Development Plan 2030 specifies providing care to families and communities by PHC teams as one of its action points for the transformation of the health system in South Africa to achieve universal health coverage. The provision of rehabilitation services to the broader population through a reengineered PHC can give at-risk populations greater life expectancy, wellbeing, and productivity. Despite the current provision of rehabilitation services at the primary platform, health service planning and provision in South Africa have overlooked rehabilitation as a component of PHC. The physical, social, and economic impact of many health conditions can be mitigated, resulting in a reduced burden of care, both economic and social, for the family and the state. Thus, the need for evidence for integrated rehabilitation services at a PHC level has critical relevance to ensuring inclusive service delivery. Therefore, it is important to review rehabilitation services at the PHC level to establish the current service delivery landscape and to guide the development of a rehabilitation integration framework for PHC within the proposed National Health Service. This study used a mixed-methods approach with three studies to address the study objectives. A scoping review was conducted to map the service guidelines, models, and protocols used in low- and middle- income countries, specifically Brazil, Russia, India, China, and South Africa (BRICS) (Phase 1). The shortage of rehabilitation personnel and limited access to services, especially in remote areas, impede the integration of rehabilitation services in BRICS. Community-based rehabilitation is confirmed as the most effective approach to integrate rehabilitation in PHC, emphasising community involvement in service provision through trained community health workers and community rehabilitation workers in transdisciplinary teams. Thus, in low- and middle-income countries with limited rehabilitation service access, community health workers, community rehabilitation workers, peer support workers, collaborative care, self-management, and the community-based rehabilitation model may help integrate rehabilitation into PHC. Using a qualitative approach, a second study was conducted with rehabilitation service providers (n = 12) to understand the extent to which rehabilitation services are integrated into PHC service delivery based on the expressed reality of rehabilitation personnel involved in service provision (Phase 2). The findings revealed a reality of structural-level suboptimal, underdeveloped, and poorly integrated rehabilitation services within the Johannesburg Metropolitan District. Despite isolated adaptations to service delivery and the adoption of components from rehabilitation integration models, such as outreach, the service remains unintegrated. As a result, health outcomes remain unmet. Gaps in the referral system, lack of human and other resources, poor knowledge and implementation of policy, and inefficient financial systems were cited as barriers to integrated care. The proactive attitudes of Page 2 of 2 rehabilitation personnel, creative thinking, and interprofessional relationships within a collaborative team dynamic were identified as facilitators and prospects for integrated rehabilitation services. Concurrently, the findings of a retrospective record review of rehabilitation records across the nine provincially funded clinics offering rehabilitation services (Phase 2) provided a profile of the characteristics of rehabilitation users. The characteristics included aspects such as their age, prevalent disabilities, and referral sources. Insights into rehabilitation service provision, including inconsistent record-keeping practices across the various PHC facilities, were also highlighted. The study results revealed the need for a multidisciplinary rehabilitation team to address diverse rehabilitation needs, improve documentation and discharge practices, expand service delivery models, and reduce disparities in service use. To ensure the perspectives of service users were represented, another qualitative study was conducted with rehabilitation service users. This study aimed to understand the nuanced experiences of rehabilitation services, the perceived impact on their functioning, and the factors influencing those experiences (Phase 3). The analysis showed that service users considered rehabilitation services at operational level to have a substantial positive impact on their activity outcomes and participation and rated them highly. Overall satisfaction of service users with rehabilitation services received in the Johannesburg Metropolitan District was expressed and were influenced by factors such as the actions of rehabilitation personnel, service users’ own active involvement in the rehabilitation process, the organisation of the rehabilitation services, improved service accessibility, and notable functional improvements. After understanding the available rehabilitation models, guidelines, protocols, and the status of rehabilitation services from both the provider and user perspectives, the study findings from phases 1- 3 were triangulated. The triangulation informed the development of a patient-centred framework for integrating rehabilitation services in primary health care (PHC) at the district level, emphasising the importance of placing the patient and communities at the centre of care (Phase 4). Understanding the current state of rehabilitation services, experiences of rehabilitation service providers, and experiences of rehabilitation service users shed light on the lack of integrated rehabilitation services in PHC. Integrated rehabilitation service delivery in PHC requires a multi-level approach at the macro, meso and micro levels. Sustainable and long-lasting solutions to accessible rehabilitation services in PHC must focus on strengthening governance and accountability, reorienting the model of care, creating an enabling environment, coordinating services within and across sectors, and engaging and empowering communities.