Disability & rural health: proofing what for whom?

1. Disability & rural health:proofing what for whom? Kate Sherry RHAP Rural-Proofing Program Stakeholders’ Forum 26th November 2013

2. 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

3. So what is “rehab”?

4. Disability in context

5. 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

6. 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 MAJORITYof health-care users are at risk (NB prevention) Most households will have a disabled member at some point

7. Role of environment in determining level of participation restriction

8. So what do therapists do?

9. Ways of thinking about disability • “Medical model”: - Individual, problem-centred focus Intervention response: “Fix what is broken” Services: technical, institution-centred, individual-focused Blind spot: impairments that cannot be “fixed”

10. Ways of thinking about disability (2) • “Welfare model” - Individual (sometimes family), basic needs & maintenance focus Intervention response: “care” Services: traditionally institution-based Blind spots: long-term sustainability, isolation

11. 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, multisectoral Blind spot: value of technical rehabilitation

12. 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)

14. 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

15. 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

16. 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)

17. 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

18. 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

19. 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 Umzimvubusubdistrict, Sherry & Watson 2010

20. 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 attitudeshift is needed

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

22. 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

23. 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

24. Rural issues in rehab • ACCESS ACCESSACCESS • Terrain and infrastructure • Economic implications • HR challenges • Sustained engagement with service Service model: home & clinic based- OUTREACH broad scope mid-level worker cadre continuity of care, record-keeping & tracing time allocations

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

26. Ensuring health policies are rehab-friendly Examples: • 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

27. Backing other rural-rehab-friendly policies • E.g. PHC re-engineering: • Shift to household-level • Strengthen CHW networks • Prevention and health promotion • We add: • Outreach budgeted and planned for • District hospital as hub • Mid-level rehab workers at clinic level • Role of therapists in schools addressed

28. 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…

29. Thank you!Questions?