As part of primary health care and making progress towards UHC, Tajikistan has established a National Rehabilitation Programme for adults and children suffering from a range of health conditions, impairments and disabilities.
Awareness of the need for rehabilitation dates back to the Alma Ata Declaration of 1978. Today, rehabilitation is more important than ever because of ageing populations and the huge increase in noncommunicable diseases.
Rehabilitative and assistive products have been included in Tajikistan’s state-guaranteed health service. The package ensures free services for certain segments of the population, especially the poorest, and over 180,000 people have benefited.
Tajikistan’s Ministry of Health and Social Protection has led the way to establish the National Rehabilitation Programme; WHO has promoted rehabilitation as a key element of a strong health system and provided policy and implementation advice.
The National Programme is a big step forward and we are confident that it will improve the health of people with disabilities, as well as support their education,employment and selfesteem for full inclusion in society
The National Programme on Rehabilitation (2017-2020) aims to create an enabling environment with equal opportunities for all. WHO’s support in involving diverse disability and development stakeholders has made a significant contribution to shaping the National Programme to better meet the needs of its users
Health and disability questionnaires are new to us, we never collected such data. It is good that WHO organized the training for us, we have learned a lot.
Robia was only six months old when she fell ill in 2009 and was unable to move her legs. After a month, doctors diagnosed her with polio and she was sent to a rehabilitation centre but for several years there was no progress. In 2013, however, things changed. Robia started to have physiotherapy and received training in everyday life skills that could make her independent. She received a support brace from the National Orthopaedic Centre, which is adjusted as she grows. She is now thriving at school, getting good grades, and continues to visit the rehabilitation centre twice a week. Her mother knows how important the services have been. “As a result my child began to feel better, more active, more cheerful. Now she walks independently using a brace and stick. She has friends and helps me around the house.”
Robia is just one of many children and adults who have benefited from the government of Tajikistan’s work to establish a national rehabilitation programme, which started in 2013. It has transformed the lives of many people, and crucially, services are free of charge to those who need them. This is a key step towards universal health coverage (UHC). WHO has provided support to the government, promoting rehabilitation as a key element of a strong health system and by providing policy and implementation advice for the programme.
What is rehabilitation and who is it for?
Rehabilitation involves a set of interventions that helps people to function in society better. It may be needed by anyone who experiences difficulties in mobility, vision, hearing, speech, swallowing or cognition, for example. While rehabilitation is often associated with disability, it is also important for people who are ageing, those who have experienced injuries, who have mental health conditions or who live with non-communicable diseases (NCDs) such as a stroke or diabetes. Rehabilitation can improve people’s ability to participate more fully in everyday life and can improve their ability to return to work or school. It can also reduce the costs of ongoing health care and support.
Awareness of the need for rehabilitation dates back to the Alma Ata Declaration of 1978 which states that to address the main health needs of people in the community, health care must include promotive, preventive, curative, rehabilitative and palliative services. Today, rehabilitation is even more significant than in previous decades because of ageing populations and the huge increase in NCDs.
In Tajikistan, NCDs have increased by 18% in the last decade and are the leading cause of death and disability, accounting for 59% of all deaths in 2014. Currently, there are over 180,000 registered children and adults with disabilities in Tajikistan. People with disabilities, older people and people with NCDs make up the largest groups in need of rehabilitation services.
As countries strive to meet Sustainable Development Goal 3 (Ensure healthy lives and promote well-being for all at all ages), rehabilitation must inevitably be part of the fundamental approach to strengthening the health system. But in the midst of other priorities it can sometimes get overlooked. Often it takes a particular ‘event’ for a government to realise the significant positive impact that rehabilitation can have on a population’s health and productivity. This is what happened in Tajikistan.
Strong government leadership
In 2010, a large polio outbreak affected several hundred adults and children who had irreversible impairments and urgently needed rehabilitation services. However, Tajikistan’s traditional approach to rehabilitation, based on an outdated model, was not working. The government approached WHO in 2012 for support in improving these crucial services. It was a perfect opportunity for WHO to promote rehabilitation as a key aspect of a strong health system.
The Government’s strong leadership and political support for rehabilitation drove significant reforms across the health system. This was trigged partially by the polio outbreak but it had an impact which reached far beyond polio. At the government’s request, WHO worked with the Ministry of Health and Social Protection (MOHSP) in 2013 to undertake a situational analysis of existing rehabilitation policy and governance and the impact of service provision on people with health conditions, impairments and disabilities.
The analysis found a scarcity of trained rehabilitation professionals (physiotherapists, occupational therapists, speech and language therapists, orthotic and prosthetic technicians, psychologists and physical and rehabilitation medicine doctors). Also, most rehabilitation services were located in urban areas, rather than rural areas where the majority of the population lives. Coordination for referrals was weak, and there was little funding for rehabilitation services. This situation, however, quickly changed.
Developing a National Programme
Between 2013 and 2016 the MOHSP developed a national policy, systems and services for rehabilitation. Beginning in 2016, the MOHSP further strengthened and expanded rehabilitation services from tertiary to primary levels, and this work is ongoing.
WHO supported this thorough policy development process with advocacy and technical advice and collaborating with development partners like United States Agency for International Development (USAID) and United Nations Partnership to Promote the Rights of Persons with Disabilities (UNPRPD) to mobilize funds for Tajikistan.
The Government developed a multi-sectoral National Programme on Rehabilitation of Persons with Disabilities (2017-2020) through a consultative process involving ministry representatives, disabled people’s organisations, national and international non-governmental organisations, and donors. Following the launch of the programme, rehabilitation and assistive products were included in the stateguaranteed health service (the basic benefit package). The package ensures guaranteed and free services for certain segments of the population, especially the poor. To date, over 180 000 men, women and children have benefitted.
Assistive products are a key aspect of rehabilitation. A national priority assistive products list was developed to guide future activities such as product development and production, service delivery, market shaping, procurement and reimbursement. For example, Tajikistan imports about 800 wheelchairs a year; however, the annual need is greater than 11 700.
MOHSP, with the support of WHO, produced a report in 2019 showing that Tajikistan’s current levels of quality wheelchairs are insufficient, and maintenance repair centres are not provided for or are underfunded. To reach universal coverage of wheelchairs, the government needs 10 000 wheelchairs annually over the next 3-5 years. This is important as the strength of the assistive product provision system influences the way a person accesses health services and integrates into society, including education and employment. People need to access assistive products that are appropriate for them and of good quality, without suffering financial hardship as a result.
Health workforce for rehabilitation
A strong multidisciplinary rehabilitation workforce, and rehabilitation concepts promoted in all health workforce education, is crucial in order to provide comprehensive rehabilitation services.
This National Programme focuses on all people with long-term physical, sensorial and intellectual impairments, those with mental health conditions and those with functional difficulties caused by NCDs, surgery, infectious diseases, neurological disorders, injuries or ageing. The Programme aims to provide all these people with high-quality services to ensure their full and equal enjoyment of human rights and to respect their dignity.
Services in the community
Before 2013, most rehabilitation services were centralized and in major urban centres; but this was a barrier to the 73.6% of the population living in remote rural areas who needed to access health and rehabilitation services in their own communities. The Tajikistan government promoted Community-delivered Rehabilitation as way to bring services to the community and ensure better access. From 2016, community rehabilitation programmes have been established in 35 of Tajikistan’s 66 districts, benefitting nearly 10 000 people in rural areas.
The MOHSP have trained and improved the capacity of rehabilitation centre staff (including physiotherapists and occupational therapists), who attended national capacity-building workshops. This led to the establishment of rehabilitation units within the hospitals and strengthening of existing rehabilitation centers. The MOHSP is supporting six local health workers – physiotherapists, occupational therapist and therapy assistants - to attend formal long-term training programmes outside Tajikistan, with the obligation to return to the country to support the MPHSP in providing rehabilitation services nationwide.
WHO is collaborating with the World Confederation for Physical Therapy and the World Federation of Occupational Therapists (WFOT) to further strengthen rehabilitation in Tajikistan. In 2018, WHO welcomed representatives of the WCPT and WFOT to Dushanbe to facilitate collaboration with the MOHSP to improve capacity building and education for rehabilitation professionals. This has led to initiation of programme to strengthen rehabilitation education in Tajikistan.
Collecting accurate and up-to-date information about health and rehabilitation is one of the most important elements for the Government of Tajikistan in order to make evidence-informed decisions and progress towards UHC. WHO provided technical support to the Agency for Statistics on how to gather reliable data on areas such as health service use, unmet needs and the financial burden on households of paying for health. Now the Household Budget Survey contains a health and disability module, and those who conducted the interviews for the survey received in-depth training on using interview technology and processing the data. The impact of this goes further, as now information on health and disability will also be included in the national census (due to take place in 2020).
"The revised health module allow us to collect data on household expenditure on health for informed policy-making and better targeting of public funds as a key strategy to mitigate the impact of out-of-pocket payments on household welfare,” said the First Deputy Director of the Agency of Statistics, Tajikistan.
With high-level political engagement and leadership, the government of Tajikistan has established a modern rehabilitation system within a relatively short period of time and has strengthened vital services to parts of the population often left behind.
Rehabilitation is an essential part of the continuum of care, along with prevention, promotion, treatment and palliative care, and should therefore be considered an essential component of integrated health services. Rehabilitation is relevant to people with many different health conditions and those experiencing disability across the lifespan and across all levels of healthcare. Through including rehabilitation as an essential element of the health system, Tajikistan is making strong progress towards UHC and health for all.
Prevention of impairments and access to quality services for different health conditions also requires a strong health system which is still an ongoing work in Tajikistan, especially for conditions amenable to primary health care such as vaccination, good hypertension and diabetes detection and management.