Wednesday, September 7, 2016

A desired momentum for physiotherapy rehabilitation sector in Nepal

According to World health organization, Physiotherapists assess, plan and implement rehabilitative programs that improve or restore human motor functions, maximize movement ability, relieve pain syndromes, and treat or prevent physical challenges associated with injuries, diseases and other impairments. Physiotherapy prevents secondary complications which are the common cause of disability if not rehabilitated well. Physiotherapy treatment has a big role to play when a person’s function or mobility is affected by pain, ageing, injury, disease, disability or long periods of inactivity.

 People who require physiotherapy service are getting aware about the importance of it gradually but if we focus on districts of Nepal still therapeutic culture for rehabilitation is not properly inculcated. This is due to the lack of education and information to both public and health workers.

Under the auspices of National Health Policy 2014, Nepal Health Sector Strategy 2015-2020 (NHSS) is the primary instrument to guide the health sector for the next five years. It adopts the vision and mission set forth by the National Health Policy and carries the ethos of constitutional provision to guarantee access to basic health services as a fundamental right of every citizen. Here, physiotherapy also falls under the basic health package of Nepal Health Sector Strategy. Specially, after Nepal earthquake 2015, physiotherapy rehabilitation units are established with the support of humanitarian agencies in the affected districts but this new establishment should not be confined to the rehabilitation of injured cases but also there is a huge unmet need not related to earthquake. Thanks to these rehabilitation unit in district hospitals that are delivering the required service in one end whereas from the another end they have also given an example of what the rehabilitation in district looks like.

Nepal health policy 2070 assures to deliver all health service to people with disability. Likewise Nepal health sector strategy clearly mentions physiotherapy service under the basic health package.  Health facility establishment, operation and up gradation guideline 2070 clearly mentions about the provision of physiotherapist starting from the hospital with 25 beds. Despite of having  sufficient national qualified physiotherapists,  they are not being mobilized in district health system this creates a big gap which is well reflected by living situation of people with disability survey, has highlighted that there is  83% service gap on the medical rehabilitation. In one side, Nepal has sufficient policy environment and human resource to have rehabilitation service integrated in health system whereas on the another side 83% service gap in medical rehabilitation depicts the huge difference in paper and implementation, hence Nepal government together with the support of like minded agencies should start thinking on how commitment can be converted into the budgeted action.

But only having the human resource in the system may not bring a miracle to address the service gap as there are lots of socioeconomic issues which remain the barrier for people to access the hospital based services. Rehabilitation services are unique in nature because it requires a periodic follow up , involvement of person and family members and also in many stances, rehabilitation service has to be coupled with assistive devices and specialized surgeries. There are villages in districts from where it requires more than a day time to reach the district hospitals where we are assuming to have the service. A person with disability/injury needs to come together with the care taker (mostly family member) to get the service. The transportation and accommodation cost is the hidden expenses here and also the productive time of another family member who is accompanying to bring the person with disability for services. This is the right time to think the hidden socioeconomic aspect of the beneficiaries which are not often considered while designing budget for the program. One of the best ways to minimize this barrier is to enhance the access to rehabilitation services at the home village. Only the hospital based programs doesn’t fulfill the need, the link of hospital based rehabilitation service has to be created in community in the form of outreach and home visit. Also, the local health facility staff needs to be trained on basic rehabilitation so that early detection, referral and minor follow up is ensured at the community level. One thing that all have to know is, earlier the detection and referral, better will be the outcome of the rehabilitation but this is not the case in Nepal. By birth disability accounts for 33.6% of the total cause. Similarly, 50.6% of disability onset took place within the age bracket 0 – 10 years. Both of these facts suggest that most of the Nepalese acquire the disability by birth and during the childhood. In my experience, most these children appear to receive rehabilitation service at age of 10-15, by that time disability is neglected and by that time cost for rehabilitation goes high with poor  prognosis.

Rehabilitation is a bit expensive if person require the assistive devices like wheelchair and artificial limb. There is always shortage of such device in market as there are no local manufactures of the components and raw materials required for it. An acceptable quality wheelchair suitable for rough terrain cost around 40,000 NRS , below knee artificial limb cost around 30,000-50,000 NRS and above knee artificial limb cost around 1,00,000 Nepalese rupees. Like the standard drug supplied by government to the public through different health facilities, the priority assistive device list has to be also made. In fact World health organization has already made it recently. Poor socioeconomic status of the person should not be the barrier to get such services; hence these sorts of devices are to be also linked with the government health insurance package. Until and unless the socioeconomic barrier are studied and side by side addressed, setting up the rehabilitation unit in government hospital may not ensure the full utilization of services.

Anyone going through this idea may have the notion that these are very expensive and do not fall on the priority. Yes, priority for Nepal is to strengthen the primary health care system which is linked to health promotion and disability prevention. It’s universally accepted that prevention is the cost effective measure to minimize the burden of health conditions. Therefore, budget aimed at prevention should not be diverted to other channel and also it doesn’t mean that huge investment in strengthening primary health care jeopardize the possible allocation for rehabilitation services. The recent twitter (HM_Nepal) update from health ministry revealed that the fund collected from health tax was 16,00,00,00,000 and the expenditure was 40,00,00,000. Not even 3% budget out of this resource was spent. This is just an example of one budget heading. A rehabilitation set up in districts with one physiotherapist, equipment, supplies and a month community outreach doesn’t cost more than 10,00,000 on the first year but from the second year(once equipment are installed) the cost even get down sized to around 7,00,000-9,00,000 in a year with full fledged community activities. If 75 physiotherapy/rehabilitation units are established, the cost would be around 7,50,00,000. If this rehabilitation investment is covered from the fund collected from health tax, rehabilitation services would only burn 0.46% of this fund. It means with the existing expenditure and added rehabilitation service expenditure the burning of this fund will not be more than (3+0.46)% =3.46 % . Still  96.14% of the fund will be unspent, out of which extra 0.5% is more than sufficient to enhances access to rehabilitation service (addressing the socioeconomic barrier of getting the rehabilitation service and covering the rehabilitation service from a health insurance package) The simple example of one particular fund of health ministry proves that money is really not a problem. Also there are sufficient policies and strategies to integrate rehabilitation in health. Then, where is the barrier? This is something that government, international agencies in this sector, service user community and professional association have to be seriously looked upon. .

There are not enough contextual studies and researches done in the sector of disability management and rehabilitation. Neither health system database gives the exact data on disability and rehabilitation services. The non-state service providers have their own database which differs from one to another. Therefore, actors in this sector should focus on generating the properly validated evidences in close collaboration of ministry of health which may give an evidence based way forward to derive the budgeted activities for rehabilitation. Also this expertise is new to ministry, therefore it’s very crucial for stakeholder to deliver the unbiased technical support. With the continuous advocacy of the stakeholders and professional association, already the focal unit for disability has been operational in department of health services, which is good example of joint effort by ministry and stakeholders. Now, the similar initiative is required to strengthen the established focal unit in department of health service so that its capable on converting the legal commitments (policies and strategies) into the real action (integration of rehabilitation in health).