In developed countries, the majority of health care costs are met by the state from public spending, whereas in developing countries public spending on health is often very low. Most of these costs are met from private spending, out-of-pocket payments by users for the most part. Yet, it is in these countries that the demand for care is the highest, as 80% of people with disabilities live in developing countries. Financial barriers are one of the main reasons why people do not receive needed health care in low-income countries. They are even more of an issue for people with disabilities.
In low-income countries, 65% of adults with disabilities aged between 18 and 49 cannot afford health care. Disability and poverty are linked: poverty can result in disability and this disability can increase poverty among individuals and their families. People with disabilities are thus more at risk of being economically underprivileged. They are also less likely to have any form of health insurance, especially the poorest among them for whom it is extremely difficult to adhere to micro-insurance or universal health coverage schemes. They are also more frequently excluded from health insurance systems provided through formal employment, as they have less access to formal employment.
To remind, rehabilitation medicine aims to improve an individual’s level of functioning via medical diagnosis and treatment of his health issues; while physical and functional rehabilitation which is a process with temporary or long-lasting impairments and disabilities (and their families), aims to restore or compensate for functional loss to prevent or slow functional deterioration. There are few physical and functional rehabilitation professionals in developing countries and most of them are concentrated in large cities. This situation increases the financial barriers to rehabilitation services, especially for disabled people living in rural areas for whom the costs are even higher (travel costs and costs of the care), making them even less likely to seek rehabilitation care. All these situations of health inequality and inequity are in breach of human rights and the rights of people with disabilities.
This key-list was prepared by Anna Boisgillot and Rozenn Béguin Botokro from Handicap International Rehabilitation technical unit.
Human resources for health
This report was presented to Member States at the World Health Assembly in May 2016 and is to be read in conjunction with A69/38: Draft global strategy on human resources for health: Workforce 2030. Report by the Secretariat. The vision of this work and report is to "Accelerate progress towards universal health coverage and the UN Sustainable Development Goals by ensuring equitable access to health workers within strengthened health systems". Objectives are "To optimise performance, quality and impact of the health workforce through evidence-informed policies on human resources for health, contributing to healthy lives and well-being, effective universal health coverage, resilience and strengthened health systems at all levels", "To align investment in human resources for health with the current and future needs of the population and of health systems, taking account of labour market dynamics and education policies; to address shortages and improve distribution of health workers, so as to enable maximum improvements in health outcomes, social welfare, employment creation and economic growth", "To build the capacity of institutions at sub-national, national, regional and global levels for effective public policy stewardship, leadership and governance of actions on human resources for health" and "to strengthen data on human resources for health, for monitoring and ensuring accountability for the implementation of national and regional strategies, and the global strategy". Global milestones by 2020 and 2030, policy options of Member States, responsibilities of the WHO Secretariat and recommendations to other stakeholders and international partners are discussed for each objective.
This report presents tasks for various types of personnel and the guidelines for their training. It also provides information on issues related to training, as well as the distribution of prosthetics and orthotics personnel and services. This report is a useful tool in the national planning of rehabilitation, and prosthetics and orthotics services
Staff costs dominate health services expenditure and ongoing shortages in the availability of health professionals present a real and direct threat to the continued delivery and development of health care services. Incentives, both financial and non-financial, provide one tool that governments and other employer bodies can use to develop and sustain a workforce with the skills and experience to deliver the required care. Financial incentives (wages and conditions, performance-linked payments and others) and nonfinancial incentives (career and professional development, workload management, flexible working arrangements, positive working arrangements and access to benefits and supports) are both discussed. The characteristics of an effective incentive scheme and the development of an incentive package are described.
A review is presented of the performance of health-workers In low and middle income countries and of strategies for improving their performances. An overview of issues and evidence about the determinants of performance is given. Health-worker practices are complex behaviours that have many potential influences. Reviews of intervention studies in low and middle income countries suggest that the simple dissemination of written guidelines is often ineffective, that supervision and audit with feedback is generally effective, and that multifaceted interventions might be more effective than single interventions. It is reported that few interventions have been evaluated with rigorous cost-effectiveness trials.
The Lancet, Volume 366, No. 9490, p1026–1035, 17 September 2005
This paper provides an introduction to the terms and tools of labour market analysis and connects these labour market principles to real-world case studies from LMIC. Three examples are provided of issues: workforce shortage in Thailand; unfilled posts in Kenya; and ghost workers in Rwanda. The labour market for health workers is considered and an integrated framework is provided. The technical structure and dynamics of the health worker market is discussed and applied to the first two examples. Task shifting, health worker performance and health worker productivity are also discussed.
Human Resources for Health Observer, No. 11
"The economic analyses in this volume focus on activities whose main objective is to improve health. Although the chapters vary considerably, all possess, nonetheless, a common core of definitions, assumptions, and methods of analysis."
"Although efficient spending on health has always been a desirable goal, it is particularly critical in the face of recent threats, such as HIV/AIDS and drug-resistant bacteria, as well as the problems presented by increasing prevalence of chronic diseases, such as diabetes and cardiovascular disease (CVD), that threaten to roll back the significant health gains achieved in the past two decades. This book is an opportunity to assess anew the costs associated with and the health gains attainable from specific interventions and thereby better inform the allocation of new health funding."
Cost-effectiveness analysis is used to evaluate medical interventions worldwide, in both developed and developing countries. This book provides process-specific instruction in a concise, structured format to provide a robust working knowledge of common methods and techniques. Each chapter includes real-world examples and tips that highlight key information. Calculations concerning disability life adjusted years are covered. The third edition contains new discussion on meta-analysis and advanced modelling techniques and a long worked example.
An overview is presented of the use of cost-effectiveness analysis in healthcare resource allocation decision-making. Threshold figures (i.e. cost per unit of health gain) currently proposed for, or applied to, resource-allocation decisions are reviewed. Disability Adjusted Life-Years (DALY) are mentioned. A table of data provides a summary of cost-effectiveness thresholds and CE ratios in terms of either QALYs (quality-adjusted life-year) or LYGs (life-year gained). Threshold figures and evolution of thresholds are discussed.
Universal health coverage
In 2015 the Millennium Development Goals (MDGs) came to an end and a post-2015 agenda, comprising 17 Sustainable Development Goals (SDGs), took their place. Trends that have defined health-related development under the MDGs, including achievements, lessons learned, unfinished business, and challenges to come are reviewed. Chapters include: economic, social and environmental context and health implications; universal health coverage; reproductive, maternal, newborn, child, adolescent health and undernutrition; infectious diseases; noncommunicable diseases; mental health and substance use; injuries and violence; and SDGs implications and challenges.
The implementation of national health insurance reforms designed to move towards universal health coverage by 9 low-income and lower-middle-income countries in Africa and Asia is reported. Five countries at intermediate stages of reform (Ghana, Indonesia, the Philippines, Rwanda, and Vietnam) and four at earlier stages (India, Kenya, Mali, and Nigeria) are considered. These countries’ approaches to raising prepaid revenues, pooling risk, and purchasing services are described using the functions-of-health-systems framework. Their progress across three dimensions of coverage: who, what services, and what proportion of health costs is assessed using the coverage-box framework. Patterns in the structure of these countries’ reforms including use of tax revenues to subsidise target populations and steps towards broader risk pools are identified. Trends in progress towards universal coverage, including increasing enrolment in government health insurance and a movement towards expanded benefits packages are reported. Common, comparable indicators of progress towards universal coverage are needed.
Many countries rely heavily on patients’ out-of-pocket payments to providers to finance their health care systems. This prevents some people from seeking care and results in financial catastrophe and impoverishment for others who do obtain care. Data from a large data set (116 surveys covering 89 countries) provided global estimates of the extent of catastrophic spending and impoverishment associated with out-of-pocket payments. Prepayment mechanisms protect people from financial catastrophe, but no strong evidence is reported that social health insurance systems offer better or worse protection than tax-based systems. Health system and population characteristics associated with high levels of catastrophic spending are examined to provide a basis for assessing the policy options available to reduce the incidence of financial catastrophe
This report measures health service coverage and financial protection to assess countries’ progress towards universal health coverage (UHC). The report follows the launch of a monitoring framework for UHC, based on broad consultation of experts from around the world. The framework focuses on indicators and targets for service coverage – including promotion, prevention, treatment, rehabilitation and palliation – and financial protection for all. Global access to essential health services including family planning, antenatal care, skilled birth attendance, child immunisation, antiretroviral therapy, tuberculosis treatment, and access to clean water and sanitation was assessed in 2013, and it was found that at least 400 million people lacked access to at least one of these services. The report also found that, across 37 countries, 6% of the population was tipped or pushed further into extreme poverty ($1.25/day) because they had to pay for health services out of their own pockets.
In 2005, the Member States of WHO adopted a resolution encouraging countries to develop health financing systems capable of achieving and/or maintaining universal coverage of health services – where all people have access to needed health services without the risk of severe financial consequences. In doing this, a major challenge for many countries will be to move away from out-of-pocket payments, which are often used as an important source of fund collection. Prepayment methods will need to be developed or expanded but, in addition to questions of revenue collection, specific attention will also have to be paid to pooling funds to spread risks and to enable their efficient and equitable use. Developing prepayment mechanisms may take time, depending on countries’ economic, social and political contexts. Specific rules for health financing policy will need to be developed and implementing organizations will need to be tailored to the level that countries can support and sustain. In this paper we propose a comprehensive framework focusing on health financing rules and organizations that can be used to support countries in developing their health financing systems in the search for universal coverage.
Universal health coverage (UHC) for inclusive and sustainable development synthesises the experiences from 11 countries—Bangladesh, Brazil, Ethiopia, France, Ghana, Indonesia, Japan, Peru, Thailand, Turkey, and Vietnam—in implementing policies and strategies to achieve and sustain UHC. These countries represent diverse geographic and economic conditions, but all have committed to UHC as a key national aspiration and are approaching it in different ways. The UHC policies for each country are examined around three common themes: (1) the political economy and policy process for adopting, achieving, and sustaining UHC; (2) health financing policies to enhance health coverage; and (3) human resources for health policies for achieving UHC. The path to UHC is specific to each country, but countries can benefit from experiences of others and avoid potential risks
General resources on rehabilitation and access to services for persons with disabilities
This practical guide is divided into three sections to present a systematic approach of access to services for people with disabilities. The principles and benchmarks section outlines key factors for accessing services and provides an analysis of the service sector for people with disabilities. The practical guide section presents the steps involved in planning at the programme level, and the toolbox section offers practical tools to implement the proposed techniques. A glossary and comprehensive bibliography are also provided. This resource is useful to those interested in access to service for people with disabilities
Article 26, Habilitation and Rehabilitation, of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) calls for: “… appropriate measures, including through peer support, to enable persons with disabilities to attain and maintain their maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life”. The Article further calls on countries to organize, strengthen, and extend comprehensive rehabilitation services and programmes, which should begin as early as possible, based on multidisciplinary assessment of individual needs and strengths, and including the provision of assistive devices and technologies. This chapter examines some typical rehabilitation measures, the need and unmet need for rehabilitation, barriers to accessing rehabilitation, and ways in which these barriers can be addressed.
These guidelines are designed to promote personal mobility and enhance the quality of life of wheelchair users. The aim is to assist Member States in developing a system of wheelchair provision that is consistent with the implementation of the Convention on the Rights of Persons with Disabilities. Chapter topics includes: design and production, service delivery, training, and policy planning
"This joint position paper was developed in response to a meeting about personal mobility and mobility devices, held on 28-29 October 2009 at World Health Organization headquarters, Geneva, Switzerland. This paper aims to guide and support countries, especially those with limited resources, in the implementation of relevant articles of the CRPD associated with the provision of mobility devices"
This document presents the physical and functional rehabilitation-specific challenges, principles and recommendations for Handicap International. Above all, it sets out the overall framework within which the theoretical underpinnings of the Rehabilitation Services Unit are applied; the primary objective is to ensure consistency between the association’s mandate and the implementation, in its programmes, of projects falling within the unit’s scope of activities. The secondary objective is to formalise the selection and/or identification of external guidelines for adaptation for internal use.
General principles requiring contextual adaptation regarding optimal policy related governance of health related rehabilitation in less resourced settings were developed from a literature review and realistic synthesis. A systematic review of literature published since 2003 was carried out. Multiple reviewers selected articles for inclusion in the realistic synthesis. A Delphi survey of expert stakeholders refined and triangulated findings from the realist synthesis. Context mechanism outcome pattern configurations (CMOCs) were identified from the literature and then developed into statements for the Delphi survey, whereby 18 expert stakeholders refined these statements to achieve consensus on recommendations for policy related governance of health related rehabilitation. Several broad principles emerged throughout formulation of recommendations: participation of persons with disabilities in policy processes; collection of disaggregated disability statistics; explicit promotion in policies of access to services for all subgroups of persons with disabilities and service-users; robust inter-sectoral coordination; and ‘institutionalising’ programmes.
"This guide describes the Sustainability Analysis Process (SAP), a coordinated planning approach that aims to facilitate the development of a common vision of sustainability among various actors in a system. Specifically, it is a participatory process which outlines how to achieve consensus on a common vision, and how to define sustainability indicators that can be used to monitor progress towards this vision within the context of the national rehabilitation system. Ultimately, the SAP outlined in this guide is a practical tool that can help all actors in a system to understand the various components of sustainability and analyse the concept of sustainability in relation to their own system"
Financial access to rehabilitation and health care services
A self-learning e-learning course on health financing for universal health coverage is available. It is a foundation course which targets participants of various levels of experience and expertise. The modules are: overview; revenue raising; pooling revenues; purchasing; benefit package design; and summary.
Health systems’ analysis is not an exact science in the sense that it is not a case of calculating an indicator and comparing that to a target that is set in stone. Instead, the analysis rests on describing elements of the existing system and critically assessing this on the basis of a clear understanding of health financing policy, the objectives associated with UHC, and relevant comparisons with and lessons from other countries. The paper attempts to provide guidance on how this can be done by highlighting the key issues that should be considered and some of the specific questions that should be addressed. It is not intended to provide a strict chapter-bychapter outline for a system assessment, but instead to foster and guide a systematic approach to the analysis of the health financing system. The health financing country diagnostic is written for Ministries of Health, advisors and others actors responsible for developing and implementing health financing policies, and provides step-by-step guidance on how to undertake a situation analysis of a country’s health financing system. Topics considered include: key contextual factors that influence health financing policy and attainment of policy goals; overview of health expenditure patterns; review of health financing arrangements; analysis UHC goals and intermediate objectives; and overall assessment - priorities for health financing reform.
Health equity funds (HEF) are a method of financing care for the poorest in countries where care is paid for. This report presents the results of a three-week mission to assess the HEFs set up by Handicap International in three different projects in sub-Saharan Africa
Disparities in access to health services in low- and middle-income countries (LMICs) are reviewed using a framework incorporating quality, geographic accessibility, availability, financial accessibility, and acceptability of services. Background data on the the numbers of doctors, nurses and beds per populations in various parts of the world is provided. "Different approaches are shown to improve access to the poor, using targeted or universal approaches, engaging government, nongovernmental, or commercial organizations, and pursuing a wide variety of strategies to finance and organize services. Key ingredients of success include concerted efforts to reach the poor, engaging communities and disadvantaged people, encouraging local adaptation, and careful monitoring of effects on the poor. Yet governments in LMICs rarely focus on the poor in their policies or the implementation or monitoring of health service strategies. There are also new innovations in financing, delivery, and regulation of health services that hold promise for improving access to the poor, such as the use of health equity funds, conditional cash transfers, and coproduction and regulation of health services. The challenge remains to find ways to ensure that vulnerable populations have a say in how strategies are developed, implemented, and accounted for in ways that demonstrate improvements in access by the poor"
Ann N Y Acad Sci. 2008;1136:161-7
"This report takes stock of the main public financing for health trends over the past fifteen years in the African region, and highlights opportunities for accelerated progress toward universal health coverage (UHC) based on better-informed budget planning and utilization decisions. The report presents new evidence on the critical role played by domestic public financial management systems on the level, effectiveness and quality of public spending on health in Africa. It argues that these systems should be reconsidered if countries are to move towards UHC. Country experience in reforming public finance systems to support progress towards UHC indicates that success depends on more than simply increasing the level of public budgets. Rather, it requires appropriately targeted health budget allocations, complete execution of health’s public budgets, and improved efficiency in the use of public resources for health.
The report is composed of three sections. The first section is articulated around three policy highlights: aligning budget resources and health priorities; closing the gap between health budget allocation and expenditure; and maximizing UHC performance with the money available. Section 2 is dedicated to providing detailed health financing information on countries, and includes 48 country profiles focused on key health financing trends. The last section includes information on progress towards the development of health financing strategies in the region, as well as regional and country benchmarks on key health financing indicators"
"This document is an overview aimed at providing an understanding of the economics of the physical and functional rehabilitation system. It is the first part of a study aimed at giving Handicap International’s teams in the field a tool for diagnosing the economic system for physical and functional rehabilitation, starting with West Africa. The proposed diagnostic tool will be the subject of another publication. The study was done in two stages. First, an analysis of the economic system for physical and functional rehabilitation was done and this led to an initial draft of a tool. Starting from that draft, a study done in Burkina Faso then helped to clarify many points and give a concrete picture of the concepts which would be useful in carrying out the analysis. This report is devoted to providing an economic analysis of the physical and functional rehabilitation system"
This manual presents indicators that "capture the difference (Community-Based Rehabilitation) CBR makes in the lives of people with disabilities in the communities where it is implemented. This manual presents these (base and supplementary) indicators and provides simple guidance on collecting the data needed to inform them. The indicators have been developed to show the difference between people living with a disability and their families and those without disabilities in relation to the information reported in the indicators. This comparability provides valuable information to CBR managers, donors and government agencies alike, which can be used to guide decision-making, support advocacy and improve accountability. Further, the ability of the indicators to provide a comparison of the populations of persons with disability to persons without disability aligns with the United Nations Convention on the Rights of Persons with Disabilities (CRPD), which states that persons with disability have equal rights to those without disabilities...this manual serves to standardize the monitoring of differences made by in the lives of people with disabilities and their families, making it possible to compare the difference CBR makes across areas and countries. This manual aligns with the WHO Global Disability Action Plan 2014–2021, and may also be used to monitor other development plans in an easy and efficient way”
This report, formed of two parts, provides robust empirical basis to support the theorized disability-poverty link. The first section presents a systematic review of the literature on the relationship between disability and economic poverty. The second section explores the economic consequences of the exclusion and inclusion of people with disabilities in the areas of education, employment and health. The key pathways through which these economic costs may arise are discussed and studies that have attempted to quantify the financial impacts are reviewed