Quality sounds like hard work
6 April 2021
Members of the ReLAB-HS consortium look at how quality management approaches can strengthen rehabilitation services in low- and middle-income countries (LMICs) without over-burdening health care workers. This blog was written by Wesley Pryor, Fleur Smith, Inès Musabyemariya, Yeti Raj Niraula and Chiara Retis.
As the global community works towards delivering on their commitments to action and frameworks to guide the growth of rehabilitation in health systems, one likely barrier to success is inadvertently adding to the burden of health staff already working under very challenging conditions, often with poor recognition of their work.
Estimates of the global need for rehabilitation have sharpened through recent work using global burden of disease data [1, 2, 3]. However, estimates of unmet needs are much more fragmented and focused on geographic sub-populations  or condition and context-specific estimates. Despite uncertainties about the size of the challenge, there is a growing and increasingly harmonious voice calling for urgent change. The challenges are likely to be greatest in under-resourced settings, where absolute growth in estimated need is greatest  – and the impact on existing health workers is likely to be the most pronounced.
World Health Worker Week
To mark Health Worker Week 2021, we wanted to explore some of the potential risks in adding to health worker burden when scaling up rehabilitation. In particular, we draw on recent experience and research to focus on the possibility that a pared-back, adaptable quality management lens might help reduce, rather than add to, health worker burden – or at least provide a useful way to illustrate the challenges they face with ever-growing demands and expectations.
WHO’s ‘Rehabilitation 2030 Call to Action’ estimated that the available health professionals to provide rehabilitation is ‘…one-tenth of that required’. This implies an urgent need to scale-up rehabilitation through increasing rehabilitation personnel. However, the Call to Action also recognized the importance of understanding barriers to existing services, and how rehabilitation can be provided more efficiently. At the same time, there is a clear imperative and emerging normative guidance to introduce standard operating procedures, data management systems, system indicators, and so on.
Our colleague Yeti Raj Niraula is a Nepalese orthotist/prosthetist working for Humanity & Inclusion in Nepal as Senior Prosthetics and Orthotics (P&O) Capacity Building Officer He knows first-hand what it means to be a health professional as the demands on constrained rehabilitation services grow. He told us:
“Professionals are exhausted. Nepal has about a fifth of the recommended P&O staff. There’s no space for them to grow professionally – or financially.”
These findings resonate with the experiences of a sample of around 50 other rehabilitation professionals . When we asked about their experiences after entering the workforce in settings where rehabilitation is not well financed and regulated, new professionals report fear and uncertainty about the future, mostly related to perceived job security, career development, salary, and professional esteem. The net result among 560 professionals for whom data were available was that on average, they left the workforce after about 17 years on average, and just 13.3 years for women.
With these reality checks, it is tempting to set aside questions about quality and focus on quantity. As Yeti put it, ‘quality is always going to be compromised unless we have more workforce available’.
However, we argue that when fit-for-purpose, the structured reflection process encouraged through quality management approaches has the dual effects of revealing the challenging conditions in which professionals are working and also the means to tap into their expertise and knowledge about the most effective and feasible responses. This lesson has emerged from Humanity & Inclusion’s work to develop a set of service delivery goals that balance outputs with efforts to improve the working conditions for professionals .
Recently, we asked a group of collaborators who have been using this approach over time to reflect on the challenges and possible benefits. Their insights reveal that while quality management in rehabilitation initially sounds like hard work, after a period of support and adaptation, the process can be a useful way to reflect on how services are responding to the needs of the population, supporting staff, and providing effective services. One expert said:
“For a long time, if someone was asking a question about where are we as a sector, and what has been the progress it is hard to answer. [Quality management processes] help minimize this gap so we can answer these questions for ourselves – to know where we are at as a sector and also to identify what needs to be done to progress and improve.”
However, we also know these effects depend on there being time, space and impetus to introduce thinking about quality in practice. Another expert told us:
“When the manager has the INGO support, they have the resources and the time to do the [quality review]. But when they are handed over to the government there is a lack of resources, so they don’t have the people in place to do their work.”
Globally, quality management approaches to health and rehabilitation are as diverse as the contexts in which they are used. Solutions range from sophisticated clinical governance measures including rehabilitation services indicators alongside functional outcome measures , to process oriented approaches adopted by Humanity & Inclusion, to a set of combined process and output indicators and targets promoted by the WHO through the Rehabilitation Indicator Menu (RIM), or profession specific standards. None of these approaches are fit-for-purpose unless they improve conditions, underlying performance and service delivery, rather than become another way to scrutinize and burden health workers.
By shifting focus to critical self-reflection among health workers, this approach also appears to contribute to – and be enhanced by – leadership development. Quality reviews explicitly require contributions from all levels of staff, from supportive and ‘junior’ roles, to senior management, which fosters a more equitable approach and helps invert hierarchies. We have learned that this is motivating and empowering. One colleague said:
“It has helped to build a strong team of rehabilitation. Previously the technical staff understood the service but after [quality review] all the staff, even the administrative and fundraising staff, understand the process of rehabilitation and the importance of it. It has helped us to make a strong team.”
In Rwanda, our colleague Inès Musabyemariya supported Rwandan Ministry of Health stakeholders to adapt and introduce these measures. Lessons from the health workers she has worked with echo our experiences elsewhere:
“[After introducing a quality management structure,] work is less stressful and more client centred. I wish I could have learned these standards earlier in my studies.”
The ReLAB-HS program will continue this work. We will explore how quality is understood in our partner countries. With local collaborators, we will learn how rehabilitation stakeholders are already working hard to deliver quality care, give voice to the many challenges they face, and use these lessons to help balance efforts to increase access to rehabilitation with the realities of working life for rehabilitation and other health workers.
Wesley Pryor and Fleur Smith work for ReLAB-HS partner, The Nossal Institute for Global Health. Inès Musabyemariya, Yeti Raj Niraula and Chiara Retis work for ReLAB-HS partner, Humanity & Inclusion. Photo credit: Taken by Wesley Pryor in Nepal