Are primary healthcare systems ready to integrate rehabilitation services? A case study from Uganda

Abstract

The Learning, Acting and Building for Rehabilitation in Health Systems (ReLAB-HS) project is supporting this initiative in the Eastern and Northern regions of Uganda. To integrate rehabilitation services into PHC in Uganda, it is necessary to understand the current capacity of the local health systems, policy support, and resources such as personnel, infrastructure, and funding. This study aimed to investigate the current capacities, opportunities, and motivation of PHCs to integrate rehabilitation services. Additionally, we explored the perspectives of PHC workers on the lessons learned from their previous experiences of undertaking new roles and services. We undertook a mixed methods study, including surveys of 143 PHC facilities and in-depth interviews with 21 PHC workers in the Eastern and Northern regions of Uganda. Current PHC facilities are overstretched and under-resourced. For sustainable integration of rehabilitation services, policy and system-level changes are needed to recruit rehabilitation staff at PHCs, allocate resources and funding, develop rehabilitation work packages at different levels of health care, and promote intersectoral collaboration. Background: Despite a high demand for rehabilitation services in Uganda, current rehabilitation services are concentrated in urban areas and are primarily provided at tertiary-level facilities or by private providers. The World Health Organization emphasizes the integration of rehabilitation in primary health care (PHC) systems to improve coverage. The Learning, Acting and Building for Rehabilitation in Health Systems (ReLAB-HS) project is supporting this initiative in the Eastern and Northern regions of Uganda. To integrate rehabilitation services into PHC in Uganda, it is necessary to understand the current capacity of the local health systems, policy support, and resources such as personnel, infrastructure, and funding. This study aimed to investigate the current capacities, opportunities, and motivation of PHCs to integrate rehabilitation services. Additionally, we explored the perspectives of PHC workers on the lessons learned from their previous experiences of undertaking new roles and services. Methods: We undertook a mixed methods study, including surveys of 143 PHC facilities and in-depth interviews with 21 PHC workers in the Eastern and Northern regions of Uganda. We applied the COM-B framework to examine the capability, opportunity and motivation of a range of behaviors that can assist in designing effective rehabilitation strategies. Results: Most facilities surveyed reported challenges with staffing shortages (59%), limited resources (73%), and inadequate funding (63%). Qualitative data further revealed increased workloads and staff burnout, which negatively affected the motivation of PHC workers. Over half (51%) of the PHC facilities reported the recent introduction of new services. The introduction of new services has brought about additional funding and resources, as well as training and mentoring opportunities for staff. This has reportedly contributed to the motivation of PHC workers to implement new services. Rehabilitation services were identified as being beneficial for the local communities because they would reduce the need, time, and cost to travel to higher-level facilities, and would improve outcomes for those in need of services. Utilizing village health teams in the communities and promoting community-based rehabilitation were identified as potential sustainable strategies for rehabilitation. However, the implementation of these strategies would require significant policy-related changes at the national and regional levels. Conclusions: Current PHC facilities are overstretched and under-resourced. For sustainable integration of rehabilitation services, policy and system level changes are needed to recruit rehabilitation staff at PHCs, allocate resources and funding, develop rehabilitation work packages at different levels of health care, and promote intersectoral collaboration