RURAL REHAB SOUTH AFRICA (RuReSA): SUBMISSION ON THE NHI

2011-11-04

  1. RE-ENGINEERING PRIMARY HEALTH CARE (PHC)
  1. Holistic health. Health is a state of physical, mental and social well-being. Mental Health Care (MHC) and rehabilitation services (in terms of primary, secondary and tertiary prevention) form an integral part of PHC and health promotion, prevention[1], early identification and early intervention services should be provided for in all three PHC streams at district, community, household and school level.
  2. A broad approach to improving access to services. Efforts to improve access to health care services for children and adults with disabilities should be inter- and multi-sectoral (including all government and civil society stakeholders) and aimed at removing barriers to access in the overall physical environment (e.g. financial, transport, roads) and not only in terms of access to facilities (health and school).
  3. Mental Health Care (MHC) and rehabilitation services. The availability of MHC and rehabilitation services for children and adults at all levels of care, including household and community, will improve access to care for those unable to attend clinics due to financial, transport and physical barriers. (It should be noted that barriers to accessing ID documents and obtaining official refugee status might seriously hamper access to health. No person may be refused health care, regardless of his or her inability to pay for it. This requires urgent and serious consideration.)
  4. Human resources for rural PHC services. Creative solutions and additional funding will be required to provide universal coverage of rural MHC and Rehabilitation needs. Of concern is the lack of attention given to the provision of human resources for MHC and rehabilitation services in the Re-engineering PHC document.
  5. District, clinic and community posts for health therapists and mid level workers (MLWs). The additional number of health therapists[2] and MLWs (including Occupational Therapy Technicians) as well as appropriate transport vehicles will be needed in order to reach the population at risk for impairment and disability.
  6. Assistive devices and specialist practitioners. If the government is serious about improving access to health care for children and adults with disabilities, then a wider range of quality assistive devices[3], appropriate for rural use, need to be made available on state tender. This will of necessity include the availability of health therapists at district level, as well as specialized practitioners for Orientation and Mobility (O&M) for people with visual impairment, Augmentative and Alternative Communication (AAC) for children and adults with little or no functional speech (LNFS)[4]. A substantial increase in budgeting for assistive devices for children and adults will be required.
  1. NATIONAL HEALTH INSURANCE (NHI)
  1. Representation and consultation: Rural Rehab South Africa (RuReSA) urges the government to include rural and urban allied health therapists (including Psychologists) in the consultation process when addressing the staffing, services and equipment norms and standards at various levels of care in the NHI. Rural-based health therapist experts should be represented on the NHI and allied health experts should be included on the Technical Advisory Committee of the NHI, when setting norms and standards at different levels of care, and developing accreditation and assessment criteria for the NHI. Treatment protocols for children and adults should be developed in conjunction with rural health therapists, who should be included in diagnosis related groups (DRGs) and consequent performance management, that are not limited to medical interventions.
  2. Management and staffing levels. Greater emphasis should be placed on improving management and staffing levels for improved health outcomes for children and adults (especially in rural areas). The understanding that rural areas have different needs in terms of human resources (HR), financial requirements and autonomy should be implicit and there should be a clear understanding that rural approaches are required in order to respond to rural community health needs.
  3. Rehabilitation services are required at all levels of care (primary, secondary and tertiary), from district to centralized and specialist hospitals. Methods of service delivery and acuteness of care differ across the spectrum due to specific circumstances in rural areas, namely the historical lack of specialist and financial resources, technology and transport.
  4. Rehabilitation midlevel workers (MLWs). The concept of rehabilitation MLWs is still a highly contentious issue among health therapists. A representative consultative forum should be held regarding the role and scope of rehabilitation MLW and their training and registration that are envisioned within the NHI. Community Care Givers (CCGs) will require to be sensitized to child and adult disability issues, to be trained to screen children and adults at risk for impairment and disability and refer appropriately, but will not be competent to provide basic rehabilitation interventions, or measure, order and issue assistive devices.
  5. Human resources for Rehabilitation and MHC services. The emphasis on providing access to appropriate care (especially at household level) within the re-engineering PHC system will demand an increase in health therapists, psychologists and rehabilitation MLWs at community level (with the required additional resources of transport and accommodation). This increased need of appropriately trained allied health workers i.e. health therapists and MLWs will need to be reviewed at tertiary level in terms of curriculum as well as numbers trained.
  6. Monitoring and Evaluation (M&E) - Rehabilitation indicators. Currently district rehabilitation indicators describe outputs and not outcomes and these should be revisited as a matter of urgency. At the national level the only rehabilitation indicator in the National Indicator Data set (NIDS) gives data on new assistive devices issued annually (wheelchairs, walking aids and hearing aids).

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[1] It is estimated that 50% of disabilities are preventable and directly linked to poverty (Department of International Development (2000) Disability, Poverty and Development. DFID

[2] Health therapists are Occupational Therapists, Physiotherapists, Speech and Language Therapists and Audiologists

[3] Assistive devices for persons with visual impairment and communication difficulties

[4] Little or no functional speech (LNFS) is defined as less than 12 words