Content » Vol 50, Issue 4

Special report

Responding to the world health organization global disability action plan in ukraine: developing a national disability, health and rehabilitation plan

Christoph Gutenbrunner, MD, FRCP1, Piotr Tederko, MD, PhD2, Klemen Grabljevec, MD, MBA3 and Boya Nugraha, MS, PhD1

From the 1Department of Rehabilitation Medicine, Hannover Medical School, Hanover, Germany, 2Department of Rehabilitation, First Medical Faculty, Medical University of Warsaw, Warsaw, Poland and 3Brain Injury Rehabilitation Department, University Rehabilitation Institute, Ljubljana, Slovenia

Abstract

In order to support the development of a National Disability, Health and Rehabilitation Plan (NDHRP) for Ukraine, a technical consultation was carried out by a Rehabilitation Advisory Team (RAT) of the International Society of Physical and Rehabilitation Medicine (ISPRM) in 2015. The consultation was based on assessment of the situation of persons with disabilities and the rehabilitation system in Ukraine.

Recommendations for activities and projects to improve rehabilitation services within the healthcare system were developed and proposed. In order to reach consensus on the recommendations, dialogues were held with different stakeholders, including the Ministry of Public Health. The recommendations included: coordination of disability and rehabilitation policies within the Ministry of Public Health and among other involved ministries; translation and adaptation of international definitions of functioning, disability, and assessment tools into Ukrainian; data collection on the epidemiology of disability and the need for rehabilitation; implementation of health-related rehabilitation services; and implementation of international definitions and curricula of rehabilitation professions.

The mission was regarded as successful and one year later a few changes had been adopted by the Ukrainian government. Further action based on this research is necessary. It will be important to track the changes and evaluate the results after an appropriate period of time.

Key words: rehabilitation service situation analysis; Rehabilitation Advisory Team; National Disability, Health and Rehabilitation Plan; rehabilitation services; rehabilitation professions.

Accepted Oct 20, 2017; Epub ahead of print Dec 22, 2017

J Rehabil Med 2018: 50: 00–00

Correspondence address: Christoph Gutenbrunner, Department of Rehabilitation Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany. E-mail: gutenbrunner.christoph@mh-hannover.de

Introduction

Ukraine has been an independent country since 1991, when it gained independence from the Soviet Union. It has a population of approximately 45 million. According to national registries 2.7 million people live with disability; 22.6% due to diseases of the circulatory system, 21.5% due to neoplasms, 11.2% due to musculoskeletal causes, and 10.8% as consequence of trauma or injury. The health system is based on a state funding system and includes some rehabilitation services. Its philosophy, and the description of health professionals, is based on the health system of the Soviet Union. The government of Ukraine (in particular the Ministry of Health) has decided to implement the principles of the World Health Organization (WHO) Global Disability Action Plan 2014–2021 (GDAP; 1).

In 2015, a technical consultation was carried out by a Rehabilitation Advisory Team (RAT) of the International Society of Physical and Rehabilitation Medicine (ISPRM) in order to support the development of a National Disability, Health and Rehabilitation Plan (NDHRP) for Ukraine (2). The mission was based on the United Nations (UN) Convention of the Rights of Persons with Disabilities (3) and the World Report on Disability (WRD; 4)). The goal-setting is derived from the WHO GDAP Better Health for All People with Disabilities (1), which was adopted by the World Health Assembly in 2014 (5).

Methods

The mission was based on assessment of the current situation of persons with disabilities and the rehabilitation system (including rehabilitation services and rehabilitation workforce training), and the application of international standards that lead to recommendations to improve the system. The mission consisted of the collection of relevant data on the health and rehabilitation system (6), site visits, and consultations with relevant stakeholders in disability and rehabilitation (2). Recommendations were developed by the advisors and discussed with different stakeholders in Ukraine. In addition, a stakeholder workshop about the recommendations was held to achieve consensus with stakeholders, including non-governmental organizations (NGOs), organizations of people with disabilities, and representatives of professional groups.

Consultations were held with different stakeholders, including representatives of the Ministries of Public Health, Social Policy and Education and Science, and the National Assembly of Invalids.

Site visits were made to the following locations:

  • Regional Hospital No. 1, Kiev (acute rehabilitation);
  • Research Institute of Orthopedics and Traumatology, Kiev (subacute rehabilitation);
  • District Centre for Social Rehabilitation, Kiev (community-based and social rehabilitation);
  • Clinical Sanatorium “Zhovten”, Kiev (sanatorium rehabilitation);
  • Dnepropetrovsk Regional Centre of Medical and Social Examination (regional level MSECs location, medical and social examination, providing certification of “invalidity” status for persons), Dnepropetrovsk;
  • State Institution (Ukrainian State Institute of Medical and Social Problems of Disability Ministry of Public Health of Ukraine), Dnepropetrovsk (tertiary care and research);
  • Dnepropetrovsk permanent child care boarding home, Dnepropetrovsk (children with disabilities long-term care and rehabilitation);
  • Ukrainian State Medical and Social Centre for War Wounded, Tsibli.

Based on the information gained from these consultations and site visits a NDHRP was drafted setting out recommendations for actions and projects to improve rehabilitation service provision. These recommendations were discussed and prioritized in a stakeholder dialogue that included the following bodies and institutions:

  • Ministry of Public Health of Ukraine;
  • Health Information and Emergency Response team of the national WHO office;
  • International NGOs (Handicap International; Ecology and Health);
  • Professional organizations (Ukrainian Society of Physical and Rehabilitation Medicine, Ukrainian Association of Physical Therapy, Ukrainian Society for Neurorehabilitation);
  • Organizations of people with disabilities (Pulmonary Hypertension Association Ukraine, Coalition for Persons with Intellectual Disabilities; Sphere of the Good (psychological rehabilitation), the Association of NGOs of Disabled People of Kiev);
  • Scientific institutions (Institute of Emergency Surgery and Rehabilitation, Ukrainian Catholic University, School of Rehabilitation Medicine);
  • Veteran organizations (Ukrainian Association of Disabled Military Men, “the fund of veterans “Unity Sworn” and the ATO Veterans Society”).

A comprehensive report and executive summary were compiled based on this information and the results of the stakeholder dialogues.

Results of situation analysis

In describing the current situation of rehabilitation service delivery, 4 main problems were identified from consultations and site visits:

  • The definition and understanding of “invalidity” does not coincide with the modern, internationally agreed understanding of disability and functioning;
  • Rehabilitation legislation and policies in Ukraine are fragmented and there is a lack of coordination between Ministries and organizations in charge;
  • Rehabilitation services traditionally are delivered in health resorts. A comprehensive system of rehabilitation services covering all phases and levels of care is lacking and rehabilitation services are not available for many persons in need;
  • The rehabilitation workforce does not match up to international and European standards, due to a different accreditation system and a lack of capacity.
Recommendations

The report recommends the following actions are implemented in order to improve health, functioning and quality of life for all persons with disability in Ukraine:

  • As rehabilitation is one of 4 main health strategies and requires services within different sectors of the health system, strong coordination is necessary within the Ministry of Public Health (optimally concentrated within a single department).
  • As rehabilitation also concerns other areas of life, such as social support, education, justice, etc., strong coordination between ministries is necessary (optimally through an inter-ministerial coordination committee with a high level of responsibility).
  • For disability and rehabilitation policy, legislation and data collection, it is crucial to translate and adapt international definitions (e.g. “functioning”, “disability”) and tools (e.g. the International Classification of Functioning, Disability and Health (ICF) Core Sets) into Ukrainian.
  • For mid-term planning of rehabilitation services, a sound database on the epidemiology of disability (including chronic and mental diseases) and the need for rehabilitation must be established. It should use international (ICF-based) tools.
  • Health-related rehabilitation services should be implemented at all levels of healthcare (primary, secondary, tertiary) and for all phases of healthcare (acute, post-acute, long-term). Since many rehabilitation services already exist in Ukraine, a transition plan has been developed. The primary healthcare sector must take a stronger role in long-term rehabilitation and as an entrance point for specialized rehabilitation services.
  • In order to establish a highly-qualified rehabilitation workforce, international definitions and curricula of rehabilitation professions (physical and rehabilitation medicine, physiotherapy, occupational therapy, speech and language therapy, prosthetist and orthotists, nurses, social workers, psychotherapists, and others) should be implemented and a new accreditation system implemented. A transition plan was proposed.
  • In light of the armed conflict in eastern Ukraine, the special needs of persons with disability living in the region, as well as the expansion of rehabilitation services for victims, should be realized.

In addition, the following projects were proposed:

  • An expert workshop to determine and agree on appropriate translations of terms such as “disability”, “functioning”, etc.
  • A project to adapt the ICF for use in Ukraine and to test the products within selected services.
  • A population-based survey, using internationally accepted methods, of the prevalence of disability in 2 regions of Ukraine.
  • Multi-professional rehabilitation teams in rehabilitation services to be set up and outcomes of rehabilitation programs evaluated.
  • Model rehabilitation services to be implemented and outcomes evaluated (acute rehabilitation services in 2 hospitals at secondary and tertiary level, post-acute rehabilitation service in at least 2 indications (e.g. stroke, limb amputation, multiple trauma, or cardiac surgery), 1 of which could integrate an existing sanatorium, and long-term service (e.g. community-based service in a rural area))
  • Model services to be implemented, including delivery and integration of assistive devices in medical rehabilitation programmes and medical and vocational rehabilitation.
  • Develop curricula for rehabilitation professionals (i.e. physical and rehabilitation medicine doctors, physiotherapists, occupational therapists) including training programmes for existing professionals.
  • Organize education and training courses for rehabilitation professionals with international support.
  • Develop a model for an adequate, motivating and fair payment system for rehabilitation services (based on international experience, a “pay per case” system, taking into account the severity of cases, is recommended)
  • A survey of existing rehabilitation facilities (number of rehabilitation institutions, departments and beds).
Discussion

The aim of this mission was the development of a NDHRP for Ukraine. The methods were based on the model of RATs, as developed by the ISPRM (2). Data collection was based on information available from public sources (WHO and NGO reports, published papers, etc.), consultations with different stakeholders, including government officials, NGOs (including professional organizations and organizations of persons with disabilities) and site visits to hospitals, rehabilitation centres and research institutions. The RAT consisted of members of the ISPRM. Data collection was structured according to a previously developed checklist (6). Before finalizing the report the recommendations for actions and projects were discussed with relevant stakeholders in disability and rehabilitation in Ukraine. During this meeting priorities were established through participant voting. The high level of agreement with the recommendations indicates that the mission has summarized relevant data on the situation of persons with disabilities and the health and rehabilitation systems and drawn relevant and comprehensive conclusions. Based on the advisors’ experience, the most relevant factors contributing to this outcome were:

  • a good level of planning of the country visit;
  • a high level of commitment from government representatives, who provided relevant information and were willing to held open discussions;
  • excellent coaching and team support from national representatives and experts, with daily discussion on the information gathered (including high-quality translation during consultations and site visits);
  • a clear concept for structuring information;
  • a well-organized stakeholder meeting with goals-oriented moderation;
  • a high level of political will of all national partners to improve the life situation of persons with disabilities, including access to health and reform of the rehabilitation system.

Regarding the situation in Ukraine with respect to disability and rehabilitation, it was important to take into consideration that the health system is based on the tradition of the former Soviet Union. Firstly, the term “invalidity” does not express the international model of disability, which is not an attribute of a person, but occurs due to the interaction of a person with a health condition and the environment (1). Since all political documents in Ukraine are based on this out-dated terminology, some changes in terminology and understanding are necessary.

Rehabilitation services are also based on the traditional central and eastern European model of health-resort medicine and sanatoria for patients with chronic health conditions. Thus, acute, post-acute and community-based rehabilitation services are scarce, and existing rehabilitation professions do not meet international standards. However, the existing services and rehabilitation workforce are good starting points from which to develop a modern rehabilitation system. Concrete recommendations for the transition of services and professions were included in the report and model projects were suggested.

Overall, the mission was successful, and 1 year later a number of changes had been adopted by the Ukrainian government (Box 1). From this starting point a good deal of further action is needed. It will also be important to monitor the changes and evaluate the results after an appropriate period of time.

Acknowledgement

The authors would like to thank Associate Professor Volodymyr Golyk, one of the representatives from Ukraine, for the success of this project.

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