Work

Health Systems Strengthening for Rehabilitation Service Delivery at the Primary Care Level: Process Evaluation Findings from Pakistan

Year: 2026

Type: preprint

Abstract: Background Rehabilitation, including assistive technology (AT), is an essential health service, yet access remains limited in low- and middle-income countries (LMICs), including Pakistan. To address gaps in rehabilitation service delivery, the Learning, Acting, and Building for Rehabilitation in Health Systems (ReLAB-HS) piloted a Networks of Care (NoC) model in Thatta and Swat districts to integrate rehabilitation into primary health care (PHC). Methods A qualitative process evaluation was conducted between May–September 2024, guided by the implementation outcomes framework. Data was collected through 61 in-depth interviews with stakeholders, including lady health workers (LHWs) and supervisors (n = 31), PHC providers (n = 12), rehabilitation professionals (n = 9), and technical working group (TWG) members (n = 9). Framework analysis was used to explore acceptability, appropriateness, feasibility, fidelity, adaptations, sustainability, and scalability. Results The NoC interventions were widely acceptable among the respondents, recognizing their relevance to community needs. The model aligned with PHC goals, though cultural barriers and bureaucratic inefficiencies limited appropriateness. Fidelity was generally high, supported by co-design, training, and digital coordination tools (eg WhatsApp), but constrained by workforce shortages and inconsistent availability of AT. Adaptations included designating rehabilitation days, flexible follow-ups, and community awareness activities. Staff shortages, patient load, and transport barriers challenged the feasibility of the interventions. Sustainability and scalability were seen as contingent on government ownership, integration into health information systems, and dedicated financing, with strong stakeholder demand for district-wide expansion and refresher trainings. Conclusions Integrating rehabilitation into PHC through a locally adapted NoC model is feasible, acceptable, and contextually appropriate in Pakistan, but requires systemic investment, supply chain strengthening, and policy-level integration for sustainability. Embedding rehabilitation into national and provincial health programs, health information systems, and financing mechanisms is critical to advancing equity and achieving universal health coverage.

Source: Research Square

DOI: 10.21203/rs.3.rs-9153326/v1