Advancing the World Health Assembly’s landmark Resolution on Strengthening Rehabilitation in Health Systems: unlocking the Future of Rehabilitation

Abstract

In May 2023, the historic Resolution on Strengthening Rehabilitation in Health Systems was adopted unanimously by the 194 Member States of the World Health Assembly (WHA), the highest health policy-setting body. The resolution aims to scale up and integrate rehabilitation into health systems as part of Universal Health Coverage (UHC) to address the growing rehabilitation needs due to the global ageing population, the increasing prevalence of non-communicable diseases, and the emergence of new infectious diseases such as COVID-19. Globally, data extracted from the Global Burden of Disease Study in 2019 showed that one out of three people could benefit from rehabilitation, while more than half of the population in many countries is not receiving essential rehabilitation services. This special article highlights the global challenges in meeting rehabilitation needs and emphasizes the importance of affordable, accessible, and quality rehabilitation services for vulnerable populations. The resolution’s path, which started in 2017 with the “Rehabilitation 2030: a Call for Action” initiative by the World Health Organization (WHO), is outlined. We summarize the key aspects of the WHA resolution, including its requests for Member States, international organizations, and the WHO Director-General. Finally, we discuss the way forward towards implementation, involving advocacy and concrete actions by all stakeholders, with the support of the newly established World Rehabilitation Alliance. The goal is to integrate rehabilitation into health systems worldwide, thus improving the well-being and socio-economic participation of those in need.

In May 2023, for the first time in 75 years, rehabilitation was on the agenda of the World Health Assembly (WHA), the highest health policy-setting body, composed of health ministers from member states, that sets the goals and policies of the World Health Organization (WHO). The WHA adopted a historic Resolution on “Strengthening Rehabilitation in Health Systems”, thanks to the collective political will of Member States and the persistent advocacy efforts of various civil society groups. The unanimous adoption of the resolution by the 194 Member States sets overarching goals for Member States, WHO leadership, and rehabilitation stakeholders worldwide to work towards scaling up and integrating rehabilitation into health systems as part of Universal Health Coverage (UHC).¹

The urgent need for a resolution on rehabilitation was underscored in the WHO Director General’s report presented to the WHO executive board in 2022,² emphasizing the demographic trends towards a global ageing population, the increasing prevalence of non-communicable diseases, and the emergence of new infectious diseases such as COVID-19. Globally, data extracted from the Global Burden of Disease Study in 2019, showed that 2.41 billion people could benefit from rehabilitation.^{3, 4}

Disturbingly, these growing rehabilitation needs are largely unmet around the world, with more than half of the population in many countries not receiving essential rehabilitation services.⁵ There is a significant shortage of rehabilitation workforce, particularly in low- and middle-income countries and remote areas as well as a widespread lack of awareness among healthcare providers of the importance of rehabilitation.^{2, 6} In addition, most countries, are scarcely equipped to deal with the sudden surge in rehabilitation needs that can result from public health emergencies.^{2, 7} Access to affordable, quality rehabilitation services and assistive technologies⁸ is often out of reach for vulnerable and marginalized populations, negatively impacting their health, well-being, and socio-economic participation. The cost of accessing rehabilitation services and related health products is frequently an out-of-pocket expense for people, leading to financial hardship and hindering progress toward UHC.²

The path towards the WHA Resolution

The first step towards the World Health Assembly’s (WHA) resolution was the launch of the “Rehabilitation 2030: a Call for Action” initiative in February 2017,⁹ in a meeting of various stakeholders, including Member States, international organizations, NGOs, and rehabilitation experts, led by the WHO secretariat. This global call emphasizes three key aspects: rehabilitation should be accessible to all, integrated into all levels of health care, recognizing its essential role in achieving UHC.⁹ The initiative commits to strengthening rehabilitation services globally by focusing on key actions such as improving governance and investment, expanding the rehabilitation workforce and services, and enhancing data collection.¹⁰ In July 2019, a second meeting was held to identify facilitators and barriers in advancing the global rehabilitation agenda.¹¹ At this meeting “functioning” was promoted as a public health goal, and as the third health indicator, together with mortality and morbidity, and rehabilitation was proposed as the key health strategy for optimizing functioning.^11-13 In addition, “Rehabilitation in health systems: a guide for action,” a resource developed by the WHO to support countries to strengthen their health systems to better provide rehabilitation, was launched.¹⁴

The emerging need to advocate for the strengthening of rehabilitation in health systems in a concerted manner led to the founding of the Global Rehabilitation Alliance (GRA). In 2019, the GRA and other rehabilitation stakeholders started to advocate for a WHA resolution on rehabilitation. Advocacy activities included the production of joint policy documents, public statements during WHO governance meetings, bilateral and regional briefings with permanent missions in Geneva and government representatives in capitals, and increased communication efforts on key international dates.

The resolution’s journey took a significant step forward in 2021, when Colombia, Israel, Kenya and Rwanda proposed an item on rehabilitation for the agenda of the WHO Executive Board. Although initially postponed due to a full agenda, the item was eventually placed on the agenda of the WHO Executive Board meeting in 2023. This led to intense negotiations among Member States and consultations with other stakeholders throughout 2022, culminating in a consolidated draft resolution presented by 19 co-sponsoring Member States at the Executive Board meeting in early 2023 when its adoption by the WHA was recommended. Finally, during the 2023 WHA, 36 speakers, including 30 delegates from Member States, five non-State actors (NSAs) and the WHO Secretariat, expressed their views on the resolution. This engagement was complemented by six additional written statements from NSAs in support of the resolution. Ultimately, the resolution was adopted unanimously by all Member States at the 76^th World Health Assembly in Geneva on May 27^th, marking an important milestone in the global commitment to strengthening rehabilitation in health systems.¹⁵

Summary of the WHA Resolution

A WHA resolution is a formal agreement or decision by the Member States of the WHO, used as an international policy instrument to make political commitments and request action from the WHO Secretariat.¹⁶ Although these resolutions are not legally binding under international law, they carry considerable weight because they represent the collective political will and the highest level of international commitment of Member States.¹⁷ The resolution on rehabilitation is divided into two sections. The first section provides preliminary considerations that highlight the need to improve rehabilitation in health systems and places this resolution in the context of previous WHO and UN resolutions and commitments. The second part outlines specific requests endorsed by the WHA: a call to action for Member States, an invitation to international organizations and other stakeholders to offer support, and a request to the WHO Director-General to develop further tools and technical guidance for countries.¹

Key preliminary considerations include the increasing and largely unmet global rehabilitation needs. The section highlights the significant long-term consequences of not addressing these needs, not only for individuals and their families, but also for broader social and economic structures.¹ It is recognized that rehabilitation is necessary to achieve Sustainable Development Goal 3, which aims to ensure healthy lives and promote well-being for all at all ages, and target 3.8 on UHC, which includes protection against financial risks, access to quality essential health services, and access to safe, effective, high-quality and affordable essential medicines and vaccines. The resolution acknowledges the contribution of rehabilitation to upholding fundamental human rights, such as the right to the highest attainable standard of physical and mental health, including sexual and reproductive health, to work, and to education. The role of rehabilitation in significantly reducing healthcare costs and the burden on healthcare providers is emphasized. Several international commitments are recalled, such as the Astana Declaration,¹⁸ other WHA resolutions, including the resolution on the International Classification of Functioning, Disability and Health,¹⁹ on Control of Noncommunicable Diseases,²⁰ the Global Strategy and Action Plan on Ageing and Health,²¹ Improving Access to Assistive Technology,²² Health Emergency Preparedness and Response,²³ Health of Persons with Disabilities,²⁴ and the Political Declaration on Universal Health Coverage.²⁵

In the second section, the resolution urges Member States to raise awareness and build national commitment to rehabilitation, including assistive technology, and to integrate rehabilitation into national health plans and policies. This includes considering appropriate ways to strengthen financing mechanisms; expanding rehabilitation to all levels of health care, from primary to tertiary; and ensuring the integrated and coordinated provision of high-quality, affordable, accessible, gender-sensitive, appropriate and evidence-based rehabilitation interventions along the continuum of care, including the timely integration of rehabilitation into emergency preparedness and response, the development of a strong multidisciplinary rehabilitation workforce, the improvement of health information systems, the promotion of high-quality rehabilitation research, and the efficient delivery of and equitable access to assistive technologies.¹

International organizations and other relevant stakeholders are invited to support Member States in their national efforts to implement the actions of the Rehabilitation 2030 Initiative, to strengthen advocacy for rehabilitation through the World Rehabilitation Alliance (WRA), a WHO global network of stakeholders whose mission is to advocate for the implementation of the Rehabilitation 2030 Initiative,²⁶ and, finally, to harness and invest in rehabilitation-related research and innovation.¹

Finally, the WHO’s Director-General is requested to prepare a WHO baseline report on rehabilitation needs by the end of 2026; to develop global rehabilitation targets and indicators for the health system; to ensure WHO’s institutional capacity to develop technical guidance and resources; and to provide ongoing support to Member States to implement the actions of the Rehabilitation 2030 initiative; and to report on progress at the World Health Assembly in 2026, 2028 and 2030.¹

The way forward towards implementation

As described above, the Resolution includes a specific paragraph inviting international organizations and other relevant stakeholders to support Member States in their national efforts to implement the actions outlined in the Rehabilitation 2030 Initiative. In particular, strengthening advocacy for rehabilitation by supporting the WRA,²⁶ investing in rehabilitation research and innovation, and promoting health policy and system research to ensure future evidence-based rehabilitation policies and practices.

In July 2023, the third Global Rehabilitation 2030 meeting was held to review the progress of the Rehabilitation 2030 Initiative and to acknowledge the resolution and discuss the steps towards its implementation. During the meeting new WHO tools, to facilitate the implementation of the resolution in countries were presented such as the Guide for rehabilitation workforce evaluation (GROWE),²⁷ the Routine health information systems (RHIS) — Rehabilitation toolkit,²⁸ and the Package of interventions for rehabilitation (PIR).²⁹

At the end of the meeting, on July 11^th, the WRA was officially launched with a concert by Ricky Kej, who even created a song for rehabilitation, and an evening reception at the WHO’s headquarters.^{26, 30} The WRA was pre-launched in September 2022 and application to membership was opened to: Member States and State bodies; intergovernmental organizations; nongovernmental organizations; private sector including international business associations; philanthropic foundations; and academic institutions. A new call for membership is planned. All members of the WRA can participate in one or more of its five workstreams: workforce, primary care, research, emergencies, and external relations. The International Society of Physical and Rehabilitation Medicine, as well as the European College of Physical and Rehabilitation Medicine currently have representatives in the first four workstreams, the “external relations” workstream not being open to members yet. The workstreams were identified as the initial areas where advocacy for rehabilitation was most urgently needed. The workforce workstream is advocating for investment in quality rehabilitation education and training of a multidisciplinary rehabilitation workforce and expanding its integration into all levels of care and practice settings. The main aims of the primary care workstream are to raise awareness of the necessity to integrate rehabilitation and primary care, engage international organizations in the development of strategies to advance the integration of rehabilitation and primary care, and develop mutual collaborations toward this aim among health professionals along the continuum of care (promotion - prevention - treatment - rehabilitation - palliation). The research workstream is promoting the generation and use of health policy and systems research evidence for rehabilitation, as well as its publication, dissemination, and implementation. The emergency workstream aims at a shared vision of the essential role of rehabilitation and tools to advocate for its inclusion in emergency preparedness and response, and at engaging policy and key decision-makers to manage surge and maintain essential rehabilitation services in emergency preparedness and response.

While the WRA’s mission is limited to advocacy activities, civil society should additionally engage in concrete actions for the implementation of the resolution. As rehabilitation professionals, and physical and rehabilitation medicine (PRM) physicians in particular, we can do this at different levels of the health system, making use of the different WHO products presented above. For example, at the micro level (individual patient or patient groups), we can implement the PIR for its 20 health conditions. At the meso level health service data provided by the healthcare workers can be collected directly from the health facilities using the RHIS - Rehabilitation toolkit. At the macro level, our national societies can advise healthcare authorities or Ministries of Health in the planning, organization, and financing of adequate rehabilitation services, according to population needs in the countries, for instance applying the GROWE tool for rehabilitation workforce planning. As PRM academics we can promote quality education for building rehabilitation workforce capacity, as explained in a recent editorial by Ceravolo et al.³¹

Conclusions

The WHA Resolution on “Strengthening Rehabilitation in Health Systems” represents a significant step forward in addressing global rehabilitation needs. The path towards implementation involves advocacy by all stakeholders, with the support of the newly established World Rehabilitation Alliance (WRA). We need to engage and invest in innovation and rehabilitation research, including on health policy and systems to allow future evidence-based decision-making. In July 2023, the third Global Rehabilitation 2030 meeting assessed the progress on the “Rehabilitation 2030: a Call for Action” initiative and presented five WHO tools to facilitate the resolution implementation.

Civil society, including rehabilitation professionals and consumers, can and should engage in concrete actions. Implementing the Package of Interventions for Rehabilitation (PIR), collecting health service data using the Routine Health Information Systems (RHIS) - Rehabilitation toolkit, and advising healthcare authorities are some of the ways to contribute to resolution implementation. With the joint efforts of Member States, and all rehabilitation stakeholders, we can propel the implementation of this resolution and ensure that rehabilitation becomes an integral part of health systems worldwide, ultimately improving the well-being and socio-economic participation of millions of people in need.