Introduction
South Africa is classified as an upper-middle-income country. This obscures its significant wealth inequality, where approximately 80% of people live in poverty with poor social circumstances such as high crime and violence levels [
1‐
4]. Concomitant low education levels make it difficult to break out of the poverty cycle, limiting upskilling and employment opportunities [
2]. This reflects in the South African 2019 unemployment rate (29.1%; before the Coronavirus disease [COVID-19] outbreak), one of the highest globally [
5].
The private healthcare sector serves 20% of the South African population, but employs 70% of the country’s doctors and attracts over 50% of its healthcare funding. The remaining 80% of the population access the poorly-resourced public healthcare sector [
6]. Over the past 3 years, South Africa’s economic growth has slowed to less than 1% and public debt levels are growing across all sectors. Many people are on waiting lists for essential services and the situation is worsening due to COVID-19. Predicted budget cuts over the next few years will further strain the health sector.
South Africa’s complex and unique health challenges are characterized by poor social determinants of health and a quadruple burden of disease (BoD). Paradoxically, the country’s health challenges have been further complicated by improved outcomes of pharmaceutical management for infectious diseases (HIV/AIDS and tuberculosis [TB]) as more people are now living with such chronic health conditions that were previously fatal. Whilst people with chronic infectious diseases may be living longer, they often suffer from compromised physical and mental functioning, disabilities and poorer quality of life, as a result of underlying disease processes and the ramifications of medication regimes [
7]. There are also increasing reports of unanticipated comorbidities and disease interactions. For example, people living with chronic HIV are more susceptible to suffering stroke, whilst people living with chronic TB are more susceptible to deafness, chronic lung disease, or musculoskeletal pain [
8‐
13].
The disease cascade and BoD consequently impact significantly on people’s wellbeing and social participation [
14,
15]. Many are forced to rely on social grants because they are unable to work, and some require daily assistance from their families for basic activities of living, which limits the earning potential of caregivers [
16].
Rehabilitation is the key health strategy to address compromised functioning and quality of life [
17]. Recently, the World Health Organization (WHO) launched an international campaign (Rehabilitation 2030 [
17]) that recognizes the importance of rehabilitation to optimize functioning. Population rehabilitation needs are increasing rapidly in low- and middle-income countries [
18‐
20]. The WHO rehabilitation strategy emphasizes that accessible, safe and affordable rehabilitation is vital in achieving the third sustainable development goal: “ensuring healthy lives and promote well-being for all, at all ages” [
21]. These aims concur with South Africa’s Constitution and the country’s White Paper on Disability Rights, which state that “all people with disability have the right to quality and accessible healthcare and rehabilitation” [
22]. To achieve global and national goals, the WHO envisions that rehabilitation should be integrated across the continuum of care and should be funded by national health insurance systems. How this will play out in South Africa is unclear, given the limited allocation in health or social services budgets to support rehabilitation [
23]. The situation may worsen when unemployment, compromised social circumstances, and mental health issues arising from COVID-19 are fully realized.
South Africa’s first National Health Insurance (NHI) Bill (11 of 2019) was published in August 2019 [
24]. The NHI scheme aims to provide universal access to essential healthcare, regardless of needs, employment status or ability to contribute. Universal access to rehabilitation in South Africa should be considered carefully, so it can be realistically positioned, costed, and included in the proposed NHI scheme, in a way that matches key South African health and rehabilitation needs. Prioritization may need to occur due to scant funds for rehabilitation. Globally, the WHO has prioritized key conditions for which rehabilitation should be provided [
25]. However, South Africa’s unique epidemiological profile requires specific consideration of rehabilitation needs. A recent cross-national comparison of physical rehabilitation needs across the BRICS nations (Brazil, Russian Federation, India, China, and South Africa), using Global Burden of Disease (GBD) estimates up to 2017 [
18], found substantial differences in the evolution of rehabilitation needs. For example, a quarter of South African physical rehabilitation needs came from HIV-related conditions, while this approximated 1% for all other BRICS nations [
18]. This analysis highlighted the importance of better understanding South Africa’s unique epidemiological and socio-economic contexts, to assist in understanding the coverage of current rehabilitation services [
13,
26‐
30].
In this paper, we specifically assessed temporal trends (1990–2017) of GBD estimates of the most common conditions (as ranked by years lived with disability [YLDs] for South Africa) that could be improved by rehabilitation. We further forecast rehabilitation needs for 5 years (2018–2022), based on recent trends (2012–2017). The current trend analysis extends from previously published comparative analyses across the BRICS nations [
18], to provide a more detailed synthesis with a focus on conditions unique to the South African context that contribute most to YLDs in this specific setting. As our synthesis incorporates the top conditions (based on their ranking by YLDs for South Africa specifically) for which evidence-based rehabilitation interventions exist to address associated disability, this paper reports on a different set of conditions (versus the BRICS paper), that are relevant to South Africa. While the paper on the BRICS nations aimed to compare regions, this paper focuses on understanding current rehabilitation service implications for the South African context based on a trend analysis and short-term 5-year forecasting extrapolated from recent historical trends (which was also not incorporated in the BRICS paper). Since South Africa is on the brink of moving towards NHI, this paper is important for designing local rehabilitation services.
Discussion
To our knowledge, this is the first paper that reports on a synthesis of GBD estimates for rehabilitation-sensitive conditions that contribute most to YLDs in South Africa. The use of different GBD estimates (prevalence and YLDs) shows that different stories can be told for conditions, which range from communication and sensory conditions, to internal medical and musculoskeletal conditions. The most appropriate information on conditions requiring rehabilitation must thus be factored into the design and implementation of the South African NHI to ensure that the need for rehabilitation is recognized and funding is directed to where it is most needed. The South African-specific GBD estimates highlight the variability of rehabilitation needs in South Africa’s top-ranked conditions, and the potential burden they impose on individuals and society. They underscore the importance of undertaking in-depth, country-specific population-rehabilitation analysis to understand current need and potentially inform resource planning and investment.
Total YLDs per condition per year increased almost two-fold from 1990 to 2017, as the YLDs counts increased in all conditions except HIV (gradual decrease of HIV YLDs from 2004). The increase in YLDs counts may be explained by the dynamic interplay of local factors over time. One of these is fluctuations in South Africa’s life expectancy, which decreased by an average of 10 years between 1993 and 2003. Roll-out of antiretroviral treatment for HIV in 2004 [
49] reversed the downward spiral of life-expectancy, which returned to 63 in 2017 [
50]. The increase in life-expectancy in association with annual population growth may thus have contributed to the total number of YLDs increasing in South Africa, reflecting that many more people are now living for longer with infectious diseases.
The proportionate contribution of each condition to total YLDs count was dramatically transformed by HIV in 2017, compared to 1990. HIV currently affects one in five adults in South Africa [
51]. Thus, in South African clinical and policy contexts, considering HIV separately from other common conditions requiring rehabilitation may be artificial, as HIV is often the underlying pathology for other conditions. These include musculoskeletal pain and trauma (such as amputations due to vascular impairments), stroke, DM2, neonatal disorders and hearing loss [
9,
52‐
54]. While it appears as if the current proportionate condition contribution to total YLDs will remain stable, biological and clinical knowledge about potential interactive effects between co-existing conditions is important for health system design. Our synthesis is descriptive only, provided per singular condition. Although GBD estimates are corrected for comorbidity, the methodology assumes independence between individual diseases [
32]. It therefore does not account for shared risk factors or diseases that may put one at risk of developing another disease [
55]. More refined methods are under development and will most likely be used in future [
56]. Moreover, the current GBD estimates do not reflect the legacy of the unprecedented COVID-19 global pandemic, which sees many people with unexpected rehabilitation needs [
57‐
59]. Therefore considering compounded effects of disease patterns and new emerging conditions on functioning are paramount in the design, type, and adaptability of South Africa’s rehabilitation services.
Changes in the age-standardized YLDs rates varied between conditions over the 28-year study period. The rates of burns, chronic respiratory disease, cardiovascular disease and fractures appeared to have decreased over time (Fig.
3) and may reflect improved access to healthcare by more South Africans since the first democratic election in 1994. Decreasing trauma rates (fractures and burns) may also reflect improved housing and the impact of public health prevention campaigns. Whilst decreasing trauma rates to 2017 did not necessarily reflect improved access to rehabilitation, it is important to maintain this momentum of change, as trauma rates in South Africa remain alarmingly high and place an excessive burden on an already-constrained healthcare system [
4]. Universal access to rehabilitation through the NHI should increase opportunities for injured South Africans to optimize function, regain dignity, and achieve community integration.
The predicted prevalence for most conditions (see Table
3) appears to be relatively stable until 2022, which supports informed service design. The discrepancy in terms of decreasing YLDs trend and slightly increased predicted prevalence noted for CVD may be due to advances in management and consequently lower disability levels; despite more people being diagnosed and/or perhaps inadequate risk factor control [
60]. Despite the relative stability observed for most conditions, more information about functional impairment, condition severity and duration, functional impairments/disability type, ability to detect people who need rehabilitation, barriers to access and health-seeking behavior is necessary for rehabilitation service design. GBD uses DWs to incorporate disability severity and duration [
33]. However, the validity of GBD DWs in lower-resourced settings such as South Africa has been questioned [
61]. DWs are derived from research, self-report data and expert panels, which may not reflect the reality of rehabilitation for many people living in poorer socio-economic circumstances within a specific context (country). Thus, while GBD provides an opportunity to dissect prevalence and disease burden on a global macro level, it is essential that national and individual micro needs are also understood when planning and costing rehabilitation care packages. Economists and legislators must understand the continuum of rehabilitation need for priority chronic conditions and be able to estimate the greatest, most impactful population need on the continuum. It is also important that they consider the potential for people who receive rehabilitation to improve, and how ‘optimum function’ for these people can be described and measured.
Rehabilitation workforce and educational implications
The projected prevalence and YLDs reported in this paper indicate that rehabilitation needs in South Africa will be substantial by 2022. To ensure that rehabilitation is an essential component of the NHI, there needs to be an adequately-sized, trained and recognized rehabilitation workforce that is sufficiently funded to address the needs of the poor and uneducated, who are mostly cared for in the public sector. South Africa’s capacity to mobilize such a workforce is probably inadequate. Tertiary-trained health professionals have traditionally delivered rehabilitation across the healthcare continuum. They take five or more years to train, and once graduated, they require high salaries. The number practising in the public sector has always been far fewer than the private sector, despite the significantly-greater need in the public sector [
8,
13,
26]. The NHI budget is unlikely to be elastic, thus it is important that in aspiring to Rehabilitation 2030’s goals, South African policy makers and health funders remain realistic in how rehabilitation is best introduced into the NHI, how it is rationed, and how its impact is measured. Reliance on trained healthcare providers to deliver rehabilitation is, by default, going to limit access for many people. Delivering rehabilitation equitably in the NHI will require innovation – including task-shifting, educating, empowering and using patients, families, communities, and skilled and semi-skilled community health workers, to nurture the rehabilitation philosophy and functional restoration so they can work alongside healthcare professionals to optimize patient function [
30].
Moreover, there are significant training implications for healthcare professionals at undergraduate and postgraduate levels to ensure consistent uptake of, and advocacy for, rehabilitation messages. Whilst undergraduate programs teach students about clinical assessment and treatment techniques, there is less focus on the skills required for rehabilitation. To achieve the rehabilitation millennium goals, health professionals providing rehabilitation must upskill to repackage their care to encompass health education, community health literacy facilitation, patient advocacy, and patient and community empowerment [
62]. Moreover, they will need to use different ways of disseminating information to deliver their messages, such as social media, internet advice; and internet/telephone counselling.
Limitations
This study was a synthesis of freely available GBD estimates. GBD condition-specific DWs may be constrained by geographical, socio-economic, and contextual issues; and do not necessarily reflect the context-specific reality of rehabilitation for many people in lower-resourced settings such as South Africa. Neither YLDs nor prevalence enable understanding of the core functional limitations that are experienced by South Africans. At the time when we conducted the study, the 2019 GBD estimates were not yet available, but our projections align well with these 2019 estimates. Thus, our main findings on trends in rehabilitation need in South Africa are not compromised. The GBD statistical modelling and estimates are dependent on good quality and sufficient local input data, which is very limited in lower income settings such as South Africa. We also did not report on sex-specific estimates, as preliminary analyses did not show any sex bias for any of the conditions included in this paper. This could be explored again in further research. Finally, as an initial description of South Africa’s rehabilitation needs, this study was not designed to distinguish between adults and children, as the top conditions contributing to YLDs in South Africa is biased to adults (except for neonatal disorders; see age distributions in Additional File
3) and do not provide an accurate reflection of the rehabilitation needs of children. Such differentiation was not the current objective, but is worth examining in future analyses to guide current and future service strategies.
Conclusion
This synthesis of trends in GBD estimates indicate that rehabilitation needs in South Africa are potentially massive and unmet. This highlights a need to move towards innovative, adaptable, and context-specific rehabilitation, considering not only current local needs but also the projected changes in needs. The results of this paper, including limitations, should be considered when making decisions about funding for rehabilitation within the NHI and other aid funds, for rehabilitation workforce investments and developments.
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