Background
Rationale for realist synthesis
Methods
Overarching research question
‘What policies, including processes of policy development, implementation, monitoring and evaluation, promote good leadership and governance of health related rehabilitation in less resourced settings?’
Searching process
Inclusion criteria | |
Publication Year | 2003 – present. |
Language | No restriction. |
Searching will be conducted in English, with any non-English titles to be translated. | |
Types of Research | Qualitative, quantitative and mixed methods: - Intervention studies - Descriptive studies |
Research and development studies. | |
Programme evaluations. | |
Theoretical. | |
Types of Documents | Primary and secondary (review) studies, including: - Journal articles, book chapters, policy reports, technical reports, conference proceedings and reports, and accessible dissertations. - Commentaries/Editorials |
Research Focus | Addresses the following: - Rehabilitation AND leadership/governance with a focus on policy - Low-income setting OR can be applied to a low-income setting |
Exclusion criteria | |
Publication Year | Prior to 2003. |
Types of Research | Protocols. |
Testing measures. | |
Types of Documents | Book reviews, abstracts, bibliographies. |
Research Focus | - Rehabilitation services delivered by different sectors, i.e. vocational rehabilitation - Not applicable to a low-income setting - Non-disability related services |
Codes for Exclusion | Rehabilitation – Article does not relate to issues of rehabilitation. |
Policy – Article does not relate to leadership/governance with a focus on policy. | |
Setting – Study location not applicable. | |
Research – Research method does not fit inclusion criteria. | |
Document – Document type does not fit inclusion criteria. |
1(a) AND 2 AND 3 | |
1(b) AND 2 AND 3 | |
1 (a) Leadership AND policy. | 1 (b) Governance AND policy. |
2. CAHD OR CBR OR ‘Community approaches to handicap in development’ OR ‘Community based inclusive development’ OR ‘Community rehabilitation’ OR ‘Community based rehabilitation’ OR ‘Functional restoration’ OR Habilitation OR ‘Health related rehabilitation’ OR ILD OR ‘Inclusive local development’ OR ‘Participatory community development’ OR Rehab* OR Rehabilitation OR ‘Restoration of function’ OR (Rehabilitation w/3 (care OR services OR support OR therapy)) OR ((therapy OR therapies) w/3 (cognitive OR complementary OR occupational OR physical OR recreational OR respiratory OR social OR speech)). | |
3. Africa OR Asia OR Caribbean OR ‘Central America’ OR ‘Eastern Europe’ OR ‘Latin America’ OR ‘Less resourced’ OR LMIC OR LIC OR ‘Low income countries’ OR ‘Low income country’ OR ‘Low and middle income countries’ OR ‘Low and middle income country’ OR Pacific OR ‘South America’ OR ‘Third world’ OR ((developing OR ‘less developed’ OR ‘least developed’ OR ‘under developed’ OR poor) w/3 (countries or country or nation or nations)). |
Selection and appraisal of documents
Quality rating of articles
Data extraction
Data syntheses
Results
Quality of articles
Context mechanism outcome pattern configurations and statements
Reference: 01 Title: Araya R, Alvarado R, Sepulveda R, Rojas G. Lessons from scaling up a depression treatment program in primary care in Chile. Rev Panam Salud Pública. 2012;32(3):234-240. | ||||||||
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Key words
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Setting
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Design
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Population
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Intervention
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System-wide or project-specific
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Sectoral or inter-sectoral
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Cadre
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Quality (MMAT)
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Community mental health services; Depression; Healthcare delivery; Mental health; Chile. | Chile: Programa Nacional de Diagnóstico y Tratamiento de la Depresión) National Depression Detection and Treatment Program (PNDTD). | Retrospective qualitative study; In-depth semi-structured interviews with six key informants. | Depression treatment programme users. | PNDTD, Chile. | This research reports on a summary of elements that led to scaling up and sustainability of the PNDTD programme, Chile, 2008. | Strategic alliances were created across sectors with strategic partners, between the Mental Health Unit and the Primary Care Division (PCD), and with the Ministry of Women. | Senior Officers at the Ministry of Health (MoH). | 3 quality score –Qualitative. |
CMOCs
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Contexts
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Mechanisms
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Outcomes
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CMOCs
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1. Scientific Evidence i) A national disease-burden study was conducted. ii) Two large psychiatric morbidity surveys were conducted. iii) Other studies showed that depression was also very common among primary care patients. iv) A trial was conducted of cost-effectiveness of an improved treatment of depression through primary care in Chile. v) A randomized controlled trial of a programme to improve the management of depressed women in the primary care setting showed positive results. vi) The MoH hired an academic institution to undertake a small scale evaluation of the effectiveness of the programme. | 1. i) The psychiatric morbidity surveys were used to advocate for more resources for the PNDTD. ii) The studies were based on local data. iii) The Mental Health Unit at the MoH leveraged available evidence effectively. iv) A workable action plan was presented to policymakers. v) There was ongoing communication between the research team and those designing the programme. | 1. The MoH decided that depression would become the country’s third highest health priority for 2002. | 1. Scientific evidence: When scientific evidence on a disease burden is collected, and used to advocate for more resources; based on local data; and effectively leveraged and presented to policymakers with a workable action plan, a specific health issue can be established as a national health priority – even in a context of socioeconomic challenges such as in a low- or middle-income country. | |||||
2. Teamwork and Leadership i) There was an informal team of leaders acting in parallel at different levels and with a shared vision. | 2. Leaders shared common features: “politically friendly” and trustworthy; good at forming alliances; able to apply technical information; and good communicators. | 2. Effective teamwork and leadership facilitated the creation of powerful strategic alliances, which facilitated institutionalizing the programme within the ministerial framework. | 2. Teamwork and Leadership: Effective teamwork and leadership – by a group of respected and “politically friendly” professionals acting as leaders in a team effort; who are capable of communicating effectively with decision-makers; with the capacity to detect emerging opportunities and react accordingly; who are capable of negotiating political agreements at all levels; who have at least basic technical knowledge, and can prepare a solid proposal; and who are trustworthy individuals capable of forming alliances with strategic partners – can create powerful strategic alliances, which can facilitate institutionalizing a programme within a ministerial framework. | |||||
3. Strategic Alliances i) There was a strategic alliance between the Mental Health Unit and the PCD. ii) Other strategic alliances were formed outside of the MoH, with the Ministry of Women and some universities. | 3. i) A strong alliance was created – the Mental Health Unit had technical capacity while the PCD had resources. ii) Academics provided information, which provided support for introducing the programme. | 3. The PCD accepted ownership and management of the programme. | 3. Strategic alliances: Strategic alliances – with key individuals who have positions of political power in a MoH; across sectors with strategic partners; that can persist over time; and with other units by which a programme may be co-owned – can result in a PCD accepting ownership and management of a programme. | |||||
4. Programme Institutionalization i) A gradual process occurred of “institutionalization” of the programme. | 4. i) The programme was aligned with well-known models of care, similar to those of other ministerial programmes. ii) The programme was introduced as another ministerial programme, complying with regulations and ring-fenced funding. iii) New and ring-fenced funding was secured. iv) A critical-mass of human resources was used. v) The programme had itemized resource allocation, e.g. resource allocation for psychologists, medication, etc. vi) The programme was highly structured in technical and financial terms. | 4. The programme was highly sustainable. | 4. Programme institutionalization: Institutionalizing a programme – by using well recognized models of healthcare delivery within the MoH; placing the programme among other well established PCD programmes; introducing personnel that are widely available and at an affordable cost with the potential to lead the programme locally; and fence-ringing any new and essential financial resources – can result in strong programme sustainability. | |||||
5. Task-shifting: i) Responsibility for most patient care was transferred to the PCD, away from specialized psychiatric services. ii) Transfer of responsibilities from psychiatrists to psychologists was conducted, who were widely available at an affordable price. iii) Psychologists were hired as key players. | 5. Task-shifting may increase the availability of human resources, allowing more patients to receive treatment. | 5. When the PNDTD was scaled up, psychologists were hired in all primary care centres and became the programme’s cornerstone. | 5. Task shifting:
In contexts of a shortage of specialized health workers, task-shifting to less specialized health workers may increase the availability of human resources for health so that more patients can access healthcare. |
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Participation of persons with disabilities in policy processes, and the research that guides such processes, to improve programme responsiveness, efficiency, effectiveness, and sustainability, and to strengthen service-user self-determination and satisfaction.
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Collection of disaggregated disability statistics, and development of health information systems, to enable a situational analysis of disability for the purposes of supporting political momentum, decision-making of policymakers, evaluation, accountability, and equitable allocation of resources.
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Explicit recognition in policies that disability may interact with other vulnerability factors, for example displaced populations with disabilities, which may create double discrimination, multiple disadvantages, and increased barriers to accessing health services. Accordingly, explicit promotion in policies of access to services for all subgroups of persons with disabilities and service-users to support equitable and accessible services.
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Strong inter-sectoral coordination for the provision of rehabilitation services, including CBR, for the purposes of creating coherent mandates across governmental departments regarding service provision.
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‘Institutionalizing’ rehabilitation programmes by aligning programmes with well-known, preexisting Ministerial models of healthcare, similar to other Ministerial programmes, to support programme sustainability.
Statements (Policy recommendations) | Examples of proposed outcomes |
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1. What works in including persons with disabilities in decision-making regarding the development, implementation and monitoring/evaluation of policies/plans? | |
1. Implementing the UNCRPD requires persons with disabilities to be involved in developing, implementing and evaluating rehabilitation policies, and for the capacity of persons with disabilities to be increased to strengthen their involvement. | 1. Supports responsiveness to needs, and shared control over agenda setting. |
2. Disability desks and focal persons should be established in all government ministries. Where persons with disabilities have appropriate levels of expertise and understanding given the context, they should be preferred candidates. | 2. Strengthens focus on disability issues. |
3. As an interim measure to promote inclusion, there should be a quota of policymakers who are persons with disabilities, which could be filled by persons with disabilities who have appropriate training and qualifications. | 3. Prioritizes rehabilitation and supports participation of persons with disabilities in policy development. |
4. New and advanced leadership pathways, such as volunteer opportunities, service on boards/committees, and leadership development workshops, should be created for disability advocates to represent persons with disabilities in service governance roles. | 4. Equips service-users with skills to participate in advocacy and policy planning. |
5. Research for rehabilitation services should be conducted with a participatory ethos. This requires that the research skills of persons with disabilities be developed, that the ability of researchers to meaningfully involve persons with disabilities is developed, and that adequate resources are provided by governments to increase such education/skill development. | 5/6. Allows persons with disabilities to gain influence over research that guides policies. |
6. More ‘emancipatory research’, or participatory research, should be conducted, allowing persons with disabilities to gain greater influence over decision-making for policies. | |
7. Helping representatives of different types of disabilities to identity and express common challenges could strengthen their influence in service provision and ensure service provision responds to the full range of the diversity of disability. | 7. Strengthens advocacy. |
8. Service users of rehabilitation services should also be involved in the governance of such services, including for example on advisory and review panels and boards of steering committees. | 8. – Strengthens programme sustainability. – Improves relevance of programmes. |
9. ICT (information and communication technologies) are promising technologies for persons with disabilities to participate in e-governance in the long-term, including planning and monitoring. | 9. Supports participation of persons with disabilities in governance. |
10. Regular community analyses, context surveys, and user needs assessments are necessary to ensure that e-governance meets the needs of persons with disabilities. | 10. – Assesses needs of subgroups of persons with disabilities to participate in e-governance. – Creates a comprehensive system design. |
11. Statistical information and training should be available and accessible to persons with disabilities and DPOs so that they can meaningfully contribute to and engage with rehabilitation policy processes. | 11. Creates a sense of ownership of research for persons with disabilities. |
12. The participation of persons with disabilities, their families and their representatives in the planning, evaluation and monitoring of rehabilitation services should be mandated at local, national, regional and international levels. | 12. – Supports service-user satisfaction. – Supports service efficiency/effectiveness. |
2. What are the features of national legislation/policies that work to support the development and provision of rehabilitation services? | |
13. A State’s Constitution and antidiscrimination laws should facilitate the realization of disability rights. | 13. Strengthens legal and policy support for persons with disabilities and service-users. |
14. It is critical that measures to support accountability and transparency in the provision of rehabilitation services are indicated in policies. | 14. Supports accountability/transparency, so that governance creates inclusive, responsive and fair processes and outcomes, and public trust in a social system. |
15. Rehabilitation should be integrated into general health policy and health sector reform plans, from primary care to tertiary hospitals with focus beginning on primary care. | 15. Supports programme continuity. |
16. CBR policies should be incorporated within existing health systems and with local and national health policies and legislation to ensure continuity and to secure annual budgets and other resources, while still allowing for a degree of flexibility of CBR projects. | 16. Strengthens programme continuity and securing of resources for CBR. |
17. Policies relating to rehabilitation should uphold the following seven primary aims for the provision of rehabilitation services (17–23 below):
Safe: Avoid injury to people, including physical or psychological harm, from the care that is intended to help them. | 17. Service-users avoid injury from care. |
18. Effective: Provide services based on available scientific evidence to all who could benefit and refrain from providing services to those not likely to benefit. | 18. Service-users receive appropriate care based on scientific evidence. |
19. Person centred: Provide care that is respectful of and responsive to individual preferences, needs and values and ensure that service-users’ values guide all practitioners’ decisions. Awareness raising and education of service-users with regard to treatment options and human rights is important. | 19. – Service-users receive appropriate, respectful and understanding care. – Service-users exercise choice. |
20. Timely: Reduce waits and potentially harmful delays for both those who receive and practitioners who provide care. | 20. Reduces waits for services. |
21. Efficient: Avoid waste, including waste of equipment, supplies, ideas, and energy and take into account views and suggestions of service-users and their families. | 21. Creates a structured system that matches resources with service demands. |
22. Equitable: Provide care that does not vary in quality due to personal characteristics, such as gender, ethnicity, geographic location, socioeconomic status or type of impairment. | 22. Supports justly distributed service provision based on need, including for vulnerable groups. |
23. Accessible: Provide care that is accessible to all, including vulnerable groups, such as ethnic minorities, with regards to physical, economic, and information access to health services. | 23. Strengthens accessible health care. |
3. Do any of the listed features of national legislation and policies have a greater risk of adverse effect on particular groups of people and types of services? | |
24. Policies should recognize that disability may interact with other vulnerability factors that increase discrimination, e.g. women or children with disabilities. | 24. Supports access to services for persons with disabilities who may experience double discrimination and multiple disadvantages (e.g. ethnic minorities with disabilities). |
25. Policies relating to rehabilitation should ensure that services are available to all groups of persons with disabilities, and allow disaggregation of data by subgroups that may be more vulnerable. | 25. Supports access to services for all subgroups of persons with disabilities, such as persons with intellectual disabilities. |
26. To promote equitable and accessible rehabilitation services, policies should specify how the particular barriers that marginalize certain groups would be overcome and associated budgetary allocation plans should be defined. | 26. Supports access to services for vulnerable groups, such as children with special needs. |
27. In national policies, specific mechanisms of exclusion in accessing health services should be addressed for different subgroups of persons with disabilities. | 27. Policies support human rights and social inclusion in service provision. |
28. The participation of persons with severe or multiple disabilities and persons with mental disabilities and/or their families/representatives in policy development should be prioritized/emphasized on an equal basis with others, with priority in contexts where they are significantly excluded from policy development. | 28. Strengthens inclusion of subpopulations of persons with disabilities, such as persons with mental disabilities, who experience specific barriers to accessing services. |
4. What are the features of a rehabilitation strategy/plan that work to achieve rehabilitation objectives? | |
29. A national Rehabilitation Plan should be in place, and developed based on the UNCRPD, other international human rights instruments, and needs based assessments, with clear implementation and monitoring protocols. | 29. Strengthens policy implementation. |
30. CBR should be implemented by mobilizing partnerships, which include CBR programmes, government Ministries, persons with disabilities and their families and representatives, DPOs and NGOs. | 30. Creates shared funding, resources, expertise, and ownership of programmes. |
31. Strong inter-sectoral coordination, including coordination of funding, for all health related rehabilitation services, including CBR, is important with regards to provision of rehabilitation services. | 31. Creates coherent mandates across governmental departments for services. |
32. Health related rehabilitation should be integrated into a broader and comprehensive strategy to provide services for people who need rehabilitation services and persons with disabilities in all aspects of society, including health, employment, and education. | 32. Strengthens access to services in all aspects of society for service-users. |
5. What are the key steps to developing national legislation/policies and related strategies/plans for rehabilitation? | |
33. Policymakers should receive rights based education/training to adopt a disability lens in the formation of all relevant policies. | 33. Improves status and prioritization of rehabilitation amongst policymakers.
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34. Governments should proactively consult with persons with disabilities, their families, DPOs, the private sector, NGOs, and international organizations throughout policy development. | 34. – Supports service effectiveness. – Increases service-user satisfaction. |
35. National authorities should align policy objectives and implementation with international instruments concerning the rights of persons with disabilities, such as the UNCRPD. | 35. Provides a holistic approach for policies as the UNCRPD covers broad needs of service-users. |
36. Mechanisms for sharing of information and experiences between countries and across regions should be strengthened for the purposes of national, regional, and local policy development. | 36. Strengthens shared learning regarding service provision and policy development. |
37. Information collected on disability should be disseminated proactively, succinctly, quickly, and in a language and format that decision-makers, as well as persons with disabilities, can easily and quickly understand. | 37. Strengthens participation of persons with disabilities in decision-making. |
6. What factors facilitate or impede the implementation of national legislation/policies and related strategies/plans for rehabilitation? | |
38. A national Implementation Plan should be devised to support the implementation of policies for rehabilitation. Where a Rehabilitation Board exists, it should contribute to devising the plan. | 38. Strengthens policy implementation. |
39. A coordination mechanism, such as a National Disability Board, should be established to oversee the implementation of rights of persons with disabilities. | 39. Oversees policy implementation, and coordinates national inter-sectoral liaison on disability. |
40. A national Code of Practice should be formulated through input from service-users and aligned with the UNCRPD to implement policies on rehabilitation. | 40. Supports implementation of policy and legislation; harmonizes public health laws. |
41. Development of strategic alliances between the Rehabilitation unit and PCD of governments is important for the equitable implementation of policies for rehabilitation. | 41. – Supports shared strengths/resources. – Creates co-ownership of a programme. |
42. The alignment/integration of rehabilitation programmes with well recognized, preexisting models of healthcare delivery within the MoH can strengthen programme delivery and the implementation of policies for rehabilitation. | 42. Supports programme sustainability. |
43. Governments should provide equitable and nondiscriminatory levels of resources to implement policies for mental health services. | 43. Promotes realizing rights in the lives of mental health service-users. |
44. All government Ministries should have budget allocations to make services inclusive and accessible. | 44. States comply with Article 9 of UNCRPD. |
45. Governments should provide adequate funding and resources within their budgets to ensure the availability of human resources for implementation of policies for rehabilitation. | 45. Provides sufficient numbers of trained rehabilitation workers. |
46. CBR implementation is dependent on the support of community leaders, government, and persons with disabilities, DPOs, NGOs, rehabilitation professionals and paraprofessionals and the community. | 46. – Increases CBR sustainability. – Enhances skills of those working in CBR. |
7. What works in monitoring and evaluating rehabilitation legislation/policies and strategies/plans? | |
47. National, regional and local Mental Health Review Boards should be in place to support mental health service-users and the provision of mental health services with participation of/contributions by service-users if prioritized by representative organizations in each context. | 47. – Oversees policy implementation, and coordinates inter-sectoral liaison. – Protects the rights of rehabilitation service-users by investigating abuse and exploitation. |
48. Governments should provide adequate levels of funding for the collection of disability statistics using both quantitative and qualitative research methods, including disaggregated information, to enable a situational analysis of disability. | 48. – Informs planning. – Creates political momentum by identifying successful interventions. |
49. A well-developed and well-implemented health management information system, which includes the collection of disability disaggregated data, should be in place with ethical privacy rules for management of data. | 49. – Supports policymaker decision-making. – Assists evaluation of CBR programmes. |
50. Government national, regional, and local CBR focal persons should be in place and regularly monitored. | 50. Oversees CBR programmes. |
51. A continuous review of processes is critical to identify areas of success and failure of any part of the process of the development, implementation and monitoring of policies. | 51. Reviews policies to identify strengths and lapses in response to changes in demands, needs of service-users, and research findings. |