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1. What evidence do I have (or need) to identify those factors and levels posing the greatest barriers to rehabilitation in my population?
While a lot of evidence exists on barriers to access to rehabilitation, limited evidence exists on barriers to access assistive technologies. Conducting a market of most prevalent rehab conditions and associated ATs that are need to support rehab efforts will be helpful to understand barriers to access from a financial, supply, demand and regulatory perspective. Conducting a market diagnostic will require looking at existing census data, demographic health data, procurement data, policies/regulations related to AT procurement, distribution, financing, etc. among other things as well as conducting key informant interviews with stakeholders including patients, government, NGOs, etc. The outputs from this diagnostic analysis will help to identify what the barriers are as well as their root causes.

2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
Given that my organization focuses on health system strengthening at the national level, I may consider implementing institutional or superstructural interventions.

3. What formative research might be needed to understand the precise intervention that would be most appropriate and impactful towards overcoming the challenges I identify?
Key informant interviews with patients and key government stakeholders (MoH, Social Ministries, Prime Minister’s Office), would be integral to understand the priorities (i.e. from patients – which assistive technologies are most needed and which ones aren’t currently available; from governments – where do they see the biggest challenges; how does this link with existing priorities such as economic productivity, universal health coverage, etc.). This can help to prioritize the area of focus for the intervention.

4. When considering potential interventions, what factors related to implementation do I need to consider?
Interventions will have to garner leadership buy-in, particularly if thinking about superstructural interventions. A cost impact analysis as well as acceptability will need to be considered (i.e. if developing product standards for specific AT products in the country and adding them to a product priority list, then the standards will have to be acceptable by the users, and meet the needs/quality expectations of users, etc.) In addition, sustainability of the intervention will need to be considered (i.e. will there be long-term and predictable financing for these products in the future; what will be the sources, etc.)?

5. What implicit biases may be at work in my culture or context and how do those implicit biases impact an individual’s ability to access and benefit from rehabilitation?
Many assistive technologies require time and investment in proper fitting, maintenance and follow-up. If patients are living very far from where AT products/services are being delivered, providers may not prescribe them any because they fear patients will not adhere to the required plan for fitting and maintenance. Providers may also be hesitant to offer any financial means for covering transport costs to overcome adherence challenges, because of the implicit bias related to income levels and fear that the money that is to be used for transport will be used for other things such as food, clothing, school, etc.

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• How does the proposed intervention fit with the priorities of your organizations?
Looking at the inner context, telerehabilitation fits within the organization priorities as there is a priority/mission to ensure healthy populations, and telerehabilitation enables greater access and availability of rehab services for all. It also fits within the larger national rehab strategy and goals of ensuring greater and equitable access to rehab services, particularly for those within remote/rural areas. It also enables economies of scale as you are able to use less resources but reach more people, and this helps address some of the challenges related to shortage or rehab/AT professionals. The only challenge is the lack of ICT infrastructure in the country. While there is a strategy to strengthen ICT across the country, how and where telerehabilitation will be delivered will have to be closely aligned with ICT priorities.

• How does it fit with community values, including the values of diverse cultural groups?
Now looking at the outer context, telerehabilitation fits in terms of values related to affordability and access. However, Tanzania is a very person-centered culture where relationships are very important and in-person care and service is needed to build relationships. For this reason, there may be some populations that may be hesitant to use telerehabilitation but I believe that the values of affordability (i.e. reducing transport costs/opportunity costs associated with travelling to get rehab services, particularly for those in remote areas) and accessibility (being able to access care closer to home) will outweigh some of the importance placed on in-person care.

• What strategies could you use to target key stakeholders’ awareness, knowledge, attitudes, and intention to integrate the new intervention?
Engagement of key stakeholders at the design of the implementation and in the implementation process itself will be very important. Engaging with clinical staff, management, key policy makers/decision makers, and clients/users in various capacities will be important to raise awareness, knowledge, attitudes and intention of the intervention.

• What strategies could you use to target the motivation and capability of individuals and organizations to engage in implementation process strategies to integrate the new intervention?
Anchoring messages on what telerehabilitation can do for rehab services in the country and targeting these messages to each different stakeholder group will be important. In addition, providing individuals and staff within an organization with the right training and tools to effectively deliver the intervention is one way to motivate and engage them. Staff can be involved in the design of the intervention (i.e. how to roll it out, where to roll it out, where to pilot, etc.) and this will make them have more ownership towards the intervention.

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In Tanzania, like many other LMICs, there is shortage of Assistive Technology health care professionals, such as wheelchair fitting specialists. For stroke patients, having wheelchairs that enable them to obtain optimal level of functioning is an important step to re-integrate into society. The intervention I would design for this case would be to incorporate wheelchair fitting training as part of the pre-service curriculum so that OTs/PTs also have this specialized training.

Leveraging the RE-AIM framework, the parts of the intervention I would focus on are the following:
1. Effectiveness: Ensuring that there is evidence-based tools/supports (i.e. like the WHO guide for wheelchair fitting in LMICs) to deliver the intervention and ensuring there are ways to collect data, satisfaction and experience from students to understand the positive and negative consequences of the intervention
2. Adoption: Perhaps piloting the training material on one cohort to understand and evaluate the value and effectiveness will be a strategy to help broader adoption and institutionalization into pre-service training curriculum for the PT and OT cadres. Developing a business case to fully articulate the cost and benefits of this intervention may also be needed.
3. Implementation: To ensure consistency, there may be a need to have a train the trainer approach (i.e. having a specialized expert in wheelchairs deliver the training to a group of professors who can then implement across all; there should be strong guidance, data collection and evaluation of the train the trainer model to ensure consistency.

In terms of measuring success, I would use the following indicators:
1. # of teachers trained on wheelchair fitting
2. # of students in cohort who received wheelchair fitting
3. # of students who graduated in wheelchair fitting and are employed in settings where these services are delivered
4. # of patients who receive wheelchair fitting services (comparison of baseline vs. 1 year post implementation)
5. Multidisciplinary Rehab for People with Complex Needs – as per the WHO RIM
6. # of universities/programs that incorporate wheelchair fitting training into pre-service curricula (i.e. a measure of adoption)
7. Satisfaction surveys from students to understand value of this intervention and the use of this training in their daily jobs

Steps in Monitoring and Evaluation:
1. Development of a M&E plan during the design of the intervention that includes both M&E experts, researchers (if applicable), teachers, clinical staff and students
2. Development of data collection tools to capture data at the teacher level, student level, individual patient level and hospital level
3. Routine monitoring of the progress leveraging both input, output and outcome indicators; this can be then used to further adopt and scale up the intervention
2.
5. #

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#3: Vision Statements

Vision Statement 1: Healthy, educated people – the foundation of prosperous societies (Results for Development)
The vision for R4D has been fairly constant over the years but I would say the approach and strategy to progress towards this vision has evolved over time. The focus of the organization remains to be in the areas of health, education and nutrition but it now really focuses on supporting local change agents to help address immediate challenges in these areas while also capacitating them to build stronger ecosystems to support and enable health and educated people.

Vision Statement 2: To ensure every person can access and afford the AT they need, enabling a lifetime of potential (ATScale)
ATScale is a fairly new organization and was established in 2022. Their mission to help achieve this vision is to catalyze action, amplify existing work, and coordinate and mobilize global stakeholders with unified strategies to increase availability of and access to AT. They have also set an ambitious goal to ensure that 500 million more people globally are reached with life-changing AT by 2030.

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2. Emotional Intelligence Questionnaire Reflection

Strengths: I scored high on being self-aware, motivating others and empathy. This resonates with who I am as a person. I am an individual who likes to self-reflect on various situations and am usually able to identify and articulate what specifically is making be feel a certain way or making me behave a certain way. I care for the people around me and often want to do what will make them happy. I also reflect on what motivates and drives other people’s behaviours and believe that there is always a reason as to why someone is being ‘difficult.’ Understanding motivating factors is also important as a leader because you are able to better understand what will drive people and create situations/opportunities that align.

Needs Attention: The area I scored lowest on was managing emotions. I always thought I was quite good at this because I am very good at hiding my emotions and not necessarily communicating to others how I am feeling. However, I am learning that keeping things bottled inside is not an effective way to manage emotions and can be manifested physically in my behaviour, tone and conversations with others. While I scored well on the social skills, it was my second lowest score and I do believe that this is still an area that needs my attention. There are certain social situations that still make me anxious and while I can push myself out of my comfort zone, my preference is to always avoid these situations if I am given the chance.

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Nevermind, I realized that I had to complete the entire module to answer all these questions. I have seen it under 2.3 – Effective Leadership. Please ignore.

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#1 Leadership Behaviours can be taught vs. leaders are born

As I reflect on this, I don’t believe that it’s black and white (i.e. one or the other). I do think that there are some that have natural leadership capabilities and are able to demonstrate them from a young age, while there are others where leadership does not come naturally and they need further training/cultivation.

For example, when I look at my older daughter, she has this innate ability to lead her group of funds and they naturally follow her. She’s not bossy but has a way of taking care of people’s needs and her friends naturally follow her lead and listen to her. This makes me to believe that she does have some innate leadership qualities that she’s able to demonstrate from a very young age. As I reflect on my leadership journey however, leadership was not something I demonstrated at a young age. I was always quiet, shy, happy to follow the majority and mindful of others needs. I never really voiced my opinion, even though I had one. As I grew older, and was trained and sometimes forced to voice my opinion or lead a group, is where I began to develop my leadership skills and have continued to evolve ever since.

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Hi Khushbu, I’m not able to find the emotional intelligence questionnaire – can you please guide me to where it is? Thanks!

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Hi – can you please guide me as to where you found this emotional intelligence questionnaire – I can’t seem to find it. Thank you for your help.

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NGOs in Tanzania include (note this is not an exhaustive list):
– Humanity and Inclusion
– Hellen Keller International
– Sightsaves
– Light for the World
– CBM
– Kilimanjaro Center for Community Opthalmology
– Results for Development
– UNICEF
– Brian Holden Vision Institute
– Open University
of Tanzania

Yes, Tanzania is using the WHO Action Guide and has conducted a situational assessment as well as developed its first national rehabilitation strategic plan.

I have experienced parents navigating the private health care system for access to spectacles and hearing aids for their children; in the private sector, if you have the resources it’s readily available and the quality of both products and services is good. However, in the public sector, there are many challenges related to awareness, stigma, access to good primary and secondary screening, lack of referral pathways, and unaffordability to products such as hearing aids that are not covered through the national health insurance program and are very expensive.

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In Tanzania, I’d say the moral model and medical model are more prevalent. For example, through my conversations with the National Eye Program Coordinator, I was told that there is a stigma attached to children wearing eyeglasses, because it makes them look more smarter or arrogant. And in these instances, the parents actually break the glasses that are given to the child.

The medical model is also prevalent; disability is seen as a defect in which you must seek treatment/therapy from a clinical institution (i.e. hospital). This is also the model that I basically grew up with; where the person is seen with the impairment and the person has to be fixed, rather than the disability being part of their identity.

While Tanzanian policies are trying to more towards a more social model of disability, implementation has not reached optimal levels and there is still some work to be done.

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Option #2: Disability is a result of the interaction between a person’s impairments, arising from disease or injury, and the environment. The environment includes both the physical structures (buildings, ramps, and braille signs) and social structures (discrimination, stigma, laws, and policies). Research what laws or policies regarding accessibility are in place in your district or country that can help reduce disability by providing access to physical structures, reduce stigma and discrimination, and provide access to health care services.

The United Republic of Tanzania undertook a situational analysis of the rights of persons with disabilities (PWD) with the report being published in 2021. The report highlights the following policies/legislations that foster rights of PWD to access services:

PWD Specific Legislations/Policies:
1. Tanzania has ratified the UN’s Convention of the Rights of Persons with Disabilities (CRPD)
2. Persons with Disabilities Act
3. National Policy on Disability

The above policies guarantee people with disabilities the right to social support, healthcare, education, employment, accessibility and rehabilitation. However, the policies do not acknowledge factors such as non-inclusive environment and infrastructure that can contribute to exclusion, particularly for children. There is not a particular focus on the specific rights of women with disabilities as well. While the policies are in place, the implementation is inadequate particularly in the areas of awareness on disability inclusion among stakeholders, social stigma, inaccessibility of services and the physical environment and inadequate funding, among others.

PWD often face challenges in accessing public infrastructure, public transportation and recreation spaces. There is further access challenges in rural settings and women and children with disabilities are more marginalized than others.

The government of Tanzania has made progress in integrating disability in service provision, with the creation of loans for students with disabilities, construction of schools inclusive of PWDs and the appointment of PWDs to ministerial positions.

The biggest challenge across these policies is lack of adequate funding for implementation and lack of awareness. With the introduction of the Universal Health Insurance Bill in Tanzania, I would advocate for inclusion of rehabilitation services and ATs in a more progressive way within the minimum benefit package as well as encourage more funding from development partners and bi-laterals to invest in data systems to monitor rehabilitation needs across the country and integrate them into national medical information systems (such as DHIS2, GoTHMIS, etc.)

Non-PWD Specific Legislation/Policies:

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Rehabilitation in Tanzania:

There has been a gradual expansion of rehab in health services, with rehabilitation departments and expertise present in national and zonal hospitals and an increasing number of regional hospitals. However, rehab services are still really lacking in district hospitals and primary health care facilities as well as in the communities such as homes, schools and work places. The barriers to access are worse for rural and remote communities. Lack of established referral pathways between levels of the health care system as well as as shortage in rehabilitation workforce further impedes barrier to access to rehab services.

The National Health Insurance Fund covers physiotherapy and rehabilitation services to inpatients and outpatients where the facility has specialists for the related services. However, only 5% of the population in Tanzania are covered through the national health insurance as per the rATA survey. Provision of ATs is also limited as part of the national health insurance schemes. For example, eye glasses are only given to the principle member, hearing aids are not provided and there is no mention of mobility aids that are provided as part of the minimum benefits package.

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