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1. Using your knowledge of the frameworks, what aspects of the intervention will you focus on to guide your planning and eventual success of the intervention?
WHO Rehabilitation in health systems: guide for action- STARS, GRASP, FRAME, ACTOR.

2. What indicators will you use to monitor the success of the intervention on an ongoing basis?
In reference to Rehabilitation Indicator Menu-
Input- rehabilitation integrated into health plans, rehabilitation expenditure, rehabilitation personnel density, rehabilitation bed density
Output-Rehabilitation in tertiary hospitals
Outcome- Multidisciplinary rehabilitation for people with complex needs
Impact- population functioning

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2. How does my own professional expertise and organizational access suggest where I might be most be effective in developing and launching an intervention?
Advocating and system mobilization to integrate rehabilitation into health system.

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?
Rehabilitation situation/status assessment and analysis is important. Based on its findings on which specific building block the rehabilitation context/status has gaps needs to be well analyzed and formulate strategies and recommendations. Example if rehabilitation financing of a particular country is weak or if there is not much budget allocated for rehabilitation or allocated rehabilitation budget needs to be tracked from national health account then likewise, activities recommendation needs to be developed/ planned.

4) When considering potential interventions, what factors related to implementation do I need to consider?
Factors such as system readiness, stake holders’ acceptance, resource availability such as budget, human resource and timeline needs to be considered.

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?
Implementation biases such as against persons based on their gender, ethnicity, race, sexual orientation, income level, educational level, employment, health status. Those implicit biases can impact an individual’s ability to access and benefit from rehabilitation by getting delay in rehabilitation intervention, making high out of pocket expenditure.

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1) Evidence is vital to determine barriers in accessing rehabilitation and Assistive technology. Some strategies to gather evidence in this regard could be by conducting survey, research with service users, service providers, caregivers to get data/information.
In Nepal, a nationwide population-based household survey was conducted from 7 December 2021 to 27 December 2021 using the WHO rapid Assistive Technology Assessment (rATA) questionnaire. Key findings related to barriers in accessing assistive technology were-
Barriers to access AT by sex:
-Among the male participants who had unmet needs of AT, majority of them reported lack of support (44.6%) as the reason for not having the product needed followed by unaffordability (36.2%).
– Among the female participants who had unmet needs of AT, majority of them reported lack of time (44.3%) as the reason for not having the product needed followed by unaffordability (41.2%).
Barriers to access AT by age groups:
Among <5years age group participants who had unmet needs of AT, cent percent of them reported unsuitability of AT as the reasons for not having AT.
-Among participants who were between 5-17 years and who had unmet needs of AT, majority of them (82.8%) reported unaffordability as the reasons for not having AT
-Among participants who were between 18-65 years and who had unmet needs of AT, majority of them (41%) reported lack of time as the reasons for not having AT
-Among participants who were >65 years and who had unmet needs of AT, nearly half of them (49.7%) reported unaffordability as the reasons for not having AT

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If i need to put a first word(s) thinking on REHABILITATION, that would be “OPTIMIZE FUNCTIONING”

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Nepal is following WHO Guide to Action to initiate its Systematic assessment of rehabilitation situation (STARS) which was conducted from October 2019 to February 2020. The STARS report has been published in 2022 following the drafting of the National Rehabilitation Strategic Plan. The STARS was conducted in a leadership of Ministry of health and population (MoHP) Nepal particularly a focal section- Leprosy control and disability Management section (LCDMS) with technical support from the WHO and USAID’s Physical Rehabilitation Activity (PRA) implemented by Handicap International (HI) Nepal. In the Southeast Asia Region, Nepal is the second country after Myanmar to have completed a STARS assessment. With successful accomplishment of STARS MoHP/LCDMS has started to draft National Rehabilitation Strategic Plan in close coordination with health and rehabilitation stakeholders which is anticipated to be finalized withing few months of time.

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As per WHO Rehabilitation Needs Estimator, in Nepal every 1 in 4 could benefit from rehabilitation. There are 8 million people who experienced health conditions that could benefit from rehabilitation. Nepal has key rehabilitation professions, but there is a shortage relative to the population’s needs. Academic course is available within Nepal for three professions: physiotherapy, audiology speech-language therapy, and clinical psychology. However, for all other rehabilitation professions, individuals must seek education abroad. Only 4% of rehabilitation personnel in Nepal are employed in government health services, with the majority (96%) working in the private sector. Nepal faces a shortage of longer-stay rehabilitation facilities and beds, leaving many individuals in need of intensive rehabilitation without access to such care. The rehabilitation departments, wards, and beds located at large tertiary hospitals are also insufficient to meet the demand.
Government tertiary hospitals have begun incorporating rehabilitation services, with 100% of them offering physiotherapists (PT). However, none of these hospitals currently have an interdisciplinary team established for rehabilitation services. Rehabilitation services are notably scarce in both secondary and primary healthcare facilities in Nepal. However, physiotherapists are placed in secondary/ district level hospitals by government as per the available provision. In addition, there has been initiated task shifting intervention at primary level of care to medical officers and health care workers which yet needs to be strengthened.

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I am Smriti Suwal from Kathmandu Nepal working as a Deputy Chief of Party in USAID Physical Rehabilitation Activity (PRA) implemented by Handicap International Nepal.
I bring more than 12 years of work experience in promoting rehabilitation through system thinking approach and continuum of care.
By profession I am a physiotherapist.

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