Adult physical functioning is affected by a variety of health conditions, such as noncommunicable diseases (NCDs) or injuries (Manini 2012). Noncommunicable diseases are increasing in prevalence worldwide and particularly in low- and middle-income countries (Gimigliano & Negrini 2017; World Health Organization [WHO] 2017). Despite the growing burden of physical disabilities in low- and middle-income countries (Jesus, Landry & Hoenig 2019; Jesus et al. 2021), which more than doubled from 1990 to 2017 in low-income countries (Jesus et al. 2019), the provision of rehabilitation is limited in many low- and middle-income countries (Bright, Wallace & Kuper 2018). Physical rehabilitation interventions optimise function and minimise physical disability for those whose physical impairments affect performance (Bowker et al. 2006, 2011, 2017), with the intent to equip people to live to their maximum potential and optimise their contribution to family, community and society (Wade 2020; Bowker et al. 2006). In high-income countries, physical rehabilitation is usually provided by credentialed, skilled health professionals, such as but not limited to rehabilitation physicians, psychologists, physiotherapist (PTs), occupational therapist (OTs), speech and language therapists (SLTs), prosthetists and orthotists (P&Os) and nurses. Despite the importance of these services, the demand for these services in many low- and middle-income countries exceeds their human resources, leading to continued poor functional outcomes (Bright et al. 2018; Jesus et al. 2019; Jesus et al. 2021; Prynn & Kuper 2019). As a result, the demand for these services exceeds the resources (Bright & Kuper 2018; Bright et al. 2018; Prynn & Kuper 2019), leading to continued poor functional outcomes.

In response to the growing need for rehabilitation, in 2017, the World Health Organization (WHO) launched the Rehabilitation 2030 initiative. This initiative brought together an international group of key stakeholders in rehabilitation service provision to develop strategies and action plans to provide quality and timely rehabilitation worldwide, particularly in low- and middle-income countries with limited rehabilitation services and the greatest need (Gimigliano & Negrini 2017). These countries were urged to collect data on rehabilitation needs and services and the accessibility and availability of services to guide the efficient implementation of quality services (WHO 2017). Evidence on disability and rehabilitation data is an important first step in understanding the needs and gaps in rehabilitation service provision to develop efficient solutions (Gimigliano & Negrini 2017; WHO 2014).

Rwanda is a low-income country in central east Africa with 13.4 million people, which has been projected to increase to 16.9 million by 2023. Life expectancy is 70 years for women and 66 years for men (Vollset et al. 2020). According to a 2012 census, 5% of Rwandans aged 5 years or older have a disability, in which 80% of those with a disability are 18 years or older, almost 90% live in rural settings and 25% report mobility limitations (walking or climbing) (National Institute of Statistics of Rwanda & Ministry of Finance and Economic Planning-Rwanda 2014). In a more recent 2019–2020 survey, 14% of Rwandans aged 5 years or older reported at least one functional limitation, in which 69% of those with a functional limitation are 18 years or older (National Institute of Statistics of Rwanda Kigali, Rwanda Ministry of Health Kigali, Rwanda & The DHS Program ICF 2021). Therefore, the number of adults in Rwanda with disabilities seems to be increasing.

Rwandan disability rates are similar to estimates from other African countries (e.g., 7.5% in South Africa in 2011) (Statistics South Africa 2014), but much lower than the Westernised rates (e.g., 22.0% in Canada in 2017) (Morris et al. 2018). Whilst both the Rwandan and South African estimates indicate there are fewer persons with disabilities, it is likely that both these estimates are inaccurate. There is a greater stigma associated with disability in African countries (Loeb 2013; M’Kumbuzi et al. 2014); therefore, persons with disabilities may be reluctant to self-identify themselves as having a disability (Loeb 2013). With increasing life expectancy and prevalence of NCDs in Rwanda, it is quite possible that actual prevalence rates for disability are at least as high as Western countries (Alleyne et al. 2013; Asiimwe-Kateera et al. 2015; Tapela et al. 2015).

In 2007, Rwanda put in effect Law no. 01/2007 of 20 January 2007 relating to the protection of persons with disabilities, with the intent of creating more inclusivity for person with disability (Rwandan Ministry of Justice 2009). However, the law was based on a medical model of disability, limiting the understanding of disability to the issues associated with the person and ignoring the role of structures (e.g., environment, systems). In 2021, the Ministry of Local Government issued the National Policy of Persons with Disability and Four Years Strategic Plan (2021–2024).¹ This policy is based on a social model of disability to indicate a shift in thinking towards disability in Rwanda. Whilst the plan is a big step in the right direction, it focuses on children with disability. The increasing prevalence of NCDs in Rwanda (Alleyne et al. 2013; Asiimwe-Kateera et al. 2015; Tapela et al. 2015) and the resultant disability are not a consideration. Rehabilitation services for adults with disabilities in Rwanda may begin in the acute hospital setting; however, a large number of patients are likely to be discharged without rehabilitation (Rhoda et al. 2015). This is regardless of the level of disability. To further add to the problem, community-based services are extremely limited. To adequately and efficiently address the rehabilitation needs of those with a disability in Rwanda, we first need to better understand more accurate and comprehensive estimates of the prevalence of disability in Rwanda to predict rehabilitation resource needs accurately.

In Rwanda, the healthcare sector is organised around national referral or university teaching hospitals, provincial referral hospitals, district hospitals, primary health centres (PHCs) and health posts (Figure 1-A1). Physical rehabilitation services are available at public and private hospitals and at semiprivate specialised rehabilitation centres. Semiprivate facilities are funded primarily by the international non-governmental organisations (INGOs), such as Humanity & Inclusion (HI) and International Committee of Red Cross (ICRC), or faith-based organisations (FBOs), such as Christian Blind Mission. For more than 2.86 million Rwandans with a disability, publicly funded rehabilitation services are available at 53 hospitals: (1) 4 national referral or teaching, (2) 7 provincial or referral and (3) 42 district hospitals. In addition, those who can pay for specialised physical rehabilitation services are available at four semiprivate rehabilitation centres (Figure 1-A1; Ministry of Health 2018).

About half of Rwanda’s population is over the age of 18 years (7 208 063 out of 13 411 153 people).² Therefore, suppose we conservatively estimate that 15% of Rwandan adults have a disability. In that case, roughly 1 000 000 Rwandan adults have access to 57 centres (including those not publicly funded) for rehabilitation interventions or approximately 17 500 persons with disabilities per centre.

Physiotherapy (PT) services are available at 53 hospitals and the 4 semiprivate specialised rehabilitation centres. According to the Rwanda Allied Health Professional Council (RAHPC), 360 PTs are registered to practice in Rwanda (Table 1), 88 of whom are employed at public facilities (Ministry of Health-Rwanda 2021), whilst the others likely work in private hospitals or INGOs. In 2019, there were 0.26 PTs per 10 000 people in Rwanda (WCPT 2019b), compared with 1.4 PTs per 10 000 people in South Africa (WCPT 2019a) and 6.6 PTs per 10 000 people in Canada (Canada Conference Board 2017). The number of PTs in Rwanda is far less than in other countries. Prosthetic and orthotic services are available at four public hospitals and at four specialised rehabilitation centres. According to the RAHPC, 68 P&Os are registered to practice, with 31 employed primarily in settings supported by INGOs. There are 0.05 P&Os per 10 000 people, which is precisely the minimum of 5 per one million (0.05 per 10 000 people) suggested by the Global Standards for Prosthetics and Orthotics (Lemaire, Supan & Ortiz 2018).

The occupational therapy programme began at the University of Rwanda in 2014, and there are now occupational therapists (OTs) at one public hospital and two specialised rehabilitation centres. Twenty-six OTs are practicing in Rwanda, with most OTs (n = 24) employed in settings supported by INGOs, such as schools and refugee camps. There are 0.02 OTs per 10 000 Rwandans, which is lower than the minimum of 750 per one million (7.5 per 10 000 people) suggested by the World Federation of Occupational Therapists (WHO 2017). Speech and language therapists are nearly absent and available at only one private tertiary hospital and one semiprivate specialised rehabilitation centre. There are no speech language therapy programmes in the country. Representative of most African countries, Rwanda does not have rehabilitation services at the PHCs (Ministry of Health-Rwanda 2021).

In 2021, the Rwandan Ministry of Health (MoH), in collaboration with the WHO, the United States Agency International Development and the ICRC published a report on the Situation Assessment of Rehabilitation in the Republic of Rwanda. This report describes the insufficient and nonexistent rehabilitation services in Rwanda (Ministry of Health-Rwanda 2021). However, prior to this report, the MoH has proposed a new employment health structure that will integrate two PTs per PHC, one P&O per district hospital and one OT and one SLT employed at each referral and provincial hospital (Official Gazette 2020) for the first time. However, the progress of implementing the new employment health structure is taking time.

In addition to a lack of funding for rehabilitation service provision, there are issues unique to low- and middle-income countries compounding difficulties in accessing services. These include transportation expenses because of long travel distances to rehabilitation facilities, long waiting times for appointments and limited knowledge of the available services, both by the public and private personnel (Aenishänslin, Amara & Magnusson 2020; Baart & Taaka 2018; Hamid et al. 2017; Rhoda et al. 2015; Zziwa et al. 2019). The four semiprivate specialised rehabilitation centres in Rwanda are intended as a national resource for all individuals; however, there is an additional cost for these services, which further limits access (Ministry of Health-Rwanda 2021). These facilities have well-established rehabilitation services for children; however, few are tailored to adults (Ministry of Health-Rwanda 2021). As a result, adults with complex needs such as stroke, traumatic brain injuries and spinal cord injuries are discharged from acute wards to attend outpatient rehabilitation at a district hospital or in the community, where these services are either insufficient or nonexistent.

With limited human resources to provide rehabilitation interventions, it is imperative to allocate existing rehabilitation resources based on the population’s needs. The data available on the Rwandan needs for healthcare services are primarily on access to healthcare services for children and those with mental health issues (Hategeka, Arsenault & Kruk 2020; Rugema et al. 2015; Ng & Harerimana 2016; Smith et al. 2017; Wanyana, Wong & Hakizimana 2021). The lack of data on rehabilitation needs of adults with disabilities, despite a growing need because of increased survival rates for those with NCDs (cardiovascular diseases [hypertension, stroke], diabetes, cancer) (Alleyne et al. 2013; Asiimwe-Kateera et al. 2015; Tapela et al. 2015), makes efficient resource allocation impossible.

To address the lack of these data, HI, an INGO that provides rehabilitation services for adults and children in Rwanda, conducted a survey to understand costs associated with the provision of outpatient rehabilitation services. Using the data from HI on adults accessing rehabilitation services, we conducted a secondary data analysis to describe the type of rehabilitation services provided, the characteristics of people who use these services and the facilitators and barriers for people to access these services.

This article describes the outpatient physical rehabilitation services at nine facilities in Rwanda. We describe the rehabilitation services by funding source (public or semiprivate) and geographical locations (urban or rural). Finally, we use patient-level data to describe the people that use these services and some patients’ facilitators and barriers to attending rehabilitation.

Data were collected from nine facilities; five (56%) were publicly funded, and four (44%) were semiprivately funded. The five publicly funded facilities serve an estimated catchment of 2 050 000 million people and included two university teaching hospitals out of four in the country and three district hospitals out of 42. No provincial referral or specialised hospitals were included. The four semiprivate specialised rehabilitation centres funded by the NGOs or FBOs, in the country were all included. These institutions serve an estimated catchment of 430 000 people (Table 1a). Four of the nine facilities were in urban areas (Table 1b). The population estimates of the catchment area are those who would need rehabilitation services in the area and do not consider the number who could pay for the services. Therefore, the number of people who can access semiprivate services is considerably less.

Rehabilitation staff at the nine health facilities include 63 PTs, 16 P&Os and 8 OTs, serving both children and adults. The availability of rehabilitation personnel ranged from 2 PTs at district hospitals to 0 OTs at public hospitals. Whilst we had 13 PTs, 6 P&Os and 5 OTs at semiprivate specialised rehabilitation centres primarily funded by NGOs or FBOs, based on catchment areas, publicly funded facilities have an average of 0.2 rehabilitation staff per 10 000 people, and semiprivately funded facilities have an average of 1.2 rehabilitation personnel per 10 000 people (Table 1a). The availability of rehabilitation personnel differed significantly by location of the facility, with urban facilities having an average of 0.2 rehabilitation staff per 10 000 people compared to 1.0 rehabilitation staff per 10 000 people at rural facilities (Table 1b).

With help from other international agencies, the Rwandan MoH published a report on a Situation Assessment of Rehabilitation in the Republic of Rwanda because of the recognition of the need to better understand rehabilitation service in Rwanda. This report highlights the lack of rehabilitation personnel, such as speech therapists, rehabilitation physicians and nurses (Ministry of Health-Rwanda 2021). This report also reveals that semiprivate funded rehabilitation centres are more equipped with resources than facilities funded by the public but falls short of understanding who is accessing rehabilitation services and why. Our data expand on the information from the Situation Assessment of Rehabilitation in the Republic of Rwanda report and other studies (Rhoda et al. 2015; Urimubenshi & Rhoda 2011) to describe resources at both public and semiprivate funded facilities in urban and rural settings and to describe who is accessing rehabilitation services. We also describe some patients’ facilitators and barriers to attending rehabilitation.

Our analysis determined that semiprivate facilities had six times more human resources than publicly funded facilities. Facilities in rural areas (predominantly semiprivately funded) had five times more human resources than those in urban areas. People accessed rehabilitation services primarily for physical disability concerns. Interestingly, the facilitators and barriers to rehabilitation services were similar across facilities, regardless of the funding source or geographic location. Our analysis highlights the most crucial facilitators for accessing rehabilitation, including patients’ confidence and trust in staff, family support and health coverage. At the same time, participants indicated transportation costs, waiting time and inaccessible buildings as some of the significant barriers.

It is well known that rehabilitation services are limited in low- and middle-income countries, which makes it imperative to use the existing resources where most needed. We demonstrated that semiprimarily funded facilities had six times more human resources than publicly funded facilities and that rural areas (predominantly semiprivately funded) had five times more human resources than those facilities in urban areas. However, it is unclear whether this distribution of resources reflects the proportion of Rwandans living with disabilities in each of these areas. Whilst rural (primarily semiprivate) facilities are better staffed, they are more difficult to access because patients must pay for services. Thus, the catchment population for the semiprivate facilities is likely much smaller, meaning that staff proportions are likely much higher for semiprivate facilities when considering people’s ability to pay. Whilst this increases the staffing ratios for those who can pay, it negatively affects the services available to those who cannot pay. Whilst numerically it seems that rural areas are better served, there are many additional considerations that suggest this may not be true. In addition to the issue of access because of payment, there is also the issue of distance to travel and costs associated with long-distance travel that may further affect access amongst the population in rural areas.

We demonstrated significant differences in some of the demographic characteristics of those who attended public versus semiprivate facilities in urban and rural settings; however, we do not know where the difference lies within these characteristics. We know that participants access rehabilitation services for physical disability concerns. However, it is unclear whether the needs of Rwandans with disability are primarily physical or whether the use of services is driven by the available services. Physiotherapists were the primary rehabilitation personnel available at all facilities, whilst P&Os were available at five facilities, of which one was publicly funded. Occupational therapists were available at one public facility and two semiprivate facilities, and there were no SLT services or physicians and nurses providing rehabilitation services. Whilst there is a clear need for rehabilitation services that address physical disabilities, it is unclear if other rehabilitation needs are not being addressed. Understanding where most Rwandans with disabilities reside and their needs is critical to optimally distribute services; however, with the available funding structure, it is unlikely that redistribution will solve the issues of access to services. In addition to better distribution, implementing the MoH’s new employment health structure proposed in 2020 will increase the overall number of rehabilitation professionals, particularly in areas with no rehabilitation services (Official Gazette 2020). Physiotherapists will be hired at PHCs, P&Os at district hospitals, OTs and SLTs employed at the referral and provincial hospitals for the first time. However, the implementation of this new structure is taking longer. The Situation Assessment of Rehabilitation in the Republic of Rwanda report emphasises the need to immediately implement the MoH’s new employment structure (Ministry of Health-Rwanda 2021). The Rwandan government is also exploring whether subsidies can be provided so that those with only universal health coverage can access semiprivately funded specialised centres. Whilst these government initiatives are positive, implementation could take time. Therefore, we suggest strategies to address the rehabilitation issues discussed without additional cost or burden to the system.

It is not surprising that most participants reported long waiting times as a significant barrier to attending rehabilitation. Even though there are six times more rehabilitation professionals at semiprivate facilities than public facilities, more than 70% of participants attending semiprivate facilities still noted waiting times as a significant barrier. This experience is similar to that of people seeking rehabilitation services in other low- and middle-income countries (Bright et al. 2018; Mlenzana et al. 2013; Ntamo, Buso & Longo-Mbenza 2013; Scheffler & Mash 2019).

Whilst the Rwandan universal healthcare coverage provides 90% – 100% (depending on the households’ economic situation) financial support for rehabilitation services at public facilities and semiprivate facilities, patients pay 100%; issues such as long waiting times and transportation costs remain significant barriers to accessing services. This is similar to issues noted in other low- and middle-income countries including South Africa and Nigeria (Bright et al. 2018; Igwesi-Chidobe 2012; Scheffler & Mash 2019). There is a critical need to identify strategies to capitalise on available resources to augment rehabilitation interventions without additional cost or burden to the system.

To decrease waiting times for those in most need, we need to develop triage referral protocols to provide faster services. This protocol could use a decision tree approach to help physicians identify those in the highest need, assign a priority rating and determine what care could likely be provided by a family member or a caregiver (Hobbs et al. 2010). Patients who need professionals’ interventions could then take the priority rating to a rehabilitation facility where one or two spots are held weekly to see priority referrals quickly. The University of Rwanda, the national associations of rehabilitation healthcare professionals, physicians and nurses could lead initiatives to develop triage protocols and decision trees to facilitate the process (Hobbs et al. 2010). Developing triage protocols could be implemented at the referral stage to prevent a constant flow of patients, long waiting lists and time. In addition, community-based interventions provided by families, community health workers (CHWs) and lay personnel might offer a sustainable alternative or complement to rehabilitation provided by health professionals (e.g., PTs) and provide an accessible and affordable approach with the potential to address the rehabilitation needs in the community in Rwanda.

Home or community-based interventions could also be developed to address the rehabilitation needs. The WHO proposed ‘task shifting’ more than a decade ago to supplement healthcare provision in low- and middle-income countries (World Health Organization 2008). More recently, ‘task sharing’ was suggested as an alternative to task shifting, when the responsibility for care provision cannot be completely assumed by those trained, skilled and credentialed to perform the tasks (Anand et al. 2019).

In addition to using the existing rehabilitation services more efficiently, we could supplement rehabilitation services by training existing healthcare providers on key aspects of rehabilitation. For example, rehabilitation professionals can offer appropriate and relevant training to nurses at PHCs, where rehabilitation services are nonexistent. The need to train nurses at PHCs was also recommended in the Situation Assessment of Rehabilitation in the Republic of Rwanda report (Ministry of Health-Rwanda 2021), and training initiatives could begin during professional training in university programmes.

Training non-healthcare professionals, such as family caregivers, CHWs and lay personnel, have been supported in previous studies conducted in low- and middle-income countries. For example, a study was conducted in Bangladesh (Rahman & Salek 2016) and Thailand (Pitthayapong et al. 2017) in which caregivers of patients with stroke were trained on incontinence care, bed positioning and activities of daily living (ADLs). The training provided to caregivers achieved positive results on patients’ outcomes, such as improved ADLs (Rahman & Salek 2016). Likewise, training CHWs in South Africa to provide rehabilitation interventions, such as transfers, bed mobility or positioning, has resulted in positive patient outcomes such as reduced pressure sores and improved mobility (Nesbit & Clark 2019).

Some studies have demonstrated the benefits of training caregivers and CHWs (Nesbit & Clark 2019; Magwood et al. 2020; Pitthayapong et al. 2017; Rahman & Salek 2016); however, additional research is needed to identify how to develop and evaluate these training programmes in Rwanda. Rehabilitation professionals could use existing community-based interventions and train CHWs to provide simple but effective physical rehabilitation interventions in the community (Anand et al. 2019; Dawson et al. 2014). The proposal to move rehabilitation from a therapist-led facility system is a significant shift; requiring buy-in from multiple stakeholders in multiple systems. It builds on the gains achieved through community-based rehabilitation (Lemmi et al. 2016; Mannan et al. 2012) and could create a community-sustained solution that could be funded at a fraction of the costs of a therapist-based facility solution for rehabilitation. We recognise this solution will take a buy on many levels and a revisioning of service provision.

Technology could also be used to augment rehabilitation services, particularly in countries with limited resources (Jesus et al. 2017; Jesus et al. 2019; Lincoln et al. 2014; Veitch et al. 2012). Low-cost technologies using mobile phones and telerehabilitation (where the Internet is available) could offer additional support for families and CHWs in Rwanda to provide rehabilitation interventions at home or in the community. For example, the University of Rwanda could introduce and support telerehabilitation interventions during outreach programmes. Telemedicine has been successfully developed and implemented in Rwanda (Roodenbeke et al. 2011). For example, mHealth programmes using mobile phones have increased maternal and child health services (Ruton et al. 2018) and increased access to antiretroviral drugs (Nsanzimana et al. 2012). These achievements have been possible because many Rwandans own a mobile phone. Telerehabilitation has provided cost-effective services in low- and middle-income countries (Fatoye et al. 2019; Sarfo et al. 2018) and could be an approach to increase access to rehabilitation services in Rwanda.

The availability of rehabilitation services for Rwandan adults with physical disabilities is limited, with greater access to services in semiprivate compared to public facilities. Whilst family support help patients attend rehabilitation, transportation costs remain a significant barrier to people attending rehabilitation. Strategies to address these issues are urgently required and should complement the MoH solutions that will be implemented in the next years. These strategies can include developing triage protocols that could be implemented at the referral stage to prevent a constant flow of patients, long waiting lists and time. In addition, community-based interventions provided by families, CHWs, and lay personnel could extend the outreach of basic rehabilitation services to those with long-term health conditions and disabilities living in the community in Rwanda. This would require a major system shift that will require buy-in from multiple stakeholders in multiple systems but could be an efficient and sustainable solution. Finally, service provision could be augmented with the use of low-cost technologies using mobile phones and telerehabilitation (where the internet is available) and could offer additional support for families and CHWs in Rwanda to provide rehabilitation interventions at home or in the community.