Globally, an estimated 15% of the population experiences some form of disability, with South Africa reporting a prevalence of approximately 7.5% (Ding et al. 2022; Lee et al. 2020). Despite progressive policies such as the framework and strategy for disability and rehabilitation (FSDR) aligning with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), challenges in effective implementation remain persistent (Hussein El Kout et al. 2022). These barriers, including insufficient resources, weak intersectoral collaboration, and inadequate monitoring mechanisms, significantly hinder the delivery of rehabilitation services (Maart, Mji & Morris 2024).

The FSDR was introduced as a strategic response to promote equitable and efficient disability and rehabilitation services (Maart et al. 2024). However, its implementation has been inconsistent, often impeded by systemic, structural, and operational challenges (Charumbira et al. 2024). These include a lack of awareness on policy implementation among stakeholders, fragmented governance, and resource limitations, all of which exacerbate disparities in access to rehabilitation services (Mudzi 2024). Understanding and addressing these barriers is critical to optimising rehabilitation outcomes and aligning South Africa’s healthcare system with global standards (Blose, Cobbing & Chetty 2021).

The aim of this study was to develop actionable implementation strategies for the FSDR, leveraging the Expert Recommendations for Implementing Change (ERIC) framework (McHugh et al. 2022). By triangulating findings from document reviews, semi-structured interviews, and focus group discussions, this study aims to provide a comprehensive evaluation of the FSDR’s implementation outcomes. The findings may contribute to strengthening disability and rehabilitation policy implementation in South Africa by offering targeted, evidence-informed strategies that enhance the practical uptake and operationalisation of policy within the health system.

This article presents a broad approach to evaluate implementation determinants, propose targeted strategies, and identify key facilitators and barriers. The insights derived from this study aim to inform the development of context-specific, stakeholder-driven solutions, bridging gaps in policy execution and advancing the realisation of the rights and well-being of persons with disabilities.

This study focused on the development of implementation strategies to guide future public health policies related to disability and rehabilitation in South Africa. Data on barriers used to map implementation strategies were drawn from an earlier phase of a larger study. This included a document review of FSDR implementation reports (Hussein El Kout et al. 2025a), 15 semi-structured interviews, and six initial focus group discussions from a linked study conducted by the same first author (Hussein El Kout et al. 2025c).

Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee (Medical). In this study, proposed implementation strategies were presented to stakeholders. For this article, the primary empirical data consisted of four additional focus group discussions, which were conducted to review and refine the proposed implementation strategies until stakeholder consensus was reached. The remaining data: document review findings, interviews, and earlier focus group discussions were drawn from a previous phase of the larger study and were used only to inform and contextualise the strategy development. The focus groups were conducted between August 2024 and November 2024. Stakeholders’ recommendations were used to finalise the strategies. This process adhered to the Partnership, Engagement, and Collaboration (PEC) approach described by Huang et al. (2018), emphasising the critical role of stakeholders’ involvement in implementation science (Hussein El Kout, Pilusa & Benjamin-Damons 2023).

The ERIC framework was used for concept mapping during the design of the implementation strategies. A total of four focus group discussions were conducted to ensure representation across South Africa’s multilevel governance structure. One focus group discussion (FGD) was held at the national level (n = 9), one at the provincial level (n = 10), one at the district level (n = 11), and one with organisations of persons with disabilities (OPDs) (n = 8), resulting in 38 participants overall. Groups of 8–15 participants engaged in discussions lasting one to two hours, conducted either in person or online, depending on availability. These groups included rehabilitation programme managers, policy advisers, implementers, health service managers, senior and junior rehabilitation professionals, and OPD representatives. Conducting FGDs across these levels allowed the study to capture variation in implementation experiences, resource contexts, and governance perspectives. The FGDs were conducted until data saturation was reached, where no new themes emerged. In this study, participants were recruited using purposive and snowball sampling, in which initially purposively sampled participants referred other participants to participate in the study. Purposively sampled participants were stakeholders identified as implementers in the FSDR process who had been involved in the implementation of the FSDR at any point between 2015 and 2022 and providing rehabilitation care at any level. Participants included rehabilitation professionals, academics, and representatives from OPDs. A discussion schedule was used to guide each session, supporting interactive dialogue and helping to minimise researcher bias through structured yet flexible engagement. The insights generated during these discussions were triangulated with findings from the document review and earlier phases of the study, enhancing the trustworthiness of the results by allowing different data sources to provide complementary and convergent perspectives. The focus groups were instrumental in reviewing and refining the proposed implementation strategies, ensuring that they reflected stakeholders’ experiences and contextual realities. The final strategies therefore represent a collaboratively developed, evidence-informed, and context-specific approach to strengthening the implementation of disability and rehabilitation policies.

The findings of this study indicated numerous determinants of FSDR policy implementation, including resource constraints, limited governance, and individualised operations as discussed by Hussein El Kout et al. (2025b). By utilising the ERIC framework, this study suggests various options to resolve these challenges. The emphasis on the need for implementation strategies that are stakeholder-driven, context-specific solutions highlights the need for specific application efforts for greater impact. This study reflects critical themes that highlight all the challenges in implementing the FSDR in South Africa. These themes align with current literature on implementation science, rehabilitation policy, and health systems improvements (Bustos, Sridhar & Drahota 2021; Shogren et al. 2020).

Noteworthy determinants of the FSDR implementation included insufficient dissemination of the FSDR policy document and inadequate training on its implementation (Hussein El Kout et al. 2025a). Many clinicians could not effectively adopt the policy because of a lack of understanding thereof. Awareness and competency-based training are critical to successful policy implementation (Morris et al. 2021). Integrating disability-inclusive modules into medical and allied health curricula could strengthen foundational knowledge. Including ongoing professional development specific to the FSDR within health professional training programmes would promote consistent engagement and application of the policy. Workshops, interactive learning modules, and simplified educational materials, such as infographics, could help with understanding the content and would be beneficial for all staff (Anaby et al. 2021).

The stakeholders highlighted resource challenges, including staffing shortages, a lack of assistive devices, and poor resource allocation (Hussein El Kout et al. 2025b). Service delivery is further limited because of logistical issues such as inadequate storage and equipment maintenance, despite available budget allocation, which is consistent with findings by Rauch, Negrini and Cieza (2019). In low- and middle-income countries, such challenges are common, with rehabilitation services often competing with other healthcare priorities. The solution to these constraints requires support for increased funding, efficient resource distribution, and innovative solutions such as public–private partnerships and community-based rehabilitation initiatives (Shogren et al. 2020). Other strategies, such as delegating responsibilities to less specialised staff, can also optimise existing human resources and alleviate staffing shortages.

Siloed operations among health disciplines significantly hindered the holistic delivery of rehabilitation services (Hussein El Kout et al. 2025). Communication and coordination across departments are vital to prevent fragmented care, which negatively impacts patient outcomes (Bustos et al. 2021). It is essential for departments to work together to ensure comprehensive rehabilitation. Multidisciplinary team meetings and joint case management sessions could encourage teamwork and improve care coordination. Digital platforms for shared patient records and collaborative treatment planning could eliminate miscommunication. Structured protocols, shared goals, and accountability mechanisms would further reinforce collaboration and support for integrated care across departments (Shogren et al. 2020).

The lack of leadership support and stakeholder engagement were identified as critical barriers to the successful implementation of the FSDR (Hussein El Kout et al. 2025). This divide between strategic policy objectives and operational execution demotivated the staff and resulted in limited policy adoption (Morris et al. 2021). Governance and leadership are vital for driving the adoption of policies. Involving senior management in the design and implementation of policies would improve their commitment. Leadership training programmes focusing on disability-inclusive governance and establishing clear communication channels between management and staff would further enhance buy-in and accountability, promoting a supportive environment for successful policy execution (Shogren et al. 2020).

A strong monitoring and evaluation (M&E) system was considered a critical requirement according to stakeholders to ensure tracking the progress and impact of the FSDR. Without performance metrics and/or feedback loops, stakeholders are unable to measure success or identify implementation challenges (Rauch et al. 2019). Effective M&E systems are essential for accountability and continuous improvement. Digital tools such as real-time dashboards can assist with data collection and reporting, enabling timely alerts where necessary. Participatory evaluation approaches involving end-users and frontline staff can improve the use of and dependability on the M&E frameworks, providing actionable insights to address bottlenecks and inform decision-making (Shogren et al. 2020).

The diversity in resources, infrastructure, and population needs across districts necessitated specific strategies to identify areas. A one-size-fits-all approach was deemed ineffective in addressing unique regional barriers, such as transportation challenges and cultural differences (Anaby et al. 2021). Specific implementation, adapted to the identified socioeconomic and cultural factors, is more likely to succeed. Engaging local stakeholders in co-designing interventions ensures that solutions are relevant and effective for their specific environments. Sharing successful models and best practices across districts can assist with the adaptation of effective solutions to similar situations (Morris et al. 2021).

The findings of this study highlight the importance of a systems-thinking approach to policy implementation. The identified challenges can be resolved with a multipronged strategy that integrates training, resource optimisation, governance, and stakeholder involvement. Leveraging global frameworks such as the ERIC and Proctor models provides a structured pathway for refining and operationalising implementation strategies (Shogren et al. 2020).

Disability and rehabilitation-related policy implementation in South Africa faces multifactorial barriers. Focusing on targeted interventions to address the identified barriers of policy implementation may improve the delivery of rehabilitation services in Gauteng and in South Africa, advancing the rights and well-being of persons with disabilities.