South African medical rehabilitation services delivery: a mixed method exploring the views of stakeholders on availability, accessibility, quality, affordability, equity, effectiveness, and efficiency.

Introduction: South Africa has endeavored to provide access to rehabilitation to more people with the greatest needs via its National Rehabilitation Policy. To achieve the aim of the Framework and Strategy for Disability and Rehabilitation Services in South Africa, scientific knowledge on rehabilitation services would be essential to inform implementation, yet little is known in the KwaZulu-Natal (KZN) province. This paper describes South African rehabilitation services delivery focused on availability, accessibility, quality, affordability, equity, effectiveness, and efficiency based on stakeholders´ perspectives in KZN. Methods: a mixed method study design was employed to investigate 99 stakeholders' opinions on rehabilitation services in three districts of South Africa´s KZN province (eThekwini, Amajuba and King Cetshwayo) using focus group discussions, interviews, and a survey. The stakeholders included practitioners (physiotherapists, occupational therapists, social workers, psychologists, nutritionists, dietitians, audiologists, speech therapists, and bio kineticist), district rehabilitation managers, provincial rehabilitation managers, and representatives from the provincial office of social development. Whilst quantitative data were analysed using descriptive statistics, thematic analysis was employed for the qualitative data. Results: of the 99 participants, 73 (74%) were female, and ages ranged from 23 to 56 years (median=29 years, IQR=12.5 years). The emerging themes were availability, accessibility, equity, quality, efficacy, and efficiency of rehabilitation. Rehabilitation services were mostly (78%, n = 42) available at the tertiary level in urban areas, and few (45%, n = 42) in rural areas. No private rehabilitation facility was found in any rural setting. Accessibility was generally agreed to be poor (with patients traveling more than 10 kilometers to access services) but with the agreement that transport routes from surrounding areas were safe and reliable for patients to reach their setting (median=2.5, IQR=1.0). This study´s participant's general sentiment on affordability and equity tended to be mixed but skewed towards agreeing that the services were indeed affordable, and provided without any social class biases. Also, the general sentiment of the participants on the quality, effectiveness, and efficiency of rehabilitation services in their settings tended to be positive. Conclusion: rehabilitation at the primary level results in accessible services as they become closer to needy communities. We recommend prioritization of human resources and budgeting for rehabilitation services at the primary level to improve access to people in rural areas.