Prioritizing Rehabilitation in Pakistan’s Health system: A Qualitative Policy Analysis 

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There are insufficient financial and human resources to address the unmet needs. Despite the increasing demand for rehabilitation and assistive technology (AT) and implications for improving health inequities, it receives little political attention. This analysis identifies the factors that shape the prioritization of rehabilitation in Pakistan’s national health system. Methods: We conducted 29 key informant interviews with actors concerned with rehabilitation policy and practice in Pakistan, complemented by a purposeful review of peer-reviewed and grey literature to achieve thematic saturation. The data was triangulated and thematically analyzed using a policy framework on national prioritization of rehabilitation services. Results: Based on the framework, we identified three key elements that shape the inadequate prioritization of rehabilitation in Pakistan. First, rehabilitation lacks a consistent problem definition; there is a lack of consensus among key actors regarding the importance and need for rehabilitation and AT in the health system. Second, governance arrangements are fragmented across multiple ministries, with rehabilitation services often being associated with disability and included under the Social Welfare Department, rather than the Ministry of National Health Services, Regulations, and Coordination (MoNHSRC). Third, with respect to structural factors, scarcity of resources in the existing health system,societal stigmas and social inequalities have negatively shaped the abilities of both rehabilitation service seekers and providers. Conclusion: Identifying the key components impeding prioritization for rehabilitation in Pakistan’s health system is a crucial first step in advancing the issue within sub-national and national policy agendas and improving equity in access to rehabilitation services. Rehabilitation professionals and other actors responsible for rehabilitation policy and practice should systematically work together to prioritize and integrate rehabilitation services within the current health system structures to advance health equity, enabling all individuals to lead fulfilling lives, regardless of their background or circumstances. Rehabilitation Prioritization Integration Health policy Health System Pakistan Figures Figure 1 Background An estimated 2.6 billion people have conditions that require and may benefit from rehabilitation. 1 The need for rehabilitation services continues to increase, especially given population aging,increasing rates of non-communicable diseases and during emergencies such as wars, outbreaks and natural disasters. 2 , 3 , 4 However, the need for rehabilitation is highly unmet and access to services remains inequitable. The World Health Organization (WHO) highlights that more than 50% of people are unable to receive the rehabilitation care they need 4 . Rehabilitation services often reflect deep-seated inequities shaped by socioeconomic status, geography, race, and disability type. The poor frequently face barriers such as limited access to specialized care, underfunded facilities, and a lack of insurance coverage, which restrict their ability to receive consistent and high-quality rehabilitation. In addition, racial and ethnic minorities often experience systemic bias, resulting in delayed treatment, misdiagnosis, or culturally insensitive care. These disparities collectively hinder recovery, access to other health services, and quality of life, perpetuating cycles of disadvantage for already marginalized populations. A systematic review shows a high rate of adult mortality in low- and middle-income countries (LMICs) due to disability resulting from disability-related inequalities 5 , 6 , 7 . The WHO launched the Rehabilitation 2030 Initiative, which draws attention to the profound unmet need for rehabilitation worldwide and emphasizes the importance of strengthening health systems to provide rehabilitation. Quality rehabilitation care encompasses a range of services, including physical therapy, occupational therapy, speech, and language therapy, orthotics and prosthetics, psychology, and assistive technology (AT). 3 , 8 Rehabilitation optimizes people’s functioning in the context of an individual’s position in life, resources, and interaction with the environment. It is an integral component of health systems in addressing Sustainable Development Goal (SDG) 3, which seeks to ensure healthy lives and promote well-being for all. 8 Despite the need and its benefits, many governments, especially in LMIC, inadequately prioritize rehabilitation and implement policies that support rehabilitation advancement in national and sub-national health systems. 9 , 10 The situation is no different in Pakistan— a state with high rehabilitation needs, relatively little prioritization and poor allocation of resources in this health domain. WHO reports that approximately 56 million individuals— approximately 1 in every 5 persons—in Pakistan have health conditions that could benefit from rehabilitation, which is the highest estimate in the Eastern Mediterranean region. 11 Rehabilitative services in Pakistan are mostly limited to tertiary care hospitals in major cities and become available on an ad hoc basis in post-disaster situations. 12 Rehabilitation has been included in the Essential Package of Health Services (EPHS) that serves as a policy framework for strategically delivering essential health services. Despite such efforts, there are no specific funds allocated for rehabilitation and AT services. Currently, the EPHS includes identification, screening, and referral for congenital hearing loss and developmental issues at community and primary health care levels. It also covers basic management of musculoskeletal injuries and disorders. However, the provision of effective, comprehensive rehabilitation services is needed. There is limited understanding of what contributes to a country’s lack of prioritization and effective policy implementation for rehabilitation. 13 , 14 , 15 Drawing on a policy framework dedicated to examining national prioritization of rehabilitation services, we conducted a qualitative case study to identify the political and bureaucratic factors that shape the prioritization of rehabilitation and the subsequent policy responses to the national rehabilitation systems in Pakistan. Methods This study is grounded in a constructivist paradigm, recognizing that knowledge is constructed through individual’s interactions, subjective experiences and meanings attributed by them within a social context. Underpinned by the study’s constructivist orientation, this article explores the perceptions of actors concerned with rehabilitation policy and practice in Pakistan via in-depth, semi-structured interviews along with a review of literature. Conceptual framework A policy framework concerning rehabilitation prioritization in LMICs, which is grounded in health policy scholarship and agenda-setting theory and developed by Neill et al, 16 was adopted to guide this study (Table 1 ). Drawing on this framework, we triangulated and thematically analyzed the data from the key informant interviews and documents we collected to understand the prioritization of rehabilitation in the country. The framework identifies three key factors crucial for understanding the prioritization of rehabilitation at the national level. These include problem definition , which involves understanding the issue and achieving consensus among relevant stakeholders for its solution; governance , which pertains to how actors organize and collaborate to advance the formulation and implementation of rehabilitation policies; and structural factors , which concern the role of sociocultural context and health system structures in shaping prioritization of rehabilitation. Drawing on the framework, we developed a semi-structured interview guide and structured the initial codes during data analysis to reflect these major categories of investigation. We acknowledge that our decision to employ the Neill et al framework shapes the conduct and presentation of our analysis. However, we tried to account for this in our approach by not only deductively coding our data in line with this framework but also incorporating an inductive approach to account for emergent themes that were not outlined by the framework and our original codes. Furthermore, given that some of the authors of this study are researchers embedded in the rehabilitation field and country, we acknowledge the influence of our positionality on data collection and interpretation given our pre-existing knowledge of the field and social norms of the country. However, we tried to account for and counterbalance any biases with the inputs of several authors that are “outsiders” to both the rehabilitation field and Pakistan. Document review We collected documents using a purposeful search of peer-reviewed and grey literature, and policy documents related to rehabilitation and AT in Pakistan on PubMed and Google Scholar. The keywords used included “rehabilitation” “assistive technology” “assistive products” “Pakistan” “policies” “acts” “programs” and “health systems”. Pakistan Bureau of Statistics (PBS) and Pakistan Demographic Health Survey (PDHS) were also consulted to locate policy documents. We used the documents to gather insights on the state of rehabilitation services, institutions, policy, and program implementation in Pakistan over time. In total, 47 pieces of literature were reviewed and included from year 1992 to 2022. We also included official policy documents, organizational reports, peer-reviewed and grey literature relevant to rehabilitation policies, acts, initiatives, and implementation in Pakistan. Relevant documents shared by key stakeholders were also included. Data Collection As part of the data collection, we conducted key informant interviews (KIIs) and identified relevant peer-reviewed and grey literature. Key informant interviews We conducted 29 KIIs with 30 key informants (KIs) working in rehabilitation and deeply familiar with rehabilitation’s governance and implementation in Pakistan (Fig. 1 ). The snowball sampling technique was used to recruit the stakeholders for which an initial list of KIs was designed by identifying the individuals and organizations from different cities and provinces of Pakistan working for rehabilitation and who are deeply familiar with rehabilitation’s governance and implementation in Pakistan. We added more KIs based on feedback from participants. Stakeholders were selected from six main categories: representatives from 1) national and 2) sub-national government, 3) developmental partners, 4) health care providers, 5) academia, and 6) non-governmental organizations (NGOs) and disabled people organizations (DPOs) who were associated with the provision of rehabilitation services. All KIIs were selected based on their knowledge of rehabilitation, AT, and health systems, with each category including at least two individuals. Participants were contacted via email or phone call to seek permission, and verbal consent was obtained. An introductory email was sent outlining the study and its objectives to the potential participants and follow-up phone calls were made. The sample size was determined based on theoretical saturation, which was achieved when no new data emerged from the analysis. We included male (n = 22) and female (n = 8) KIs. KIIs with stakeholders were conducted between January and July 2023. Interviews were conducted, both in-person and through video conferencing via Zoom, that lasted for 60–90 minutes. Researchers were trained on the interview guide before initiating data collection, KIIs were asked about the extent to which rehabilitation is prioritized by different actors (public/private/philanthropic), how they conceptualize the problem, the implementation of policies supporting rehabilitation, and the factors influencing the prioritization and implementation of rehabilitation within the health system of Pakistan. All interviews were conducted either in English or Urdu and were digitally recorded. The interviews were transcribed verbatim and then translated into English. The translations were reviewed for grammatical errors while preserving the contextual accuracies of the data. The profile of key informants is provided in Fig. 1 . Data Analysis We used a thematic analysis methodology to analyze the data. We used a pre-established policy framework 16 to organize and deductively analyze participant responses into specific themes: problem definition, governance, and structural factors (Table 1 ). The analysis revealed challenges to prioritizing rehabilitation in Pakistan, such as limited understanding of rehabilitation and AT among actors, inconsistent data for the rehabilitation needs, fragmented ownership across health and social welfare, stigma associated with disability and seeking rehabilitation care services, lack of financial resources for rehabilitation and assistive products, and shortage of trained healthcare workforce. These thematic findings were categorized under each of the policy framework’s components. We also analyzed the documents by reading them in full and taking notes to extract key findings, using both deductive and inductive methods for the analysis. Document collection and analysis were iterative. We stopped our literature search and conduct of KIIs when we reached theoretical saturation. 17 Biweekly Zoom meetings with researchers of AKU and JHU were held to discuss the key themes and emergent findings. However, during the analysis, since an iterative approach was used to improve the concept, some responses did not appear to fit into any existing theme which presented an opportunity to gain additional insights from the data. The inductive, open coding method was employed to accommodate these unique responses, allowing for a more flexible and exploratory approach to analyzing the data. This approach enriched the understanding of the data and captured important nuances that might have been missed with a limited deductive analysis approach. In the final phases of the analysis, identified themes were reviewed critically to ensure that each of those represented a distinct aspect of the participants’ responses. Additionally, some responses were repositioned or reallocated to better align with the most appropriate theme, improving the accuracy and precision of the findings. This approach allowed for a comprehensive exploration of the data, capturing diverse perspectives and unique aspects of the participant’s responses, ultimately leading to a richer and more nuanced understanding of the qualitative data. Ethical Consideration The study was approved by the Ethical Review Committee of Aga Khan University (AKU) (ERC#: 2022-7361-22291) and the Institutional Review Board of Johns Hopkins University (JHU) (IRB #: 00018269). Verbal consent was obtained from all the study participants before the interview. Permission was obtained from respondents to tape-record the interviews on the assurances of confidentiality. Moreover, all participants were assured about the confidentiality and anonymity of the collected data and were informed about their free will to be part of the discussion. To ensure the privacy of the participants, a unique ID code was assigned to each participant. Information from the recruitment list was kept separate from the audio recordings, transcripts, and field notes. All data was de-identified before analysis. Results Evolution of Rehabilitation Policy and Programming in Pakistan Pakistan’s current state of rehabilitation priority can be understood by contextualizing key historical policy and programming developments (Table 2). The beginning of access to rehabilitation services traces back to the 1960s. 3 At this time, Dr. Kirmani, who is regarded as the founder of physical medicine and rehabilitation (PMR) in the country, founded Pakistan’s first department of rehabilitation medicine at the Jinnah Post Graduate Medical Center (JPMC). 3 ,8 The School of Occupational therapy was then established in 1973, and a similar department dedicated to PMR was instituted in Punjab at the Mayo hospital Lahore in 1980s. In 1981, government of Pakistan initiated its first law “Disabled Persons (Employment and Rehabilitation) Ordinance 1981” to address the concerns of disabled persons. 18, 19 Also during this time, the President of the country—who had a special needs child —issued a directive for establishing two centres of excellence in rehabilitation medicine, and eventually integrated PMR in the Pakistan military, with the funding of Armed Force Institute of Rehabilitation Medicine (AFIRM) in 1991. 1 3, 8 In 2002, the first national policy for PWDs was announced in consultation with the health, education, labor, housing, science, and technology ministries, as well as relevant non-governmental organizations (NGOs) and local organizations. 18 The 2005 earthquake in Pakistan—which resulted in 70,000 casualties and left 120,000 injured—highlighted the need for rehabilitation services further, catalyzing extensive collaborations in the field such as the formation of Earthquake Rehabilitation and Reconstruction Authority (ERRA) with the technical support of WHO, 8 as well as the coalition between Community Based and Institution Based Rehabilitation. In 2006, the National Plan of Action (NPA) for PWDs was introduced. 18 In 2020, the Rights of Persons with Disability Act was formulated. Recently, AT scale’s CEO visited Pakistan to initiate a new AT scale-supported program aimed to improve access to assistive technology for vision and hearing. Despite these development and progress, the majority of people in Pakistan to date experience difficulties in accessing basic health and rehabilitation services. These have impacts on the individuals themselves, their communities, and the country’s economy, with Pakistan’s economy losing an estimated USD 12 billion by excluding PWDs from employment. 18 Key factors shaping national priority of rehabilitation services in Pakistan Key elements concerning problem definition, governance, and structural factors shape the prioritization of rehabilitation in Pakistan’s national health systems. These are briefly described in Table 1. Problem Definition One key challenge to advancing priority for rehabilitation concerns the variability in perspectives and lack of clarity among different actors on the nature of the problem, as well as the solutions to better advance rehabilitation in the health system. Problem Clarity Limited understanding of rehabilitation and AP among the a ctors . Respondents highlight that health care providers are largely unaware of rehabilitation and what it encompasses. For example, there is limited awareness of AT— customized and individualized products that enable people to achieve independence in performing their daily activities—among physicians, which hampers its access 20 ,21 [HCP-5, Mn-4, and DP-1] as highlighted by a healthcare provider: “Our health care professionals, the non-rehabilitation doctors are not clear as to what assistive technology may be recommended and for what type of disability .” (Healthcare Providers (HCP-5)) Synonymizing physiotherapy with rehabilitation was a major challenge identified during interviews with respondents. While some actors emphasized the multidisciplinary or holistic nature of rehabilitation, many medical professionals reiterated the common misconception that physiotherapy was all-encompassing rehabilitation. One informant noted: “A common misconception among people is that rehabilitation medicine is merely physical therapy. However, physical therapy is essential but constitutes only approximately 20% of rehabilitation medicine.” (HCP-3) In addition, rehabilitation is often misunderstood as a service for people with disabilities rather than being recognized as a broader health concern for everyone. 3 It therefore doesn’t get enough recognition and weightage in the society when compared to other healthcare services. “When somebody is disabled only then you need rehabilitation. So, the tag of the disability is very necessary for rehabilitation service in Pakistan.” (Professional Institute (PI)-2) Furthermore, rehabilitation is perceived as a luxury, given its long-term commitment to multiple sessions, and its relative expense, with many paying for it out of pocket [HCP-5, DP-1]. 22 This has complicated efforts to frame rehabilitation as a basic need, worthy of policymaker action. Unclear understanding of rehabilitations needs may partly be driving the inconsistency of data on this subject. WHO has reported that 56 million people in Pakistan have health conditions that could benefit from rehabilitation. 11 However, according to the Pakistan Bureau of Statistics (PBS) record, there are over 370,000 National Database & Registration Authority (NADRA)-registered PWDS in Pakistan. 23 This doesn’t equate to the actual rehabilitation need in Pakistan which goes beyond the needs of persons with disabilities. There is a dire need for the data [Mn-5, Dt-2, Dt-1, NGO-3, NGO-2, Mn-4, Mn-7, NGO-5, DP-1, PI-6, HCP-3, and NGO-5]. Specialized surveys at the district level can serve as an input to developing evidence base to inform policymaking [DP-1, NGO-5, Mn-5]. Accurate data is essential for a comprehensive understanding of the demand for rehabilitation services and to persuade policymakers to prioritize and allocate the necessary human and financial resources as described by an informant: “The most crucial thing is to have data, based on which we should set our priorities for the next five years about which disease we need to tackle and from what perspective. Resources are not available for anything until you present its facts and figures; only then can you mobilize funds.” (NGO-5) Governance Another key challenge to advancing priority for rehabilitation in Pakistan concerns governance—effective mechanisms that enable effective decisions, resource allocations, regulations, and collective action among relevant actors for rehabilitation policy and programming advancement. Governance Arrangements Fragmented ownership of rehabilitation across health and social welfare One of the biggest challenges to prioritizing rehabilitation in the national health system is its ownership in Pakistan. Rehabilitation services are often associated with disability and are typically included under Social Welfare department, rather than the MoNHSRC, which is responsible for all healthcare-related affairs [NGO-5, DP-1, DP-2, Mn-5, Mn-1, and HCP-2]. An informant discussed the tension: "Unfortunately, the government’s priorities are a lot different. To date, the government is unable to decide whether it is a problem of the health department or comes under the social welfare department.” (PI-4) “Pakistan is a complex country and in federal countries, decision-making in governance always occurs at multiple levels... (Mt-5) There is no single dedicated legislative body aimed at setting guidelines for rehabilitative care services, monitoring rehabilitation programs, safeguarding the rights of rehabilitation professionals, and overseeing the regulation of human and financial resources 15 [PI-6, PI-3, Mn-4, PI-2, DP-2, DP-1, and HCP-5]. An informant discussed the need for such a body dedicated to rehabilitations services: “We talk about it in every forum that rehabilitation directorate should be formed … When it will form then there will be a rehabilitation director who will present his budget by himself… and he will get it approved himself… rehabilitation budget should not be in the hands of another person… otherwise they will manipulate… In this way, we will face a lot of difficulties.” (PI-3) Political instability, frequent government turnovers, and delays in governmental responses In addition to the lack of bureaucratic ownership for rehabilitation, the issue lacks priority given political instability, frequent turnover in government, and delays in governmental response. These obstacles hinder the formulation and implementation of rehabilitation policies [HCP-1, PI-4, NGO-3, Mn-4, Mn-5, and Mn-7]. “The social welfare department is working but again we have differences of opinion on how work should be done. Other than that Sehat Ehsas program was started but now we don’t know about it because you know our progress is being made from one government to another. Once the government is changed then after that names get changed, and programs get changed, things don’t remain the same.”(NGO-3) “If you go to government offices and write a letter, you have to wait months to get a response. So, sometimes, if there is planned activity then the time frame of that activity passes”(HCP-1) Limited governance authority at the local level presents another challenge within many administrative systems, which makes it difficult in decision making and causes delays in the implementation of policies and programs relevant to rehabilitation that involves providing services, initiating awareness campaigns, and hiring more rehabilitation professionals. [Dt-2 and Dt-3]. This often translates into a lack of effective decision-making, resource allocation, and policy implementation mechanisms, as noted by a district health officer: “I have some constraints… I can’t buy equipment voluntarily. I can’t procure medicine. I can’t hire staff. If I do, I have to justify it. So, we have to send requests, the system is complicated…if I had the authority to do so, I could have hired doctors and staff members who are dedicated to rehabilitation.” (Dt-2) Domestic Advocacy Coalitions Isolated efforts of all relevant actors in the field of rehabilitation Various actors, including the MoNHSRC, Ministry of Special Education, Ministry of Planning and Development, Social Welfare Department in each province, Ministry of Transport and Communication, Pakistan Bait-ul-Maal, Department of Empowerment of Persons with Disabilities (DEPD) in Sindh province, Non-Governmental Organizations, Disable People Organizations (DPOs), International donors, and PWDs are involved in the field of rehabilitation in various capacities like Social Welfare and Baitul Mal provides services to underprivileged and vulnerable individuals including disable persons. While MoNHSRC and Ministry of Special Education are involved in different capacities for providing health services and quality education. However, they all work in isolation with their mandates. There is a significant gap in coordination among these actors, which present a substantial impediment to governance and service delivery of rehabilitation services [PI-3, HCP-4, PI-5, NGO-3, HCP-1, NGO-4, NGO-5]. Moreover, the 18 th Amendment to the constitution of Pakistan, enacted in 2010, led to a significant shift in Pakistan's governance structure in the context of the healthcare system, resulting in the devolution of power and responsibilities from the federal to the provincial governments. Every province has their own departments, programs, and initiatives which work on the different aspects of healthcare. Similarly, each province has unique challenges and opportunities based on the needs of people and available resources. Some provinces and institutes demonstrate commendable efforts to provide improved access to rehabilitation services like SIPMR institute at Sindh. Some provinces have shown a significant advancement in prioritizing rehabilitation while other provinces still lag behind. This has also led to significant implications for various aspects of governance [PI-3, PI-6, NGO-5, DP-1, HCP-1, and Mn-7]. 24 It was also stated by an informant: “We have CRS (comprehensive rehabilitation services) here, if we talk about Sindh specifically, we have SIPMR that is providing services at this level. Along with the provision of CRS, they also provide assistive products that fall in the category of mobility aids.On a national level, many hospitals in Islamabad are working on it. As we’ve discussed KPK earlier, there is a Paraplegic Centre in Peshawar (PCP) which is working efficiently on spinal cord injuries rehabilitation.”(NGO-1) “Significant work has been done. Institutions have been established, with Dow University now transformed into Sindh IPMR. The situation in Balochistan is not as developed, but in Punjab, the Indus Hospital has made considerable strides. The CHAL Foundationis also active. We have successful models at our disposal. These are mostly concentrated in one place, specifically urban settings.”(PI-6) When navigating the landscape of rehabilitation services, distinct challenges are encountered by the NGOs, shaped by their scope within the healthcare sector [HCP-1, Dt-1, NGO-3, NGO-4 Mn-4, DP-1, PI-6]. A limited number of NGOs are dedicated to rehabilitation service provision and their primary focus remains on other prevalent health, social issues and community development. An informant explained: “Specifically, regarding rehabilitation, I have not observed any organization working on raising awareness, working for its propagation, or working proportionally ... NGOs only engage in activities that are financed. They are told to distribute APs, so they purchase them and distribute them forward … However, the work that should be conducted at the grassroots level within the community- the fieldwork- is absent.” (Mn-4) In addition to the efforts of other actors, PWDs play a significant role in actively engaging with government officials and advocating for prioritization of rehabilitation. 15 They can be the role models for the support of other PWDs and can provide support in the development of programs/initiatives in the community. However, their scope needs to go beyond the rehabilitation needs of PWDs. In Pakistan there are very few champions who can contribute and play a significant role in shaping policies and programs related to rehabilitation services. A representative from the ministry exemplified: “I know a man... He moves around in a wheelchair; he is a young man affected by polio. I see him going to office, and working in an NGO, and in addition to that, I think he is also an employee of the Paraplegic Center… without saying anything, he communicates a lot.” (Mn-3) While some international effort towards rehabilitation comes forward mostly during rain, flood, disaster, and emergencies it remains limited [HCP-5, PI-2, DA-2. NGO-5]. This limitation poses a significant challenge and impacts the domestic rehabilitation programs in Pakistan. There are no organized platforms where work can be done with proper planning. Institutions lack the technical expertise and resources to support rehabilitation programs. There is no proper mechanism whereby relevant ministries and organization could generate a report on a yearly or bi-yearly basis detailing the data related to the need of rehabilitation services in different regions. An informant described the nature of international involvement with rehabilitation services in Pakistan: “Very patchy, and small-level rehabilitative work is there. There is no systematic or international level work which is being done… not even by UN.” (HCP-5) “There is quite a bit of work being done internationally in this regard... The medium-level international organizations focused on disability are very few. There are one or two or three that are working very focused on disability, otherwise I haven't seen such a focus.”(NGO-5) Structural Factors Finally structural factors—such as dynamics related to national legacies, socio-cultural context, and health system structures —have shaped prioritization of rehabilitations in Pakistan. National Legacies Focus driven for rehabilitation services only after disasters and conflicts The 2005 earthquake in the northern part of Pakistan and Kashmir —which resulted in 73,338 deaths, 69,412 severely injured, and 3.5 million people homeless 25 —led to a sudden increase in disabilities, necessitating the establishment of rehabilitation services and resource provision [HCP-2, DP-1, HCP-3, HCP-5, Mn-5, Mn-2, PI-5]. An informant explained its impact on rehabilitations policy priority: “After the 2005 earthquake, there was an increased awareness regarding rehabilitation. Individuals at both the national and international levels became involved... This led to increased funding and training opportunities. They realized that this is a specialty that requires attention and making contributions to this field would make a difference...” (HCP-3) The earthquake also led to a significant increase in NGOs that provided rehabilitation care in affected communities [PI-3, Dt-3, NGO-5, NGO-1, HCP-5, Mn-1, Mn-5], 26 ,27 as described by a actor : “ When the earthquake hit Pakistan in 2005... There were so many NGOs in our health care system that started to work … NGOs have a very important role to play and there is a very positive history of the role they have played in developing Rehabilitation services in Pakistan after the disaster and even once this settles down.” (HCP-5) Despite these efforts, there has been insufficient sustained support and resources for ongoing rehabilitation needs. “When there is a flood or rain emergency, our rehabilitation services get available at that time... But on a regular basis, these services are lacking, and patients are deprived of them.” (Dt-1) Sociocultural Context : Stigma associated with disability and seeking rehabilitation care services Negative cultural stereotypes, societal attitudes towards PWDs and lack of awareness about who needs rehabilitation have been identified as major barriers to the prioritization of rehabilitation. 28,29 Family members often hesitate to seek support due to the fear of stigma, mainly associated with mental health issues [PI-1, PI-2, NGO-1, Dt-1, Mn-1, Mn-7]. Several informants described how stigma associated with disability has negatively impacted demand for rehabilitations services: “Stigma associated with disability is a major reason that PWDs remain invisible in our society. They are not seen and remain uncounted, unheard, invisible, and the inclusion that is needed for them in society does not take place.” (NGO-4) “The situation for mental health is just as bad, if not worse than it is for physical health, primarily because there's a stigma attached to it which makes the community reluctant to seek help.” (Mn-7) People with disability and those suffering from conditions that require rehabilitation are subject to discrimination and exclusion within the society. They face barriers to accessing appropriate housing, employment, mobility challenges and essential services in daily life– including education and health care 7 . “Our environment is not disabled-friendly. How many buildings, parks, clubs, and hospitals are there that have ramps? And even if they do have ramps, they are so steep that a person who is pushing a wheelchair or if that person climbs on it then he will fall backward due to gravity.” (H CP- 2) Health System Structures : Rehabilitation is an overlooked domain within the healthcare system Among the various health system challenges influencing the prioritization of rehabilitative services, the most critical issue highlighted is its status within the healthcare sector [Mn-4, HCP-2, NGO-1]. 13 Despite the growing need and significant role of rehabilitation in enhancing one's quality of life, it remains inadequately addressed as mentioned by the representative from the ministry: “Rehabilitation has historically been a neglected field in Pakistan. The root cause of this neglect lies in the dominance of the medical model within our healthcare system … Furthermore, professionals in rehabilitation, be it doctors or workers, are not accorded the same esteem within society as traditional doctors.” (Mn-4) Rehabilitation is inadequately prioritized and rehabilitation professionals are not given importance as compared to other medical professionals. It is typically found in tertiary care hospitals, primarily in major cities in Pakistan and are not accessible to the general population. Furthermore, none of these facilities have all the essential components of rehabilitation [DP-1, DP-2, HCP-4, HCP-5, Dt-4, NGO-1, PI-2, and Dt-3]. This poses a significant challenge for patients to travel long distances for seeking rehabilitation services or getting APs, especially for residents of rural areas. Most of them travel 5-25 km or more than 25 km to obtain the APs [DP-2, Mn-7, Mn-6, Dt-4, NGO-4, and Dt-3]. 30 This also leads to overburdened tertiary hospitals and an increased workload for their staff [NGO-3]. It is in realm of private rather than public sector not seen as government mandate to provide rehabilitation service to general population. Informants from the ministry emphasizes that despite rehabilitative services being available in the private sector, these are beyond the reach of many due to substantial costs [Mn-2 and Mn-5]. This issue was also highlighted by the people from the ministry: “The problem lies in accessibility; for instance, if a person in need of physical rehabilitation resides in a remote district, it is not feasible for them to access the centralized tertiary-level services. It is exceedingly difficult to travel, especially since physical rehabilitation doesn’t usually involve a one-time visit but requires regular visits” (Mn-7) “There is no facility (public sector) at the district level… Private centers are available for physical rehabilitation. But none of them are free of cost.” (Mn-2) In addition, most of the distribution of APs in Pakistan is driven by the private sector with limited involvement from the public sector. While most of the AP users bear the financial burden themselves. 20 This indicates a gap in subsidized and public funding support in Pakistan. Participants pointed out a notable weakness in the current healthcare system, the insufficient funding for necessary human and material resources for the provision of rehabilitation services. Furthermore, concerns were raised regarding the vacant positions of rehabilitation professionals especially at the district level [Dt-2, DP-1, NGO-5, Mn-3, Dt-1]. It was explained by the informants as: “We need to allocate funds for the procurement of instruments, equipment, and machinery required for rehabilitation. Additionally, we also need to allocate funds for the hiring of specialized staff dedicated to rehabilitation services. For their salaries too, no budget is allocated for this.” (Dt-2) “At the district level, audiologists, orthotics, and physiotherapists, there are many districts with vacant positions, which are not being filled by advertisements or through the proper recruitment process.” (DP-1) Finally, healthcare professionals at all levels, from lady health workers to medical officers, lack adequate training in rehabilitation services. This results in people not receiving appropriate rehabilitation care and not being referred to the relevant professionals. Furthermore, even medical curriculum does not include any subjects related to rehabilitation. [HCP-3, HCP-2, PI-3, Mn-7, Mn-5]. It was explained as: “The barriers are that our health professionals (medical doctors) don’t even have an idea that this is a medical field. It is a need of the day and should be included in MBBS final-year curriculum… This field should be included in their final year of medicine.” (HCP-2) Proposed Solutions Strategies for Awareness of Rehabilitation and AT Among Actors at Different Levels Several measures can be implemented to raise awareness at every level, from the citizens to the government officials. 2 Informants emphasized driving the focus on early-stage parental counseling to prioritize the needs of children with disabilities. They also proposed to sensitize and actively engage the government officials, community leaders, and individuals who have benefited from rehabilitation given their influencing role [Dt-1, Mn-2, HCP-2, Dt-2, HCP-4, Mn-7, NGO-5, NGO-4, Mn-4, Mn-5, PI-6, and NGO-1]. There is a need for initiating mental rehabilitation which is now emerging an issue in society and has not given importance in previous years. Conducting awareness campaigns and seminars for the community can also play a pivotal role in making people realize the significance of rehabilitation in enhancing the quality of life. These efforts at the community level can help with focusing on the need of rehabilitation and its prioritization at the policy level so that it could be an essential part of the system at all levels. An informant outlined its importance by saying: “The healthcare ministers, secretaries, and all relevant a ctors should be approached. It would be advantageous if we could present it to them and elucidate how even a little assistance can make a significant difference.” (HCP-3) Significant efforts have been made to improve access to assistive products. One such step is the development of the Priority Assistive Products List (APL) launched by the WHO in May 2016 after multiple rounds of discussions. The list comprises 50 priority APs, identified and finalized through multiple rounds of discussions and a two-day consensus meeting held in March 2016. Actors from various sectors, including those involved in service provision and policymaking, researchers, and users of assistive products, attended this meeting. The purpose was to design a model that could guide all member states in developing their national priority APL, tailored to their specific needs and available resources. This enables individuals to lead productive and independent lives. 21 This served as the foundation for the National Priority APL for Pakistan, championed by the First Lady. This type of political commitment draws attention to the need for assistive technology in Pakistan. An informant mentioned: “I think you must be familiar with the WHO Priority Assistive Product List, which is 50 APs in the domain of physical impairment, hearing, vision, environment, and communication. Out of that, we selected the highest priority products 25 APL. So, I think that is one thing that has given some direction and framework to the country now.” (DP-1) Discussion The findings of this study shed light on the scope of rehabilitation, its understanding, and the challenges faced by Pakistan's rehabilitation sector. Based on the analysis of the data collected from the KIIs and literature review, challenges were identified under three main themes—problem definition, governance, and structural factors—that influence the prioritization of rehabilitation in Pakistan. Concerning problem definition, we identified a limited understanding of rehabilitation and AT among actors and little consistent data to highlight the rehabilitation needs. Furthermore, rehabilitation is perceived as a "luxury" rather than a necessity. This problem can be addressed by generating reliable data on rehabilitation needs and available services to advocate the necessity for the proper allocation of human and financial resources in the sector. This can also be resolved by creating awareness about rehabilitation at various levels. There is a need to leverage social media and other digital platforms to educate the general population including medical doctors on the importance and role of rehabilitation and AT. In the realm of governance, the main challenge concerns the ownership of rehabilitation services. Despite being considered a health service for all and managed by the Ministry of Health, rehabilitation is often regarded as a service specifically for persons with disabilities and is placed under the mandate of social welfare. This challenge is mainly due to the lack of an accreditation body for the regulation and monitoring of rehabilitation-related affairs. In order to reduce inequities and improve health outcomes, there is a need to develop a national strategic plan for rehabilitation to align ministries working for rehabilitation, focusing on improving coordination and collaboration between relevant actors. Finally, with respect to structural constraints, the social stigma associated with those who seek rehabilitation services hampers the accessibility and, consequently, the demand of these services in the country. A similar study in Kenya revealed that the attitudes and beliefs associated with disability represent one of the most complex barriers that limit access to healthcare, education, employment, civic rights, and opportunities for socialization for PWDs. 31 In addition, there is a shortage of trained rehabilitation workforce, which is also a global issue that is most pronounced in LMICs. 32 Based on our findings, priority can be driven by addressing that there is a need that should be fulfilled. This should be accomplished by determining the rehabilitation need and preparedness of the system to address the need. An accurate database needs to be established with relevant actors for further action and interventions. Moreover, exploring the perspectives of patients can also be beneficial in identifying the status of rehabilitation in Pakistan and planning strategies for their improvement. Existing rehabilitation services should be targeted to expand the workforce and also to improve access with the provision of rehabilitation services in rural areas. Community initiatives like the lady health worker program could be strengthened to provide both awareness and cost-effective services at a large scale on the community level. Further, government and donors should invest funding in rehabilitation services for all age groups including mental health which itself is an important domain of public health research. The situation for PWDs in Pakistan is completely different as compared to that in the developed world, where PWDs get equal opportunities and access to comprehensive healthcare services allowing them to lead independent lives. However, some provinces have made commendable efforts to enhance access to services, particularly for PWDs. For instance, they effectively works across sectors to support the rehabilitation of PWDs through education, health, and vocational activities for all age groups. 33 Furthermore, few institutions have made a lot of progress in various provinces, such as the Sindh Institute of Physical Medicine and Rehabilitation (SIPMR), 34 Paraplegic Centre in Peshawar (PCP), 35 and Armed Forces Institute of Rehabilitation Medicine (AFIRM) excelling in the delivery of comprehensive rehabilitation services to the people. 36 Rehabilitation services need to be strengthened in community settings to particularly target individuals who have difficulty accessing rehabilitation care services. The services should be expanded to ensure that all dependent individuals, regardless of age or disability, have access to essential care 7 . The EPHS serves as a policy framework for strategic service for delivering essential health services including rehabilitation, to all individuals, especially those with limited resources. Currently, the EPHS includes limited rehabilitation services at community and primary health care levels for the identification/screening, of the early childhood development issues. 37 It covers pressure area prevention and supportive seating interventions for wheelchair users and also addresses the basic management of musculoskeletal and neurological injuries and disorders. However, these services under the rehabilitation package should be expanded to address various issues and provide services at all levels with a proper referral mechanism. Healthcare professionals at all levels, from lady health workers (LHWs) to medical doctors, need to be well-informed and trained in the identification of disabilities and educating the patients in the community. Governments and health system leaders should promote equity in health by investing in primary health care systems that provide continuous, accessible, and high-quality services for both physical and mental health across all stages of life. This includes expanding service delivery platforms, integrating mental health into routine care, and ensuring community-level accessibility for underserved populations 7 . LHWs play an integral role in delivering services within communities, forming the cornerstone for the success of Primary Health Care (PHC). 38 The National Programme for Family Planning and Primary Health Care program, commonly called the LHW Program, was launched by the Government of Pakistan. This program was initiated to ensure the provision of family planning and primary healthcare services at the doorstep of the community to increase the utilization of promotive, preventive, rehabilitative, and curative services in poor and underserved areas. Currently, this programme covers approximately 38% of the total population across all districts of Pakistan, delivering essential primary healthcare services through trained female community health workers. Evaluations conducted in 2019-20 revealed that the program had a positive impact on health outcomes and health status per unit of cost as compared to the alternative services provided through the public health system. Lastly, the findings underscore the importance of embedding health equity considerations into emergency preparedness and response efforts in order to reduce the disproportionate impact of crises on vulnerable populations 7 . Despite the challenges, there are many positive developments for rehabilitation and Assistive technology. Successful initiatives have been initiated at the provincial level, like the DEPD in Sindh, which works effectively across sectors to support the rehabilitation of persons with disabilities through education, health, and vocational activities. Physical therapy schools are coming up across the country through which rehabilitation professionals will be trained and contribute in serving the country. There is momentum in efforts to improve access to assistive technology. National priority Assistive Products List (APL) was launched by the First Lady of Pakistan. Recently, country has received funding to introduce a new AT scale-supported program aimed at improving access to assistive technology for vision and hearing. This support through external funding underscores the global commitment to enhance assistive technology infrastructure in Pakistan. Strengths and limitations To the best of our knowledge, this is the first policy-level analysis of rehabilitation to be undertaken in Pakistan, where we communicated with different actors to assess the scope of rehabilitation in Pakistan’s health system. Secondly, a few of our key informants belonging to the Disabled Persons Organization and Ministry category were PWDs and therefore, we were able to know their perspective as service users as well. While we examined specific factors key to the prioritization of rehabilitation in Pakistan, our study had some limitations. For example, no actors from Baluchistan province were included, despite our inclusion of actors from almost all provinces. In addition, in some categories it was harder to achieve saturation like development partners where we interviewed only two organizations. This is mainly because not many are interested in rehabilitation. In our study, the literature reviews primarily identified the challenges related to the rehabilitation services mainly due to its poor prioritization in the country. However, we also triangulated it with informant recommendations and discussed both enablers and barriers. It is possible that additional positive cases exist within this domain that were not identified through our purposeful, rehabilitation focused search strategy. Our sample of KIs was largely from ministries, professional institutes and NGOs, with no representation of patients groups that could have provided a much broader aspect. This was due to our inability to identify specific individuals to contact for virtual interviews. Our literature search was also limited to publications in English. Given these limitations, future research should focus on validating, applying, and adapting the findings across diverse country contexts to enhance their generalizability and relevance. Conclusion This study provided an in-depth investigation into the challenges of prioritizing rehabilitation services in Pakistan and identified strategic opportunities for advancing rehabilitation in a context where there are many competing priorities and limited resources. Rehabilitation remains a critically underprioritized area in Pakistan’s health system, with inadequate financial and human resource allocations hindering the ability to meet growing population needs. There is little clarity on what rehabilitation is in practice, who owns it, and how to provide it via existing health and social systems. Embracing evidence-based strategies can help the country address these challenges and guide actors in taking action to create a more inclusive and equitable society where individuals with diverse healthcare needs can lead fulfilling lives. Given that rehabilitation can significantly improve quality of life and has multiple benefits, prioritization and investment in long-term sustainable interventions in this domain is highly recommended. Abbreviations MoNHSRC Ministry of National Health Services, Regulations, and Coordination AT Assistive Technology WHO World Health Organization SDG Sustainable Development Goal LMIC low- and middle-income countries EPHS Essential Package of Health Services PBS Pakistan Bureau of Statistics PDHS Pakistan Demographic Health Survey KIIs key informant interviews KIs key informants NGOs Non-governmental organizations DPOs Disabled people organizations MoPDSI Ministry of planning and development and special initiatives SWD Social Welfare department DEPD Department of empowerment of persons with disabilities AKU Aga Khan University JHU Johns Hopkins University JPMC Jinnah Post Graduate Medical Center AFIRM Armed Force Institute of Rehabilitation Medicine PWDs People with Disabilities ERRA Earthquake Rehabilitation and Reconstruction Authority NPA National Plan of Action HCP Healthcare Providers NADRA National Database & Registration Authority SIPMR Sindh Institute of Physical Medicine and Rehabilitation PCP Paraplegic Centre in Peshawar LHWS lady health workers PHC Primary Health Care Declarations Ethics approval and consent to participate The study was approved by the Ethical Review Committee of Aga Khan University (AKU) (ERC#: 2022-7361-22291) and the Institutional Review Board of Johns Hopkins University (JHU) (IRB #: 00018269). Verbal consent was obtained from all the study participants before the interview. Consent for publication Not applicable Availability of data and materials Data supporting the research findings are found in result section. All data generated or analyzed during this study are included in this article. All secondary data is included in the reference list and quotes are included from the key informant interview data in the result section. Key informants were instructed that transcripts would not be shared. Competing interests The authors declare no competing Interests Funding The work was supported by United States Agency for International Development (USAID). Authors' contributions Conceptualization and Methodology: A.M.B., A.L., N.Z., S.S., Y.R.S. Funding acquisition: A.M.B. Data Acquisition: R.S.T., Q.S., M.F., S.S.H., M.E., A.L., P.D. Project administration: R.S.T., S.C. Data Analysis and Interpretation: F.A., M.A., M.E., M.F., N.Z., Q.S., R.S.T., S.S.H., Y.R.S. Writing – Original draft: M.F., Q.S., R.S.T., S.S.H. Writing - Review and Revision: A.M.B., A.L., F.A., M.A., M.E., N.Z., P.D., S.C., S.S., Y.R.S. All authors reviewed the manuscript Acknowledgements We thank USAID for funding the project. We also acknowledge the support of our local stakeholders in Pakistan and the research team who assisted with the project. References Global key findings, WHO Rehabilitation Need Estimator, Institute for Health and Metrics Evaluation. http://ihmeuw.org/6ima . http://ihmeuw.org/6ima. Published 2021. Accessed December 27, 2024. Gimigliano F, Negrini S. The World Health Organization “Rehabilitation 2030: a call for action.” Eur J Phys Rehabil Med . 2017;53(2). doi:10.23736/S1973-9087.17.04746-3 Stucki G, Bickenbach J. Functioning: the third health indicator in the health system and the key indicator for rehabilitation. 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J Rehabil Med . 2017;49(1):10-21. doi:10.2340/16501977-2149 Ministry of National Health Services RaC G of Pakistan. Universal Health Coverage Benefit Package of Pakistan Essential Package of Health Services .; 2020. Sohail S, Wajid G, Chaudhry S. Perceptions of Lady Health Workers and their trainers about their curriculum for implementing the interventions identified for Essential Package of Health Services for Pakistan. Pak J Med Sci . 2021;37(5). doi:10.12669/pjms.37.5.4175 Tables Table 1 . Overview of the framework for the prioritization of rehabilitation Themes Sub-themes Identified Challenges Description Problem Definition Problem Clarity Limited understanding of rehabilitation and assistive technology among actors Actors, including medical doctors, often misunderstand rehabilitation, equating it with physical therapy and sometimes even with charity work. This misconception limits the prioritization of comprehensive rehabilitation services in Pakistan. Inconsistent data for the rehabilitation needs Underestimation of the need for rehabilitation, resulting in insufficient allocation of necessary resources for the delivery of quality services. Governance Governance Arrangements Fragmented ownership of rehabilitation across health and social welfare This leads to a lack of coordination and inconsistent policies, making it difficult to create a unified approach for the regulation and effective implementation of rehabilitation services Challenges like political instability, frequent government turnovers, and delays in governmental responses These challenges hinder the sustainability of rehabilitation programs Domestic Advocacy Coalitions Isolated efforts of all relevant actors in the field of rehabilitation Various actors including ministries at federal and provincial levels, NGOs and PWDs are working to promote rehabilitation in Pakistan but their work remains insignificant as that is done in silos and doesn’t get the image Structural Factors National Legacies Focus driven on rehabilitation services only after disasters and conflicts Services that receive attention only after certain incidents fail to remain sustained until prioritized within the health system Sociocultural Context Stigma associated with disability and seeking rehabilitation care services Beliefs, practices, and social norms within a society influence social behaviors and act as a barrier to the prioritization of rehabilitation Health system structures Rehabilitation: An overlooked domain within the healthcare system Inadequate representation of rehabilitation in the health system of Pakistan results in the unavailability of adequate rehabilitation services in many parts of the country, impacting the people with need for rehabilitation Lack of financial resources for rehabilitation and assistive products Gaps in financial support and unsustainable funding mechanisms, disrupt the availability of necessary resources for the provision of rehabilitation services. Shortage of trained healthcare workforce for timely service provision and referrals This results in people not receiving appropriate rehabilitation care and not being referred to the relevant professionals, underestimating the need for rehabilitation Table 2 . Timeline of major developments of Pakistan rehabilitations policy and programming Date Categorization of event Event details Early 1960s Establishment of schools/institutes First department of rehabilitation medicine at the Jinnah Post Graduate Medical Center (JPMC) 1973 Set-up of school of occupational therapy 1980s School of occupational therapy with focus on PMR Mayo hospital Lahore 1991 Armed Force Institute of Rehabilitation Medicine (AFIRM) founded 2005 Event with national significance Earthquake that drew national attention towards the significance of rehab services 1981 Policy Disabled Persons (Employment and Rehabilitation) Ordinance - National Council for the Rehabilitation of Disabled Persons was established to formulate policy for the employment, rehabilitation and welfare of the disabled persons 2002 National Policy for Persons with Disabilities was prepared 2006 National Plan of Action for Persons with Disabilities was introduced, that incorporated a roadmap to operationalize the national policy of 2002 2006-2015 “National Plan of Action for Children” was ratified to promulgate the rights of children with disabilities. 2010 Event with national significance 18th constitutional amendment leading to devolution of Ministry of Health and health became a provincial subject, the Ministry of National Health Services, Regulation and Coordination was formed instead 2017 WHO-EMRO-Islamabad declaration was prepared to improve access to AT in the WHO region 2017 Baluchistan Persons with Disabilities Act 2017 2018 Policy Sindh Empowerment of ‘Persons with Disabilities ‘Act 2018 2019 The Gilgit-Baltistan Persons with Disabilities Act 2019 2019 Event with national significance Ehsaas Kafaalat for Special Persons Policy included within the The Ehsaas Kifalat programme, an unconditional cash transfer programme launched by the Government of Pakistan 2020 Event with national significance Supreme Court made a decisive judgement regarding the rights of PWDs that potentially triggered the adoption of Rights of Persons with Disability Act 2020 Policy Rights of Persons with Disability Act 2020 2022 The Punjab Empowerment of Persons with Disabilities Act 2022 May, 2024 Event with national significance Visit of AT scale Leadership: AT scale’s CEO visited Pakistan to introduce a new AT scale-supported program aimed at improving access to assistive technology for vision and hearing. June, 2024 The global community, along with key actors in Pakistan, celebrated the first ever day for Assistive Technology Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Jan, 2026 Read the published version in International Journal for Equity in Health → Version 1 posted Editorial decision: Revision requested 13 Oct, 2025 Reviews received at journal 06 Sep, 2025 Reviewers agreed at journal 05 Sep, 2025 Reviews received at journal 28 Aug, 2025 Reviewers agreed at journal 08 Aug, 2025 Reviewers invited by journal 07 Aug, 2025 Submission checks completed at journal 07 Jul, 2025 First submitted to journal 07 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6202625","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":499299809,"identity":"8297af71-093e-4eb0-bb01-cd2872522417","order_by":0,"name":"Rozina Salman Thobani","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Rozina","middleName":"Salman","lastName":"Thobani","suffix":""},{"id":499299811,"identity":"ffdff0fe-2948-4a63-befa-1d8b336209cd","order_by":1,"name":"Yusra Ribhi Shawar","email":"","orcid":"","institution":"Johns Hopkins University Blomberg School of Public Health \u0026 Paul H. Nitze School of Advanced International Studies","correspondingAuthor":false,"prefix":"","firstName":"Yusra","middleName":"Ribhi","lastName":"Shawar","suffix":""},{"id":499299813,"identity":"e6734044-fac8-4ca1-96fe-ba0292bfb81e","order_by":2,"name":"Quratulain Shalwani","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Quratulain","middleName":"","lastName":"Shalwani","suffix":""},{"id":499299814,"identity":"37af91d4-a563-4b31-8ade-3c0e604978b7","order_by":3,"name":"Maheen Fazal","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Maheen","middleName":"","lastName":"Fazal","suffix":""},{"id":499299815,"identity":"8a6912a9-7281-42ac-a737-6fecf4e4b88f","order_by":4,"name":"Muslima Ejaz","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Muslima","middleName":"","lastName":"Ejaz","suffix":""},{"id":499299816,"identity":"7bd9238c-ebfe-4c89-8341-b99d03103da4","order_by":5,"name":"Syeda Sehrish Haider","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Syeda","middleName":"Sehrish","lastName":"Haider","suffix":""},{"id":499299817,"identity":"d58f2dfe-e5d4-499a-8983-a976d54a63f7","order_by":6,"name":"Priyanka Das","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Priyanka","middleName":"","lastName":"Das","suffix":""},{"id":499299818,"identity":"3fdb142e-03ea-4952-8cfb-4ddeea09bd8b","order_by":7,"name":"Nukhba Zia","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Nukhba","middleName":"","lastName":"Zia","suffix":""},{"id":499299819,"identity":"04372460-68f7-4c61-840b-aa2a2a693f74","order_by":8,"name":"Farzana Aziz","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Farzana","middleName":"","lastName":"Aziz","suffix":""},{"id":499299820,"identity":"ee3eb67d-f233-4f20-a695-b021ee41464f","order_by":9,"name":"Suhail Chanar","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Suhail","middleName":"","lastName":"Chanar","suffix":""},{"id":499299821,"identity":"22d65477-fa3f-4a56-9a26-417b102290ef","order_by":10,"name":"Muhammad Asim","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"","lastName":"Asim","suffix":""},{"id":499299822,"identity":"fb689372-e509-4eb8-93eb-8e879a45d906","order_by":11,"name":"Sameen Siddiqi","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Sameen","middleName":"","lastName":"Siddiqi","suffix":""},{"id":499299824,"identity":"d3524f5f-4bbb-4f67-9f09-2a27e617d0a3","order_by":12,"name":"Abdulgafoor M. Bachani","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Abdulgafoor","middleName":"M.","lastName":"Bachani","suffix":""},{"id":499299825,"identity":"89900614-8edf-48a9-b7f9-346f019e8fc0","order_by":13,"name":"Asad Latif","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYJACCYYCBgY25sMHGBtA3ANEaTFgkGBjS0sgUQsDW44BcVr4+w8/vMFgYFfHx8bz8ePMNgY5vhsJBGy4kWZswWCQDHQY72bJjW0MxpKEtDDcYDADOoxZgk2+d4PkwzaGxA2EtMifP/4NqKUeaAvP459ALfUEtRgcyAHZchikhQ3ksAQDQloMb+QUWyQYHJdsY2Mzs5xxTsJw5pkH+LXInT++8caHimp++Tbmxzd7ymzk+Y4TsAUMkNRIEKF8FIyCUTAKRgFBAAC4Mj+YbeJkWwAAAABJRU5ErkJggg==","orcid":"","institution":"Aga Khan University","correspondingAuthor":true,"prefix":"","firstName":"Asad","middleName":"","lastName":"Latif","suffix":""}],"badges":[],"createdAt":"2025-03-11 11:53:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6202625/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6202625/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12939-026-02760-y","type":"published","date":"2026-01-28T15:58:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88972280,"identity":"d458779a-8da7-42cb-a29d-941be22b2d9c","added_by":"auto","created_at":"2025-08-13 09:51:52","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":78009,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNumber of KIIs conducted with different categories of actors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMoNHSRC: Ministry of national health services, regulation, and coordination; MoPDSI; Ministry of planning and development and special initiatives, SWD; Social Welfare department, DEPD: Department of empowerment of persons with disabilities.\u003c/p\u003e\n\u003cp\u003e* This included a group interview with two participants from the same organization\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6202625/v1/8a4229718dc10afaf7980513.jpg"},{"id":101690567,"identity":"c1b31f1b-1f99-4eaf-99e7-529f99a63f2a","added_by":"auto","created_at":"2026-02-02 16:05:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1541238,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6202625/v1/06758c55-1127-4e51-b545-39e0034dde89.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prioritizing Rehabilitation in Pakistan’s Health system: A Qualitative Policy Analysis ","fulltext":[{"header":"Background","content":"\u003cp\u003eAn estimated 2.6\u0026nbsp;billion people have conditions that require and may benefit from rehabilitation.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The need for rehabilitation services continues to increase, especially given population aging,increasing rates of non-communicable diseases and during emergencies such as wars, outbreaks and natural disasters.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, the need for rehabilitation is highly unmet and access to services remains inequitable. The World Health Organization (WHO) highlights that more than 50% of people are unable to receive the rehabilitation care they need\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Rehabilitation services often reflect deep-seated inequities shaped by socioeconomic status, geography, race, and disability type. The poor frequently face barriers such as limited access to specialized care, underfunded facilities, and a lack of insurance coverage, which restrict their ability to receive consistent and high-quality rehabilitation. In addition, racial and ethnic minorities often experience systemic bias, resulting in delayed treatment, misdiagnosis, or culturally insensitive care. These disparities collectively hinder recovery, access to other health services, and quality of life, perpetuating cycles of disadvantage for already marginalized populations. A systematic review shows a high rate of adult mortality in low- and middle-income countries (LMICs) due to disability resulting from disability-related inequalities\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe WHO launched the Rehabilitation 2030 Initiative, which draws attention to the profound unmet need for rehabilitation worldwide and emphasizes the importance of strengthening health systems to provide rehabilitation. Quality rehabilitation care encompasses a range of services, including physical therapy, occupational therapy, speech, and language therapy, orthotics and prosthetics, psychology, and assistive technology (AT).\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Rehabilitation optimizes people’s functioning in the context of an individual’s position in life, resources, and interaction with the environment. It is an integral component of health systems in addressing Sustainable Development Goal (SDG) 3, which seeks to ensure healthy lives and promote well-being for all.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Despite the need and its benefits, many governments, especially in LMIC, inadequately prioritize rehabilitation and implement policies that support rehabilitation advancement in national and sub-national health systems.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e The situation is no different in Pakistan— a state with high rehabilitation needs, relatively little prioritization and poor allocation of resources in this health domain.\u003c/p\u003e\u003cp\u003eWHO reports that approximately 56\u0026nbsp;million individuals— approximately 1 in every 5 persons—in Pakistan have health conditions that could benefit from rehabilitation, which is the highest estimate in the Eastern Mediterranean region.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Rehabilitative services in Pakistan are mostly limited to tertiary care hospitals in major cities and become available on an ad hoc basis in post-disaster situations.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Rehabilitation has been included in the Essential Package of Health Services (EPHS) that serves as a policy framework for strategically delivering essential health services. Despite such efforts, there are no specific funds allocated for rehabilitation and AT services. Currently, the EPHS includes identification, screening, and referral for congenital hearing loss and developmental issues at community and primary health care levels. It also covers basic management of musculoskeletal injuries and disorders. However, the provision of effective, comprehensive rehabilitation services is needed. There is limited understanding of what contributes to a country’s lack of prioritization and effective policy implementation for rehabilitation.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003eDrawing on a policy framework dedicated to examining national prioritization of rehabilitation services, we conducted a qualitative case study to identify the political and bureaucratic factors that shape the prioritization of rehabilitation and the subsequent policy responses to the national rehabilitation systems in Pakistan.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study is grounded in a constructivist paradigm, recognizing that knowledge is constructed through individual’s interactions, subjective experiences and meanings attributed by them within a social context. Underpinned by the study’s constructivist orientation, this article explores the perceptions of actors concerned with rehabilitation policy and practice in Pakistan via in-depth, semi-structured interviews along with a review of literature.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConceptual framework\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA policy framework concerning rehabilitation prioritization in LMICs, which is grounded in health policy scholarship and agenda-setting theory and developed by Neill et al,\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e was adopted to guide this study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Drawing on this framework, we triangulated and thematically analyzed the data from the key informant interviews and documents we collected to understand the prioritization of rehabilitation in the country. The framework identifies three key factors crucial for understanding the prioritization of rehabilitation at the national level. These include \u003cb\u003eproblem definition\u003c/b\u003e, which involves understanding the issue and achieving consensus among relevant stakeholders for its solution; \u003cb\u003egovernance\u003c/b\u003e, which pertains to how actors organize and collaborate to advance the formulation and implementation of rehabilitation policies; and \u003cb\u003estructural factors\u003c/b\u003e, which concern the role of sociocultural context and health system structures in shaping prioritization of rehabilitation. Drawing on the framework, we developed a semi-structured interview guide and structured the initial codes during data analysis to reflect these major categories of investigation.\u003c/p\u003e\u003cp\u003eWe acknowledge that our decision to employ the Neill et al framework shapes the conduct and presentation of our analysis. However, we tried to account for this in our approach by not only deductively coding our data in line with this framework but also incorporating an inductive approach to account for emergent themes that were not outlined by the framework and our original codes. Furthermore, given that some of the authors of this study are researchers embedded in the rehabilitation field and country, we acknowledge the influence of our positionality on data collection and interpretation given our pre-existing knowledge of the field and social norms of the country. However, we tried to account for and counterbalance any biases with the inputs of several authors that are “outsiders” to both the rehabilitation field and Pakistan.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDocument review\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe collected documents using a purposeful search of peer-reviewed and grey literature, and policy documents related to rehabilitation and AT in Pakistan on PubMed and Google Scholar. The keywords used included “rehabilitation” “assistive technology” “assistive products” “Pakistan” “policies” “acts” “programs” and “health systems”. Pakistan Bureau of Statistics (PBS) and Pakistan Demographic Health Survey (PDHS) were also consulted to locate policy documents.\u003c/p\u003e\u003cp\u003eWe used the documents to gather insights on the state of rehabilitation services, institutions, policy, and program implementation in Pakistan over time. In total, 47 pieces of literature were reviewed and included from year 1992 to 2022. We also included official policy documents, organizational reports, peer-reviewed and grey literature relevant to rehabilitation policies, acts, initiatives, and implementation in Pakistan. Relevant documents shared by key stakeholders were also included.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAs part of the data collection, we conducted key informant interviews (KIIs) and identified relevant peer-reviewed and grey literature.\u003c/p\u003e\u003cp\u003e\u003cb\u003eKey informant interviews\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted 29 KIIs with 30 key informants (KIs) working in rehabilitation and deeply familiar with rehabilitation’s governance and implementation in Pakistan (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The snowball sampling technique was used to recruit the stakeholders for which an initial list of KIs was designed by identifying the individuals and organizations from different cities and provinces of Pakistan working for rehabilitation and who are deeply familiar with rehabilitation’s governance and implementation in Pakistan. We added more KIs based on feedback from participants. Stakeholders were selected from six main categories: representatives from 1) national and 2) sub-national government, 3) developmental partners, 4) health care providers, 5) academia, and 6) non-governmental organizations (NGOs) and disabled people organizations (DPOs) who were associated with the provision of rehabilitation services. All KIIs were selected based on their knowledge of rehabilitation, AT, and health systems, with each category including at least two individuals.\u003c/p\u003e\u003cp\u003eParticipants were contacted via email or phone call to seek permission, and verbal consent was obtained. An introductory email was sent outlining the study and its objectives to the potential participants and follow-up phone calls were made. The sample size was determined based on theoretical saturation, which was achieved when no new data emerged from the analysis. We included male (n = 22) and female (n = 8) KIs. KIIs with stakeholders were conducted between January and July 2023. Interviews were conducted, both in-person and through video conferencing via Zoom, that lasted for 60–90 minutes. Researchers were trained on the interview guide before initiating data collection, KIIs were asked about the extent to which rehabilitation is prioritized by different actors (public/private/philanthropic), how they conceptualize the problem, the implementation of policies supporting rehabilitation, and the factors influencing the prioritization and implementation of rehabilitation within the health system of Pakistan. All interviews were conducted either in English or Urdu and were digitally recorded. The interviews were transcribed verbatim and then translated into English. The translations were reviewed for grammatical errors while preserving the contextual accuracies of the data. The profile of key informants is provided in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eWe used a thematic analysis methodology to analyze the data. We used a pre-established policy framework \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e to organize and deductively analyze participant responses into specific themes: problem definition, governance, and structural factors (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The analysis revealed challenges to prioritizing rehabilitation in Pakistan, such as limited understanding of rehabilitation and AT among actors, inconsistent data for the rehabilitation needs, fragmented ownership across health and social welfare, stigma associated with disability and seeking rehabilitation care services, lack of financial resources for rehabilitation and assistive products, and shortage of trained healthcare workforce. These thematic findings were categorized under each of the policy framework’s components. We also analyzed the documents by reading them in full and taking notes to extract key findings, using both deductive and inductive methods for the analysis. Document collection and analysis were iterative. We stopped our literature search and conduct of KIIs when we reached theoretical saturation.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eBiweekly Zoom meetings with researchers of AKU and JHU were held to discuss the key themes and emergent findings. However, during the analysis, since an iterative approach was used to improve the concept, some responses did not appear to fit into any existing theme which presented an opportunity to gain additional insights from the data. The inductive, open coding method was employed to accommodate these unique responses, allowing for a more flexible and exploratory approach to analyzing the data. This approach enriched the understanding of the data and captured important nuances that might have been missed with a limited deductive analysis approach.\u003c/p\u003e\u003cp\u003eIn the final phases of the analysis, identified themes were reviewed critically to ensure that each of those represented a distinct aspect of the participants’ responses. Additionally, some responses were repositioned or reallocated to better align with the most appropriate theme, improving the accuracy and precision of the findings. This approach allowed for a comprehensive exploration of the data, capturing diverse perspectives and unique aspects of the participant’s responses, ultimately leading to a richer and more nuanced understanding of the qualitative data.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical Consideration\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study was approved by the Ethical Review Committee of Aga Khan University (AKU) (ERC#: 2022-7361-22291) and the Institutional Review Board of Johns Hopkins University (JHU) (IRB #: 00018269). Verbal consent was obtained from all the study participants before the interview. Permission was obtained from respondents to tape-record the interviews on the assurances of confidentiality. Moreover, all participants were assured about the confidentiality and anonymity of the collected data and were informed about their free will to be part of the discussion. To ensure the privacy of the participants, a unique ID code was assigned to each participant. Information from the recruitment list was kept separate from the audio recordings, transcripts, and field notes. All data was de-identified before analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eEvolution of Rehabilitation Policy and Programming in Pakistan\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePakistan’s current state of rehabilitation priority can be understood by contextualizing key historical policy and programming developments (Table 2). The beginning of access to rehabilitation services traces back to the 1960s. \u003csup\u003e3\u003c/sup\u003eAt this time, Dr. Kirmani, who is regarded as the founder of physical medicine and rehabilitation (PMR) in the country, founded Pakistan’s first department of rehabilitation medicine at the Jinnah Post Graduate Medical Center (JPMC).\u003csup\u003e3\u003c/sup\u003e\u003csup\u003e,8\u003c/sup\u003e The School of Occupational therapy was then established in 1973, and a similar department dedicated to PMR was instituted in Punjab at the Mayo hospital Lahore in 1980s. In 1981, government of Pakistan initiated its first law “Disabled Persons (Employment and Rehabilitation) Ordinance 1981” to address the concerns of disabled persons.\u003csup\u003e\u0026nbsp;18,\u003c/sup\u003e \u003csup\u003e19\u003c/sup\u003eAlso\u0026nbsp;during this time, the President of the country—who had a \u0026nbsp; special needs child —issued a directive for establishing two centres of excellence in rehabilitation medicine, and eventually integrated \u0026nbsp;PMR in the Pakistan military, with the funding of Armed Force Institute of Rehabilitation Medicine (AFIRM) in 1991.\u003csup\u003e1\u003c/sup\u003e \u003csup\u003e3,\u003c/sup\u003e \u003csup\u003e8\u003c/sup\u003eIn 2002, the first national policy for PWDs was announced in consultation with the health, education, labor, housing, science, and technology ministries, as well as relevant non-governmental organizations (NGOs) and local organizations.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe 2005 earthquake in Pakistan—which resulted in 70,000 casualties and left 120,000 injured—highlighted the need for rehabilitation services further, catalyzing extensive collaborations in the field such as the formation of Earthquake Rehabilitation and Reconstruction Authority (ERRA) with the technical support of WHO,\u003csup\u003e8\u003c/sup\u003e as well as the coalition between Community Based and Institution Based Rehabilitation. In 2006, the National Plan of Action (NPA) for PWDs was introduced.\u003csup\u003e18\u003c/sup\u003e In 2020, the Rights of Persons with Disability Act was formulated. Recently, AT scale’s CEO visited Pakistan to initiate a new\u0026nbsp;AT scale-supported program aimed to improve access to assistive technology for vision and hearing.\u003c/p\u003e\n\u003cp\u003eDespite these development and progress, the majority of people in Pakistan to date experience difficulties in accessing basic health and rehabilitation services. These have impacts on the individuals themselves, their communities, and the country’s economy, with Pakistan’s economy losing an estimated USD 12 billion by excluding PWDs from employment.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKey factors shaping national priority of rehabilitation services in Pakistan\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKey elements concerning problem definition, governance, and structural factors shape the prioritization of rehabilitation in Pakistan’s national health systems. These are briefly described in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProblem Definition\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne key challenge to advancing priority for rehabilitation concerns the variability in perspectives and lack of clarity among different actors\u0026nbsp;on the nature of the problem, as well as the solutions to better advance rehabilitation in the health system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eProblem Clarity\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimited understanding of rehabilitation and AP among the\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003ea\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003ectors\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Respondents highlight that \u0026nbsp;health care providers are largely unaware of rehabilitation and what it encompasses. For example, there is limited awareness of AT— customized and individualized products that enable people to achieve independence in performing their daily activities—among physicians, which hampers its \u0026nbsp;access \u003csup\u003e20\u003c/sup\u003e\u003csup\u003e,21\u003c/sup\u003e [HCP-5, Mn-4, and DP-1] as highlighted by a healthcare provider:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Our health care professionals, the non-rehabilitation doctors are not clear as to what assistive technology may be recommended and for what type of disability\u003cstrong\u003e.” (Healthcare Providers (HCP-5))\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSynonymizing physiotherapy with rehabilitation was a major challenge identified during interviews with respondents. While some actors emphasized the multidisciplinary or holistic nature of rehabilitation, many medical professionals reiterated the common misconception that physiotherapy was all-encompassing rehabilitation. One informant noted:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“A common misconception among people is that rehabilitation medicine is merely physical therapy. However, physical therapy is essential but constitutes only approximately 20% of rehabilitation medicine.” \u003cstrong\u003e(HCP-3)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition, rehabilitation is often misunderstood as a service for people with disabilities rather than being recognized as a broader health concern for everyone.\u003csup\u003e3\u003c/sup\u003e It therefore doesn’t get enough recognition and weightage in the society when compared to other healthcare services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“When somebody is disabled only then you need rehabilitation. So, the tag of the disability is very necessary for rehabilitation service in Pakistan.” \u003cstrong\u003e(Professional Institute (PI)-2)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurthermore, rehabilitation is perceived as a luxury, given its long-term commitment to multiple sessions, and its relative expense, with many paying for it out of pocket [HCP-5, DP-1].\u003csup\u003e22\u003c/sup\u003e This has complicated efforts to frame rehabilitation as a basic need, worthy of policymaker action.\u003c/p\u003e\n\u003cp\u003eUnclear understanding of rehabilitations needs may partly be driving the inconsistency of data on this subject. WHO has reported that 56 million people in Pakistan have health conditions that could benefit from rehabilitation.\u003csup\u003e11\u003c/sup\u003e\u0026nbsp; However, according to the Pakistan Bureau of Statistics (PBS) record, there are over 370,000 National Database \u0026amp; Registration Authority (NADRA)-registered PWDS in Pakistan.\u003csup\u003e23\u003c/sup\u003e This doesn’t equate to the actual rehabilitation need in Pakistan which goes beyond the needs of persons with disabilities.\u0026nbsp;There is a dire need for\u0026nbsp;the data\u0026nbsp;\u0026nbsp;[Mn-5, Dt-2, Dt-1, NGO-3, NGO-2, Mn-4, Mn-7, NGO-5, DP-1, PI-6, HCP-3, and NGO-5]. Specialized surveys at the district level can serve as\u0026nbsp;an input to developing evidence base to inform policymaking\u0026nbsp;[DP-1, NGO-5, Mn-5]. Accurate data is essential for a comprehensive understanding of the demand for rehabilitation services and to persuade policymakers to prioritize and allocate the necessary human and financial resources as described by an informant:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The most crucial thing is to have data, based on which we should set our priorities for the next five years about which disease we need to tackle and from what perspective. Resources are not available for anything until you present its facts and figures; only then can you mobilize funds.” \u003cstrong\u003e(NGO-5)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGovernance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnother key challenge to advancing priority for rehabilitation in Pakistan concerns governance—effective mechanisms that enable effective decisions, resource allocations, regulations, and collective action among relevant actors \u0026nbsp;for rehabilitation policy and programming advancement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eGovernance Arrangements\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFragmented ownership of rehabilitation across health and social welfare\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne of the biggest challenges to prioritizing rehabilitation in the national health system is its ownership in Pakistan. Rehabilitation services are often associated with disability and are typically included under Social Welfare department, rather than the MoNHSRC, which is responsible for all healthcare-related affairs [NGO-5, DP-1, DP-2, Mn-5, Mn-1, and HCP-2]. An informant discussed the tension:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"Unfortunately, the government’s priorities are a lot different. To date, the government is unable to decide whether it is a problem of the health department or comes under the social welfare department.”\u0026nbsp;\u003cstrong\u003e(PI-4)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Pakistan is a complex country and in federal countries, decision-making in governance always occurs at multiple levels... (Mt-5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere is no single dedicated legislative body aimed at setting guidelines for rehabilitative care services, monitoring rehabilitation programs, safeguarding the rights of rehabilitation professionals, and overseeing the regulation of human and financial resources\u003csup\u003e15\u003c/sup\u003e [PI-6, PI-3, Mn-4, PI-2, DP-2, DP-1, and HCP-5]. An informant discussed the need for such a body dedicated to rehabilitations services:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“We talk about it in every forum that rehabilitation directorate should be formed … When it will form then there will be a rehabilitation director who will present his budget by himself… and he will get it approved himself… rehabilitation budget should not be in the hands of another person… otherwise they will manipulate… In this way, we will face a lot of difficulties.”\u003cstrong\u003e\u0026nbsp;(PI-3)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePolitical instability, frequent government turnovers, and delays in governmental responses\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to the lack of bureaucratic ownership for rehabilitation, the issue lacks priority given political instability, frequent turnover in government, and delays in governmental response. These obstacles hinder the formulation and implementation of rehabilitation policies [HCP-1, PI-4, NGO-3, Mn-4, Mn-5, and Mn-7].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The social welfare department is working but again we have differences of opinion on how work should be done. Other than that Sehat Ehsas program was started but now we don’t know about it because you know our progress is being made from one government to another. Once the government is changed then after that names get changed, and programs get changed, things don’t remain the same.”(NGO-3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“If you go to government offices and write a letter, you have to wait months to get a response. So, sometimes, if there is planned activity then the time frame of that activity passes”(HCP-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLimited governance authority at the local level presents another challenge within many administrative systems, which makes it difficult in decision making and causes delays in the implementation of policies and programs relevant to rehabilitation that involves providing services, initiating awareness campaigns, and hiring more rehabilitation professionals. \u0026nbsp;[Dt-2 and Dt-3]. This often translates into a lack of effective decision-making, resource allocation, and policy implementation mechanisms, as noted by a district health officer:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I have some constraints… I can’t buy equipment voluntarily. I can’t procure medicine. I can’t hire staff. If I do, I have to justify it. So, we have to send requests, the system is complicated…if I had the authority to do so, I could have hired doctors and staff members who are dedicated to rehabilitation.” \u003cstrong\u003e(Dt-2)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eDomestic Advocacy Coalitions\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIsolated efforts of all relevant\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eactors\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003ein the field of rehabilitation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVarious actors, including the MoNHSRC,\u0026nbsp;Ministry of Special Education,\u0026nbsp;Ministry of Planning and Development,\u0026nbsp;Social Welfare Department in each province,\u0026nbsp;Ministry of Transport and Communication,\u0026nbsp;Pakistan Bait-ul-Maal,\u0026nbsp;Department of Empowerment of Persons with Disabilities (DEPD) in Sindh province,\u0026nbsp;Non-Governmental Organizations, Disable People Organizations (DPOs), International donors,\u0026nbsp;and PWDs are involved in the field of rehabilitation in various capacities like Social Welfare and Baitul Mal provides services to underprivileged and vulnerable individuals including disable persons. \u0026nbsp;While MoNHSRC and Ministry of\u0026nbsp;Special\u0026nbsp;Education are involved in different capacities for providing health services and quality education. However, they all work in isolation with their\u0026nbsp;mandates. There is a significant gap in coordination among these actors,\u0026nbsp;which present a substantial impediment to governance and service delivery of rehabilitation services [PI-3, HCP-4, PI-5, NGO-3, HCP-1, NGO-4, NGO-5].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, the 18\u003csup\u003eth\u003c/sup\u003e Amendment to the constitution of Pakistan, enacted in 2010, led to a significant shift in Pakistan's governance structure in the context of the healthcare system, resulting in the devolution of power and responsibilities from the federal to the provincial governments. Every province has their own departments, programs, and initiatives which work on the different aspects of healthcare. Similarly, each province has unique challenges and opportunities based on the needs of people and available resources. \u0026nbsp;Some provinces and institutes demonstrate\u0026nbsp;commendable efforts\u0026nbsp;to\u0026nbsp;provide\u0026nbsp;improved access to rehabilitation services\u0026nbsp;like SIPMR institute at Sindh. Some provinces have shown a significant advancement in prioritizing rehabilitation while other provinces still lag behind. This has also led to significant implications for various aspects of governance [PI-3, PI-6, NGO-5, DP-1, HCP-1, and Mn-7].\u003csup\u003e24\u003c/sup\u003e It was also stated by an informant:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“We have CRS (comprehensive rehabilitation services) here, if we talk about Sindh specifically, we have SIPMR that is providing services at this level. Along with the provision of CRS, they also provide assistive products that fall in the category of mobility aids.On a national level, many hospitals in Islamabad are working on it. As we’ve discussed KPK earlier, there is a Paraplegic Centre in Peshawar (PCP) which is working efficiently on spinal cord injuries rehabilitation.”(NGO-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Significant work has been done. Institutions have been established, with Dow University now transformed into Sindh IPMR. The situation in Balochistan is not as developed, but in Punjab, the Indus Hospital has made considerable strides. The CHAL Foundationis also active. We have successful models at our disposal. These are mostly concentrated in one place, specifically urban settings.”(PI-6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhen navigating the landscape of rehabilitation services, distinct challenges are encountered by the NGOs, shaped by their scope within the healthcare sector [HCP-1, Dt-1, NGO-3, NGO-4 Mn-4, DP-1, PI-6]. A limited number of NGOs are dedicated to rehabilitation service provision and their primary focus remains on other prevalent health, social issues and community development. An informant explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Specifically, regarding rehabilitation, I have not observed any organization working on raising awareness, working for its propagation, or working proportionally ... NGOs only engage in activities that are financed. They are told to distribute APs, so they purchase them and distribute them forward … However, the work that should be conducted at the grassroots level within the community- the fieldwork- is absent.” \u003cstrong\u003e(Mn-4)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to the efforts of other actors, PWDs play a significant role in actively engaging with government officials and advocating for prioritization of rehabilitation.\u003csup\u003e15\u003c/sup\u003e They can be the role models for the support of other PWDs and can provide support in the development of programs/initiatives in the community. However, their scope needs to go beyond the rehabilitation needs of PWDs. In Pakistan there are very few champions who can contribute and play a significant role in shaping policies and programs related to rehabilitation services.\u0026nbsp;A representative from the ministry exemplified:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I know a man... He moves around in a wheelchair; he is a young man affected by polio. I see him going to office, and working in an NGO, and in addition to that, I think he is also an employee of the Paraplegic Center… without saying anything, he communicates a lot.” \u003cstrong\u003e(Mn-3)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile some international effort towards rehabilitation comes forward mostly during rain, flood, disaster, and emergencies it remains limited [HCP-5, PI-2, DA-2. NGO-5]. This limitation poses a significant challenge and impacts the domestic rehabilitation programs in Pakistan. There are no organized platforms where work can be done with proper planning. Institutions lack the technical expertise and resources to support rehabilitation programs. \u0026nbsp;There is no proper mechanism whereby relevant ministries and organization could generate a report on a yearly or bi-yearly basis detailing the data related to the need of rehabilitation services in different regions. An informant described the nature of international involvement with rehabilitation services in Pakistan:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Very patchy, and small-level rehabilitative work is there. There is no systematic or international level work which is being done… not even by UN.” \u003cstrong\u003e(HCP-5)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“There is quite a bit of work being done internationally in this regard... The medium-level international organizations focused on disability are very few. There are one or two or three that are working very focused on disability, otherwise I haven't seen such a focus.”(NGO-5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStructural Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinally structural factors—such as dynamics related to national legacies, socio-cultural context, and health system structures —have shaped prioritization of rehabilitations in Pakistan.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eNational Legacies\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFocus driven for rehabilitation services only after disasters and conflicts\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 2005 earthquake in the northern part of Pakistan and Kashmir —which resulted in 73,338 deaths, 69,412 severely injured, and 3.5 million people homeless \u003csup\u003e25\u003c/sup\u003e —led to a sudden increase in disabilities, necessitating the establishment of rehabilitation services and resource provision [HCP-2, DP-1, HCP-3, HCP-5, Mn-5, Mn-2, PI-5].\u0026nbsp;An informant explained its impact on rehabilitations policy priority:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“After the 2005 earthquake, there was an increased awareness regarding rehabilitation. Individuals at both the national and international levels became involved... This led to increased funding and training opportunities. They realized that this is a specialty that requires attention and making contributions to this field would make a difference...”\u003cstrong\u003e\u0026nbsp;(HCP-3)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe earthquake also led to a significant increase in NGOs that provided rehabilitation care in affected communities [PI-3, Dt-3, NGO-5, NGO-1, HCP-5, Mn-1, Mn-5],\u003csup\u003e26\u003c/sup\u003e \u003csup\u003e,27\u003c/sup\u003eas described by a actor :\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eWhen the earthquake hit Pakistan in 2005... There were so many NGOs in our health care system that started to work … NGOs have a very important role to play and there is a very positive history of the role they have played in developing Rehabilitation services in Pakistan after the disaster and even once this settles down.” \u003cstrong\u003e(HCP-5)\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDespite these efforts, there has been insufficient sustained support and resources for ongoing rehabilitation needs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“When there is a flood or rain emergency, our rehabilitation services get available at that time... But on a regular basis, these services are lacking, and patients are deprived of them.”\u003c/em\u003e \u003cstrong\u003e\u003cem\u003e(Dt-1)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eSociocultural Context\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStigma associated with disability and seeking rehabilitation care services\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNegative cultural stereotypes, societal attitudes towards PWDs and lack of awareness about who needs rehabilitation have been identified as major barriers to the prioritization of rehabilitation.\u003csup\u003e28,29\u003c/sup\u003e Family members often hesitate to seek support due to the fear of stigma, mainly associated with mental health issues [PI-1, PI-2, NGO-1, Dt-1, Mn-1, Mn-7]. Several informants described how stigma associated with disability has negatively impacted demand for rehabilitations services:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Stigma associated with disability is a major reason that PWDs remain invisible in our society. They are not seen and remain uncounted, unheard, invisible, and the inclusion that is needed for them in society does not take place.” \u003cstrong\u003e(NGO-4)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The situation for mental health is just as bad, if not worse than it is for physical health, primarily because there's a stigma attached to it which makes the community reluctant to seek help.” \u003cstrong\u003e(Mn-7)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePeople with disability and those suffering from conditions that require rehabilitation are subject to discrimination and exclusion within the society. They face barriers to accessing appropriate housing, employment, mobility challenges and essential services in daily life– including education and health care\u003csup\u003e7\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Our environment is not disabled-friendly. How many buildings, parks, clubs, and hospitals are there that have ramps? And even if they do have ramps, they are so steep that a person who is pushing a wheelchair or if that person climbs on it then he will fall backward due to gravity.” \u003cstrong\u003e(H\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u003cem\u003eCP-\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e2)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eHealth System Structures\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRehabilitation is an overlooked domain within the healthcare system\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the various health system challenges influencing the prioritization of rehabilitative services, the most critical issue highlighted is its status within the healthcare sector [Mn-4, HCP-2, NGO-1].\u003csup\u003e13\u003c/sup\u003e Despite the growing need and significant role of rehabilitation in enhancing one's quality of life, it remains inadequately addressed as mentioned by the representative from the ministry:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Rehabilitation has historically been a neglected field in Pakistan. The root cause of this neglect lies in the dominance of the medical model within our healthcare system … Furthermore, professionals in rehabilitation, be it doctors or workers, are not accorded the same esteem within society as traditional doctors.” \u003cstrong\u003e(Mn-4)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRehabilitation is inadequately prioritized and rehabilitation professionals are not given importance as compared to other medical professionals. It is typically found in tertiary care hospitals, primarily in major cities in Pakistan and are not accessible to the general population. Furthermore, none of these facilities have all the essential components of rehabilitation [DP-1, DP-2, HCP-4, HCP-5, Dt-4, NGO-1, PI-2, and Dt-3]. This poses a significant challenge for patients to travel long distances for seeking rehabilitation services or getting APs, especially for residents of rural areas. Most of them travel 5-25 km or more than 25 km to obtain the APs [DP-2, Mn-7, Mn-6, Dt-4, NGO-4, and Dt-3].\u003csup\u003e30\u0026nbsp;\u003c/sup\u003eThis also leads to overburdened tertiary hospitals and an increased workload for their staff [NGO-3]. It is in realm of private rather than public sector not seen as government mandate to provide rehabilitation service to general population.\u0026nbsp;Informants from the ministry emphasizes that despite rehabilitative services being available in the private sector, these are beyond the reach of many due to substantial costs [Mn-2 and Mn-5]. This issue was also highlighted by the people from the ministry:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The problem lies in accessibility; for instance, if a person in need of physical rehabilitation resides in a remote district, it is not feasible for them to access the centralized tertiary-level services. It is exceedingly difficult to travel, especially since physical rehabilitation doesn’t usually involve a one-time visit but requires regular visits” \u003cstrong\u003e(Mn-7)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“There is no facility (public sector) at the district level… Private centers are available for physical rehabilitation. But none of them are free of cost.” \u003cstrong\u003e(Mn-2)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition, most of the distribution of APs in Pakistan is driven by the private sector with limited involvement from the public sector. While most of the AP users bear the financial burden themselves.\u003csup\u003e20\u003c/sup\u003e This indicates a gap in subsidized and public funding support in Pakistan.\u0026nbsp;Participants pointed out a notable weakness in the current healthcare system, the insufficient funding for necessary human and material resources for the provision of rehabilitation services. Furthermore, concerns were raised regarding the vacant positions of rehabilitation professionals especially at the district level [Dt-2, DP-1, NGO-5, Mn-3, Dt-1]. It was explained by the informants as:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“We need to allocate funds for the procurement of instruments, equipment, and machinery required for rehabilitation. Additionally, we also need to allocate funds for the hiring of specialized staff dedicated to rehabilitation services. For their salaries too, no budget is allocated for this.” \u003cstrong\u003e(Dt-2)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“At the district level, audiologists, orthotics, and physiotherapists, there are many districts with vacant positions, which are not being filled by advertisements or through the proper recruitment process.” \u003cstrong\u003e(DP-1)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFinally, healthcare professionals at all levels, from lady health workers to medical officers, lack adequate training in rehabilitation services. This results in people not receiving appropriate rehabilitation care and not being referred to the relevant professionals. Furthermore, even medical curriculum does not include any subjects related to rehabilitation. [HCP-3, HCP-2, PI-3, Mn-7, Mn-5]. It was explained as:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The barriers are that our health professionals (medical doctors) don’t even have an idea that this is a medical field. It is a need of the day and should be included in MBBS final-year curriculum… This field should be included in their final year of medicine.” \u003cstrong\u003e(HCP-2)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eProposed Solutions\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrategies for Awareness of Rehabilitation and AT Among\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eActors\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;at Different Levels\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral measures can be implemented to raise awareness at every level, from the citizens to the government officials.\u003csup\u003e2\u003c/sup\u003e Informants emphasized driving the focus on early-stage parental counseling to prioritize the needs of children with disabilities. They also proposed to sensitize and actively engage the government officials, community leaders, and individuals who have benefited from rehabilitation given their influencing role [Dt-1, Mn-2, HCP-2, Dt-2, HCP-4, Mn-7, NGO-5, NGO-4, Mn-4, Mn-5, PI-6, and NGO-1]. There is a need for initiating mental rehabilitation which is now emerging an issue in society and has not given importance in previous years. Conducting awareness campaigns and seminars for the community can also play a pivotal role in making people realize the significance of rehabilitation in enhancing the quality of life. These efforts at the community level can help with focusing on the need of rehabilitation and its prioritization at the policy level so that it could be an essential part of the system at all levels. An informant outlined its importance by saying:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The healthcare ministers, secretaries, and all relevant\u0026nbsp;\u003c/em\u003e\u003cem\u003ea\u003c/em\u003e\u003cem\u003ectors\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026nbsp;should be approached. It would be advantageous if we could present it to them and elucidate how even a little assistance can make a significant difference.” \u003cstrong\u003e(HCP-3)\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSignificant efforts have been made to improve access to assistive products. One such step is the development of the Priority Assistive Products List (APL) launched by the WHO in May 2016 after multiple rounds of discussions. The list comprises 50 priority APs, identified and finalized through multiple rounds of discussions and a two-day consensus meeting held in March 2016. Actors from various sectors, including those involved in service provision and policymaking, researchers, and users of assistive products, attended this meeting. The purpose was to design a model that could guide all member states in developing their national priority APL, tailored to their specific needs and available resources. This enables individuals to lead productive and independent lives.\u003csup\u003e21\u003c/sup\u003e This served as the foundation for the National Priority APL for Pakistan, championed by the First Lady. This type of political commitment draws attention to the need for assistive technology in Pakistan. An informant mentioned:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I think you must be familiar with the WHO Priority Assistive Product List, which is 50 APs in the domain of physical impairment, hearing, vision, environment, and communication. Out of that, we selected the highest priority products 25 APL. So, I think that is one thing that has given some direction and framework to the country now.” \u003cstrong\u003e(DP-1)\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study shed light on the scope of rehabilitation, its understanding, and the challenges faced by Pakistan's rehabilitation sector. Based on the analysis of the data collected from the KIIs and literature review, challenges were identified under three main themes\u0026mdash;problem definition, governance, and structural factors\u0026mdash;that influence the prioritization of rehabilitation in Pakistan. Concerning problem definition, we identified a limited understanding of rehabilitation and AT among actors and little consistent data to highlight the rehabilitation needs. Furthermore, rehabilitation is perceived as a \"luxury\" rather than a necessity. This problem can be addressed by generating reliable data on rehabilitation needs and available services to advocate the necessity for the proper allocation of human and financial resources in the sector. This can also be resolved by creating awareness about rehabilitation at various levels. There is a need to leverage social media and other digital platforms to educate the general population including medical doctors on the importance and role of rehabilitation and AT.\u003c/p\u003e\u003cp\u003eIn the realm of governance, the main challenge concerns the ownership of rehabilitation services. Despite being considered a health service for all and managed by the Ministry of Health, rehabilitation is often regarded as a service specifically for persons with disabilities and is placed under the mandate of social welfare. This challenge is mainly due to the lack of an accreditation body for the regulation and monitoring of rehabilitation-related affairs. In order to reduce inequities and improve health outcomes, there is a need to develop a national strategic plan for rehabilitation to align ministries working for rehabilitation, focusing on improving coordination and collaboration between relevant actors.\u003c/p\u003e\u003cp\u003eFinally, with respect to structural constraints, the social stigma associated with those who seek rehabilitation services hampers the accessibility and, consequently, the demand of these services in the country. A similar study in Kenya revealed that the attitudes and beliefs associated with disability represent one of the most complex barriers that limit access to healthcare, education, employment, civic rights, and opportunities for socialization for PWDs.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e In addition, there is a shortage of trained rehabilitation workforce, which is also a global issue that is most pronounced in LMICs.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eBased on our findings, priority can be driven by addressing that there is a need that should be fulfilled. This should be accomplished by determining the rehabilitation need and preparedness of the system to address the need. An accurate database needs to be established with relevant actors for further action and interventions. Moreover, exploring the perspectives of patients can also be beneficial in identifying the status of rehabilitation in Pakistan and planning strategies for their improvement. Existing rehabilitation services should be targeted to expand the workforce and also to improve access with the provision of rehabilitation services in rural areas. Community initiatives like the lady health worker program could be strengthened to provide both awareness and cost-effective services at a large scale on the community level. Further, government and donors should invest funding in rehabilitation services for all age groups including mental health which itself is an important domain of public health research.\u003c/p\u003e\u003cp\u003eThe situation for PWDs in Pakistan is completely different as compared to that in the developed world, where PWDs get equal opportunities and access to comprehensive healthcare services allowing them to lead independent lives. However, some provinces have made commendable efforts to enhance access to services, particularly for PWDs. For instance, they effectively works across sectors to support the rehabilitation of PWDs through education, health, and vocational activities for all age groups.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Furthermore, few institutions have made a lot of progress in various provinces, such as the Sindh Institute of Physical Medicine and Rehabilitation (SIPMR),\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Paraplegic Centre in Peshawar (PCP),\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e and Armed Forces Institute of Rehabilitation Medicine (AFIRM) excelling in the delivery of comprehensive rehabilitation services to the people.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eRehabilitation services need to be strengthened in community settings to particularly target individuals who have difficulty accessing rehabilitation care services. The services should be expanded to ensure that all dependent individuals, regardless of age or disability, have access to essential care \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. The EPHS serves as a policy framework for strategic service for delivering essential health services including rehabilitation, to all individuals, especially those with limited resources. Currently, the EPHS includes limited rehabilitation services at community and primary health care levels for the identification/screening, of the early childhood development issues.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e It covers pressure area prevention and supportive seating interventions for wheelchair users and also addresses the basic management of musculoskeletal and neurological injuries and disorders. However, these services under the rehabilitation package should be expanded to address various issues and provide services at all levels with a proper referral mechanism. Healthcare professionals at all levels, from lady health workers (LHWs) to medical doctors, need to be well-informed and trained in the identification of disabilities and educating the patients in the community. Governments and health system leaders should promote equity in health by investing in primary health care systems that provide continuous, accessible, and high-quality services for both physical and mental health across all stages of life. This includes expanding service delivery platforms, integrating mental health into routine care, and ensuring community-level accessibility for underserved populations\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. LHWs play an integral role in delivering services within communities, forming the cornerstone for the success of Primary Health Care (PHC).\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e The National Programme for Family Planning and Primary Health Care program, commonly called the LHW Program, was launched by the Government of Pakistan. This program was initiated to ensure the provision of family planning and primary healthcare services at the doorstep of the community to increase the utilization of promotive, preventive, rehabilitative, and curative services in poor and underserved areas. Currently, this programme covers approximately 38% of the total population across all districts of Pakistan, delivering essential primary healthcare services through trained female community health workers. Evaluations conducted in 2019-20 revealed that the program had a positive impact on health outcomes and health status per unit of cost as compared to the alternative services provided through the public health system. Lastly, the findings underscore the importance of embedding health equity considerations into emergency preparedness and response efforts in order to reduce the disproportionate impact of crises on vulnerable populations\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDespite the challenges, there are many positive developments for rehabilitation and Assistive technology. Successful initiatives have been initiated at the provincial level, like the DEPD in Sindh, which works effectively across sectors to support the rehabilitation of persons with disabilities through education, health, and vocational activities. Physical therapy schools are coming up across the country through which rehabilitation professionals will be trained and contribute in serving the country. There is momentum in efforts to improve access to assistive technology. National priority Assistive Products List (APL) was launched by the First Lady of Pakistan. Recently, country has received funding to introduce a new AT scale-supported program aimed at improving access to assistive technology for vision and hearing. This support through external funding underscores the global commitment to enhance assistive technology infrastructure in Pakistan.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, this is the first policy-level analysis of rehabilitation to be undertaken in Pakistan, where we communicated with different actors to assess the scope of rehabilitation in Pakistan\u0026rsquo;s health system. Secondly, a few of our key informants belonging to the Disabled Persons Organization and Ministry category were PWDs and therefore, we were able to know their perspective as service users as well. While we examined specific factors key to the prioritization of rehabilitation in Pakistan, our study had some limitations. For example, no actors from Baluchistan province were included, despite our inclusion of actors from almost all provinces. In addition, in some categories it was harder to achieve saturation like development partners where we interviewed only two organizations. This is mainly because not many are interested in rehabilitation. In our study, the literature reviews primarily identified the challenges related to the rehabilitation services mainly due to its poor prioritization in the country. However, we also triangulated it with informant recommendations and discussed both enablers and barriers. It is possible that additional positive cases exist within this domain that were not identified through our purposeful, rehabilitation focused search strategy. Our sample of KIs was largely from ministries, professional institutes and NGOs, with no representation of patients groups that could have provided a much broader aspect. This was due to our inability to identify specific individuals to contact for virtual interviews. Our literature search was also limited to publications in English. Given these limitations, future research should focus on validating, applying, and adapting the findings across diverse country contexts to enhance their generalizability and relevance.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provided an in-depth investigation into the challenges of prioritizing rehabilitation services in Pakistan and identified strategic opportunities for advancing rehabilitation in a context where there are many competing priorities and limited resources. Rehabilitation remains a critically underprioritized area in Pakistan\u0026rsquo;s health system, with inadequate financial and human resource allocations hindering the ability to meet growing population needs. There is little clarity on what rehabilitation is in practice, who owns it, and how to provide it via existing health and social systems. Embracing evidence-based strategies can help the country address these challenges and guide actors in taking action to create a more inclusive and equitable society where individuals with diverse healthcare needs can lead fulfilling lives. Given that rehabilitation can significantly improve quality of life and has multiple benefits, prioritization and investment in long-term sustainable interventions in this domain is highly recommended.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMoNHSRC Ministry of National Health Services, Regulations, and Coordination\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAT Assistive Technology\u003c/p\u003e\n\u003cp\u003eWHO World Health Organization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSDG Sustainable Development Goal\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLMIC low- and middle-income countries\u003c/p\u003e\n\u003cp\u003eEPHS Essential Package of Health Services\u003c/p\u003e\n\u003cp\u003ePBS Pakistan Bureau of Statistics\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePDHS Pakistan Demographic Health Survey\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKIIs key informant interviews\u003c/p\u003e\n\u003cp\u003eKIs key informants\u003c/p\u003e\n\u003cp\u003eNGOs Non-governmental organizations\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDPOs Disabled people organizations\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoPDSI Ministry of planning and development and special initiatives\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSWD Social Welfare department\u003c/p\u003e\n\u003cp\u003eDEPD Department of empowerment of persons with disabilities\u003c/p\u003e\n\u003cp\u003eAKU Aga Khan University\u003c/p\u003e\n\u003cp\u003eJHU Johns Hopkins University\u003c/p\u003e\n\u003cp\u003eJPMC Jinnah Post Graduate Medical Center\u003c/p\u003e\n\u003cp\u003eAFIRM Armed Force Institute of Rehabilitation Medicine\u003c/p\u003e\n\u003cp\u003ePWDs People with Disabilities\u003c/p\u003e\n\u003cp\u003eERRA Earthquake Rehabilitation and Reconstruction Authority\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNPA National Plan of Action\u003c/p\u003e\n\u003cp\u003eHCP Healthcare Providers\u003c/p\u003e\n\u003cp\u003eNADRA National Database \u0026amp; Registration Authority\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSIPMR Sindh Institute of Physical Medicine and Rehabilitation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePCP Paraplegic Centre in Peshawar\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLHWS lady health workers\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePHC Primary Health Care\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethical Review Committee of Aga Khan University (AKU) (ERC#: 2022-7361-22291) and the Institutional Review Board of Johns Hopkins University (JHU) (IRB #: 00018269). Verbal consent was obtained from all the study participants before the interview.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData supporting the research findings are found in result section. All data generated or analyzed during this study are included in this article. All secondary data is included in the reference list and quotes are included from the key informant interview data in the result section. Key informants were instructed that transcripts would not be shared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing Interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe work was supported by United States Agency for International Development (USAID).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConceptualization and Methodology:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eA.M.B., A.L., N.Z., S.S., Y.R.S.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding acquisition:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eA.M.B.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Acquisition:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eR.S.T., Q.S., M.F., S.S.H., M.E., A.L., P.D.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eProject administration:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eR.S.T., S.C.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Analysis and Interpretation:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eF.A., M.A., M.E., M.F., N.Z., Q.S., R.S.T., \u0026nbsp;S.S.H., Y.R.S.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWriting \u0026ndash; Original draft:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eM.F., Q.S., R.S.T., \u0026nbsp;S.S.H.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWriting - Review and Revision:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eA.M.B., A.L., F.A., M.A., M.E., N.Z., P.D., S.C., S.S., Y.R.S.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAll authors reviewed the manuscript\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank USAID for funding the project. We also acknowledge the support of our local stakeholders in Pakistan and the research team who assisted with the project.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal key findings, WHO Rehabilitation Need Estimator, Institute for Health and Metrics Evaluation. http://ihmeuw.org/6ima . http://ihmeuw.org/6ima. Published 2021. Accessed December 27, 2024.\u003c/li\u003e\n\u003cli\u003eGimigliano F, Negrini S. The World Health Organization \u0026ldquo;Rehabilitation 2030: a call for action.\u0026rdquo; \u003cem\u003eEur J Phys Rehabil Med\u003c/em\u003e. 2017;53(2). doi:10.23736/S1973-9087.17.04746-3 \u003c/li\u003e\n\u003cli\u003eStucki G, Bickenbach J. 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Improving access to assistive technologies: challenges and solutions in low- and middle-income countries. \u003cem\u003eWHO South East Asia J Public Health\u003c/em\u003e. 2018;7(2):84. doi:10.4103/2224-3151.239419\u003c/li\u003e\n\u003cli\u003eWHO. Assistive Product List - APL . https://www.who.int/publications/i/item/priority-assistive-products-list.\u003c/li\u003e\n\u003cli\u003eNicholls DA. Is physiotherapy a luxury? What can the perplexing absence of the physical therapies tell us about the profession\u0026rsquo;s future? \u003cem\u003ePhysiother Theory Pract\u003c/em\u003e. 2024;40(8):1815-1829. doi:10.1080/09593985.2023.2211675\u003c/li\u003e\n\u003cli\u003eStatistics PBo. Disability details from NADRA. . https://www.pbs.gov.pk/content/disability-statistics.\u003c/li\u003e\n\u003cli\u003eZaidi SA, Bigdeli M, Langlois E V, et al. Health systems changes after decentralisation: progress, challenges and dynamics in Pakistan. \u003cem\u003eBMJ Glob Health\u003c/em\u003e. 2019;4(1):e001013. doi:10.1136/bmjgh-2018-001013\u003c/li\u003e\n\u003cli\u003eShah I, Mahmood T, Khan SA, et al. Inter-agency collaboration and disaster management: A case study of the 2005 earthquake disaster in Pakistan. \u003cem\u003eJ\u0026agrave;mb\u0026aacute; Journal of Disaster Risk Studies\u003c/em\u003e. 2022;14(1). doi:10.4102/jamba.v14i1.1088\u003c/li\u003e\n\u003cli\u003eDashti Asghar MMAM. Role of NGOs in South Asia: A Case Study of Pakistan . \u003cem\u003ePakistan Journal of International Affairs\u003c/em\u003e. June 2021.\u003c/li\u003e\n\u003cli\u003eBhattacharya Sanchita. Civil society in pakistan: functioning and challenges. . \u003cem\u003eSouth-Asian Journal of Multidisciplinary Studies (SAJMS)\u003c/em\u003e. 2016.\u003c/li\u003e\n\u003cli\u003eMamoona Mushtaq AA RJMNIAASMHADastgir.Stigma of disability, social phobia and self-es-teem in adolescents with physical disability. \u003cem\u003eJournal of Postgraduate Medical Institute\u003c/em\u003e. 2020.\u003c/li\u003e\n\u003cli\u003eSajjad Hussain Akhtar Munir Muhammad Ibrar. Children with disability: Problems and challenges in Pakistan. \u003cem\u003eJournal of Humanities and Social Sciences\u003c/em\u003e. 2020.\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eBaseline Survey in Pakistan Rapid Assistive Technology Assessment (RATA)\u003c/em\u003e.; 2023.\u003c/li\u003e\n\u003cli\u003eBarbareschi G, Carew MT, Johnson EA, Kopi N, Holloway C. \u0026ldquo;When They See a Wheelchair, They\u0026rsquo;ve Not Even Seen Me\u0026rdquo;\u0026mdash;Factors Shaping the Experience of Disability Stigma and Discrimination in Kenya. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2021;18(8):4272. doi:10.3390/ijerph18084272\u003c/li\u003e\n\u003cli\u003eDeprez D, Busch AJ, Ramirez PA, Pedrozo Araque E, Bidonde J. Capacity-building and continuing professional development in healthcare and rehabilitation in low- and middle-income countries\u0026mdash;a scoping review protocol. \u003cem\u003eSyst Rev\u003c/em\u003e. 2023;12(1):22. doi:10.1186/s13643-023-02188-3\u003c/li\u003e\n\u003cli\u003eSindh Go. The Sindh Goverment Gazatte.\u003c/li\u003e\n\u003cli\u003eSindh Institute of Physical Medicine and Rehabilitation. https://sipmr.edu.pk/.\u003c/li\u003e\n\u003cli\u003eParaplegic Center Peshawar. https://paraplegiccenter.org/.\u003c/li\u003e\n\u003cli\u003eKhan F, Amatya B, Sayed T, et al. World Health Organisation Global Disability Action Plan 2014\u0026ndash;2021: Challenges and perspectives for physical medicine and rehabilitation in Pakistan. \u003cem\u003eJ Rehabil Med\u003c/em\u003e. 2017;49(1):10-21. doi:10.2340/16501977-2149\u003c/li\u003e\n\u003cli\u003eMinistry of National Health Services RaC G of Pakistan. \u003cem\u003eUniversal Health Coverage Benefit Package of Pakistan Essential Package of Health Services\u003c/em\u003e.; 2020.\u003c/li\u003e\n\u003cli\u003eSohail S, Wajid G, Chaudhry S. Perceptions of Lady Health Workers and their trainers about their curriculum for implementing the interventions identified for Essential Package of Health Services for Pakistan. \u003cem\u003ePak J Med Sci\u003c/em\u003e. 2021;37(5). doi:10.12669/pjms.37.5.4175\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e. Overview of the framework for the prioritization of rehabilitation\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"733\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSub-themes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIdentified Challenges\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 327px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eProblem Definition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eProblem Clarity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eLimited understanding of rehabilitation and assistive technology among\u0026nbsp;actors\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 327px;\"\u003e\n \u003cp\u003eActors, including medical doctors, often misunderstand rehabilitation, equating it with physical therapy and sometimes even with charity work.\u0026nbsp;This misconception limits the prioritization of comprehensive rehabilitation services in Pakistan.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eInconsistent data for the rehabilitation needs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 327px;\"\u003e\n \u003cp\u003eUnderestimation of the need for rehabilitation, resulting in insufficient allocation of necessary resources for the delivery of quality services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGovernance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGovernance Arrangements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eFragmented ownership of rehabilitation across health and social welfare\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 327px;\"\u003e\n \u003cp\u003eThis leads to a lack of coordination and inconsistent policies, making it difficult to create a unified approach for the regulation and effective implementation of rehabilitation services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eChallenges like political instability, frequent government turnovers, and delays in governmental responses\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 327px;\"\u003e\n \u003cp\u003eThese challenges hinder the sustainability of rehabilitation programs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDomestic Advocacy Coalitions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eIsolated efforts of all relevant\u0026nbsp;actors in the field of rehabilitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 327px;\"\u003e\n \u003cp\u003eVarious\u0026nbsp;actors including ministries at federal and provincial levels, NGOs and PWDs are working to promote rehabilitation in Pakistan but their work remains insignificant as that is done in silos and doesn\u0026rsquo;t get the image\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStructural Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eNational Legacies\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eFocus driven on rehabilitation services only after disasters and conflicts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 327px;\"\u003e\n \u003cp\u003eServices that receive \u0026nbsp;attention only after certain incidents fail to remain sustained until prioritized within the health system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eSociocultural Context\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eStigma associated with disability and seeking rehabilitation care services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 327px;\"\u003e\n \u003cp\u003eBeliefs, practices, and social norms within a society influence social behaviors and act as a barrier to the prioritization of rehabilitation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHealth system structures\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eRehabilitation: An overlooked domain within the healthcare system\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 327px;\"\u003e\n \u003cp\u003eInadequate representation of rehabilitation in the health system of Pakistan results in the unavailability of adequate rehabilitation services in many parts of the country, impacting the people with need for rehabilitation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eLack of financial resources for rehabilitation and assistive products\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 327px;\"\u003e\n \u003cp\u003eGaps in financial support and unsustainable funding mechanisms, disrupt the availability of necessary resources for the provision of rehabilitation services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eShortage of trained healthcare workforce for timely service provision and referrals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 327px;\"\u003e\n \u003cp\u003eThis results in people not receiving appropriate rehabilitation care and not being referred to the relevant professionals, underestimating the need for rehabilitation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e \u003cstrong\u003eTimeline of major developments of Pakistan rehabilitations policy and programming\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"704\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategorization of event\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEvent details\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eEarly 1960s\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 133px;\"\u003e\n \u003cp\u003eEstablishment of schools/institutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eFirst department of rehabilitation medicine at the Jinnah Post Graduate Medical Center (JPMC)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1973\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eSet-up of school of occupational therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1980s\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eSchool of occupational therapy with focus on PMR Mayo hospital Lahore\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1991\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eArmed Force Institute of Rehabilitation Medicine (AFIRM) founded\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eEvent with national significance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eEarthquake that drew national attention towards the significance of rehab services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e1981\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 133px;\"\u003e\n \u003cp\u003ePolicy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eDisabled Persons (Employment and Rehabilitation) Ordinance - National Council for the Rehabilitation of Disabled Persons was established to formulate policy for the employment, rehabilitation and welfare of the disabled persons\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eNational Policy for Persons with Disabilities was prepared\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eNational Plan of Action for Persons with Disabilities was introduced, that incorporated a roadmap to operationalize the national policy of 2002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2006-2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003e\u0026ldquo;National Plan of Action for Children\u0026rdquo; was ratified to promulgate the rights of children with disabilities.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 133px;\"\u003e\n \u003cp\u003eEvent with national significance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003e18th constitutional amendment leading to devolution of Ministry of Health and health became a provincial subject, the Ministry of National Health Services, Regulation and Coordination was formed instead\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eWHO-EMRO-Islamabad declaration was prepared to improve access to AT in the WHO region\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eBaluchistan Persons with Disabilities Act 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 133px;\"\u003e\n \u003cp\u003ePolicy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eSindh Empowerment of \u0026lsquo;Persons with Disabilities \u0026lsquo;Act 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eThe Gilgit-Baltistan Persons with Disabilities Act 2019\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eEvent with national significance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eEhsaas Kafaalat for Special Persons Policy included within the The Ehsaas Kifalat programme, an unconditional cash transfer programme launched by the Government of Pakistan\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eEvent with national significance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eSupreme Court made a decisive judgement regarding the rights of PWDs that potentially triggered the adoption of Rights of Persons with Disability Act\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 133px;\"\u003e\n \u003cp\u003ePolicy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eRights of Persons with Disability Act 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eThe Punjab Empowerment of Persons with Disabilities Act 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eMay, 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 133px;\"\u003e\n \u003cp\u003eEvent with national significance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eVisit of AT scale Leadership: AT scale\u0026rsquo;s CEO visited Pakistan to introduce a new AT scale-supported program aimed at improving access to assistive technology for vision and hearing.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eJune, 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 486px;\"\u003e\n \u003cp\u003eThe global community, along with key actors in Pakistan, celebrated the first ever day for Assistive Technology\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Rehabilitation, Prioritization, Integration, Health policy, Health System, Pakistan","lastPublishedDoi":"10.21203/rs.3.rs-6202625/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6202625/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRehabilitation,is a neglected domain in Pakistan’s health system. There are insufficient financial and human resources to address the unmet needs. Despite the increasing demand for rehabilitation and assistive technology (AT) and implications for improving health inequities, it receives little political attention. This analysis identifies the factors that shape the prioritization of rehabilitation in Pakistan’s national health system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted 29 key informant interviews with actors concerned with rehabilitation policy and practice in Pakistan, complemented by a purposeful review of peer-reviewed and grey literature to achieve thematic saturation. The data was triangulated and thematically analyzed using a policy framework on national prioritization of rehabilitation services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eBased on the framework, we identified three key elements that shape the inadequate prioritization of rehabilitation in Pakistan. First, rehabilitation lacks a consistent problem definition; there is a lack of consensus among key actors regarding the importance and need for rehabilitation and AT in the health system. Second, governance arrangements are fragmented across multiple ministries, with rehabilitation services often being associated with disability and included under the Social Welfare Department, rather than the Ministry of National Health Services, Regulations, and Coordination (MoNHSRC). Third, with respect to structural factors, scarcity of resources in the existing health system,societal stigmas and social inequalities have negatively shaped the abilities of both rehabilitation service seekers and providers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIdentifying the key components impeding prioritization for rehabilitation in Pakistan’s health system is a crucial first step in advancing the issue within sub-national and national policy agendas and improving equity in access to rehabilitation services. Rehabilitation professionals and other actors responsible for rehabilitation policy and practice should systematically work together to \u0026nbsp;prioritize and integrate rehabilitation services within the current health system structures to advance health equity, enabling all individuals to lead fulfilling lives, regardless of their background or circumstances.\u003c/p\u003e","manuscriptTitle":"Prioritizing Rehabilitation in Pakistan’s Health system: A Qualitative Policy Analysis ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-13 09:43:47","doi":"10.21203/rs.3.rs-6202625/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-13T12:54:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-06T08:05:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151535086797843477244456833389551068622","date":"2025-09-05T08:26:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-28T08:02:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220280806472471518114001039128277528695","date":"2025-08-08T11:09:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-07T14:23:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-08T01:21:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2025-07-07T15:59:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ef64f405-e217-4b8c-9072-dfe1f6f34f55","owner":[],"postedDate":"August 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:02:28+00:00","versionOfRecord":{"articleIdentity":"rs-6202625","link":"https://doi.org/10.1186/s12939-026-02760-y","journal":{"identity":"international-journal-for-equity-in-health","isVorOnly":false,"title":"International Journal for Equity in Health"},"publishedOn":"2026-01-28 15:58:43","publishedOnDateReadable":"January 28th, 2026"},"versionCreatedAt":"2025-08-13 09:43:47","video":"","vorDoi":"10.1186/s12939-026-02760-y","vorDoiUrl":"https://doi.org/10.1186/s12939-026-02760-y","workflowStages":[]},"version":"v1","identity":"rs-6202625","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6202625","identity":"rs-6202625","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}