On-line version ISSN 2310-3833
Print version ISSN 0038-2337
S. Afr. j. occup. ther. vol.45 n.3 Pretoria Dec. 2015
This position statement is the response of the Occupational Therapy Association of South Africa (OTASA) to the Re-engineering of Primary Health Care (PHC) and the Green Paper on the National Health Insurance. It serves to articulate the profession's commitment to equity and social justice through a transforming health-care system in South Africa.
PHC shares its core principles with Community-Based Rehabilitation (CBR), the rights-based and multisectoral philosophy on which South African disability legislation is based (including the Integrated National Disability Strategy 1997, Draft Policy on Mainstreaming the Rights of People with Disabilities 2015 & National Rehabilitation Strategy 2015). In reaffirming our commitment to PHC as OTASA, we are also expressing our support for CBR as the overarching framework within which health rehabilitation should be provided.
Statement of OTASA position
OTASA subscribes to the comprehensive definition of health as described in the Alma Ata Declaration1. Occupational therapists believe that health, well-being and development is shaped by the ordinary things people do every day, including work, play, learning, caring and socialising. This perspective informs occupational therapy practices which address people's health needs within their own context. This is done by taking account of the social determinants of health, and often acting directly on the social determinants of health (e.g. by helping an injured breadwinner to return to work, it often enables the continued education and adequate nutrition of dependents).
The unique contribution of occupational therapy lies in understanding the complex relationships between the things people do (occupations), their environment and their health. Occupational therapy intervention aims to create a better fit between these, so that people are able to meet the challenges they face, and their health is promoted, restored and maintained. Occupational therapy essentially forms a bridge between biomedical health services and an understanding of social realities, for productive and meaningful living in society.
In this way, occupational therapy embodies the spirit of PHC, offering local interventions that address injustices and promote productive and healthy lives and communities, and "not merely the absence of disease or illness" 1. At all levels, occupational therapists are committed to multi-professional teamwork, intersectoral collaboration, and partnerships with people and communities.
OTASA expresses its support of the principles of PHC in the interest of facilitating the right to health of all South Africans, as follows:
φ Right to access: OTASA embraces the partial shifting of resources (including human) away from institutions and into the District Health System, bringing services closer to where people live. OTASA calls for special measures to address the access challenges faced by people with disabilities, especially in rural and remote areas, including dedicated therapist transport for outreach and home visits.
φ Effectiveness: Occupational therapists at PHC level promote screening, early intervention, prevention and health promotion, through population-based programmes that seek to reduce the incidence and impact of serious disability and morbidity. OTASA commits itself to the continued development of the evidence base for PHC-based occupational therapy practice.
φ Appropriateness: Occupational therapists strive to make their services responsive to the complex needs of the people with whom they work and are committed to deepening the cultural fit and sensitivity of practice.
φ Equity: Through appropriate provision of medical, educational, psychosocial and vocational rehabilitation services as well as assistive devices, occupational therapy seeks to overcome the barriers to full participation of people with disabilities. OTASA recognises the need for special measures to address equity for vulnerable groups such as the very poor, women, and people who live in rural areas.
φ Affordability: OTASA calls for sufficient ring-fenced funding for occupational therapy PHC services, so that scarce human and financial resources can be optimally utilised. This will reduce the hidden but significant costs to society of people living with unnecessary disabilities.
Implications of this OTASA position to the profession
This position will require reorientation of the profession, from undergraduate curriculum to the professional community:
1. Graduates must be equipped with the necessary broad clinical, managerial and training skills to work in complex new environments, in non-traditional roles, and to plan and deliver services at population level;
2. Targeted support is needed for the professional development of new graduates, who currently deliver the majority of PHC occupational therapy services;
3. Continuing professional development must target the skill-base needs of generalist practitioners, and should be both physically and financially accessible;
4. Creative approaches to service delivery must be considered, taking account of resource constraints and the level of need. Task-shifting, for example to appropriately trained and supported mid-level rehabilitation workers and other categories of community based workers, may be included.
5. Intersectoral collaboration must become a reality, under the overarching vision of CBR.
Impact of the OTASA position to society
By making occupational therapy services accessible to the broader population through re-engineered PHC, the following can be expected:
φ Greater life expectancy, well-being and productivity for at-risk populations2-9.
φ Mitigation of the physical, social and economic impact of many health conditions, resulting in:
- Reduced burden of care, both economic and social, to family and state2,10.
- Cost savings in health care through the prevention of complications, e.g. pressure sores, mental health relapse11-14; and
- Increased rates of social and economic productivity, through occupational therapy interventions which target education and employment for injured workers, people with disabilities and vulnerable groups15,16 e.g. youth living with HIV
This statement positions occupational therapy as an essential service provider within the context of the National Department of Health's (DOH) vision for transformed service delivery. We commend the DOH for the steps they are taking to achieve universal coverage, and commit ourselves to supporting the transformation this implies. We invite the Department's further engagement with OTASA and other relevant stakeholders over post structures, financial commitments and other resource allocation necessary to realise occupational therapy's contribution to "a long and healthy life for all South Africans"17.
φ Ms. Kate Sherry and Profs Madeleine Duncan and Ruth Watson, who were proponents for the current position statement,
φ The National Occupational Therapy Forum, through which a call for this position statement was made, and a platform through which draft statements received comment from public sector occupational therapists.
1. World Health Organisation. Report of the International Conference on Primary Healthcare. Alma-Ata, Geneva: World Health Organisation, 1978. [ Links ]
2. Arbesman, M., Bazyk, S., & Nochajski, S. M. . Systematic review of occupational therapy and mental health promotion, prevention, and intervention for children and youth. American Journal of Occupational Therapy, 2013; 67 (3), e120-e130. http://dx.doi.org/10.5014/ajot.2013.008359. [ Links ]
3. Arbesman, M. and Mosley, L. J. Systematic review of occupation- and activity-based health management and maintenance interventions for community-dwelling older adults. American Journal of Occupational Therapy, 2012; 66 (3), 277-283. http://dx.doi.org/10.5014/ajot.2012.003327. [ Links ]
4. McColl., M.A., Shortt, S., Godwin, M., Smith, K., Rowe, K., O'Brien, P, and Donnelly, C. Models for integrating rehabilitation and primary care: A scoping study. Archives of Physical Medicine and Rehabilitation, 2009; 90, 1523-1531. doi: 10.1016/j.apmr.2009.03.017. [ Links ]
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6. Braveman, B., & Metzler, C. A. Health Policy Perspectives-Health care reform implementation and occupational therapy. American Journal of Occupational Therapy, 2012; 66, 11-14. http://dx.doi.org/10.5014/ajot.2012.661001. [ Links ]
7. Mannan, H., Boostrom, C., Maclachlan, M., McAuliffe, E., Khasnabis, C., & Gupta, N. A systematic review of the effectiveness of alternative cadres in community based rehabilitation. Human Resources for Health, 2012; 10(1), 20-20. doi:10.1186/1478-4491-10-20. [ Links ]
8. Kingsley, K., & Mailloux, Z. Evidence for the effectiveness of different service delivery models in early intervention services. American Journal of Occupational Therapy, 2013; 67(4), 431-436. http://dx.doi.org/10.5014/ajot.2013.006171. [ Links ]
9. Watson, R. A population approach to occupational therapy. South African Journal of Occupational Therapy, 2013; 43 (1), 35-39. [ Links ]
10. Graff, M., Vernooij-Dassen, M., Thijssen, M., Deller, J., Hoefnagels, W., & Rikkert, M. G. Effects of community occupational therapy on quality of life, mood, and health status in dementia patients and their caregivers: A randomized controlled trial. Journal of Gerontology: Medical Sciences, 2007; 62A (9), 1002-1009. [ Links ]
11. Case-Smith, J. Systematic review of interventions to promote social-emotional development in young children with or at risk for disability. American Journal of Occupational Therapy, 2013; 67, 395-404. http://dx.doi.org/10.5014/ajot.2013.004713. [ Links ]
12. Richardson, J., Letts, L., Chan, D., Stratford, P, Hand, C., Price, D., Law, M. Rehabilitation in a primary care setting for persons with chronic illness: A randomized controlled trial. Primary Health Care Research and Development, 2010; 11, 382-395. doi:10.1017/ S1463423610000113. [ Links ]
13. Orellano, E., Colón, W. I., & Arbesman, M. Effect of occupation- and activity-based interventions on instrumental activities of daily living performance among community dwelling older adults: A systematic review. American Journal of Occupational Therapy, 2012; 66, 292-300. http://dx.doi.org/10.5014/ajot.2012.003053. [ Links ]
14. Rexe, K., Lammi, B., & von Zweck, C. Occupational therapy: Cost-effective solutions for changing health system needs. Healthcare Quarterly, 2013; 16(1), 69-75. [ Links ]
15. Van Bruggen, H. Competencies for Poverty Reduction (COPORE). Final Report. Public part: 2011. [ Links ]
16. Désiron HAM, de Rijk A, Van Hoof E, Donceel P Occupational therapy and return to work. A systematic literature review. BMC Public Health, 2011; 11:615 doi:10.1186/1471-2458-11-615. [ Links ]
17. Department of Health. Negotiated Service Delivery Agreement. Pretoria: 2013. [ Links ]
Date Ratified: 29/06/2015