Rehabilitation is defined by the World Health Organization (WHO) as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment” (WHO, 2020). It plays an important role in the care and recovery of people. It is a main element to improve the health and physical or mental well-being of individuals, enabling and supporting them to achieve their full potential and – where possible – to live full and active lives. Anybody may need rehabilitation at some point in their lives, following an injury, surgery, disease or illness, or because their functional capacity has declined with age.

Rehabilitation needs are on the rise. The reasons for this are multiple and include changing health risk factors triggering an increased prevalence of chronic conditions and higher occurrence of mental health issues among younger working-age populations. The most important factor for the need to strengthen rehabilitation, however, is the rapid population ageing taking place in many regions around the world.

People live longer – with the number of people over 60 years of age predicted to double by 2050 – and more and more people are living with chronic diseases such as diabetes, stroke and cancer. Disability is one of the main challenges that social security institutions face in this context, as it impacts on individuals, societies, economies and the financial sustainability of social security systems.  

Rehabilitation at all ages is imperative to support individuals and promote inclusion, activity and employment. Complementing prevention and early intervention strategies, increased investment in holistic and people-centred rehabilitation is a key means to promote longer working lives and delay needs for care.

Therefore, the International Social Security Association (ISSA) is stepping up its work on rehabilitation (ISSA, 2021), including by taking into account the impact of the COVID-19 pandemic on rehabilitation needs and capacities. The multidisciplinary nature of rehabilitation – involving work injury, health care, employment support and sickness benefits – motivated the recent establishment of the ISSA Special Working Group on Rehabilitation. With members from Austria, Azerbaijan, Belgium, Canada, Finland, Germany, Indonesia, Italy, the Republic of Korea, Malaysia, Mexico, Nigeria, United Kingdom and the United States, the working group addresses the role of rehabilitation for active living and enhanced labour market participation.  Based on a cross-sectoral approach – in coordination with the respective ISSA technical commissions – it offers a transversal platform for exchanges of good practices, promoting a holistic view of rehabilitation as an important pillar of social security.

Through a range of activities including webinars, the ISSA investigates the systems for rehabilitation in place and analyses what factors play a role in the development and implementation of an effective rehabilitation and return-to-work system. Systems for rehabilitating sick and injured workers are increasingly viewed as important elements of national policy approaches towards an ageing workforce. These activities will provide input to the development and update of ISSA Guidelines on Return to Work and Reintegration and related areas of social security administration, and contribute to a number of key events, to make sure that international cooperation and the exchange of good practices in this area is taken one step further.

A first ISSA webinar focusing on Rehabilitation strategies post-COVID-19 was held on 27 January 2021 with experts from the International Labour Organization (ILO) and ISSA member organisations from Belgium, Canada, Germany and the Republic of Korea, who shared their concerns and solutions regarding the impact of the pandemic.

A second ISSA Webinar addressed Rehabilitation and return to work policies: the need for holistic approaches, which took place on 21 April 2021. It provided a solid overview of challenges shared by WHO and responses to growing rehabilitation needs, illustrated with country experiences by ISSA member organisations from Belgium and Canada.

In this context, the article outlines the key issues raised by the international organizations and ISSA member institutions, and discusses different aspects of rehabilitation.

A broader scope of rehabilitation

Rehabilitation should be understood broadly, covering all medical, occupational and social measures that serve to enable people to regain their appropriate place in occupational and economic life and in society. Medical rehabilitation aims to restore the functional or mental ability and quality of life of people with physical or mental impairments or disabilities.  Vocational (or occupational) rehabilitation enables persons with physical or mental impairments or disabilities to overcome barriers to accessing, maintaining or returning to employment. Finally, social rehabilitation facilitates the participation of people with disabilities in social life.

Rehabilitation includes medical, therapeutic, nursing, social, vocational, educational or technical services including the adaptation of the person's environment.  It can be provided in many different settings, from inpatient or outpatient hospital settings to private clinics, or in community settings, such as an individual’s home, thereby meeting the needs of older people or those with multiple long-term conditions who wish to live independently. Improving community-based rehabilitation services is integral to the rehabilitative approach, as is the prevention of dependency on care and support services through the promotion of independent living.

The benefits of rehabilitation

Rehabilitation is an investment with costs and benefits for both the individuals and society. It can reduce the disabling impact of a broad range of health conditions, including acute or chronic diseases, illnesses or injuries. It can help to avoid costly hospitalization, reduce hospital length of stay, and prevent reߛadmissions. It also enables individuals to participate in education and gainful employment, remain independent at home, and minimize the need for financial or caregiver support.

The ISSA, together with its Technical Commission on Insurance against Employment Accidents and Occupational Diseases, has conducted a study on the Return on Work Reintegration (Echarti; Schüring and Kemper, 2017). It estimates the global return on investments directed at medical and vocational rehabilitation measures for injured workers and workers absent on the grounds of health, with the goal of permitting reintegration in the workplace. This cost benefit analysis revealed that the average returnߛonߛinvestment ratio for employers is 3.7 and for social security systems, it is 2.9. From a societal perspective, the estimated productivity gains outweigh investments by a factor of 2.8.

The need for a holistic approach

Strengthening the health system

Health is a major element of the 2030 Sustainable Development Goals (SDGs) agenda (UN, 2015), with one comprehensive goal – SDG 3: “Ensure healthy lives and promote wellbeing for all at all ages”. When individuals face challenges to their physical or mental well-being, they experience an impact on their quality of life. Rehabilitation is fundamentally about enabling and supporting individuals to recover or adjust during this time, to regain their functional capacity.

For rehabilitation to reach its full potential, efforts should be directed towards strengthening the health system and making rehabilitation part of health care at all levels, as part of universal health coverage (UHC). Every person should be able to access the medical services and medicines they need without suffering financial hardship. This includes, as specified by the WHO, access to rehabilitation services, which are becoming increasingly important due to the growing prevalence of chronic conditions and aging populations.

In 2017, WHO launched the Rehabilitation 2030 initiative (WHO, 2017) which calls for all stakeholders worldwide to come together to work on different priority areas, including improving leadership and governance, developing a strong multidisciplinary rehabilitation workforce, expanding financing for rehabilitation and improving data collection and research.

To reach these objectives, WHO provides practical guidance for governments to strengthen the different building blocks of the health system for rehabilitation, supporting ministries of health in making decisions around service planning and budgeting for rehabilitation according to the countries’ needs and priorities.

Cross-branch social security responses

Social security systems must adapt to the evolving needs of all population groups, looking holistically at empowering people, thereby preventing the need for benefits and services while supporting labour market participation, activity and productivity.

Population ageing will alter the demand for adequate and sustainable social security and healthcare and will at the same time, and all other things equal, lead to reduced levels of contributions and increased social expenditures. To contribute to the financial sustainability of social security programmes, social security administrations tailor individualized responses that support the proactive rehabilitation and the reinsertion into economic activity of people who are excluded from the labour market.

The context for persons with disabilities has evolved considerably in recent times relative to when long-term disability benefits programmes were first introduced. Medical advances, the changing nature of work and more accessible work environments have increased the potential for persons with disabilities to regain work capacity and find employment. Despite this new reality, low return-to-work rates persist. As a result, disability programmes are increasingly looking at effective methods to reduce disincentives and strengthen support in order to maximize labour market participation of beneficiaries.

As long-term sickness absence is one major pathway to inactivity, it is an important predictor for exit from the labour market, including through disability pension (OECD, 2010) and early retirement. These are major financial burdens for ISSA members and society. Actions aimed at prevention avoiding sickness – both at the workplace (occupational safety and health (OSH) interventions) and outside the workplace (public health interventions) – are clearly important. If sickness occurs, early intervention measures focusing on rehabilitation and return-to-work are essential to minimise absence leading to disability.

Rehabilitation is also important to ensure that the future of work is inclusive, leaving no one behind. The ILO Centenary Declaration for the Future of Work (ILO, 2019), adopted by the ILO in June 2019, highlights the necessity for a human-centred approach and incorporates an explicit reference to the need to ensure equal opportunities and treatment for persons with disabilities. The rights-based approach towards persons with disabilities reflected in the 2030 SDG Agenda, is aligned with the United Nations Convention on the Rights of Persons with Disabilities (CRPD) (UN, 2016).

In Canada, the Saskatchewan Workers’ Compensation Board (WCB) has established minimum expectations related to early and proactive contact with customers, in order to identify and resolve the barriers to effective rehabilitation and return-to-work. It has recognized significant opportunities to training staff and employers on a more customer-centric model for work disability prevention and return-to-work.

Employment and Social Development Canada (ESDC) is undertaking a renewal of the post‑grant elements of the Canada Pension Plan Disability (CPPD) Program, intended to make improvements to aspects of the programme after an individual is granted benefits. Work is underway to build the evidence base to inform improvements, including international comparative research on best practices to encourage labour market participation of disability support beneficiaries, in collaboration with ISSA.

Impact of COVID-19

The COVID-19 pandemic has highlighted the crucial importance of rehabilitation. Both directly and because of social isolation, movement restriction and healthcare system disruption, it threatens to generate a huge increase in the need for rehabilitation, in particular for older people.

The pandemic has also put many rehabilitation institutions and services in a squeeze. While on the one hand they have been doing their best to cope with an increasing demand, on the other hand they have been required to follow rules on restricting access to facilities, social distancing and hygiene measures.

The lack of early, intensive rehabilitation during a critical time window can affect the chances for recovery. Furthermore, the related economic crisis may affect rehabilitation opportunities for people suffering from other chronic diseases.

The impact of the pandemic on rehabilitation services is illustrated by the German Federal Pension Insurance (Deutsche Rentenversicherung Bund – DRV Bund). Central objectives of its rehabilitation activities are to maintain the long-term work capacity and preserve employment of the working age population through disability prevention, return-to-work and stay-at-work programmes and policies. Undoubtedly, prevention is very important to avoid disability pensions and early retirement. Across the country, the German Pension Insurance is running 90 rehabilitation clinics, in addition to about 1,000 private providers. The German Pension Insurance is responsible for both medical and vocational rehabilitation.

Since the first COVID-19 lockdown in Germany, patients face a considerably reduced access to rehabilitation services. Due to the pandemic, some rehabilitation clinics had to close completely. Others had to change their focus and accept only follow-up or quarantined patients with mild conditions, reducing their capacity in order to live up to the strict hygiene requirements. Others had to act as acute clinics for COVID-19 patients or serve as long-term care facilities.

Many vulnerable groups (e.g. elderly people) could not access rehabilitation facilities and numerous patients avoided to make use of rehabilitation services. Chronic diseases were not treated sufficiently, as surgery was postponed. In addition, an increased need for rehabilitation after infection with COVID-19 arose.

Towards human-oriented and data-based rehabilitation services

The COVID-19 pandemic also provides an opportunity to transform and redesign rehabilitation services to be more human-oriented and resilient to future pandemic waves. Hybrid forms of rehabilitation services are developed through e-health and online applications. Rehabilitation systems benefit from digital innovation in a rapidly changing work environment, such as tele-rehabilitation programmes for workers. Further, information and communication technologies (ICT) can be used to assess disability as the first step in successful rehabilitation.

In the Republic of Korea, the Korea Workers’ Compensation and Welfare Service (COMWEL) provides customized integrated programmes to industrially injured workers, including tailored medical care, rehabilitation or compensation in a timely and systematic way, thereby helping the worker’s return to work and social life. Designing rehabilitation services that respond to the users’ needs, the use of data linkage and machine learning applications can enhance  customized services and return-to-work solutions. Shifting the rehabilitation paradigm from service-centred to human-oriented, from work-focused to integrated preventive rehabilitation and from face-to-face services to digital, the rehabilitation strategy for the post-COVID-19 era also focuses on creating synergies through partnerships with external organisations and international collaboration.

The National Institute for Health and Disability Insurance (Institut national d'assurance maladie-invalidité – INAMI) of Belgium has launched initiatives to assess disability as the first step in successful rehabilitation, based on the use of artificial intelligence in the framework of the International Classification of Functioning, Disability and Health (ICF). In the context of a growing number of people on work incapacity, INAMI is continuously looking for tools to support the work of the insurance physicians who are responsible for the medical evaluation of work incapacity.

The way ahead

Ageing populations and COVID-19 call for profound changes and holistic approaches towards rehabilitation. Rehabilitation systems need to adapt to new challenges and develop post-COVID-19 rehabilitation strategies, particularly in the development of the long COVID syndrome. In countries where rehabilitation services are fragmented, the current crisis offers an opportunity to redesign human-centred integrated systems that are more resilient to future pandemic waves.

Many ISSA members are facing these challenges and are in the process of rethinking rehabilitation services. Based on a cross-sectoral approach, the ISSA Special Working Group on Rehabilitation will address the role of rehabilitation for active living and enhanced labour market participation, promoting good practices and supporting ISSA members in working towards rehabilitation strategies that meet the challenges and exploit the opportunities post-COVID-19.

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