Message from the President: Global Health Policy

The history of our profession is well documented and sometimes differs depending on the perspectives you read. However, the intrinsic relationship between occupation, health and well-being is universally accepted, evidenced and debated. Our linguistics may differ among our member countries, in both how we say the word occupational therapy and how we apply it in the communities in which we work. Our terminology has evolved; 25 years ago, occupational science, models and frameworks of practice were concepts and ideas put forward by a small number of occupational therapists working in academia. Now they form part of our everyday vocabulary.

Occupational therapy continues to evolve beyond the boundaries of tertiary level rehabilitation – occupation (WFOT, 2016a) is recognised now as a human right and linked to the social determinants of health. Indeed, it is very interesting to see that in some domains, outcome measures are now focusing on user/patient satisfaction rather than clinical and cost effectiveness, focusing on the person and the person’s satisfaction with their outcome. The alternate focus does not come as a surprise to us as occupational therapists and this is where Global Health Policy is driving health and healthcare delivery.

In some countries, occupational therapy is embedded within a medical model where diagnosis, prognosis and remediation are the primary basis for intervention. In a number of countries, a referral to an occupational therapist can only be made by a medical doctor, without which our assessments and interventions cannot be undertaken. Equally, the medical model has been imperative to the development and evolution of the profession – as evidenced in our history. In many instances, the establishment of occupational therapy has been pioneered by medical and rehabilitation doctors or physical therapists. And in some countries, occupational therapy is mandated to be a branch of medicine, whereby only doctors/physicians can undertake a qualification in occupational therapy before being able to practice. This may surprise occupational therapists who work and live in a community where occupational therapists work outside the constraints of the medical model. However, it remains a feature of how the profession continues to evolve in some parts of the world.

In other countries, the profession has seen organic growth within the social model of disability, not primarily involved or engaged with the medical facilities or diagnosis, but working with communities from a societal perspective based on the principles of inclusion and social enterprise as a mechanism to access occupations. Many countries in Latin America provide a fantastic example of occupational therapy in this context. Therapists work with individuals and groups to establish communities, citizenship and self-reliance, often resulting in their community becoming involved in their outputs which, in turn, fosters societal acceptance and integration. Often services within this model receive little or no government funding and, therefore, thrive on the outcomes of their enterprises.

Throughout the history of occupational therapy, members of the profession have created or identified and acted upon opportunities – leading to the development of practice and transformation of services. There are continuing opportunities available to us all – locally, nationally as well as globally.

As occupational therapists, we collectively hold a vision for healthy and inclusive populations and communities. Many variables impact upon this vision including increased global connectivity through technology; science developing and providing more answers; the climate impacting the earth; populations aging; peoples migrating because of conflict or disaster – all lead to our profession expanding and evolving. And our profession is expanding.

We know there are nearly 500,000 practising occupational therapists worldwide, with 778 academic institutions delivering WFOT-approved education programmes worldwide. The most frequently cited areas of shortage are in the domains of mental health, dementia, older people and stroke rehabilitation (World Federation of Occupational Therapists [WFOT], 2016b)

The trends are clear and exciting. Between 2006 and 2016 there has been a 79% increase in the number of practising occupational therapists worldwide.

However, these exciting trends bring challenges. The profession needs to become more focused on interpreting and projecting demographic and societal changes at a national level to enhance workforce planning. Supporting the conversion of non-approved WFOT education programmes to approved status is imperative. Monitoring migration and immigration trends should form an important part of WFOT Member Organisations’ human resources strategies. We need to be poised to meet the increasing opportunities and challenges brought about by current Global Health Policy.

Established in 1952, the WFOT is the key international representative for occupational therapists and occupational therapy around the world and the official international organisation for the promotion of occupational therapy. WFOT promotes occupational therapy as an art and science internationally. The Federation supports the development, use and practice of occupational therapy worldwide, demonstrating its relevance and contribution to society (WFOT 2016c).

On 25 September 2015, member states of the United Nations adopted a set of goals to end poverty, protect the planet and ensure prosperity for all as part of a new sustainable development agenda. The Sustainable Development Goals (SDGs), otherwise known as the Global Goals, are a universal call to action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity.

These 17 Goals build on the successes of the Millennium Development Goals, while including new areas such as climate change, economic inequality, innovation, sustainable consumption, peace and justice, among other priorities. The goals are interconnected – often the key to success on one will involve tackling issues more commonly associated with another.

The SDGs work in the spirit of partnership and pragmatism to make the right choices now to improve life, in a sustainable way, for future generations. They provide clear guidelines and targets for all countries to adopt in accordance with their own priorities and the environmental challenges of the world at large. The SDGs are an inclusive agenda. They tackle the root causes of poverty and unite us together to make a positive change for both people and planet. ‘Poverty eradication is at the heart of the 2030 Agenda, and so is the commitment to leave no-one behind,’ United Nations Development Programme (UNDP) Administrator Achim Steiner said. ‘The Agenda offers a unique opportunity to put the whole world on a more prosperous and sustainable development path. In many ways, it reflects what UNDP was created for’ (United Nations, 2016) (Figure 1).

Figure 1. Sustainable Development Goals.

Many of these goals hold relevance to occupational therapists as international professional citizens.

As the world is now our backyard, the knowledge, skills and attitudes of the occupational therapy profession are coloured and shaped by diverse transcultural exposure, a oneness with humanity and fairness.

Interconnectedness with the world promotes a desire to make decisions that will create a better place through engagement in occupations. (Bahá’í International Community, 2008)

Through WFOT’s official relations with the World Health Organisation (WHO), we have an active working relationship both regionally and internationally which keeps us up to date with global health trends and healthy populations. Our vision for healthy people relates to the SDGs which focus on ending poverty, fighting inequality and injustice, tackling climate change and promoting health. This involves changing the way we do things.

Most recently WFOT has been working on projects and actions around the following major initiatives:

World report on disability 2011

This report (WHO, 2011) told us that more than a billion people in the world experience disability and people with disabilities have generally poorer health, lower education achievements, fewer economic opportunities and higher rates of poverty than those without disabilities. The report provides the best available evidence about best practices to overcome barriers to health care, rehabilitation, education, employment and support services, and create enabling environments where people with disabilities may flourish. As a result of the World Report on Disability, a broad range of strategies have been identified which in many ways are interlinked. These include activity around better health for persons with disability, health and ageing, non-communicable diseases (NCDs), Global cooperation on Assistive Health Technology (GATE) and mental health.

WHO global disability action plan 2014–2021: better health for all people with disability.

The WHO action plan 2014–2021 (WHO, 2015a) calls for removal of barriers and improved access to health services and programmes; strengthened and extended rehabilitation, assistive devices and support services and community-based rehabilitation; enhanced collection of relevant and internationally comparable data on disability, research on disability and related services.

In its initial and ongoing dialogue with WHO, the WFOT agreed strongly that disability was an issue of public health, human rights and development. WFOT requested that the Disability Action Plan should include explicit statements of vision, goals and objectives focusing on social change for all persons in all countries that will enable optimal participation as valued citizens. WFOT affirmed that the goal and objectives from this vision needed to articulate the features of a disability-friendly society in housing, employment, transportation, recreation and general community sectors. The presence or absence of disability in any life can be transient, changing and responsive to circumstances that are in constant flux. It is essential that this perspective be adopted when considering the growing co-morbidity of non-communicable disorders (NCDs) where periods of remission and exacerbation will have a major impact on the ability of those individuals to maintain participation in their communities and engagement in activities. Working directly with citizens facing complex problems related to readjustment and stabilisation is a key area for occupational therapy involvement. Changes in health policy made by nation states, therefore, will have more impact on mediating the effect of activity limitations on the public sector and promoting health and well-being of citizens.

The vision of disability needs to emphasise that all people including children and older adults have the right to make an informed decision regarding what occupations are meaningful and necessary for their quality of life, social inclusion and justice regardless of bodily function. The language of everyday occupation (WFOT, 2016a) will vary across socio-cultural contexts, but the intent is to recognise that when this term is broadly defined, occupations refer to all forms of engagement and enactment by citizens in home, school, the workplace and in employment, recreation, transportation, the natural environment and other societal sectors from childhood to end of life.

The WFOT acknowledges that active rehabilitation needs will fluctuate for individuals however the challenge was given to the social and public services to accommodate environmental and structural social changes to enable full participation.

World Report on Ageing and Health 2015

The World Health Report on Health and Ageing (WHO, 2015b) tells us that populations are getting older overall. The number of people aged 60 years or older will rise from 900 million to 2 billion between 2015 and 2050 (moving from 12% to 22% of the total global population).

We also know that population ageing is happening much more quickly than in the past as people are living longer. In more recent times, the intergovernmental discourse has moved toward understanding how to enable older people to maximise their capacity and capabilities rather than focus on the sometimes unattainable goal of independence. All individuals should be able to freely choose the direction of their personal lives, to develop their talents and capabilities to the full regardless of their age.

One important thread in public and political debates is the potential of rehabilitation (‘pre-habilitation’) for older people as a proactive response to declining function as opposed to rehabilitation within a geriatric care model. There are of course two sides to this discussion – one focussed on autonomy and quality of life and the other on the potential cost containment of public expenditure linked to self-management and personal responsibility. As a profession, we need to be able to articulate the cost effectiveness across a range of occupational therapy interventions in particular related to self-management.

For instance, a person with symptomatology and behaviours of advanced dementia is more likely to require clinical and social care within a facility whereas a person with complications associated with diabetes such as kidney disease, foot complications and visual impairment may have the functional capacity to live with assistance in the community. The clinical syndrome of frailty characterised by a person’s increased risk for poor health outcomes including falls, incident disability, hospitalisation and mortality is an increasingly common event. However, early identification of individuals at-risk of frailty and intervention on those components that are first affected may mean that reversal may be possible.

Whether it is a gradual change in capacity or a more acute change from the point of diagnosis onwards, individuals acquire and require knowledge, skills and confidence to make informed decisions concerning treatment options. With informed choice, they will be better able to carry out treatment regimens, to cope with the psychosocial consequences of their condition, and to perform self-care activities.

The World Report on Ageing and Health 2015 led to the development of the Global Strategy and Action plan on Ageing and Health 2016–2020 (WHO, 2016).

The Global Strategy and Action plan on Ageing and Health 2016–2020 focusses on five major areas all of which have a high degree of relevance for occupational therapists. They are:

• commitment to action on Healthy Ageing in every country;

• developing age-friendly environments;

• aligning health systems to the needs of older populations;

• developing sustainable and equitable systems for providing long-term care (home, communities, institutions); and

• improving measurement, monitoring and research on Healthy Ageing.

Occupational therapists need to be involved in such activities as setting policy, community education, environmental design, research and development of innovative and cost-effective multi-disciplinary models of care. If we are not actively involved, we may not be included – for example, the International Federation of Ageing (IFA) recently advertised the following opportunity however occupational therapy is not listed in the potential target group:

EuroAgeism is seeking 15 excellent early stage researchers (ESR) for a 3-year fully funded Ph.D. program in multiple research areas. EuroAgeism is a prestigious program that is a consortium of high profile universities, research institutions, and an NGO that are located in Israel, Belgium, Czech Republic, Poland, the Netherlands, United Kingdom, Finland and Sweden, which is funded under Horizon 2020, MSCA-Innovative training network as international, multidisciplinary, inter-sectorial training program. (IFA, 2017)

Global Action Plan for the Prevention and Control of NCDs 2013–2020 (WHO, 2013)

NCDs – mainly cardiovascular diseases, cancers, chronic respiratory diseases and diabetes – are the biggest cause of death worldwide.

WFOT has been working with WHO on a global coordination mechanism for the continued Global Strategy for the Prevention and Control of Noncommunicable Diseases (WHO GCM/NCD) and WFOT was invited to become a participant of the WHO Global Coordination Mechanism for the Prevention and Control of NCDs (WHO GCM/NCD).

The scope and purpose of the WHO GCM/NCD are to facilitate and enhance coordination of activities, multi-stakeholder engagement and action across sectors at the local, national, regional and global levels, in order to contribute to the implementation of the WHO Global NCD Action Plan 2013–2020 (WHO 2013).

The functions of the WHO GCM/NCD are:

• Advocating and raising awareness on NCDs

• Disseminating knowledge and information on how to address NCDs

• Encouraging innovation and identifying barriers

• Advancing multisectoral action for NCDs

• Advocating for the mobilisation of resources for NCDs

WFOT is actively involved in initiatives for the WHO GCM/NCD Global Action Plan.

GATE (Global cooperation on assistive health technology)

Assistive devices and technologies are those whose primary purpose is to maintain or improve an individual’s functioning and independence to facilitate participation and to enhance overall well-being. They can also help prevent impairments and secondary health conditions.

Globally only 1 in 10 people has access to appropriate technology – both low and high tech. In response, WHO developed the Global Cooperation on Assistive Technology (GATE) – in partnership with UN Agencies, international organisations, donor agencies, professional organisations, academia, and organisations of/for persons with disabilities.

An interesting debate is now occurring as to what constitutes ‘assistive technology’ and occupational therapy needs to be at the forefront of this discussion. We need to caution that technological solutions are not the only answer and it may be more important in some cases to address the causes of a problem rather than circumvent it through the use of technology: for example, before suggesting a fall-detector system for an older client the cause of the falls needs to be identified and a non-assistive technology solution may lower the falls risk and avoid injury all together.

WHO defines assistive devices and technologies as ‘those whose primary purpose is to maintain or improve an individual’s functioning and independence to facilitate participation and to enhance overall well-being’. As occupational therapists, we work with people to achieve their goals and assist them to start living the life they want – we are experts in the provision of assistive technology associated with participating in all activities of daily living; we need to caution and advise on the wisdom of untrained personnel providing these solutions. A device that is assistive for one person can be extremely dangerous for someone else if wrongly prescribed.

Rehabilitation2030: call to action 2017

This most recent call to action (WHO, 2017) is one that appeals for equitable access to rehabilitation services in every country. Occupational therapists have enormous experience and expertise to contribute, however, in many countries we are not included as part of health workforce planning. In the International Standard Classification of Occupations: International Labour Organisation (ILO, 2008), Occupational Therapy is listed as ‘an occupation not classified elsewhere’ unlike physiotherapy which is listed with its own code. We will not be included in global health care planning unless this situation changes and occupational therapy gains its own code. WFOT is conducting an active lobbying campaign through our member organisations to their national governments requesting support at the ILO level, particularly at the 20th International Conference of Labour Statisticians in October 2018.

Bringing stakeholders together in the Rehabilitation 2030: A Call for Action meeting was invaluable for discussing the strategic direction for coordinated action and joint commitments raising the profile of rehabilitation as a health strategy relevant to the whole population, across the lifespan and across the continuum of care.

WFOT were in attendance at this meeting and were one of few organisations present to submit a statement (WFOT, 2017).

WFOT congratulated WHO on the production of the document Rehabilitation in Health Systems and affirmed the principles of the Call for Action. WFOT committed to collaborative efforts and were delighted to see the inclusion of mental health within the rehabilitation framework.

WFOT applauded the client-centred approach and urged that this vision of rehabilitation needed to emphasise that all people including children and older adults have the right to make an informed decision regarding what occupations are meaningful and necessary for their quality of life, social inclusion and justice.

WFOT reinforced that occupational therapists have always been willing participants in the multi-disciplinary team approach and WFOT is keen to pursue universal and/or global partnerships and clearly sees the opportunity for significant collaborations such as joint position statements, collaborative educational events, the development of a global consortium, MoU’s and reciprocal organisational membership options.

WFOT confirmed its willingness and enthusiasm to engage with WHO and to enable the attainment of the goals and objectives of the Call for Action through the involvement of occupational therapy and occupational therapists in collaboration with our colleagues across the action spectrum.

Conclusion

As the key international organisation for occupational therapists worldwide, and a Federation of member organisations, WFOT develops its priorities by identifying, anticipating and strategising for the future developments within the political and environmental landscape in which it operates. During its Council Meeting in May 2018, representatives from its 95 Member Organisations will work within their regional groups to confirm and consolidate critical issues and trends that will have a significant impact on the delivery and evolution of occupational therapy within their countries and regions. These discussions underpin the strategic plan for WFOT in the years 2019–2024.

In addition, WFOT will incorporate its informed perspective to ensure international agendas and trends form part of this global strategy. Examples of these include:

• SDGs

• Global strategies and Action Plans – Disability, Rehabilitation, Ageing and Health, NCDs, GATE

• Disaster response and recovery

• Informatics and data sets related to health outcomes

• Human Resources – recruitment, retention and migration

• Technology

• Population demographics – projections, demand and strategy

• Global alliances and strategic partnerships

Global health is a concept that includes many pertinent issues relevant to occupational therapy. The current climate facing health professionals is one in which occupational therapy can play a major role through the enablement of and engagement in chosen and necessary occupations, participation in communities and the creation of more meaningful lives. If we think about the future as a book in which the pages are blank then current Global Health Policy will enable us to put the words on the pages ourselves. The book is called Opportunity and its first chapter starts today.