Introduction
The World Health Organization (WHO) estimates that more than 1 billion people (approximately 15% of world population) live with disability [1-5]. In Iran, according to the 2011 census, out of 75149669 population, about 1017659 (1.4%) had severe disability. According to the WHO, disability includes a set of defects, mobility limitations, and barriers to social participation that make a person unable to interact with the environment. In addition, about half of people with disability lack access to healthcare facilities or pay for healthcare charges. Therefore, timely health services, especially rehabilitation, are of particular significance for people with disability [2, 3, 5].
In Iran, rehabilitation services are provided at different levels. These services are limited to the inpatient part of rehabilitation hospitals. Outpatient rehabilitation services include comprehensive rehabilitation centers, offices of physical medicine and rehabilitation specialists, physiotherapy, occupational therapy, speech therapy, audiology, technical orthopedics, and daily centers provided by the Ministry of Health and Medical Education and Welfare Organization [1, 6-8]. Community-based centers covering homecare centers, vocational training, and long-term care in the form of daycare centers are provided by the Welfare Organization [9-14]. Notably, these services are now offered at different levels by different institutions and bodies with no systematic relationship. Therefore, the result is inconsistent and incoherent services stretching from the policy level to the lowest level of implementation [15-19]. 
The integrated health system should create a strong funding mechanism, trained staff, and reliable information to make sound health decisions and policies [20-23]. In 2003, the WHO identified integrated services as a key to reforming the health system, a logical connection between treatment and care [9, 10, 12-14, 16, 17]. Lack of integration of services is an essential barrier to the creation of a health system. The resulting challenges include lack of a specific trustee; mismanagement and no treatment plan; poor communication among patients, medical systems, rehabilitation, and care facilities; and lack of comprehensive insight on patient issues and attention to the needs of only one patient [24].
According to the policies of WHO, integrated and transparent design of rehabilitation programs along with effective integration with the health system is essential [25]. Rehabilitation services are better presented at all three levels of health systems to identify needs and provide effective treatment during recovery. Multidisciplinary rehabilitation in the health system offers a wide range of rehabilitation services for people with different conditions, such as chronic or complex cases and improves the quality of life [1-5, 7, 26-30]. 
Financing and procurement policies should ensure that additional products are available to all who need them. These products are essential in improving performance and increasing individual independence and participation, but access to these products is difficult, especially in low- to middle-income countries [31-34]. Educating people who use these products is also very important. Rehabilitation specialists could ensure that the products people receive are appropriate for them, and their environment is tailored to the users’ needs [35-41]. Globally, especially in low- and middle-income countries, rehabilitation in health systems needs to be strengthened so that high-quality and affordable services are available to all people in need [42-47]. As global health coverage is recognized as the third goal of sustainable health development, countries are encouraged to ensure equitable access to high-quality and affordable health services, including rehabilitation [48-54]. 
Currently, rehabilitation services are provided by different executive bodies at different levels with various policies. Considering the lack of integrated services, the large number of people in need of rehabilitation services, and the emphasis of health policy on implementing the health system transformation plan, providing comprehensive and integrated rehabilitation services is necessary. Therefore, the present study was conducted to review the national documents of middle- and high-income countries considering the goals and policies in the field of rehabilitation and, finally, compare the policies of those countries with the existing policies in Iran in terms of access for people with disability to rehabilitation services. Recommendations are made to health and rehabilitation policymakers and executive agencies to provide rehabilitation services to improve quality and high access to rehabilitation services.

Materials and Methods
Type of study
The study is a scoping review type with a systematic search. Five steps are considered as follows. First, we identified the research question. Second, all relevant studies were identified and selected for more detailed analysis. Fourth, data were drawn based on the main concepts. Finally, the findings from the studies chosen were collected and summarized.

Research population 
The statistical population of this study comprised the papers and documents available in Scopus, PubMed, Google Scholar, Google, Scientific Information Database (SID), Documentation Research Institute (IranDoc), books, sites related to the Ministry of Health and the WHO of each country, as well as sources and references presented at conferences. In the group discussion section, experts and veterans of rehabilitation policy had a group discussion with the research team about the search results. 

Search strategy 
The present study was conducted based on the following objectives.
1. Identifying the system of providing rehabilitation services and their implementation in middle- and high-income countries and Iran,
2. Conducting a review of the studies on national rehabilitation policies in middle- and high-income countries and Iran, and
3. Having an overview of the processes and methods of policymaking in the field of rehabilitation in middle- and high-income countries as well as Iran.
The combination of the following keywords “rehabilitation”, “disability”, “policy”, “national policy”, “high-income countries”, “middle-income countries”, “strategy”, and “program” were searched in the available databases, for the documents and books related to the purpose of the study. All studies were found by two faculty members of the university who were thoroughly familiar with and experienced in the field of searching and screening papers. The obtained papers were first checked based on their titles, and the papers related to the purpose of the study were screened and included in the study. Then, the full text of the papers and documents were carefully studied, and the rehabilitation service delivery system/programs and policies in middle- and high-income countries were identified. Finally, all the extracted data were assessed in a group discussion session.
It should be noted that to review all available data, there was no time interval for searching documents. The inclusion criteria included studies and documents directly referring to the rehabilitation service delivery system in middle- and high-income countries. The exclusion criteria included studies published about low-income countries and or in a non-English language. The search strategy, following the study’s first purpose, is presented in Table 1.


After reviewing the experiences of other countries in the group discussion, the following items were finally proposed, and based on the results of the studies, the best policies and programs proposed for Iran were presented in the form of the following three objectives: First, removing barriers and developing access to rehabilitation services similar to the policies of other communities; second, improving the quality and development of rehabilitation services, required technology, community-based support, and rehabilitation services; and third, strengthening the collection of international data comparable in disability and supporting disability research and related services.

Results
This section presents the results in the following three sections according to the study objectives.
The first section identifies the system of providing services/ programs and rehabilitation policies in middle- and high-income countries (Table 2).


The second section discusses rehabilitation policies of middle and high-income countries.
The results in the four main areas were examined and presented in Table 3.


These 4 areas include integration of rehabilitation services in the health system in a serious way, the necessity of implementing rehabilitation services in an interdisciplinary manner at all three levels of health, necessity of providing rehabilitation services in hospitals, communities, and specialized rehabilitation clinics, and finally, strengthening the financial and insurance resources.
Based on the four main areas of rehabilitation policies, the important approaches to rehabilitation policies are as follows: Increasing quality of life, participation in society, supporting and providing cohesive social services, health promotion, security and development of rehabilitation at all levels of the health system, social integration, improving welfare of people with disability, preventing discrimination, especially in employment, building a society where disabled people can fully participate in life and society, developing rehabilitation in line with the rights of people with disability, and developing a national rehabilitation program to achieve independent living in people with disability. 
The third section discusses rehabilitation process and policies in middle and high-middle-income countries (Table 4).



Discussion 
Identifying the system of providing rehabilitation services in the middle- and high-income countries and Iran
Two areas where the governments have made structural changes in recent decades are social health and welfare, that complement each other. WHO has also recommended “cross-sectoral and intra-sectoral coordination” strategies in countries’ health systems to solve these problems and create alignment and coordination among them [7]. 
The results of a comparative study and research findings on the structure of health, welfare, and social security in Iran indicate the following six facts:
1. Centralization of planning,
2. Government’s attention to strategic management, planning, and macro control of the comprehensive system of health, welfare, and social security,
3. Restriction of the main activity of the government in the field of social welfare and health to the general system and creating the ground for determining the standards for monitoring the implementation of welfare and social security regulations in accordance with national documents and laws,
4. Responsibility of the Ministry of Health for formulating policies, planning, and providing health and medical services, and creating coordination in health ,
5. Responsibility of the Ministry of Welfare and Social Security and its affiliated organizations for formulating and setting policies, planning for the provision of welfare services and social security, and 
6. Welfare and social security issues mainly include services such as retirement, health insurance, medical services, rehabilitation of the disabled and injured, support for the needy people, the elderly, children, and women without pay and pension. 
In general, the most important structural problems and shortcomings of this section can be mentioned as follows: Separation of the management of the health and treatment system and the health insurance system and rehabilitation and support services in the two ministries, which may cause incoherence in the management of the welfare system and social security; heterogeneity of duties assigned to the institutions in charge of health, welfare, and social security; lack of necessary information and statistics in the field of health, welfare, and social security; and lack of a comprehensive insurance system.
Results of this study showed that the Ministry of Welfare and Social Security, which was formed based on the law of the welfare system and social security structure, includes insurance and relief organizations; their tasks and missions are diverse and numerous. The diversity, multiplicity, large volume of operations, and areas of activity of the welfare and social security system, on the one hand, and the characteristics of these services, as well as skills required by those services, on the other hand, indicate that such an organizational structure needs re-engineering. Therefore, designing a new model for Iran’s health, welfare, and social security sector is inevitable. Based on the results of this study, the health and social welfare system of the selected countries, and the principles mentioned, we suggest the following items.
To promote and focus on policymaking, planning, guidance, monitoring and evaluation, and increasing coordination in issues related to health and social welfare in terms of responsibilities and duties, the government should merge the Ministry of Welfare and Social Security with the Ministry of Health, functioning as the Ministry of Health and Social Welfare within its legal framework and in connection with this new ministry.
Insurance organizations, which are now under the Ministry of Welfare and Social Security should go under the Ministry of Health and Welfare. Under the new ministry, insurance organizations will function separately and be managed based on insurance principles with preservation of independence and legal nature. 
The medical field should not monopolize the management of the health sector, and due to the diversity and scope of the duties of the new ministry, managers with experience and expertise in different fields should be used appropriately. 
For population coverage, only the nationality of the property and the basis of population coverage should be used, and other sub-categories and classifications should be removed. 
It should be noted that with the merger of the Ministry of Social Welfare and the Ministry of Health and the establishment of the Ministry of Health and Social Welfare, coordination and coherence in policymaking, planning, proper allocation of health resources, and the level of welfare and social security will increase. The healthcare system will be inefficient if we do not consider the social security system. Thus, health, welfare, and social security should not work separately because of overlapping responsibilities and ignoring others. The government should consider merging to avoid dissatisfaction, confusion, and significant financial and economic losses. 

A review of studies related to national rehabilitation policies in the middle- and high-income countries including Iran
As the findings of the present study show, most countries’ strategies align with two goals of WHO, namely strengthening and developing rehabilitation and support services and community-based rehabilitation. Findings from different countries’ experiences in the rehabilitation field are presented as a conceptual framework for national policy. As stated earlier, this framework is part of the objectives of the WHO action plan. To overcome obstacles to achieve this goal, we believe that the following items should be provided: Legal support for policy documents, access to public media and opportunities to express themselves in an empowered community, adaptation to the physical environment and public transportation, government support to create job opportunities for people with disabilities and encouraging them to be employed with the help of entrepreneurs, passing mandatory laws to employ disabled people in the private sector or to allocate income to disabled people, allocating sufficient budget resources, transferring rehabilitation knowledge to the community to reduce negative perceptions, and familiarity with providers and types of rehabilitation services.
To strengthen and develop rehabilitation services, it is necessary to pay extensive attention to issues, such as the development of rehabilitation technology, the development of training and management of the rehabilitation system, the expansion of various types of rehabilitation services, and the development of rehabilitation levels. In this regard, one of the most important parts is the development of service levels; rehabilitation services are provided at four levels: Inpatient, outpatient, community-based, and rehabilitation services in long-term care and palliative care in different countries. 
In addition to medical rehabilitation, other types of rehabilitation services have also been developed in several countries; medical services available in different countries range from standard rehabilitation services, such as physiotherapy and occupational therapy, to new reproductive and cardiac rehabilitation services. These services are provided in two types based on disruption or target groups [18, 19]. Meanwhile, disorder services can be used in the field of physical disorders such as occupational therapy, physiotherapy/water physiotherapy, speech therapy, respiratory rehabilitation, musculoskeletal rehabilitation, post-stroke rehabilitation, spinal cord injury rehabilitation, sports orthopedic treatment, fall prevention, vestibular rehabilitation (middle ear balance), rehabilitation in visual impairment, new special education for the deaf, or neurological and cognitive/mental health services such as neurological rehabilitation for Parkinson, Alzheimer, dementia, brain tumor, stroke, and Guillain-Barré syndrome, social skills, attention to clinical psychology and learning disabilities, stress reduction programs, learning capacity assessment for people with mental disorders, or interdisciplinary services such as cardiac rehabilitation (ECG-based monitoring with physiotherapist, nurse, nutritionist, as well as stress management interventions, physical activity, smoking cessation, and treatment regimen). 
Providing services at various levels requires accurate, coherent, and productive organizational training and management. To deliver comprehensive rehabilitation programs, in some countries such as Japan, rehabilitation services are integrated into the entire health system [23], or there is an inter-agency coordination office to provide integrated services. In some African countries, the National Community-Based Rehabilitation Organization has been established due to the importance of the range of services [10].
A proper referral system from remote neighborhoods or villages and the establishment of a regional center for rehabilitation are also critical issues. Action plans also emphasize that rehabilitation centers are close to existing regional hospitals. Meanwhile, home delivery is more concentrated in countries like the UK. Also, the expansion of rehabilitation hospitals is one of the infrastructures of rehabilitation system management. To generate income, countries such as India have invested in “health tourism” by establishing special rehabilitation hospitals that provide various community services or health villages with special medical rehabilitation facilities for the elderly or children [15]. 
In addition, it is essential to pay attention to technology as a suitable platform to improve the efficiency of the rehabilitation system in countries. Developed countries in rehabilitation technology, such as Germany, Sweden, and the UK, successfully provided gadgets that improve the independence of people with disabilities in everyday life. In some other countries, standard devices such as mobile technology track treatment adherence [5]. Technology can also be utilized to make the rehabilitation system more efficient, and with an online network, connections can be created between existing rehabilitation programs at the community level. In some countries, the communication networks and information exchange between people with disabilities and their families with rehabilitation centers are also considered [22].
Finally, we want to mention that the whole rehabilitation system in Iran needs continuous monitoring to observe health rights such as availability, access, effectiveness, and search for inappropriate functions. There is also a need to strengthen the statistical information system between the various departments and assess the upcoming year’s rehabilitation needs for interdepartmental cooperation. Last but not least, in the framework of national rehabilitation policy, it is necessary to pay attention to the recommendations of the WHO and to raise awareness and deepen knowledge about the concept of disability among policymakers so that various trustees, such as the Ministry of Health would not neglect health issues. Meanwhile, compared to other middle- and high-income countries, Iran faces the following serious problems: Lack of insurance coverage for special medical and rehabilitation needs, inadequate physical access to health and medical centers, high direct costs of medical services and rehabilitation, lack of special rehabilitation and medical services in many medical centers, inappropriate treatment of health service providers, high cost of rehabilitation equipment, and lack of inadequate access to the public transportation system in many provinces of the country.
3. An overview of the process and method of policymaking in the field of rehabilitation in middle- and high-income countries including Iran
In many countries studied, the health and rehabilitation policy process is decentralized to a specific institution. In most of these countries, the central government has formulated general policies and then left the implementation of those policies to regional governments. According to a review of middle- and high-income countries, they have tried to avoid centralism and, on the other hand, have put more emphasis on prevention and care in the country’s future health and rehabilitation programs. Whereas, in Iran, there is a strong centralism in the policymaking system, as well as the implementation of health system and rehabilitation policies, which is a tiny part of health system policies. Also, policies are only formulated in the Ministry of Health, as well as the Ministry of Welfare without coordination with other organizations. Meanwhile, the country must implement those policies without the slightest change. The important policies of the countries under review in this study are better access to high-quality health and rehabilitation services, financing, and a strong insurance system. In most countries, financing is provided through the tax system and with full insurance coverage; thus, out-of-pocket payments account for a tiny percentage. Compared to the studied countries, Iran has a fragile insurance system for financing. Also, it has high out-of-pocket expenses for various health services, especially rehabilitation, that are provided only for one field, namely physiotherapy, and only for essential insurance coverage services, and all costs of patients’ rehabilitation treatment are paid out-of-pocket. In Iran, only two organizations, the Ministry of Health and the Ministry of Welfare (specifically the Welfare Organization), are responsible for rehabilitation policy and budget processes. The Welfare Organization provides resources in the form of grants to rehabilitation service providers to help people with proven disabilities, according to the ICF definition, at outpatient, community-based, and residential levels. The financial resources required by the Ministry of Health and the Welfare Organization in Iran are provided by the Program and Budget Organization. Other institutions, such as the Iran Red Crescent Society, a non-governmental organization mainly active in medical equipment, and the Martyr Foundation, which is solely responsible for providing services to veterans, are funded separately. 
It seems that policymakers do not see the interests and needs of minority groups such as people with disabilities, and also are not reflected in society. The main concern is that policymakers tend to move toward policies that have greater outcomes and effects for both the community and themselves; thus, issues of minority groups, such as people with disabilities, are usually not attractive and noteworthy for a majority of policymakers who tend to focus their energy on issues that are hot topics in main media, rather than those in the margins. Also, it has been suggested that minority groups do not create much financial benefit for managers and policymakers. Policymakers often prefer to work for organizations with less budget constraints that maximize their financial benefits. Overall, these issues have led policymakers to pay little attention to the vulnerable minority groups. 

Conclusion
As the results of this study on the experiences of different countries show, the ultimate goal of policymaking in rehabilitation is the social integration of people with severe and mild disabilities to provide them with a normal and functional life. This goal in various countries includes the following: Comprehensive support for people with disabilities, the development of a society without barriers to the participation of people with disabilities in society, freedom, equality, dignity, and independence in daily life. According to the findings, in high-income countries such as Australia, the emphasis is more on the social inclusion of people with disabilities in the workplace, or in Germany, with the help of entrepreneurs, to help people with severe disabilities to function as normally as possible. On the other hand, in middle-income countries, it is a mission to provide a place where people with disabilities can live independently. According to the findings of this study, to achieve the goal of social inclusion and integration, it is necessary first to lay the groundwork and then develop strategies and operational plans. In this regard, laying the groundwork is one of the essential tools for achieving a decent life for people with disabilities, after which the National Rehabilitation Program needs to pay attention to the development of services offered by hospitals at community-based levels, as well as by providing services for target groups such as children and the older people. 
The trend of social and political developments regarding people with disability in developed countries shows that campaigning has been an essential driving force to put the issues of people with disabilities on the agenda. Alongside this, governments must ensure the conditions under which such events occur. In leading countries in meeting the health needs of people with disabilities, these campaigns have played an influential role in raising public awareness, changing attitudes, and seeing and hearing the demands of these people. Hiring experienced managers in the field of policymaking can be a practical step toward putting the issues of people with disability on the agenda. Employing people whose performance is nationally recognized and can influence various institutions is effective in forming political lobbies and introducing new laws and regulations. This condition can further accelerate the process of examining the issues of disabled people. Meanwhile, these people, with their power and influence, can bypass the organizational hierarchy and directly raise the problems of people with disability.

Ethical Considerations
Compliance with ethical guidelines
This study was made as a narrative review and it was not necessary to receive the ethical code for review studies.

Funding
This project was supported by the Technical and Research Secretary of the University of Social Welfare and Rehabilitation Sciences.

Authors' contributions
Conceptualization: Nahid Rahmani, Amirhossein Takian, and Mehrnaz Kajbafvala; Methodology: Amirhossein Takian, Marziyeh Shirazikhah, Nahid Rahmani, and Mehrnaz Kajbafvala; Investigation: Nahid Rahmani, and Mehrnaz Kajbafvala; Funding acquisition and resources: Amirhossein Takian and Marziyeh Shirazikhah; Writing the original draft: Nahid Rahmani and Mehrnaz Kajbafvala; Review and editing: Hadi Hamidi and Seyed Jafar Ehsanzadeh; Supervision: Marziyeh Shirazikhah, Nahid Rahmani, and Mehrnaz Kajbafvala.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The research team acknowledges from the research and technical secretary and social determinant of health research center of the University of Social Welfare and Rehabilitation Sciences. 


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