The global demand for rehabilitation services is increasing at an unprecedented pace, driven by ageing populations, a rising burden of noncommunicable diseases, and improved survival following acute medical conditions. Despite this growing need, access to rehabilitation services remains uneven, particularly in low- and middle-income countries.1 Within this context, occupational therapy (OT) plays a critical role in enabling individuals to achieve functional independence and meaningful participation. However, in India, the presence of OT services continues to be inconsistent across sectors and regions. This uneven distribution raises an important and often under-discussed question: When OT services are limited or absent in certain domains, are we inadvertently creating space for role substitution by other professionals? SERVICE GAPS: A PERSISTENT REALITY Service gaps in OT are multifactorial. Workforce shortages, urban-centric distribution, and limited integration into public health systems contribute significantly to the problem. Global evidence highlights persistent shortages and uneven distribution of the OT workforce across regions.2 In India, OT services are still largely concentrated in tertiary care settings, with limited penetration into primary healthcare, community-based rehabilitation, mental health, geriatrics, and acute care services. The enactment of the National Commission for Allied and Healthcare Professions Act-2021 was a landmark step toward regulating and standardizing allied health professions, including OT. While the Act provides a framework for education, registration, and professional recognition, its translation into service expansion and workforce deployment remains a work in progress. Simultaneously, the professional leadership of the All India Occupational Therapists Association (AIOTA) has historically contributed to the development of educational standards and professional identity. However, the current healthcare landscape demands a renewed focus on service visibility, policy engagement, and expansion into underrepresented areas. FROM SERVICE GAP TO ROLE SUBSTITUTION Healthcare systems are inherently adaptive. When specific services are unavailable, other professionals often step in to address unmet needs. This phenomenon, widely recognized as task sharing or role substitution in global health systems,1 reflects attempts to maintain continuity of care. However, in the absence of OT, the distinct occupational perspective – centered on function, participation, and context – may be diluted. Functional training and activity-based interventions may still occur, but often without the integration that characterizes OT practice. For example: In mental health settings, the absence of occupational therapists may lead to an over-reliance on pharmacological and symptom-focused interventions, with limited emphasis on functional recovery and role resumption3 In broader rehabilitation settings, a lack of interdisciplinary balance may compromise comprehensive care delivery.4 It is important to emphasize that this is not an issue of professional encroachment, but rather a reflection of professional absence. IMPLICATIONS FOR REHABILITATION OUTCOMES The absence or underrepresentation of OT has tangible consequences for patient care. Rehabilitation that lacks an occupational perspective may become: Impairment-focused rather than participation-oriented Less responsive to contextual and cultural factors. This gap often manifests as: Reduced independence in daily activities Poor translation of clinical gains into real-life functioning Increased caregiver burden. Evidence consistently supports that effective rehabilitation requires a well-coordinated multidisciplinary workforce, where each discipline contributes its unique expertise.4 PROFESSIONAL IDENTITY AT RISK Service gaps also affect the professional identity and visibility of OT. When the profession is not actively engaged across healthcare settings: Its role becomes less understood Its inclusion in policy and programs is reduced. Studies on rehabilitation workforce development highlight that a lack of clarity in roles and competencies can limit effective utilization of professionals.5 This is particularly relevant in contexts where OT is still evolving. BEYOND EXTERNAL FACTORS: A NEED FOR PROFESSIONAL INTROSPECTION While systemic barriers are significant, internal factors within the profession must also be acknowledged. These include limited expansion into emerging areas, variability in practice approaches, and gaps in advocacy. Addressing these challenges requires a shift toward proactive professional positioning, supported by workforce strengthening and competency development strategies.5 THE WAY FORWARD Expanding into underserved domains Strengthening workforce distribution and training Reinforcing occupation-based identity Enhancing policy advocacy through bodies like the AIOTA Promoting interdisciplinary/multidisciplinary collaboration. Such measures are aligned with global recommendations for strengthening rehabilitation services and workforce capacity.1,2 CONCLUSION Service gaps in OT are not merely logistical concerns; they shape the quality and direction of rehabilitation services. When OT is absent, the needs it addresses are met in alternative ways, often without the depth of occupational focus required for holistic care. The issue is not of encroachment, but of absence. The future of OT lies in expanding its presence, strengthening its identity, and ensuring its integration into all relevant domains of healthcare.
Pankaj Bajpai (Tue,) studied this question.