Disability manual for the health sector, draft for comments from stakeholders, 6 May 2007

Chapter 5: Rehabilitation

This chapter gives a definition of rehabilitation in the perspective of physical rehabilitation and explains rehabilitation at different levels, from community based to highly specialized and centre based physical rehabilitation

5.1 Definitions of rehabilitation:

Rehabilitation includes a wide range of activities in addition to medical care, including physical, psychosocial and occupational therapy. It is a process aimed at enabling people with disabilities to reach and maintain their optimal physical, sensory, intellectual, psychological and/or social functional levels. Rehabilitation provides people with disabilities with the tools they need to attain independence and self-determination, including measures to provide and/or restore functions, or compensate for the loss or absence of a function or for a functional limitation.

Also rehabilitation is about building self-esteem of people with disability and removing barriers. So rehabilitation is a process of removing the barriers that prevent a disabled person from being integrated into society. These barriers may be caused by:

  • The impairment itself
  • The attitudes of non-disabled people and society
  • Physical obstacles such as the inaccessibility of buildings and transport
  • A combination of all three

In general the verb to rehabilitate means to bring back something to an earlier level of construction or function that is better than the present level. In English usage you can for example:

  • Rehabilitate buildings that has been damaged or worn down, back to the original condition or to a better condition than originally.
  • Rehabilitate persons that have been physically impaired because of physical trauma or a physically impairing illness, back to the previous level of functioning or at least back to a level of better functioning than just after the impairment

Physical rehabilitationin this sense refers to the process aimed at enabling persons with functional limitations because of physical impairments, to reach a level of optimal physical functioning. Rehabilitation may include measures to provide and / or restore physical functions, or compensate for the loss or absence of a function or for a functional limitation. The rehabilitation process does not involve initial medical care[1].

5.2 Types of Rehabilitation:

  1. Community Based Rehabilitation
  2. Outreach Rehabilitation
  3. Center Based Rehabilitation

5.2.1 Community Based Rehabilitation – CBR

Community Based Rehabilitation was worked out by WHO as a strategy of rehabilitation within the community so that people with disability should have easy access to services of low cost. It is an approach that came out of the Alma Ata declaration “Health for all” in 1978, where the principles of Primary health Care (PHC) was laid down. According to the joint report by WHO and UNICEF 1978, PHC was to address “- the main health problems in the community, providing promotive, preventive, curative and rehabilitative health services”. CBR therefore has its roots in PHC and is supposed to be delivered along-side promotive, preventive and curative care[2].

In later years the emphasis of CBR has shifted much more to a rights based approach regarding access to services and community development in general. CBR can now be defined as: “a strategy within general community development for the rehabilitation, equalisation of opportunities and social inclusion of all people with disabilities[3]”

The implementation of CBR implies combined efforts of people with disabilities themselves, their families, DPOs and communities, relevant governmental and non-governmental services in all sectors. The objectives of CBR are to ensure that people with disabilities are able to[4]:

Maximise their physical and mental abilities

Access regular services and opportunities

Become active contributors to the community and society at large

In Afghanistan there have been CBR programmes for more than 10 years, which have been implemented by NGOs. They are still going on in the regions of Maimana, Mazar-e-Sharif; Taloqan, Faizabad, around Kabul, Herat, Kandahar and Jalalabad with relations to regional rehabilitation centres in the cities, but main activities are in the districts around.

The community should be active to promote and protect the human rights of people with disabilities. The Human Rights Approach to disability has as its main objective to promote the rights of persons with disabilities to live as equal citizens within the community. A new UN Convention is being approved now to strengthen the state obligations to promote the rights of people with disabilities. The Afghan CBR programmes follow up this development.

There is a strong correlation between disability and poverty. All the Millennium Development Goals are relevant to disability; of them are 3 goals of particular concern to people with disabilities and their families:

  • Eradicate severe poverty and hunger
  • Achieve universal primary education
  • Promote gender equality and empower women

CBR is a multi sectorial approach – to health, education, social development, employment, informal sector and civil society. CBR will need coordination at national, province/district and local levels. There should be national coordination among sectors, where Government and NGOs should work in close partnerships in order to develop specific services and to include disability components in general programmes; one example is to include physical rehabilitation services into basic health packages. Experience has shown that the province/district level is a key point for coordination of support to communities. At local level full community involvement and leadership is crucial; community workers are always the core of CBR programmes.

In Afghanistan CBR field workers and volunteers have surveys in villages to register new persons with disabilities in need for rehabilitation and support. Above all it is important to assist families with disabled children. CBR workers visit homes and advise on home based training for movement, seeing, hearing and learning impaired children and young persons. If the children or youth are able to, they are referred to Community Rehabilitation and Development Centres (CRDC) for training and social activities. They may also be referred to more specialised medical services, for example children affected by polio may need orthopaedic/corrective surgery. We will discuss more on CBR as part of PHC in chapter 5.3

5.2.2 Outreach Rehabilitation:

In recognition of the need to cover more people, some rehabilitation centers have initiated outreach programs, in which they send out teams to treat People with Disability where they live or in district centers. These clearly have some advantages over closed institutions in terms of coverage, but because they are entirely operated by usually an urban-based institution they not owned by local communities and are therefore not very sustainable.

An extension of the outreach concept is to run community level services, again with an institution as the main initiator. The idea is to have services available at local level, but funded by sources and provided by people from outside the community. This model has some advantages over outreach model in that there will be greater follow up of individual cases, but it not sustainable in the way CBR is intended to be.

5.2.3 Center Based Rehabilitation:

Until the arrival of the concept of CBR in the late 1970s this was the most usual way of providing services for People with Disability. Institutions for People with Disability were and are usually set up with the best intentions in order to do something for People with Disability; who are regarded as unfortunate and in need of special help. There are two main problems with this approach to rehabilitation:

  1. Unfortunately many of these institutions become places where People with Disability are parked and forgotten. They are isolated from their own communities and this has two negative results: People with Disability are not socially integrated and non disabled have little knowledge on disability.
  2. Institutions can only cover a fraction of need. Most People with Disability in countries remain without any services at all.

Nevertheless, institutions should not be regarded as wholly unnecessary or undesirable. They can become important resources for training, developing new ideas and research. For some disabilities, for example profound deafness, integration in normal school may be impossible and special school of children with hearing disability may be necessary.

5.2.4 Physical rehabilitation in the form of physiotherapy

The Guidelines for BPHS implementers gives an overview of the components of disability training and physical rehabilitation at various service levels of BPHS. Here is a summary:

Physiotherapy, or Physical Therapy, is a healthcare profession concerned with the assessment, maintenance, and restoration of the physical function and performance of the body. It is a distinct form of care which can be performed either in isolation or in conjunction with other types of medical management. Used in conjunction with certain medical or surgical techniques, physiotherapy can complement these techniques to help provide a speedy and complication-free return to normal activity. The majority of patients treated by physiotherapists currently in Afghanistan are not patients with permanent disabilities or impairments but those suffering temporary impairments (post-fracture, post-operative, bad backs and bad necks). Treatment of these patients through physiotherapy can restore and improves mobility and function.

5.2.5 Physical rehabilitation at different levels of health facilities:

Persons requiring physical rehabilitation can be identified and registered at all levels. From Health Posts (HPs) and Basic Health Centres (BHCs) patients can be referred to Comprehensive Health Centres (CHCs). If rehabilitation staff are available at CHC level they can provide outreach services to HPs and BHCs as well as home-based training for patients with disabilities where required. Centre based physical rehabilitation services are proposed at the CHC level with basic equipment and staff consisting of one male and one female Physiotherapist (PT). This is in order to treat adult male patients and female patients separately. Children can be treated by either a male or a female PT. More PTs are initially expected to be based in physiotherapy clinics at DistrictHospital level where patient numbers are higher. The physiotherapy clinics will be run as outpatient clinics with patients required to come for several treatment sessions on a daily or weekly basis. PTs in a district hospital will also provide treatment for inpatients in the hospital wards as is required.

There are services that are related to CBR, where the physiotherapist acts as advisor for families and community workers on basic physical exercises and stimulation of children with disabilities. Rehabilitation services are linked to all levels in the health system. In Guidelines the services are described in the following way:

Outreach Physiotherapy Services

Outreach physiotherapy services are a means of providing physiotherapy treatment and follow up to patients in rural areas, either in their own homes, or on regular visits to see patients at HPs and BHCs. Outreach services are of particular benefit for those individuals who have severe movement or mobility problems and who cannot attend rehabilitation services at CHC or DH level. An important aspect of the outreach services, as in all physiotherapy services, is to providing training and support to the family members of the disabled patient in order to promote better social inclusion of the disabled in the community and to spread disability awareness amongst other medical staff and Community Health Workers (CHWs).

Centre Based Services:

Centre based services provide more comprehensive forms of physiotherapy treatment than those available in an outreach service. The physiotherapy clinic requires a large, well-lit room which can fit 2 or 3 treatment beds, storage space and a waiting area nearby for patients. There should be separate treatment rooms for men and women. Children should also preferably be treated in a separate room or a space with mats on the floor for therapy. The physiotherapy clinic should be accessible for the disabled especially wheelchair users and toilet facilities adapted for the disabled should be accessible in the clinic.

A comprehensive list of pathologies in which physiotherapy can help is provided in the Guidelines. It is indicated at what health service level the different pathologies may be treated.

Orthopaedic Workshop Services:

Orthopaedic workshops or centres provide mobility aids (crutches, walking frames), assistive devices (callipers, artificial legs) and wheelchairs to persons with disabilities. These services are not included in BPHS but come under provincial and regional centres in the EPHS. However, it is important that these services have close links with the rehabilitation staff and are known to all staff in the BPHS staff for referral and follow up. Mobile outreach services from orthopaedic workshops can also be organised at PT clinics where necessary for measuring of patients for mobility aids. A list of existing orthopaedic centres is attached in the Annexes.

Orthopaedic / corrective surgery:

When physical impairments such as for example club feet, contractures in limbs due to polio or different other paralyses cannot be treated successfully with physiotherapy or orthopaedic devices, surgery may be indicated as part of the rehabilitation process.

The importance of teamwork in physical rehabilitation

Successful physical rehabilitation work is always characterised by close cooperation and good communication between various health and other professions, different levels of the health system, supporting agencies from other sectors, for example employment support, and above all, the person with disabilities her/him self and the family. The person with disabilities should always have a decisive influence on rehabilitation plans.

There should an effective coordination and cooperation between physical rehabilitation staff and community rehabilitation workers especially in home based activities. Such efforts definitely will be in the benefit of people with disability. The rehabilitation workers at the community level should convince people with disability and their families to take supportive role in the rehabilitation process. Family trainers should have regular access to rehabilitation centres to give up to date trainings.

5.3 CBR and PHC[5]:

Although CBR started as a strategy under primary health care (PHC), it was soon realized that many of the concerns of people with disability and their families did not fall under the mandate of health sector; hence CBR shifted its approach to a multi sectoral one. Despite this shift CBR and other community health services have many similarity in approach, which could be advantageous to both. CBR has made a contribution to general health care development by bringing to the surface hidden conditions that have bypassed the attention of PHC worker because this worker was only aiming at stemming death. People with disability do not access most of the health services other people do. Even within existing disability services, the control of professionals renders them irrelevant to people with disability. It recommended that CBR, community health services and people with disability collaborate in service development with one aim, “equal right to health care”. People with disability in collaboration with health and rehabilitation personal should guide rehabilitation services. Data collection system of general health care and CBR should be linked and research originating from either should include the other. “Poverty and health” are interlinked- it is through sharing approaches and resources that poverty and lack of access to health care among people with disability can be addressed. CBR is about meeting basic needs – accessing health, education, livelihood and equal membership of the community.

5.3.1 Poor health and disability – a hindrance to community development:

As it mentioned in chapter one the link between poverty, illiteracy, poor health and disability is well established. The WHO believes that provision of better health provides an exit from the poverty cycle and that investment in health is an asset to economic development. Community health[6] is therefore, a result of and prerequisite of community development[7].

In 1978 at Alma Ata, nations agreed that the strategy to improve people’s health should be through the Primary Health Care (PHC)[8]. PHC was to “address the main health problems in the community, providing promotive, preventive, curative and rehabilitative health services.” CBR therefore has its roots in PHC and is supposed to be delivered along-side promotive, preventive and curative care. Very few governments, NGOs and UN agencies have implemented this holistic approach to health care.

An example of the contradiction between people and service providers is illustrated in the following table. It can be seen that the priorities for the professionals are different from people with disability.

Experience indicates that a professionally directed program often fails to meet the priorities of people with disability and their families. CBR needs to be a community action to ensure that people with disabilities have the same rights and opportunities as all other community members. This includes, for example, equal access to health care, education, skills training, employment, family life, social mobility and political empowerment. The professional’s role is to support these actions, but not to decide on behalf of people with disabilities.

5.3.3 PHC and CBR as part of community development; overlap between CBR and PHC:

PHC focused on community improving health (removing ill health) and CBR focused on the integration of people with disability into community. PHC was embraced by community development as sectorial walls began to break. For example one of the reasons for success of immunizations revitalization is the use of community health workers and local leaders to mobilize families for various immunization campaigns, instead of depending on health workers alone.