July 2006Page 1 of 14
ICRC strategic framework for supporting physicalrehabilitation
Preamble
Global context
History
The ICRC and other agencies
The ICRC’s physical rehabilitation framework
The guiding principles of assistance
Guiding principles for physical rehabilitation programmes: three pillars
Types of assistance
Modes of action
Distribution of responsibilities between physical rehabilitation programmes and the Special Fund for the Disabled
Complementarity between physical rehabilitation programmes and the Special Fund for the Disabled
Continuity of service
Conclusions
Annex
ICRC operational framework for supporting physical rehabilitation
Note: Unless stated otherwise, “ICRC” includes both the ICRC’s operational physical rehabilitation programmes (PRPs) and the physical rehabilitation programmes of the ICRC Special Fund for the Disabled (SFD).
Preamble
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance. And physical rehabilitation programmes help restore dignity. They get disabled people upright again – not just physically but in the sense of helping them reintegrate into family, community, employment and education.
The ICRC started physical rehabilitation before 1979, but that was the year in which the organization set up its Physical Rehabilitation Department, marking the start of a serious commitment. That same year, the ICRC launched two operational projects under its newly established physical rehabilitation programmes (PRP). 1983 saw a further major commitment, with the creation of the ICRC Special Fund for the Disabled (SFD) at the recommendation of the 1981 International Conference, held in connection with the Year of the Disabled. The mission of the SFD is to ensure the continuation of work started under ICRC operational programmes for people affected by conflict, and to support physical rehabilitation centres in developing countries.
As part of its mandate, therefore, the ICRC supports the physical rehabilitation of the victims of conflict and violence through its physical rehabilitation programmes and through the Special Fund for the Disabled. The PRP and the SFD provide similar support, and it is primarily the political context and the needs that decide which channel the ICRC uses in a given situation.
Since 1979, the ICRC's physical rehabilitation activities have diversified and its activities have expanded throughout the world. Physical rehabilitation as part of humanitarian assistance has progressed well beyond emergency response, as people who need physical rehabilitation will need it for the rest of their lives.
This document redefines the ICRC strategic framework for supporting physical rehabilitation that the Directorate of Operations approved in 1998. Revision also complements the ICRC Assistance Policy (Doctrine 49), taking account of experience gained and of various policy papers and guidelines. The main document sets out the strategic framework for supporting physical rehabilitation, while an annex describes the operational framework.
The aim of this document is threefold:
- to guide decisionmaking on support for physical rehabilitation and, to ensure a professional, coherent, integrated approach that meets the essential needs of individuals and communities affected by armed conflict and other situations of violence;
- to clarify the role of both the operational physical rehabilitation programmes and the ICRC Special Fund for the Disabled, and affirm the position of physical rehabilitation work within the ICRC;
- to serve as a reference framework for guidelines on physical rehabilitation.
Global context
The disabled population is increasing as a result of population growth, ageing, chronic conditions, malnutrition, war, landmines, violence, road traffic, domestic and occupational injuries and other causes – often related to poverty. These trends are creating an overwhelming demand for health and rehabilitation services and in most countries; demand is growing faster than service provision. Although no exact figures are available, the World Health Organization (WHO) estimates that people with physical disabilities in developing countries who need physical rehabilitation services (prostheses, orthoses, walking aids, wheelchairs or physiotherapy) represent 0.5% of the population. Situations of conflict or violence have a direct effect on:
- the general health of the population (the number of injuries increases);
- the health system (which may collapse due to lack of personnel, infrastructure and funds);
- the link between needs and services (access to services may become more difficult).
In such situations, it is not only people directly affected by the conflict who need physical rehabilitation services – those injured by landmines, bombs and other ordnance. People indirectly affected will also require such services – people who become physically disabled because the breakdown of normal health services prevents them from receiving proper care and/or vaccinations. Drawing a clear line between these two groups might therefore be difficult. And to the person affected, such a distinction is irrelevant.
Physical rehabilitation services exist in most countries. However, they are frequently inadequate, in either quantity or quality. In the vast majority of low-income countries, facilities are too few in number and/or too centralized and their output is too low to meet the needs of the whole population. Frequently, the technologies used are inappropriate, the quality of the devices is poor and the number and skills of the personnel do not match demand. A multitude of other priorities mean that the needs of people with disabilities – including physical rehabilitation – are rarely a primary concern for governments of low-income countries. As long as the needs of people with disabilities remain so great and as long as the situation does not improve, there will be a need to raise awareness, both nationally and internationally. Providing physical rehabilitation services is a labour-intensive activity that is difficult to rationalize and impossible to sustain on a purely commercial basis. The fact that prostheses and orthoses (P&O) are manufactured according to the measurements and specific anatomic features of each individual makes mass production difficult. Production is hence time-consuming. Even if the most inexpensive materials were used, the services would still be considered expensive in low-income countries. At the same time, it is often impossible to ask users for more than a token payment, which means services, cannot be financially self-sustaining. As a result, physical rehabilitation services often require considerable additional funding.
Physical rehabilitation is not an objective in itself; it is an essential part of ensuring the full rehabilitation and reintegration into society of people with disabilities. Enabling a person with a disability to walk and move about is in itself a great achievement. But the fact that this may be essential in order for the person to participate in social life, work and education adds another dimension to the work of physical rehabilitation services. One of the particularities of people with physical disabilities is that most cannot be cured; their disability is permanent. Disabled people will therefore need rehabilitation services for the rest of their lives if they are to continue to play their role in society. After receiving a device, the user will need to have it repaired and/or replaced regularly.
The complicated nature of physical rehabilitation services and the challenges associated with sustaining them mean that establishing and developing a physical rehabilitation programme is a long-term commitment. Success will depend on the determination and long-term involvement not only of the local agency or organization providing the actual services, but also of supporting organizations and donors.
History
Over time, the ICRC has acquired a leadership position in physical rehabilitation, mainly on account of the worldwide scope of its activities, the technology it has developed, its expertise and its longterm commitment to the projects it supports. In most countries where ICRC physical rehabilitation programme (PRP) have provided support for physical rehabilitation, such services were previously minimal or nonexistent. In most cases, ICRC support has been the basis for establishing a national service.
Projects and beneficiaries
Between 1979 and 2005, the ICRC physical rehabilitation programme supported 102 projects (i.e.centres) in 37 countries. This is an average of four new projects a year. Over half the centres were built from scratch, with the ICRC frequently covering a large proportion of the construction and equipment costs. The ICRC’s operational physical rehabilitation activities expanded from two centres in two countries in 1979 to a total of 71 assisted projects in 23 countries in 2005.
The PRP manages 90% of projects in close cooperation with a national partner, generally the government authority responsible for such work in the country concerned. The PRP has only ever run a small number of such centres on its own. Where it has done so it was either due to the absence of a suitable partner at the time of starting (Afghanistan) or because the centre was to treat victims from a neighbouring country (Pakistan, Kenya, and Sudan).
Since 1983, the SFD has supported 77 projects in 37 countries. Unlike the operational projects, all SFDassisted centres are run jointly with local partners. The SFD has never been involved in the construction of new centres and running its own project. The SFD’s activities expanded from one project in one country in 1983 to a total of 53 projects in 26 countries in 2005.
Altogether, the ICRC has been involved in physical rehabilitation in 54 countries (17 PRP only, 17 SFD only and 20 where work started under the auspices of a PRP and was subsequently taken over by the SFD).
The increasing number of centres assisted has resulted in an increased number of beneficiaries. Since 1979, almost 290,000 people have benefited from ICRC-supported physical rehabilitation services (prostheses, orthoses and physiotherapy); 230,000 through the PRP and 60,000 through the SFD. In addition, many people have received walking aids or wheelchairs. The benefits of the infrastructure and know-how that the ICRC has helped put into place were not limited to the patients treated during the assistance period; they have continued after assistance ended. The real number of beneficiaries is therefore higher than indicated, as patients treated after the ICRC withdrew from an assisted centre are not included in the statistics.
Over the years, the ICRC has changed its strategy to include more and more people indirectly affected by conflict. In most countries, their number exceeds the number of amputees among the populations affected by conflict. However, their treatment can be more complicated and often demands a higher degree of rehabilitative knowledge, requiring a multidisciplinary approach and more frequent follow-up than for amputees. By 2005, the number of services the ICRC provided to non-amputees had exceeded the number of services provided to amputees, but the ICRC remains the main organization providing services for the direct victims of conflict. During 2004, approximately 80% of all devices provided to mine survivors worldwide were supplied through ICRC PRPassisted centres.[1] The proportion of mine victims among all assisted amputees is approximately 60% for the operational programmes and approximately 40% for those of the SFD.
Where possible, the ICRC promotes socioeconomic integration programmes through referrals and/or cooperation with other organizations. In Afghanistan, where the ICRC itself possesses the necessary know-how on account of its dedicated personnel and longterm presence, several thousand people with disabilities have benefited from ICRC vocational, educational and micro-credit programmes after their physical rehabilitation.
ICRC technology
Initially, the ICRC used imported materials and machines from established Western suppliers. To reduce running costs and improve quality, the ICRC soon started developing a new, appropriate technology that would allow the provision of quality services at an affordable cost. In 2004, the International Society for Prosthetics and Orthotics (ISPO) recognized the ICRC’s important role in making rehabilitative devices more readily available by developing and introducing low-cost, quality technology when it awarded the organization its Brian Blatchford Prize. ICRC technology has become a standard and is used by an increasing number of organizations.[2]
The ICRC as a centre of expertise
With a large international force of experts (45 fulltime expatriate ortho-prosthetists and 15 fulltime expatriate physiotherapists from 24 countries in 2005), the ICRC employs by far the largest number of specialists of any international organization in this field. Over time, the average number of expatriates has fallen from seven per project to just one, mainly because of the experience that both the ICRC and the national personnel in the centres have acquired. In addition, physiotherapists from the PRP are involved in hospitals supported by the ICRC, as members of multidisciplinary teams.
Longterm commitment
In the early days of ICRC involvement in physical rehabilitation, some facilities continued successfully after the ICRC withdrew, but in other cases the result a year or so later was an empty centre with no materials, no trained personnel and no patients. As mentioned above, the needs of people with disabilities – including physical rehabilitation – are rarely top priority for the governments of low-income countries. This results in a lack of funding and support for the centres. Apart from the direct suffering this causes to patients and personnel, it represents a significant loss of investment in human capital and materials. A person with a disability is handicapped for life and needs lifelong access to functioning rehabilitation
services.
To increase the chances of services continuing after it withdraws, the ICRC has adopted a longterm approach to the implementation and management of its physical rehabilitation projects. While the main priorities are to increase accessibility and quality, the ICRC always bears in mind the need to boost its partner’s capacity to manage the services, right from the start of the support period. It achieves this through training and mentoring, in addition to material/financial assistance. Furthermore, the ICRC encourages the authorities to develop and implement a national physical rehabilitation policy. Whether or not services continue longterm depends on financial, organizational and technical factors:
- Finance: ICRC polypropylene technology helps minimize centre running costs.
- Organization: The ICRC has developed management tools (stock management, patient management and treatment protocols, etc.) to support management teams.
- Technical: Appointing highly qualified expatriate specialists (ortho-prosthetists and physiotherapists) helps ensure quality of treatment. Over the years, the ICRC has been increasingly involved in training, as training is an important part of promoting the long-term functioning of services. In 2003, the ICRC developed an in-house training package for prosthetic/orthotic technicians, the Certificate of Professional Competency (CPC), which is recognized by the ISPO. Since then, the CPC has been implemented in Ethiopia and Sudan. In addition, the ICRC sponsors many staff to attend formal training in P&O and physiotherapy. ICRC specialists also provide on-the-job training. In 2004, the PRPs developed a training policy for personnel at assisted centres, specifying how the ICRC would support personnel development.
Over the last 25 years, the average duration of fulltime ICRC expatriate presence in ICRC PRPassisted projects has been seven years. If parttime expatriate presence is included, the follow-up is even longer. Technical assistance can be reduced from fulltime to parttime as long as the necessary steps are taken during the implementation phase. In addition, and if needed, the ICRC Special Fund for the Disabled can provide follow-up once the ICRC has completely withdrawn from a country. This longterm commitment to patients and facilities is unique among assistance organizations and is much appreciated by the ICRC's partners at both centre and government levels. It is also one of the ICRC’s major strengths.
The ICRC and other agencies
Because of its leadership position, the ICRC interacts with many organizations involved in physical rehabilitation, working with:
- international organizations such as the International Society for Prosthetics and Orthotics (ISPO), the World Confederation of Physical Therapy (WCPT) and the WHO in defining standards for appropriate technology, guidelines for training P&O personnel in developing countries, etc.;
- international organizations that provide services to beneficiaries, such as Handicap International, Cambodia Trust, Vietnam Veterans of America Foundation, etc.;
- academic institutions in developed and developing countries, to promote the training of staff involved in providing services;
- national and international mine action groups, to actively support the provision of assistance to people injured by landmines.
The ICRC also works with donors to support their involvement in implementing physical rehabilitation projects. At country level, the ICRC promotes and supports national coordinating bodies for physical rehabilitation, in which all agencies can participate, hence improving the response. In addition, the ICRC actively supports the efforts of national and regional organizations such as the Fédération Africaine des Techniciens Orthoprothésistes (FATO) to promote and develop physical rehabilitation activities.
The ICRC’s physical rehabilitation framework
As physical rehabilitation is a core ICRC activity, the associated programmes have acquired the skills and logistics capacity needed for their work. They also have the ability to upgrade operational skills and methods and to develop new standards, enabling them to adapt their guidelines and operations to the changing environment. The main aims of ICRC support are to:
- facilitate access to services;
- improve quality of service;
- ensure that services continue long-term.
These are the three main pillars of ICRC projects that support physical rehabilitation.