Mr. Ahyan Shandilya Domain Coordinator (Rehabilitation and Health) Handicap International ICHPO – Virtual day of Allied Health & Rehabilitation 2015

Project: Towards disability inclusive development through a strengthened rehabilitation sector in South Asia Period: June 2011 to June 2014 (three years) Mapping of physical rehabilitation services in Afghanistan, Bangladesh, India (Odisha) and Sri Lanka Title of the presentation

1. Improve the evidence and information on physical rehabilitation with an overview of unmet needs 2, Create coordination and dialogue on physical rehabilitation among policy makers, service users and service providers Highlighted Availability and situation of trained human resources, lack of standards in education and training, geographical distribution of professionals and governance of physical rehabilitation services The analysis also provided an opportunity to prepare an action plan for lobbying with the government(s) for policy inclusion. Aim (two fold)

Countries -Afghanistan -Bangladesh -India (Odisha) -Sri Lanka CountriesHDIPeople with disabilities Afghanistan1693.7% Bangladesh1425,6% India % Sri Lanka737%

Context – Estimates by WHO and World Bank for developing countries: prevalence of about 10% (ranging different to each country) – Absence of systematic mapping in these target areas – Limited information available – availability, accessibility and quality of services – Lack of data on disability delayed coordinated development of physical rehabilitation (services and human resources) – Provide a platform for the service users (people with disabilities) and service providers (physical rehabilitation professionals) to share their concerns with the decision makers (policy makers) – MDGs focused mainly on reducing specific diseases and mortality, particularly of women and children (little about quality of life)

Global facts – Access to physical rehabilitation  Only 3% of individuals who need rehabilitation globally are estimated to actually receive support  One third of countries globally did not allocate any specific budget to rehabilitation services in 2005  An estimated 105 million people across the world need an appropriate wheelchair  Only between 5–15% of people in low and middle-income countries who require assistive devices/ technologies actually receive relevant equipment  Children with disabilities are less likely to start school and have lower rates of staying and being promoted in school

Physical Rehabilitation Summarize  Treating the underlying pathology or injury  Reducing the impairment and/or disability  Preventing and treating complications  Improving functioning and activity  Enabling participation Inclusive One aspect of disability inclusive development  Estimated that 92% of the disease burden in the world is related to causes that require health professionals associated with physical rehabilitation*  By 2030, the top ten causes of disease will be conditions that require physical rehabilitation** Need

Afghanistan AvailabilityAccessibilityAccountabilityQuality Shortage of services in rural areas Economical situationRegulatory framework slow Quality looked at technical view Limited organizations/institu tions Less understanding about benefits Few DPOs and organizations for rights No analysis was done for services providers Lack of female staffPoor infrastructure, social and cultural barriers Existence of some professional associations Lack of indicators (HMIS) Funding constraint (hiring and training) Ongoing conflict situation Not any qualitative review Challenge for common quality indicators Less action orientedLack of coordinationRequired more in- depth analysis Need to monitor and invest Lack of awareness and information Limited freedom of movement Need to harmonize procedures Improving transparency

Bangladesh AvailabilityAccessibilityAccountabilityQuality Shortage in many districts Scarcity of fundsNeeded regulatory framework No analysis for service providers Absent from primary, secondary care Absence of policy and strategy hinders Key procedures for equal access Lack of indicators Handful of specialized hospitals Services very far from the living places Not done any qualitative analysis Investment in human resources and coverage Improper referrals and limited awareness Non-integration with health system In-depth analysis for internal procedures Absence of common quality indicators Lack of transportation Stigma and negative attitudes Less participation by people with disabilities Limited transparencya Lack of human and material, financial resources, Information about benefits Influence is weakLack of monitoring mechanism

India (Odisha) AvailabilityAccessibilityAccountabilityQuality Shortage in many districts (rural areas) Services located far from the living places Needed comprehensive framework No analysis for service providers Few CBR programmes and limited coverage Absence of policy and strategy hinders Build on existing mechanisms which are in place Lack of indicators and monitoring mechanism Improper referrals coordination and limited awareness Socio-economic conditions Not done any qualitative analysis Investment in human resources and coverage Establishment of DDRCs Difficulty in continuation of treatment/ follow up Coordination and harmonization procedures Absence of trained human resources in rural areas Limited human and material, and financial resources Lack of manpower, stigma and negative attitude Less participation by people with disabilities and DPOs Lack of clarity on information system Specialized services in urban areas and lack of information Information about benefits Referrals information not centralized Need to define incentives for quality services

Sri Lanka AvailabilityAccessibilityAccountabilityQuality Critical lack at community and primary heath care Lack of awareness and Information Regulatory framework still weak No analysis for service providers Tertiary care is more developed; opportunity also Challenging socio- economic conditions Many procedures are yet to define Lack of indicators Lack of trained human resources Inaccessible infrastructure Not done any qualitative analysis Investment in human resources and coverage Need to increase investment and guidelines Discontinuation or lack of follow ups No information system in place about benefits Absence of common quality indicators Lack of transportation to avail services Services availability far from living places Concept of user involvement/particip ation not applied Limited transparency Lack of coordination among various players Coordination issuesDPOs new but getting improved Lack of monitoring mechanism

Limitations – Security situation prevented participation of stakeholders – Political situation sometimes obstructed some key workshops – Not covered any qualitative review of actual service delivery Scope Focusing specifically on physical rehabilitation; doesn’t include rehabilitation linked to other types of disabilities

Main achievements In spite of varying situation and context in each country, the consultative process on mapping highlighted the common challenges.  Specific recommendations were incorporated in Vision-2020, a document on disability and rehabilitation by Government of Odisha  Recommendations contributed in drafting the National Action Plan for Disability in Sri Lanka  In Afghanistan, the MOPH has endorsed the mapping report, which will be reflected in their future policy and programmatic work  Helpful to other countries (Nepal): Discussions with Ministry of Health ongoing for including disability in the health policy  Process provided a platform for the service users (people with disabilities) and service providers (physical rehabilitation professionals) to share their concerns with the decision makers (policy makers)

Based on: Key role in health sector Three out of six building blocks of World Health Organization (WHO) health systems: 1. Service delivery (physical rehabilitation services) 2. Health workforce (rehabilitation professionals) 3. Leadership and governance (regulatory and legislative) Recommendations

Services Increase awareness of communities and persons with disability about the benefits Which services, what level, estimated human resources Strategy for regulatory mechanisms and guidance Implementation of policy and adequate matching financial budget Indicators in Health Management Information System (HMIS) User-centred approach Define minimum quality standards

Human Resources Ensure physical rehabilitation professionals are included health strategies Capacity development plan to produce the requisite HR Ensure trainings in non-urban settings to facilitate better geographic distribution Increase awareness and facilitate timely and adequate referrals Clear job descriptions exist for each group of professionals Quality standards required to deliver physical rehabilitation services Mainstream physical rehabilitation within other public health disciplines

Leadership and governance Establish a physical rehabilitation taskforce Key actors: Ministries, service providers, users, professional organizations and NGOs Continue and improve coordination Ensure that CBR programs support strengthen the voice of persons with disabilities Strengthen the capacity of professional associations Enhance involvement (disabled persons organizations, user groups NGOs) to participate

Key factors in process  Relationship and willingness by different stakeholders  Constant engagement and regular follow  Formation of core committees and its active lead  Participatory process ensuring that the recommendations  Coordinated planning approach  Complimentary analyses drawn from well-defined frameworks for analyzing rehabilitation system had been conducted previously  Availability of various national and international expertise on health and rehabilitation

Thank You !!!