community-based rehabilitation in zimbabwe

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Community-based Rehabilitation in Zimbabwe MARY McALISTER MCSP Key words: Zimbabwe. CIIR. community-based rehabilitation. Rehabilitation Assistants Training School. Ministry of Health. appropriate training programmes, primary health care. Summary: This article gives a brief outline of rehabilitation including community-based services in Zimbabwe. Biography: Mary McAlister qualified from the Dublin School of Physiotherapy and Trinity College in 1981. She worked in Dublin for a year before moving to Calgary, Alberta, Canada, where she worked primarily in paediatrics. In 1986 she returned to Dublin and worked in the Mater Hospital. Dublin. She went to Zimbabwe in May 1988, recruited by CIIR, to work with the Ministry of Health. Mary is based at a small provincial hospital and is responsible for supporting and developing existing hospital and community-based services in the area, and setting up new CBR projects throughout the country. Tafadzwa's Experience TAFADZWA is 15 years old and one of a family of six. Three years ago he contracted tuberculosis of the spinal cord. Due to severe spasticity affecting all four limbs and a marked scoliosis, he does not walk and is bound to his wheelchair. He needs assistance in most activities of daily living. With great difficulty he can turn the pages of a book. It takes him a long time to write his name, which is barely legible. Tafadzwa's mother struggles to feed and clothe her family. Her husband died of tuberculosis last year. Two more sons have similar diagnoses. The family was not immunised. Tafadzwa is a bright intelligent boy who is being denied an education. His family cannot afford private education and the specialised schools have no place for him. The local school does not feel confident about accepting a disabled pupil. Rehabilitation in Zimbabwe Zimbabwe is a landlocked country in Southern Africa. It has a population of 8.6 million, 80% of whom live in the rural areas. Agriculture is the most important economic activity with four-fifths of the population dependent on it. There is a vast difference between predominantly white- owned commercial farming and black communal or subsistence farming. The most common food crop is maize. Since Zimbabwe gained independence in 1980 the Ministry of Health (MOH) has begun to acknowledge rehabilitation as a component of primary health care. In 1981 the MOH launched the Rehabilitation Assistants Training School. The school runs a two-year course covering basic aspects of speech and occupational therapy and physiotherapy. 0 nce qua I if ied , the reha bi I i t a t ion assistants are deployed to rehabilitation departments attached to small district hospitals in the rural areas. Although they receive some supervision from therapists, they work virtually independently. Most of Zimbabwe's therapists are expatriates on two- or three-year contracts. The University 2f Zimbabwe has recently begun to train occupational therapists and the first students will graduate in 1991. The MOH has recently launched its national plan for CBR. By the end of 1989 it hopes to have initiated eight pilot CBR projects, one in each of the country's eight provinces. Community-based Rehabititation A battle has begun in Zimbabwe to steer people away from institutionalised care for disabled people. Community-based rehabilitation (CBR) is an exciting new alternative. CBR aims at developing rehabilitation services within the framework of primary health care and existing community services in a given area. It is developed within the community, identifying its needs and developing an appropriate strategy which teaches the members of the community to take responsibility for their own disabled members. Although the definition of a family unit in Zimbabwe has undergone some changes in recent years, and seems likely to continue to change, the family remains the most basic social institution responsible for the care and integration of new members into the community. The 'extended family' in Zimbabwe compels relatives to stay together and give each other support when in need and comfort in difficult times. Bearing these points in mind, it makes sense to set up a service that utilises these qualities. Following a meeting with the MOH, two representatives from each province were chosen to run a proposed CBR project. A plan of action was drawn up and a one-year plan for implementing the project was developed. The project will be primarily run by a rehabilitation assistant who will be given a motorcycle as hidher mode of transport. The project will be supervised by the provincial therapist who relies on transport from the provincial office. Obviously as the project develops the therapist's input lessens. The initial phase of the project is set up over a four-week period. The project begins with education and motivation of the community leaders. These include chiefs, councillors, headmasters, teachers, health staff, traditional midwives, traditional healers, prophets and church leaders. It is essential to have the confidence and support of community leaders and they should be motivated to mobilise their own people. In the second week of the project a group of community members is chosen for specific training. These people usually include village health workers and Red Cross volunteers. They are taught basic concepts of identification and referral of the disabled. The training is done in the community and appropriate teaching and visual aids are used. During the training week, the volunteers are taught to use a simple survey form. These are used in the third week to conduct a house-to-house survey by the local volunteers to identify and register the disabled in their areas. Finally, the fourth week involves screening whereby all the identified clients are assessed by rehabilitation personnel. The clients are registered and appropriate training programmes initiated. 432 Physiotherapy, July 1989, vol 75, no 7

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Community-based Rehabilitation in Zimbabwe MARY McALISTER MCSP

Key words: Zimbabwe. CIIR. community-based rehabilitation. Rehabilitation Assistants Training School. Ministry of Health. appropriate training programmes, primary health care.

Summary: This article gives a brief outline of rehabilitation including community-based services in Zimbabwe.

Biography: Mary McAlister qualified from the Dublin School of Physiotherapy and Trinity College in 1981. She worked in Dublin for a year before moving to Calgary, Alberta, Canada, where she worked primarily in paediatrics. In 1986 she returned to Dublin and worked in the Mater Hospital. Dublin. She went to Zimbabwe in May 1988, recruited by CIIR, to work with the Ministry of Health. Mary is based at a small provincial hospital and is responsible for supporting and developing existing hospital and community-based services in the area, and setting up new CBR projects throughout the country.

Tafadzwa's Experience

TAFADZWA is 15 years old and one of a family of six. Three years ago he contracted tuberculosis of the spinal cord. Due to severe spasticity affecting all four limbs and a marked scoliosis, he does not walk and is bound to his wheelchair. He needs assistance in most activities of daily living. With great difficulty he can turn the pages of a book. It takes him a long time to write his name, which is barely legible.

Tafadzwa's mother struggles to feed and clothe her family. Her husband died of tuberculosis last year. Two more sons have similar diagnoses. The family was not immunised.

Tafadzwa is a bright intelligent boy who is being denied an education. His family cannot afford private education and the specialised schools have no place for him. The local school does not feel confident about accepting a disabled pupil.

Rehabilitation in Zimbabwe Zimbabwe is a landlocked country in Southern Africa. It

has a population of 8.6 million, 80% of whom live in the rural areas. Agriculture is the most important economic activity wi th four-fifths of the population dependent on it. There is a vast difference between predominantly white- owned commercial farming and black communal or subsistence farming. The most common food crop is maize.

Since Zimbabwe gained independence in 1980 the Ministry of Health (MOH) has begun to acknowledge rehabilitation as a component of primary health care. In 1981 the MOH launched the Rehabilitation Assistants Training School. The school runs a two-year course covering basic aspects of speech and occupational therapy and physiotherapy. 0 n ce qua I if ied , the re h a bi I i t a t io n assistants are deployed t o rehabilitation departments attached to small district hospitals in the rural areas. Although they receive

some supervision from therapists, they work virtually independently. Most of Zimbabwe's therapists are expatriates on two- or three-year contracts. The University 2f Zimbabwe has recently begun to train occupational therapists and the first students will graduate in 1991.

The MOH has recently launched its national plan for CBR. By the end of 1989 it hopes to have initiated eight pilot CBR projects, one in each of the country's eight provinces.

Community-based Rehabititation A battle has begun in Zimbabwe to steer people away from

institutionalised care for disabled people. Community-based rehabilitation (CBR) is an exciting new alternative.

CBR aims at developing rehabilitation services within the framework of primary health care and existing community services in a given area. It is developed within the community, identifying its needs and developing an appropriate strategy which teaches the members of the community to take responsibility for their own disabled members.

Although the definition of a family unit in Zimbabwe has undergone some changes in recent years, and seems likely t o continue t o change, the family remains the most basic social institution responsible for the care and integration of new members into the community. The 'extended family' in Zimbabwe compels relatives t o stay together and give each other support when in need and comfort in difficult times. Bearing these points in mind, it makes sense to set up a service that utilises these qualities.

Following a meeting wi th the MOH, two representatives from each province were chosen to run a proposed CBR project. A plan of action was drawn up and a one-year plan for implementing the project was developed. The project will be primarily run by a rehabilitation assistant who will be given a motorcycle as hidher mode of transport. The project will be supervised by the provincial therapist who relies on transport from the provincial office. Obviously as the project develops the therapist's input lessens.

The initial phase of the project is set up over a four-week period. The project begins wi th education and motivation of the community leaders. These include chiefs, councillors, headmasters, teachers, health staff, traditional midwives, traditional healers, prophets and church leaders. It is essential to have the confidence and support of community leaders and they should be motivated to mobilise their own people. In the second week of the project a group of community members is chosen for specific training. These people usually include village health workers and Red Cross volunteers. They are taught basic concepts of identification and referral of the disabled. The training is done in the community and appropriate teaching and visual aids are used. During the training week, the volunteers are taught to use a simple survey form. These are used in the third week to conduct a house-to-house survey by the local volunteers to identify and register the disabled in their areas. Finally, the fourth week involves screening whereby all the identified clients are assessed by rehabilitation personnel. The clients are registered and appropriate training programmes initiated.

432 Physiotherapy, July 1989, vol 75, no 7

Disabled child with a locally produced toy in Zimbabwe

Mothers and children at a CBR group in Harare

Disabled child with a locally produced toy used for learning purposes

-~

Physiotherapy, July 1989, vol 75, no 7 433

In order for a CBR programme to be successful it is essential to have a solid infrastructure and referral service. This includes an established accessible rehabilitation depart- ment and hospital for referral of cases which cannot be helped at grassroots level. It is necessary to involve all members of the medical team in the screening week so that clients w i th medical, social or other problems can be dealt with.

As the CBR programme advances it is hoped that income- generating projects can be developed which encourage the disabled people to become active members of their community. We need to look closely at the problems of the disabled person not only personally but also within their local community. It is also hoped that existing community co- operative schemes can be expanded to include the disabled community.

Low-cost Aids and Appliances Zimbabwe has a serious shortage of foreign currency. It

is therefore appropriate t o produce orthopaedic aids and appliances, education toys, and other rehabilitation equipment, using local resources and materials. However, when choosing an aid for a client it is necessary t o seek a good balance between usefulness and attractiveness, that helps the client f i t in best with his family and community. Sometimes as rehabilitation experts, we place great emphasis on function and less emphasis on whether the aid is acceptable t o the client. Appropriate paper-based technology is a successful new concept introduced in Zimbabwe, which utilises paper and cardboard in making aids and appliances for disabled people.

Traditional Beliefs Cultural beliefs do have some impact on establishing

successful CBR programmes and it is important to appreciate their existence. Traditionally people believe in n’angas or spiritual healers. Many diseases are believed to be the result

A traditional healer (n’anga) practising in Zimbabwe

Children with hearing disabilities at a school for the deaf in Gweru, mid-Zimbabwe

of being possessed by ancestral spirits. Since n’angas are believed to work wi th the spiritual world, they can therefore restore the afflicted person.

An epileptic patient is often believed to be possessed. A family may blame a mother who has a cerebral palsied baby and traditionally her husband has the right t o seek another wife. In the case of a stroke victim the results of rehabilitation are often slow and frustrating. Patients in this case often default from medical treatment and seek the help of the n‘anga.

In our CBR programmes we try and include the n’anga in our initial education. We encourage the spiritual healers t o identify and refer clients t o us. It is also important for us to be ready to understand their beliefs and treatments.

Evaluation of CBR It will take some time before these CBR projects can be

evaluated. A small committee has been established to monitor the progress of the individual projects and the initial evaluation will be carried out early in 1990. It is expected that many alterations will be needed, as problems have already been identified. CBR is in its infant stages, but having witnessed the motivation and joy of the community following our first project, I feel confident that it is an appropriate method of establishing rehabilitation services in Zimbabwe.

Working in Zimbabwe Zimbabwe is an exciting country t o live and work in. More

and more emphasis is being placed on rehabilitation being an integral part of its health system. However, since rehabilitation services are still in their infancy, expatriate therapists encounter many frustrations and limitations in their work as it involves many administrative duties. It is important to appreciate Zimbabwe for the country that it is and the culture it holds. We must f i t our experience and skills into its system and not the other way round. Initially, it is essential to stand back, observe and learn about the people. This is an enriching and enjoyable experience! As well as providing tremendous work satisfaction, Zimbabwe is also a beautiful country to visit. It has wonderful national parks, wildlife, mountains and, of course, the Victoria Falls. Having spent t w o years there I wonder how I will ever again survive the Irish weather!

Information about working as a physiotherapist in Zimbabwe i s available from CIIR, 22 Coleman Fields, London N1 7AF.

All photographs by Chris Mclvor

434 Physiotherapy, July 1989, vul 75, no 7