vietnam and activities of community-based rehabilitation
TRANSCRIPT
d i s a b i l i t y a n d r e h a b i l i t a t i o n , 1999; v o l . 21, n o s . 10± 11, 474± 478
Vietnam and activities of community-basedrehabilitation
TRAN TRONG HAI ‹ and TRAN VAN CHUONG Œ
‹ Rehabilitation Department, Institute for Protection of Child Health, Hanoi, Vietnam
Œ Rehabilitation Department, Bach Mai Hospital, Hanoi, Vietnam
Summary
This paper describes the development of, and currentsituation regarding, community-based rehabilitation (CBR) inVietnam. Vietnam is one of the few countries to universallyadoptCBR as a meansof deliveringeŒective rehabilitationto itscitizens. Some information regarding the demography of thecountry is presented. The administrative structure associatedwith rehabilitation delivery and the prevalence of disability inthe country are also discussed. Finally, the strengths, weak-nesses and constraints of CBR are discussed.
Background
Vietnam is a country occupying 331700 square
kilometres at the centre of South East Asia. It is
bordered by Laos and Cambodia on the west, the
People’ s Republic of China to the north, and bounded by
the Paci® c and Indian Oceans to the east and south. The
country is divided into ® ve geographical regions : coastal
region, alluvial plains, a middle region, low mountain
region and a high mountain region. The two wide fertile
alluvial deltas have a great potential for agriculture.
The population of Vietnam comprises 64.3 million
persons, of whom approximately 50% are 20 years of
age and under. This population is growing at a rate of
2.1% per annum, and the life expectancy at birth is 64
years for men and 66 years for women. The under-5 years
of age mortality rate per 1000 livebirths is 65. The major
contributory causes of this death rate are acute res-
piratory infection, diarrhoeal diseases, preventable trans-
missible diseases, and malnutrition. The majority of the
population (81%) live in rural areas.
The administrative structure in Vietnam consists of
three levels: 40 provinces which include three major cities
(Hanoi, Haiphong, and Ho Chi Minh), a special zone,
and 444 districts which include quarters in rural areas
and 9611 communes which incorporate residential blocks
in urban areas. Each local unit has provincial councils
and people’ s committees.
Administrative structure for disability-related matters
Primary health care and the improvement in the
quality of health care are the two main tasks of Vietnam’s
health services. The concept of preventative medicine,
the rationalization and maximization of local resources,
and the assistance of international agencies are among
the aims and objectives of the health-care system.
Disability-related issues are dealt with by the Ministry
of Labour, Invalids and Social AŒairs (LISA), the
Ministry of Health, and the Ministry of Education. LISA
has eight rehabilitation centres and orthopaedic work-
shops responsible for social welfare and job placement.
The Ministry of Health is responsible for disease
prevention, primary health care, and rehabilitation.
Rehabilitation and medical care for disabled persons
provided by provincial, district hospitals, or communal
medical workers are the principal tasks of the Ministry of
Public Health. This Ministry is responsible for the
establishment of the community-based rehabilitation
(CBR) strategy and ensures that it is integrated into the
primary health-care system. The Ministry of Public
Health also ensures that the curriculum in all medical
schools is adapted to accommodate the concepts and
strategies of CBR.
The special education section in the Ministry of
Education’ s general education department is responsible
for the administration of educational programmes
delivered to disabled children in special schools. The
National Institute of Education and Science carries out
research on optimizing educational opportunities for
disabled children.
Facts on disability
A survey of the prevalence of disability was conducted
in 1983 by the Ministry of Labour, Invalids and Social
AŒairs in cooperation with the Ministry of Health and
Disability and Rehabilitation ISSN 0963± 8288 print} ISSN 1464± 5165 online # 1999 Taylor & Francis Ltdhttp:} } www.tandf.co.uk} JNLS } ids.htm
http:} } www.taylorandfrancis.com} JNLS } ids.htm
Dis
abil
Reh
abil
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
1/14
For
pers
onal
use
onl
y.
Vietnam and activities of CBR
Table 1 Principal disabilities identi® ed in 1983 survey
Disability Percentage
Motor disability, including amputees, and polio-
aŒected people
55
Sensory disability, including visually impaired and
hearing-impaired persons
34
Mental retardation 8
Other 3
the Department of General Statistics. According to that
survey 1485000 persons (2.7% of the population) were
identi® ed as disabled. The principal disabilities identi® ed
in this survey are presented in table 1.
Among the 1485000 disabled persons, 950000 were
working, 370000 were capable of bene® ting from further
rehabilitation, 340000 were dependent on assistance in
their daily lives and, 210000 were totally dependent.
Disability prevention and rehabilitation programmes
Basic or primary-health workers are principally re-
sponsible for disability prevention and ensuring correct
nutrition. These people work under the supervision of
the management of a communal health station. Each
commune, consisting of 5000± 6000 persons, has a
communal health station. Primary health-care services
provided at these stations include immunization, pre-
natal examination, dental care, delivery of babies, minor
surgery and CBR. A station is generally staŒed by an
assistant physician, a nurse and a midwife. There are also
some inter-communal polyclinics which are able to
provide more extensive services.
At the district level there are general hospitals which
provide somewhat more specialized treatment than is
available at the communal stations. These hospitals have
hygienic and epidemiological brigades which serve to
control malaria and to provide vaccinations. At the
provincial level there are both general and specialist
hospitals. The latter hospitals encompass social disease
dispensaries (which deal with trachoma, goitre, venereal
skin disease, and mental illness), sanitaria, maternal
protection and family-planning stations, and rehabili-
tation departments.
At the top of the primary health-care pyramid is the
Ministry of Health. There are some specialized institutes
attached to this Ministry. These institutes are the
Institute for the Protection of Children’ s Health; the
National Institute of Nutrition; the Institute of Hygiene
and Epidemiology; the Institute of Dermatology and
Venereology; the Centre for Health Education and
Propaganda ; the Human Resource Centre for Health;
the Institute for the Protection of Mother and Infant; the
Institute of Tuberculosis and Respiratory Diseases ; the
Institute of Malariology, Parasitology and Entomology;
and the Institute of Traditional Medicine.
Vietnam has eight orthopaedic and rehabilitation
centres associated with orthopaedic workshops in the
major cities of Hanoi, Ho Chi Minh, and Haiphong.
There are three rehabilitation centres for children and
one orthopaedic factory which trains orthopaedic tech-
nicians and produces part-completed articles such as
arti® cial limbs. The part-completed products are tailored
to ® t individuals in the orthopaedic workshops. In
addition to rehabilitation sections in district and prov-
incial hospitals there are homes for disabled persons,
handicraft cooperatives, and a rubber factory run by the
Association of the Blind.
The Special Education section, the Department of
Education in the Ministry of Education, is responsible
for the education of disabled children. The centre of
special education for the impaired children, the National
Institute of Educational Sciences, provides expertise in
teaching children with blindness, deafness, mental re-
tardation, and speech problems. This Institute
administers two schools for the blind in Hanoi and Ho
Chi Minh cities, one school for the deaf in Haiphong,
one school for the mentally retarded in Hanoi, and one
school for those with speech di� culties in Hanoi. Other
special education schools and educational programmes
for physically disabled children are conducted under the
Ministry of Labour, Invalids and Social AŒairs. This
Ministry also conducts 15 schools for deaf children ;
however, the teachers are trained by the Ministry of
Health.
Braille classes are also conducted by the Association of
the Blind. These classes are for both children and adults
who have limited or no access to educational oppor-
tunities as a consequence of their disability. The Nguyen
Dinh Chieu school for the blind in Hanoi has commenced
a pilot programme of integrating blind and sighted
children into the one school.
Steps to develop the CBR programme in Vietnam
CBR commenced in Vietnam in 1986 in a number of
pilot centres. Today 115 communes in 15 districts of the
seven provinces have CBR programmes. However, only
1300000 persons (including 53000 disabled) are covered
by these CBR programmes.
The steps taken to implement CBR in Vietnam are as
follows. Initially there was adoption of the World Health
Organization publication Training Disabled People in the
Community and its subsequent translation into
Vietnamese. The pilot schemes proved to be of such
475
Dis
abil
Reh
abil
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
1/14
For
pers
onal
use
onl
y.
T. T. Hai and T. V. Chuong
Table 2 Results of the house-to-house survey of Cai Lay District
Communes No. of hamlets Households Population Disabled Prevalence (%)
Ngu hiep 7 1785 10868 180 1.67
Long trung 14 2334 11429 250 2.1Nhi qui 5 1880 9825 133 1.39
Phu nhuan 6 1057 8092 155 1.71
Nhi my 5 1121 5338 121 2.25
Trung an 9 2013 10048 211 2.09
Total 46 10190 55600 1050 1.88
Table 3 Manpower model for training in CBR
Form of training Duration Who trains whom Managed by
National and international
specialists
National Steering Committee
Seminars 7 days National regional leaders of
diŒerent sections
Training course 4 weeks Doctors, assistant doctors,
therapists, teachers
Provincial steering committee
Seminars 2 days Provincial district leaders of
diŒerent sections
Training course 14 days Brigade nurses, Red Cross
members, teachers
CBR steering committee at community level
Practical demonstration on disabled at home,
discussion meetings
Family members Family, community
The disabled person
bene® t to the country that, within 2 years of im-
plementation of the pilot schemes, processes for national
implementation had been developed.
When communes in districts or provinces wished to
initiate a CBR programme they were required to follow
the following steps developed by the National Steering
Committee :
(1) Conduct and attend introductory seminars at
diŒerent levels for the various kinds of leaders.
(2) Ensure that there is an established steering
committee at the community, district and prov-
incial levels.
(3) Implement a training course for intermediate-level
workers (doctors, assistant doctors, teachers,
therapists).
(4) The trained intermediate-level workers would then
conduct training courses for primary health
workers (brigade nurses, Red Cross members,
family members).
(5) The trained primary health-care workers (or CBR
workers) conduct house-to-house surveys to
identify the disabled and to assess who will bene® t
from rehabilitation. The survey in each commune
to be completed within 1 week with the assistance
of doctors and the assistant doctors from the
established referring institutions (commune health
station, district hospital, etc.). The results of these
surveys to be compiled and forwarded to the
Ministry of Health in the prescribed format (see
table 1).
(6) Identify the family or community member who
will be the `family ’ trainer of the disabled person.
(7) Commence the home-based training and include
the disabled person in the decision-making pro-
cess.
To provide some indication of the prevalence of disability
in Vietnam the results of the screening programme
conducted in Cai Lay District are given in table 2."
Manpower for CBR in Vietnam
The model for training personnel at the various levels
in the CBR programme has been developed at the
national level. Manpower training of CBR has been
integrated into the primary health-care training pro-
gramme. The established model is illustrated in table 3.#
Impact of CBR
One of the major impacts following the introduction
of CBR has been changes to and modi® cation of a
variety of training curricula. Speci® cally new curricula
476
Dis
abil
Reh
abil
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
1/14
For
pers
onal
use
onl
y.
Vietnam and activities of CBR
have been adopted for physiotherapists (who are now
designated rehabilitation therapists), a CBR orientation
is now included in medical student training, and CBR
training is incorporated into all mid-level medical schools
(assistant doctors, midwives, nurses).
In 1990 the National Assembly passed laws for the
protection of people’ s health. In these laws there is an
article which states that `the approach of solving
problems of disabilities in Vietnam must be through
Community Based Rehabilitation’ .
Strength of the CBR programme
The strength of the CBR programme is evidenced by
the enactment of laws at the national level. This has been
as a direct consequence of the interest shown by Party
leadership and people’ s committees from provincial to
commune levels. CBR has involved the local com-
munities both in mass organizations and as individuals.
One of the major strengths which has grown out of the
CBR programme has been the availability of, and access
to, medical referral institutions. Special health pro-
grammes such as prevention of leprosy, mental illness,
and trachoma have received support from provincial and
district health bureaus. These latter bureaus have
undertaken the management of the special health
programmes within the primary health-care network and
have ensured delivery and access to all communes and
hamlets.
The apparent success of the CBR programme has
resulted in a high degree of motivation of directors of
commune schools and school teachers. More and more
disabled children are being accepted into and trained in
the mainstream educational system.
Individuals, families and their community
The greatest success of CBR lies in its impact on the
lives of the people that it has served ; those with
handicaps, their families, and their community members.
This impact appears to be immeasurable. Changes that it
has brought about in the relatively short time the
programme has been operational are often dramatic.
These changes have served to stimulate an awareness and
interest in the rehabilitation needs of handicapped
community members. It has also become apparent that
rehabilitation needs can be met by community eŒort, and
there is consequently a high degree of community
satisfaction with their involvement.
More than 50% of the disabled in Vietnam are
children and most of these have bene® ted from the CBR
approach. Since the family is the basic structure of the
community in Vietnam it has become the basis of the
approach to disability prevention. Once the family (the
extended family) is trained by the local supervisor
(usually a brigade nurse) in prevention, early detection,
and intervention the CBR scheme appears to become
self-su� cient and creates an eŒective network in the
reduction of childhood disability. In the ® ve provinces
which currently have adopted CBR, 80% of the disabled
children attend school with their non-disabled peers.
The CBR programme has also adopted a community-
based approach to the delivery of disability prevention
and intervention through the use of existing community
resources. Community involvement is one of the guiding
principles of the programme. This approach enables
access to rehabilitation for a great number of persons at
a cost that can be maintained by the community and the
family.
In most instances trainers are family members such as
mother, father, grandparents, or sibling. In those cases
where family members are unavailable (such as elderly
persons living alone) the primary health-care workers
have undertaken the role of trainer. However, it should
be noted that the primary health-care worker is fre-
quently either a family member or a close neighbour. In
future the primary health-care worker will recruit other
members of the community to undertaken the role of
family trainer for the isolated disabled person.
Constraints and conclusions
The major problem confronting the CBR programme
is the lack of middle-level rehabilitation support. Despite
this it is concluded that CBR has been successfully
integrated into the country’ s primary health-care service
at all levels under the direction of the Party leadership
and the People’ s Committees with management
delegated to the health sector.
People with handicaps and their families can suc-
cessfully carry out rehabilitation intervention, which has
resulted in the social integration of the disabled. The
success of this integration is determined by the support
of the Party organization and the People’ s Committees in
their commune, and the support of the health, ® nance
and education sectors. Support from social aŒairs,
collective organizations, women and youth movements,
the Red Cross and other societies is essential for the CBR
programme to achieve optimum outcomes.
Primary health workers, people with handicaps and
their families can eŒectively use the Vietnamese manual
Training Disabled People in the Community. The value of
the manual has also been proved in the provision of basic
rehabilitation technology. Primary health workers, fol-
lowing the appropriate training, can successfully carry
477
Dis
abil
Reh
abil
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
1/14
For
pers
onal
use
onl
y.
T. T. Hai and T. V. Chuong
out rehabilitation tasks with the support of assistant
doctors and therapists.
Following appropriate training the assistant doctors
assume the management, organization, and adminis-
tration of CBR as part of their duties in the health
station. These assistant doctors can provide a certain
amount of technical support to the primary health
workers, but this assistance is complemented by physio-
therapists who have a more specialized knowledge of,
and skill in, rehabilitation.
The commune, district and provincial health services
can and do meet the existing referral needs of the CBR
programme. It can be seen that the CBR project has
made a signi® cant social impact on the lives of people
with handicaps, their families and the community. This
impact has resulted in other communes initiating CBR
programmes.
The achievements of the CBR programme to date
clearly con® rm that:
(1) CBR is an excellent tool for improving the
participation of disabled persons in decision-
making, and their integration into society.
(2) The programme has made a signi® cant impact on
the lives of disabled persons (particularly children),
their families, and community, and has been a
major stimulus to the development of primary
health care in the communes.
(3) CBR has promoted the mobilization of community
resources, human resources, the disabled, and the
coordination and integration of services at com-
munity and intermediate levels. Functions and
responsibilities at the national level have been
further evolved to consider a national programme
and appropriate curriculum for training rehabili-
tation workers.
(4) The CBR programme has increased public aware-
ness of disability and the need to equalize
opportunities for the disabled.
References
1 Hai TT. Vietnam and activities of community-based rehabilitationprogrammes. Intercountry Workshop on Planning and Manage-ment of Community-based Rehabilitation Programmes.Guangzhou, Guangdong Province, People’s Republic of China,10± 14 June 1991.
2 Hai TT, Chuong TV. Activities of CBR programmes in Vietnam.Intercountry Workshop on Planning and Management ofCommunity-based Rehabilitation Programmes. Guangzhou,Guangdong Province, People’s Republic of China, 10± 14 June1991.
478
Dis
abil
Reh
abil
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Mic
higa
n U
nive
rsity
on
11/0
1/14
For
pers
onal
use
onl
y.