CBR and Inclusive Health in Humanitarian Context of Afghanistan Bikram Keshari Mohapatra, Senior Disability Programme Specialist Swedish Committee for Afghanistan

Introduction Persons with disabilities have same health needs like any other person. They also need specific health care and rehabilitation services for their impairments Article 25 and 26, of the UNCRPD, 2006 asserts full access pf persons with disabilities to health and rehabilitation services According Alma Ata Declaration in 1978, primary health care should “address the main health problems in the community, providing promotive, preventive, curative and rehabilitative services” Therefore, Disability inclusive health refers to the process of including people with disabilities in those health care services that are available to the general population(WHO) All the health programmes should address health disparities for persons with disabilities and lay the foundation for greater inclusion of persons with disabilities in public health programs

Barriers in accessing Health Services Physical inaccessibility, Prohibitive costs like costs of transportation treatment cost Limited availability of services and Limited capacity of health staff

Background of study Mental health and physical rehabilitation services included in Basic Packages of Health Services (BPHS) and Essential Packages of Health Services (EPHS) in Afghanistan The Swedish Committee for Afghanistan (SCA) is one of the leading agencies in Afghanistan implements comprehensive community based rehabilitation, large scale health, education, rural development programmes in 14 provinces of Afghanistan The health programme of SCA, implements BPHS and EPHS in Afghanistan and has the mandate to include physical rehabilitation and mental health in their programme. First Strategic objective of SCA- “Equitable access to and utilization of health services by women, children, people with disabilities and rural communities”. The Disability programme provides technical guidance for inclusion of disability in health programmes

Study objective and Methods To understand how the inclusion of physical rehabilitation; incorporation of accessibility features in health infrastructures; awareness; training, and coordination between health and disability programmes have contributed towards improved access of persons with disabilities to health and physical rehabilitation services Study area: Laghman Provinces in Afghanistan Participants of study: Community Health workers, CBR Staff, Physiotherapists, Health Director and health staff in Laghman The participatory approaches study adopted both qualitative and quantitative methods Data collection tools Qualitative tools – Focus groups discussion, semi structured interview, meetings, accessibility study Quantitative tools- Review of database, Limitation of the study- As it is a small qualitative study, the findings can not be generalized Inclusion of mental health was not covered under the study due to time limitations

Findings Output of training organized for health staff in 2015 Target group No Training topic Result Doctors, nurses, midwives and vaccinators 114 Disability, physical rehabilitation and health rights Better understanding of physical rehabilitation and developed a positive attitude towards persons with disabilities 29 children with DDH and club feet identified and referred to physiotherapy centers by health staff in Laghman Doctors, nurses and final year students of community midwifery education 121 Role of physical rehabilitation in the prevention and treatment Practical training on management of Developmental Dysplasia of Hip (DDH), club feet management Medical students under internship from the Jalalabad Medical College 240 Symptoms of various of impairments, early identification, referral system to existing services and importance of physical rehabilitation

Findings Output of training organized for health staff in 2015 Target group No Topic Immediate output Health committee members (Shuras) and Community Health Workers trained 31 Causes, prevention, early identification of persons with disabilities and referral system. CHWs and health shuras have identified 60 persons with disabilities and referred to disability programme CBRWs have identified and referred 75 persons with different disabling diseases to the nearest clinics for further treatment Awareness and coordination among health and disability programme have helped them to complement and supplement each other’s activity Concerned staff of public health department,, DPOs, BPHS and EPHS implementers involved in the planning and monitoring of physical rehabilitation activities Quarterly coordination meetings among health, disability programme and Public health Dept. 4 Issues, challenges in the in coordination. Challenges in accessing physical Rehabilitation services

Inclusion of Physiotherapy in Health programme 4 clinics closed due to lack of human resources Increased coordination among health and disability programme contributed to increased percentage On request from MOPH to increase Human resources, SCA, Handicap International and Norwegian Afghanistan Committee started physiotherapy and prosthetic & Orthotic Training with support of EU Physiotherapy Clinics status NO/percentage No of clinics managed by SCA 35 No of Clinics Handed over to MOPH between 2009-2015 23 No of Handed over clinics functional after Handing over 19 No of clinics defunct after handing over 4 Percentage of increase or decrease in physiotherapy service users in first quarter of 2016 10% increase

Accessibility Assessment of SCA Health Facilities Accessibility features in Hospitals No / percentage No of health facilities where study was conducted 102 % of health facilities with accessible paths 66% % of health facilities with ramps 34% % of health facilities with accessible doors 91% % of health facilities with wider corridors 63% % of health facilities with slip resistance floors 78% % of health facilities with large &visible sign boards 47% % of health facilities with accessible men’s toilet 19% % of health facilities with accessible women’s toilet 7%

Conclusions and Recommendations Inclusion of physical rehabilitation and mental health services is a major step taken by the Government of Afghanistan. Inclusive health is the first initiative of its kind in Afghanistan started by SCA The initial progress is successful in following areas like: Handing over of physiotherapy centres to BPHS and Implementers Retrofitting of health infrastructures to make them accessible; Collaborative efforts to address rehabilitation and health issues of people with disabilities Development of positive attitudes of health staff towards people with disabilities and acceptance of physical rehabilitation under health programme Medical students under internship understood the importance of physical rehabilitation in the treatment and prevention of disabling diseases.

Recommendations SCA to include disability inclusive health activities in programming and budgeting. DPOs and representatives of persons with disabilities need to be consulted in entire programme and project cycle management Persons with disabilities at community level need to be interviewed to understand effectiveness of inclusive health programme Efforts should be made to train rehabilitation professionals like speech therapist and audiologist, clinical psychologist, mobility trainers, Disability, health and rehabilitation should be included in training and course curriculum for CHWs, midwives and nurses Advocacy should be done to include provisions for prevention and treatment of other segregated groups of disabilities like visual, hearing, and intellectual impairments in BPHS and EPHS guidelines

Recommendations SCA to make efforts to create some model health infrastructures which are accessible for all with following features Men’s toilets, women’s toilets, and safe room should be made accessible. Other features like warning and guiding tactile, alarms with flash light and other features should be included in health infrastructure The health staff should learn to communicate and deal with different disabilities. Finally, Effort should be made to get Statistics of segregated groups of men, women, boys and girls with disabilities Number of people with disabilities availing health and rehabilitation services, Morbidity and mortality rates of children and mothers with disabilities.

Thank you