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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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 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

9. 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%

10. 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.

11. 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

12. 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.

13. Thank you