PIHRS-IH Model 2020-Final Revised

romoting
nclusive
ealth
nd
ehabilitation
ervices
(PIHRS)
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CONTENT PAGE
AN INSIGHT ON
Bangladesh………………………………………………………………………………………………… Page 4
Health…………………………………………………………………………………………………………… Page 5
Disability & Definition…………………………………………………………………………… Page 6/7
Link between Poverty & Disability ……………………………………………………Page 7
PIHRS OVERVIEW
All about PIHRS Project………………………………………………………………………… Page 8-10
Research Study (Methodology & Survey on IH Rights)………………Page 11-16
Evaluation Report (Methodology/Limitations & Findings )…………Page 17-19
• Quality & Equality……………………………………………………………………………………… Page 20-21
• Sustainability…………………………………………………………………………………………………………Page 22
• Lesson Learned………………………………………………………………………………………… Page 23-24
PIHRS PROJECT
• Good Practice ……………………………………………………………………………………………… Page 25-27
Case Study………………………………………………………………………………… ………………….Page 28-31
References…………………………………………………………………………………………………… Page 32
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DRRA’S
INCLUSIVE HEALTH (IH)
MODEL
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An Insight on Bangladesh- Bangladesh is not only one of the most heavily populated
countries in the world (926 people per square kilometer) but also one of the largest delta
in the world, facing the Himalayas in the North, bordering India in the West, North and
East, Myanmar in the South East and the Bay of Bengal in the South. The geographical
location makes the nation highly vulnerable to natural disasters. Crisscrossed by two
hundred and thirty recognized rivers, about 30% of the net cultivable land is flooded each
year, while during extreme floods, which occur every four to seven years, as much as 60%
of the net cultivable land of the country is affected. However, considering that the Bay of
Bengal is home to the world's most severe storm surge disasters, Bangladesh's heavily
populated coastal regions are prone to almost every year dangerous cyclones. These are
further exacerbated by tornadoes that strike the plains almost every year, leaving a trail
of death and disability. Economically, Bangladesh has one of the lowest annual per capita
incomes in the world (under US$ 450). While agriculture is the premium bread earner of
the common person and country, it also has the highest percentage of people living in
poverty where the poorest 10% and the middle 75% of the population are severely and
chronically undernourished. The vast majority of the population is Muslim, and almost all
people speak a single language, Bangla. A nation with a population of nearly 150 million,
it has a large human resource base. This is compounded by a range of natural resources
and a potential area for tourism that can multiply the country's profile.
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Health- Globally, more than one billion people are living with some type of disability,
and between 110 and 190 million adults are experiencing difficulties in carrying out
everyday activities and engaging in life situations. We are now seeing a rise in the size of
the elderly population and a change in the global burden of diseases from communicable
to non- communicable diseases. As a result, the number of people with disabilities is
growing worldwide. While the number of people with physical disabilities (PWPDs) is
certainly high and growing globally, there is a shortage of primary health care programs
that are responsive to the particular needs of PWPDs and seldom promote preventive
health care services or health promotion initiatives tailored to their needs. A variety of
factors, such as prohibitive cost and insufficient availability of health care resources,
physical obstacles to accessing health care facilities, lack of expertise and skills on the part
of health care professionals and perceived discrimination, have a negative effect on
PWPDs and discourage them from pursuing health care.
Socio-demographic factors, such as age, socio-economic status, education and place of
residence, also have a significant effect on health care targeting the actions of PWPDs.
Moreover, perceived prejudice often plays a significant role in the promotion of action by
PWPDs in health care. Persons with disabilities are more likely to suffer from
complications requiring primary health care services than those without disabilities.
Bangladesh has a high number of disabilities. The Bangladesh Bureau of Statistics (BBS)
measured the prevalence of disability in Bangladesh at 9.07 per cent for males and 10 per
cent for females. A research by Titumir and Hossain found that 27.8% of people living with
disabilities in Bangladesh have physical disabilities and 10.7% have multiple disabilities.
As a result, the number of people with physical disabilities is assumed to be very high
given that there are around 158 million people in the world. Nevertheless, there is a lack
of empirical evidence linked to primary health care for PWPD conduct in Bangladesh.
Few studies have been conducted in Bangladesh to examine the actions of PWPDs in
health care in the treatment and rehabilitation of their infirm health condition, but no
such studies have been conducted in relation to primary health care finding the actions
of PWPDs. Awareness of behavioral health care is helpful in recognizing accessible health
resources and evaluating the use of these resources by the community. This awareness
can also be used to facilitate meaningful improvements in the actions of the target
population in the health care field. Improving access to affordable health care may avoid
a drop in income mostly due to ill health. This awareness can also be used to facilitate
meaningful improvements in the actions of the target population in the health care field.
Improving access to affordable health care may avoid a drop in income mostly due to ill
health. For order to ensure the efficiency of PWPD health initiatives, it is important to
ensure the involvement of PWPDs. In this regard, it is important to consider the needs
and priorities of PWPDs in relation to their overall health.
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Proper understanding of health care seeking behavior for general illness and the factors
determining health care seeking behavior will help policy makers to design effective
public health interventions in a way that will ensure participation of PWPDs. Moreover,
this information will help policy makers to minimize the barriers to health care seeking
behaviors.
The traditional health network in Bangladesh has general hospitals (known as the Sadar
Hospital) in all districts and sub-districts (known as the Upazila Health Complex), but
clinics are unable to offer appropriate health care to people with disabilities. District and
sub-district-level Government hospitals do not have qualified medical practitioners
specialized in disability; neither there is any allocated services and equipment, nor any
open infrastructure. Medical facilities for people with disabilities are only available in
specialist care establishments far from the population, and are most mostly situated in
the capital city of Dhaka. In Bangladesh, however, access to care for people with
disabilities is comparatively weak compared to other nations, not only because of their
physical and emotional disorders, but also because of the lack of access to facilities in
their poor areas.
Disability- To understand how disability is currently viewed, it is helpful to look at the
way the concept of disability has evolved over time. Historically, disability was largely
understood in mythological or religious terms, e.g. persons with disabilities were
considered to be possessed by devils or spirits; disability was also often seen as a
punishment for past wrongdoing. These views are still present today in many traditional
societies. In the nineteenth and twentieth century’s, developments in science and
medicine helped to create an understanding that disability has a biological or medical
basis, with impairments in body function and structure being associated with different
health conditions. This medical model views disability as a problem of the individual and
is primarily focused on cure and the provision of medical care by professionals.
Later, in the 1960s and 1970s, the individual and medical view of disability was challenged
and a range of social approaches were developed, e.g. the social model of disability. These
approaches shifted attention away from the medical aspects of disability and instead
focused on the social barriers and discrimination that persons with disabilities face.
Disability was reddened as a societal problem rather than an individual problem and
solutions became focused on removing barriers and social change, not just medical cure.
Central to this change in understanding of disability was the disabled people’s movement,
which began in the late 1960s in North America and Europe and has since spread
throughout the world.
Defining Disability- There are many different definitions of disability. The
Convention on the Rights of Persons with Disabilities states that disability is an evolving
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concept and results from the interaction between persons with impairments and
attitudinal and environmental barriers that hinders their full and effective participation in
society on an equal basis with others. People’s experiences of disability are extremely
varied. There are different kinds of impairments and people are affected in different ways.
Some people have one impairment, others multiple; some are born with an impairment,
while others may acquire an impairment during the course of their life. For example, a
child born with a congenital condition, such as cerebral palsy, a young soldier who loses
his leg to a landmine, a middle-aged woman who develops diabetes and loses her vision,
an older person with dementia may all be described as people who have disabilities. The
Convention on the Rights of Persons with Disabilities describes persons with disabilities
as those who have long-term physical, mental, intellectual or sensory impairments.
Link between poverty and disability-
Poverty is both a cause and consequence of poor people are more likely to become
disabled, and disabled people are more likely to become poor. Poverty has many aspects
and is more than just a lack of money or income – Poverty erodes or nullies economic and
social rights such as the right to health, adequate housing, food and safe water, and the
right to. People with inadequate resources tend to have lower awareness and
understanding of disability and access to basic health care services which lead to a greater
risk of developing an impairment. Poverty also reinforces negative attitudes towards
persons with disabilities, acting as a barrier to inclusion and service delivery and
transforming impairments into disabilities.
Persons with disabilities are often neglected, discriminated against and excluded from
mainstream development initiatives, and it is difficult to access health, education, and
housing and livelihood opportunities. This results in greater poverty or chronic poverty,
isolation, and even premature death. The costs of medical treatment, physical
rehabilitation and assistive devices also contribute to the poverty cycle of many persons
with disabilities. Addressing disability is a concrete step to reducing the risk of poverty in
any country. At the same time, addressing poverty reduces disability. This link was
recognized in 2009, when the UN General Assembly adopted a resolution on realizing the
Millennium Development Goals for Persons with Disabilities recognizing that inclusion of
persons with disabilities in mainstream development is essential for achievement of the
Millennium Development Goals which aim among other things to eradicate extreme
poverty and hunger and provide universal primary education.
Because poverty specifically needs to be reduced in order to create a greater quality of
life for people with disabilities, DRRA's initiatives seek to minimize poverty by ensuring
that people with disabilities have access to health, education and livelihood
opportunities.
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PIHRS OVERVIEW
DRRA has been implementing the project 'Promoting Inclusive Health and Rehabilitation
Services (PIHRS) for People with Disabilities in th e Satkhira, Manikganj and Chittagong
districts of Bangladesh' since 1 January 2015. The ultimate objective of this phase is to
establish rehabilitation services for people with disabilities through enhanced access,
awareness-raising and equitable strategies within the government health system across
three districts (9 Upazilas) of Bangladesh. The phase 1 project is scheduled to be finished
by December 2018 (3 years).
Chattogram District
Our Project Locations:
Manikgonj District
Satkhira District
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The phase II project is scheduled from 1 st January 2019 The overall objective is to
contribute to increased access of people with disabilities to health services leading to
improved health and better quality of life. Which is scheduled to be finished by 31 st
December 2021 (3 years). Through a sustainability measure, the purpose is to show
innovative solutions to disability integration in upazila and community health programs
that can be scaled up nationwide by the Ministry of Health.
In this daunting background, DRRA has been implementing the 'Promoting Comprehens ive
Health and Rehabilitation Services (PIHRS) for People with Disabilities' project in
Bangladesh's Satkhira, Manikganj and Chittagong districts.
The project has three specific objectives:
1. To strengthen government hospitals in three districts (9 Upaz ilas) for delivery of
inclusive health and rehabilitation services for people with disability.
2. To empower people with disability through community awareness, knowledge and
facilitation of access to services at government hospitals in three districts (9 Upazilas).
3. To influence policy makers towards inclusive health service delivery for people with
disability through government health systems.
Key Stakeholders of PIHRS:
• People with disability, people at the risk of disability and people with seconda ry
health complications from disability.
• People with psycho-social disabilities, epilepsy and Neuro-developmental Disability
• Disabled people’s organizations (DPOs)
• Family/parents/caregivers of children with disability
• Local community
• Health Assistant (HA) & Family Welfare Assistance (FWA)
• Union Parishod
• National & local print & electronic media
• Doctors in Upazia & District government hospitals.
• National level policy makers and health administrators.
• Medical institutions specialized in health care to people with disabilities.
• NGOs, INGOs, development workers and other private organizations working on
disability.
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Key Stakeholder OF PIHRS from State:
• Ministry of Health & Family Welfare (MoHFW)
• District civil surgeon office
• Sadar Hospital at district level
• Upazila Health Complex
• Community Clinic
• National Specialized Medical Institutions
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A research study was conducted by DRRA on Inclusive Health Rights to identify the
gaps and barriers in Government Policy as well as health service delivery system in
Bangladesh.
Persons with disabilities are the most disadvantaged and oppressed category in the
country. Actually, approximately 15 per cent of the world's overall population face
any form of illness, of which about 200 million have severe physical disabilities. In
2008 Alma Ata Deceleration, WHO described health as "a period of full physical,
mental and social well-being and not merely a lack of disease or infirmity" which is
very much a reflection of the objective of the SD G-3. Then in 1999, right to vision by
2020 supports the incorporation of eye health into current health systems where
possible. Lastly, the WHO Global Action Plan 2014 to 2021 seeks to improve and
incorporate rehabilitation into the current health system. The adoption by the UN
General Assembly of the Convention on the Rights of Persons with Disabilities (CRPD)
in 2006 further strengthened international cooperation on this critical topic and put
the issue squarely on the global agenda.
Research/Study
On
Health
(Methodology &
Survey on
Inclusive Health
Rights)
Bangladesh, as a signatory member, should have a specific policy and
recommendations on health and rehabilitation within the current health service. So
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this research is the first study that has been conducted in Bangladesh to recognize
those key gaps and primary challenges in the government health system.
Research Methodology:
The study followed a mixed approach with more focus on the qualitative portion,
consisting of both quantitative and qualitative methods. For the implementation of
this study were selected two urban districts D haka & Chattogram and two rural
districts- Manikganj & Satkhira. The survey sampling frame consisted of three
variables to include e.g., age, sex and all forms of disabilities.
STUDY DESIGN
DESK
OBSERVATION
STUDY
DESIGN
NATIONAL
CONSULATION
(1)
FGD (10)
DIRECT
OBSERVATION
(24)
DISTRICT
CONSULTATION
(2)
KII (27) SURVEY (207)
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The Identification and treatment for persons with disabilities-
Facilities were found to be lacking at the lowest level (union leve l), as well as at the
secondary (upazila) and tertiary (district / national) level. In terms of a disability -
friendly environment; direct observation showed that even where there were
facilities such as ramps at newly built upazila health complexes, these were not
handicapped-friendly. Most ramps lacked the proper slope and railing. Ramps at
specialized hospitals and medical colleges were largely designed to promote patient
transfers. The locations of the ramps have also not been explicitly defined.
Specialized hospitals for people with disabilities had elevators to go upstairs for
diagnosis. The question of appropriate placing of signs for individuals with
disabilities during the visits was also found to be a concern. Many hospitals lack
toilets which are available. Full functionality, such as front desk, internal touch, logo
and symbol, and functionality for people with visual impairments were also not
available. The building code was not observed during construction of hospital
buildings.
FGD studies, in-depth research and observation reviews have shown that most
clinics and community centers lack adequate specialist facilities for people with
disabilities, such as physiotherapy, occupational therapy and eye / hearing
assessments. It has also been recognized that the behavioral and attitudinal
influences of service providers have worsened the condition of people with
disabilities in many health centers. In addition, qualitative studies have underscored
the lack of disability-related service coverage and, in many cases, the lack of
disability-related service coverage relative to needs. One hospital director reported
that when the actions of people with disabilities in finding health was analysed,
“It was found that 86.9 per cent of people with disabilities
surveyed were finding general health care, while only 46.4 per
cent were seeking health care for their disabilities .”
By comparison, more females with disabilities have received general health and
disability-related treatment than males with disabilities.
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“The study finding are that approximately 23 medical colleges provide
outdoor mental health services, but a total of 800 beds have been
allocated to mentally ill patients in Bangladesh. That isn't enough! As
we're only able to provide serving only 20 percent at the moment.”
Only 22.8%
People with disabilities have
access to rehabilitation facilities,
with the relative number being
the highest in Dhaka.
1
The lowest in
Chattogram
With 14.8%, which
represented suburban
settings.
5
Followed Through
Manikganj With 26.2%
& Satkhira being 21.3%
Health-seeking behaviors of people with
disabilities, the distinction between
facilities visited for general health and
facilities visited for disability-related
health care have also been explored in
order to ascertain which source they
prefer.
This could help prepare potential
service delivery projects to make service
delivery more available and affordable
for them. State hospitals / facilities were
the primary destinations of people with
disabilities for both general and medical
treatment.
4
3
2
Through evaluation it
came to focus that only
22.8% of persons with
disabilities received
rehabilitation services
while accessing it.
The relative percentage
being the highest in Dhaka
with 35.8%, which
represented urban setting
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Services Satisfaction & Behavior/Quality of
Existing Healthcare Providers towards “Persons with Disabilities”
“Behavior has been more or less suitable for mainstream health care providers.
Approximately 45% of the respondents indicated that the conduct of health care
providers was quiet fair and about 38% expressed to be fine. Likewise, only about
9.6% said to be bad or worst. According to 81% of the respondents, the standards of
the mainstream service was acceptable or good. Only about 8% expressed that the
quality of the service was very good.”
The study also shows that as the Government
facilities are responsible for most visits for People
with Disabilities, but very few were satisfied and
only one-third were reasonably pleased with the
services. By comparison, almost one-fifth shared
their contentment and a small proportion reported
their disappointment about private health care
services. The unfriendly behavior of health care
professionals and the lack of commitment to
people with disabilities, who are in the most need
of the treatment are described as grounds for
discontentment.
Government services account for the majority o
f visits from people with disabilities, but the
fact is:
Only about 29% of persons with disabilities
were satisfied while another 34.5% were
moderately satisfied.
In contrast, 61.5% of persons with
disabilities were satisfied, with private
facilities and another 7.7% were moderately
satisfied.
About 52% of persons with disabilities were
satisfied with NGO facilities and another
24.1% were moderately satisfied.
Specialized physician services had almost
the same level of client satisfaction as
government facilities, where
About 31.5% of people with disabilities were
satisfied, and another 21.1 per cent were
moderately satisfied.
On the other hand, it was found that people with
physical conditions had the greatest degree of
disappointment which is almost to 35.7% when
requesting disability services. In terms of gender
analysis of service satisfaction, a higher percentage
of males with disabilities has been found to be
satisfied compared to females with disabi lities.
When the client satisfaction level was analyzed for
type of disability, while accessing disability health
services, the outcome of dissatisfaction levels are
given below:
Dissatisfaction for the persons with
intellectual disabilities was 16.1%
Visual disabilities- 14.3%,
Autism- 12.5%
Hearing disabilities -12.5%
Speech disability - 10.7%,
Intellectual disabilities = 10.7%,
Cerebral palsy - 8.9%,
Deaf/blindness - 7.1%,
Down syndrome - 1.8% and
Persons with multiple disabilities had
dissatisfaction of 1.8%.
Insights from FGDs of people of disabilities and
community leaders pointed to behavioral causes and
lack of service commitment.
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The Research also implicated that people with disabilities on average spends about
BDT 26932.5 annually on health care. Medicine was put as the number one costly factor of
all components related to the health care service followed by assertive equipment.
Many of the people with disabilities who were surveyed, around 60.3% of them did not obtain any
kind of financial assistance from any source; neither from the State nor from any non-government
sources.
For those who provided assistance, the primary source of support was the disability stipend from the
Department of Social Services, which is the only source of funding from the Government.
Nevertheless, the sum of the stipend was very minimal, leaving them behind with a major crises of
Affordability & Finance
Challenges & Gaps were also indicated in this study, it’s been found that even as policy and
social perceptions are beginning to shift, the requisite disability health care procedures and effective
infrastructure in hospitals and public facilities remain largely unacknowledged. Social security does not
yet cover a sufficient percentage of people with disabilities, and processes for obtaining these programs
are still non-disability-friendly. In addition, primary health care for people with disabilities is often not
provided or funded in the Community Health Service Centers, as a result of which most of them will not
receive or acknowledge or diagnose their much-needed services.
Due to following barriers:
• Unestablished Referral System
• lack of proper information about disability
• less knowledge about government’s existing provision & facilities regarding disability creates accessing barrier,
• Inadequate counselling support causing confusion for the family members which led them to run from one source
to another (adding to costs and confusions),
• For Primary health services, the persons with disabilities are not included in the community healthcare centers,
causing them to travel long distances from rural communities to national level hospitals.
• The inadequacy in mainstreaming the health systems to provide services like- early detection, requires
assessment & curative/corrective intervention which are essential to develop a community level medical, social,
and economic rehabilitation and integration plan. These key missing factors, limits the effective roll-out of
Community Based Rehabilitation in (CBR) programs.
• Mobility and developmental devices are of vital significance to people with some certain disabilities like the
hearing and/or speech impaired but need-based devices are not accessible at district level. For most cases,
therefore, they have to rely on NGOs to provide assertive devices, although many of these assertive devices have
not been adapted to suit their needs.
• There is a shortage of adequate human resource capacity in mainstream health facilities. Ability deficits have been
shown to occur at the level of the technological and attitudinal skills to be required in relation to disability.
Numerous studies have documented substantial quality gaps in teaching strategies, learning practices and
facilities for training health workers / educational institutions, especially in the field of disability.
• Misconception regarding disability was also established as a significant attitudinal obstacle. Many myths have
been found to be linked to disability in wide circulation. The lack of awareness within the society is also found to
be as an obstacle and a barrier.
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Evaluation Report
(Methodology/Limitations & Findings)
The previous Health study helped in indicating and identifying the gaps and challenges on
Inclusive Health prospective of Bangladesh. Afterwards An evaluation report was
conducted, with the ending of the PIHRS phase I project, through
MDF Training and Consultancy to provide an overview of the strengths and limitations of
the initiative in the phase I, and how gender and disability integration have been
implemented across main performance fields -through this phase.
The evaluation covered the period from January 2015 to December 2017 and it evaluated
by focusing- on the goals of the project and phase I. scrutinizing the goals of PHASE I-
Evaluating whether or not the targets of the project have reached the initial expectations
and conclusions, according to the initial expectations.
“It also stressed on the procedures that has been used to accomplish
The Four Main Results
And represented the strengths, weaknesses and lessons learnt in the
execution of the project. “
1
2 3 4
9 government hospitals
and two hundred and
forty Community Clinics
equipped with
leadership, medical
professional and
knowledge on disability
to ensure diagnosis,
treatment, rehabilitation
and referral services for
people with disability
Enhanced
participation of
disabled people and
their organizations in
government health
service delivery
system through
district and Upazila
hospitals and
community
Clinics
National policy
instruments for
disability health
Care
Operationalized
Through
Government
Hospitals in
District and
Upazilas
Increased awareness,
knowledge and
understanding of
disability health and
benefits of therapy
& support services in
family, community
leaders, media, policy
makers & general
public
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It was aimed to identify strategies for implementation of stakeholders (DRRA and the
Ministry of Health and Family Welfare) through an appreciation of the effects of the
programme. It had a participatory approach and was led by an external evaluator from MDF
Bangladesh, who worked together with a team of staff members from DRRA. During data
collection process in the field, representative members of DPOs from the respective
Upazila were involved in the evaluation process.
The process included the following steps:
Discussions were conducted at the initial stage of planning and decided that this
participatory evaluation should be carried out by MDF BD with the help of DRRA. A
preliminary 'Terms of Reference' was drawn up an d a formal preparation meeting was
conducted to reflect on the project and finalize the field work timetable, decide on the
basic questions to be used and define the problems to be addressed in the assessment. In
order to carry out the assessment.
The following focus areas were considered:
•Inclusive health and rehabilitation services delivery from government hospitals and
community clinics in three districts (9 Upazilas)
• Awareness on disability health, benefits of therapy and support services amongst
community leaders, family and general public
• Knowledge and understanding of the community regarding facilitation of access to
services at government hospitals
• Participation of disabled people and their organizations in government health service
delivery systems through district and Upazilla hospitals and community clinics.
• National policy instruments towards inclusive health service delivery for people with
disability through government health systems.
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Bearing in mind the geographical differenc es and the availability of time during the
participatory appraisal process, it was determined that 2 Upazilas would be selected for
this evaluation in each district.
The following data collection approaches were used:
• Desk research: review of accessible records as well as progress notes to consider what
has been done relative to what has been expected
• Interviews with DRRA workers
• Individual interviews with eligible beneficiaries as well as findings (hospitals,
neighborhood clinics)
• Group meetings with DPOs, journalists
• Key informant interviews (government officials, members of Inclusive Health Alliance)
The research team included people with disabilities who assisted them through the
interviews and presented their interpretation of the finding s.
Limitations-
Although the evaluation methodology was mainly qualitative, though the team inspected
the collection, which is perceived to be a fair reflection of the whole project. Although the
assessment did not include the whole project area, the fi ndings are limited to what has
been verified and observed by the team. In fact, the results are often focused on the
objective evidence given by the partners and the workers themselves. For example, DRRA
identified 137 participants of the targeted DPOs, th e assessment teams did not reach all
the participants, but found such statistics to be facts. In addition, several concerns have
been posed during the fieldwork, such as the last -minute un-availability of the main
informants concerned.
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Quality & Equality
With Challenges Came Changes….
• The establishment of Nine Upazila Health and Rehabilitation Centers (UHRC) and government hospitals
are now well- within their premises.
• Physical mobility for people with disabilities has increased in targeted government hospitals through
the construction of ramps and adequate toilets (currently accessible in two UHRCs).
• After 2015, people with different types of disabilities and people at risk of disability have been seeking
care, rehabilitation including referral services from all of the nine target hospitals, with separate queues
for them as well.
• For most cases, PWDS has provided priority access to doctor's rooms, but the experience of patients
varied from hospital to hospital for terms of waiting time for treatment and treatment services.
• Based on the visits and interviews with the correspondents, the results indicated that infrastructure
accessibility was expressly built for people with physical disabilities as a result of the project.
• Patients having vision, hearing, intellectual disabilities and difficulties in speech are now well informed
regarding furthering their treatment services considering the types and need of their issues.
• A Monthly reporting system has been established on disability health and counseling services from
Community Clinic to UHC and from UHC to Civil Surgeon Office.
• DRRA, along with Directorate General of Health Services (DG-Health) has developed a curriculum for
capacity building of doctors working in both district and Upazila level. a total of 115 doctors, received
training on disability assessment and identification which enables them to assess and identify different
types of disabilities
• About 242 Community Health Care Providers (CHCP) received orientation on disability identification and
referral.
• Over the project period, 11,620 patients have received rehabilitation and/or referral services and a total
of 52,518 patients with PWD’s visited across the nine target hospitals.
• It was also noticed that the decision-making for continuation of treatment and therapies for female
children and adults has improved significantly, with a noticeable reduction in the gender discrimination
mindset as well.
• Progress was made in Satkhira and Manikganj to involve DPOs in most of the Community clinics and
they are they were found to be more organized and informative regarding disability and its prevention,
identification and referral.
• Upazila Disability Health Committees (UDHCs) were established in each Upazila Health Complex (UHC).
Upazila Health and Family Planning Officer (UHFPO), the Chief Executive Officer of UHC, served as the
focal person. The Committee also comprises Upazila Social Welfare Officer, 4 members of the DPOs and
along with few other elite persons engaged in voluntary social work. They meet quarterly to reflect on
the results of this initiative.
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• Issues in favor of PWD’s have been now addressed through these forums such as making ramp,
allocating specific bed in indoor wards, making separate line for ticket in outdoor, making tickets
free in some UHCs and subsidizing pathological services.
• The project was carried out in partnership with relevant stakeholders of the Ministry of Health
and Family Welfare (MoHFW) and is actively engaged in developing the curriculum for capacity
development of the doctors at Upazila and District level.’
• In addition, the government has shown interest in enhancing its facilities and making it available
for PWD's. The intention itself reflects the determination to collaborate with DRRA. The
government has made available space for rehabilitation services in hospitals. Wheelchair ramps
and special toilets have been installed with government funding to improve the physical
accessibility of their facilities. Acknowledging the value of quality health and rehabilitation
services, the government has also sent their doctors to participate in the training conducted
by DRRA.
• Furthermore, the government invited DRRA as a national key player for presenting the inclusive
health concept at Regional Forum in Asia & CBR network.
• A major achievement on a national level, was that most of the recommendations from the study
‘Access to Mainstream Health Services for Persons with Disabilities in Bangladesh’ have been
included in the next 5 years National Action Plan.
• Interviews with different stakeholders (DPOs, community people, CHCP, CM), has indicated that
a level of awareness and sensitization on disability issues has taken a positive effect. For instance,
social stigma about people with disability is reduced considerably in most of the intervened areas.
• The community mobilizers have developed a partnership with a national newspaper “Bhorer
Kagoj” and information has been shared with some of the local level newspapers in each district.
They regularly covers important events and news related to disability and project activities. These
journalists were also involved in UDHC which created a platform and played a vital role for the
DPOs to share opinions on behalf of person with disabilities, for thousands to read and know
about the changes that has been taking place.
• The efforts of the project have had a positive impact on the demand for inclusive healthcare
services. Especially families of people with disabilities are not embarrassed of their family member
with disability anymore and people are no longer treating the disability as a curse or disgraceful.
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Sustainability
Promotion and support
Working with community members and local
Stakeholders for raising awareness, voice
And lobbying to promote rights of the person
With disability according to Rights &
Protection Act 2013.
For sustainability, support from
Government is required to adopt
Inclusive health in the mainstream
Health service
And SoP.
Empower Persons with disabilities through
CBID strategy (health, education,
Employment and
Others).
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esson
earned
• The partnership with government helped to establish the service delivery for people with
disability in Upazila level. The service and equipment support provision through the therapy
units is worthy. The factors of this is the successful engagement of the government from the
very beginning of the project.
• The decrease of new patients in the third year (as can be seen in figure 2 and 3) can possibly
be explained by the following: Most of the patients have been reached and no new patients
are ‘available’. This could be due to all new patients with easy access (resource wise and
location wise) have been reached and have been treated or are now regular patients.
• As the hospitals are not able to treat all disabilities for all the care required. Therefore, the
referral system was helpful. However, referring does not automatically lead to people being
treated, as specialized hospitals or private clinics are not easy to access. The reasons could
be they are not always nearby (decreased accessibility) and are often too expensive (financial
constraints). Referring people with disabilities is only th e first step in their treatment.
• There seems to be a difference regarding accessibility for people living close to the health
centers and hospitals and people living in remote areas. The degree of awareness and
sensitivity but also physical access to the clinics/hospitals are important elements
determining whether people are make use of the services that are offered. These issues must
be considered during the designing and implementing an inclusive health project.
• Though there is significant increase in women using the services there are more men using
the health services provided by the project. A reason could be that girls and women are more
restricted in terms of decision making and movement due to safety and cultural and religious
believers and practices. Furthermore, absence of female therapists could be another reason
that the female clients might be reluctant to the centers.
• Diagnosis and treatment of disability is efficient and effective when specialist doctors such
as a neuro medicine specialist is available in the hospitals. Those doctors are particularly
needed when dealing with people with complex or multiple disabilities. It might be effective
if the neuro medicine, physical medicine or child health specialist act as focal person in
specific cases to ensure actual diagnosis and treatment of disability, especially autism,
intellectual disability, Down syndrome and convulsive disorders.
• Recruiting and retaining technical persons like Occupational Therapists is a challenge due to
less eligible persons and high turnover. This has impacted the continuity of rehabilitation
plans and assistance to people with disabilities. Possible reasons are less interest of people
to study in this area due to limited opportunity for carrier development, especially in Govt.
sector.
• The difference between Satkhira and Manikganj and Chittagong can be partly explained by
the fact that the disable persons in Banshkhali and Raojan of Chittagong were not organized
from the beginning of the project.
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• DPOs involvement in project activities and their capacity in defending the interests of people
with disabilities is determined by many factors. The empowerment of DPOs on disability
related issues, should not be limited to sensitizing them on disability r ights. Financial
dependency and limited capacity in negotiation and internal management could be main
reasons for inadequate participation and contribution.
• The voice of DPOs are likely more legitimate and credible when they are well organized and
coordinated. The district level DPOs could act as the resource persons to develop the
capacity of the comparatively smaller DPOs utilizing their experiences and expertise.
• The government has shown an interest in improving their services and accessibility for
people with disabilities. Nevertheless, the Government is still depending on external service
providers like DRRA for the implementation of National policy instruments and for the
provision of healthcare services of people with disabilities. This is likely t o remain like this
for the coming years. This justifies the continuity of the project and further expansion to
other areas until the government is ready to take over and build on from the initiatives.
• It also appears that the project is becoming the ‘soun ding board’ resonating the mindset of
the people with disabilities and needed inclusive health and rehabilitation services. Thereby
it could become an effective lobbying mechanism towards the government policy makers.
• The national government has recognized the PIHRS project as a model and it can be
replicated to other part of the country (NDD Strategy).
• It was found that disability prevention and services has been included under Non -
Communicable Disease Control (NCDC) plan. It seems that the project inven tion has given a
credibility to DRRA to have ‘voice’ in national forums and policy dialogues.
• Awareness raising on disability issues could be more effective if it’s done through acceptable
and recognized manner; for instance, technical persons (APT/ OT) c ould have used the
Community Clinic platform periodically.
• Information Education and Communication (IEC) materials reflecting all types of disability
need to be accessed and understood by the mass community people. For instance, visual
medium of IEC material can be a good tool for the awareness raising of the community.
• The community mobilization is an integral part for the project and needs intensive and
continuous effort. Therefore, number of Community Mobilizers not sufficient based on the
population ratio. The limited awareness and sensitization, particularly in remote areas.
Besides, community mobilizers that were available in this project and the large areas they had
to cover larger areas with limited money allocation to travel.
• The effects of the sensitization were limited due to the lack of funds and manpower. Only
one Community Mobilizer (CM) per Upazila was involved all the activities related to
community mobilization and raising awareness.
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Our
Good Practices
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Hospital based disability
focal and committee was
established.
Allocate budget by
UHC
Separate ticket counter and
reserved bed for residential
patient with disabilities
Barrier free
And Disabled
friendly UHC
Govt order for disability
Section and specialized
committee formation
245 CHCPs are taking
leads on Disability
Identification and
referral process
Monitoring process
established
Within UHC
By Government
Hands on training
orientation was given
to NDD parents that
has covered
counseling to person
with disabilities and
their Care givers.
UPs took initiatives
on disability health
issues by allocating
budget & support
along with also
monitoring
community health
services.
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Influences in the Government policy level
• The Government initiated to develop national NDD strategy and action plan. The project
concept has been adapted in this strategy as model.
• Disability prevention and service is considering under NCDC plan.
• Most of Health Study recommendations has been included in the next 5 years NAP (2018-
2022).
• Chittagong City Corporation operating H&R unit at Menon Hospital as well as Doctors &
Technical staffs has been trained on Disability Identification and Prevention.
• Govt of Bangladesh in collaboration with DRRA and WHO has worked to develop a
comprehensive community in 2017 at three district as pilot for resource mapping.
• Qqualitative monitoring will be conducted according to PWDs satisfaction.
• M-Chart and Red flag were translated in poster along with Children Milestones for the
identification of NDD children at early stage by CC and Govt CHW.
• Training module for Govt doctors and CHW has already been developed and Govt is
going to conduct the training in larger targeted groups.
• DGH used DRRA’s online Data base system for their program design and working
regarding disability data inclusion in 2017 December.
Recognition and Replication
• Government recognizes that the PIHRS project is a model and it can be replicated to other
parts of the country as well (NDD Strategy)
• Government has invited DRRA to act as a national key player for presenting the inclusive
health concept at Regional Forum in Asia & CBR network.
• WHO, DG Health and DRRA are working together to create data base of people with
disabilities for medical rehabilitation as part of mainstreaming data base (DGHS-II).
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CCase Study
“His parents were really concerned but had no idea what to do and
where to go.”
Limon Miah is only 5 years old and has cerebral palsy He use to have
continuous secretion of saliva from his mouth, lacked the ability to m anage
his arm movements, he could not stand properly, neither could he walk. He
used to have constant seizures, and left hand had no strength for
movement. His parents were really concerned but had no idea what to do
and where to go.
Then they went to the Dhaka Children's Hospital, where he was referred to
CRP, Savar for treatment, exercise and physiotherapy. But it wasn't possible
for a middle class family like theirs to stay and get treatment because it was
very expensive, so they had to bring him back home. They were not yet
aware that there is an organization called DRRA which, through its PIHRS
project, provides full- health and rehabilitation services at the Upozila
Health Complex. Then, through the PIHRS CM project, they came to know
about the services and were amazed to know that their child would finally
get the proper treatment. After visiting PIHRS, a representative informed
them regarding their son’s disability and all about the services that they will
provide. An APT took his assessment, IRP and did the registration and
provided them with card.
They are currently going to the Therapy Center three times a week for
therapy and other services and can see the changes that are taking place in
their child physic. That he's getting his strength back in his shoulder, legs,
and hands. Now his saliva dripping problem has gone as well. They pray to
God that their child will soon be well and pray for DRRA as well as they feel
it would not be possible for them to see this day without their help. They
are very confident that he will get well soon with the support of the family
and the DRRA.
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“Aalal says “It Feels like being born again”
Md. Aalal is a 45 year old man and has been diagnosed with physical disability after
an incident. He has been living happily in the east outskirts of Khalilpur village in
Bolra at Harirampur, Manikgang district. Along with his two beautiful daughter and
wife, life seems to be moving gracefully for them so far. Being the only breadwinner
in the family he had all the responsibilities on his shoulders. So he took job as a
construction worker in Dubai, far away from his family just in hopes to provide a
better life for his both daughters. Though he never had the premonition of what
was yet to come.
One day at work in the construction site, he suddenly he had a stroke and was
rushed to a hospital right away. In this senseless condition he stayed there for 5
days in ICU and after coming to senses, was transferred to Bangladesh to his family.
Here in Dhaka, he got admitted to Apolo hospital and went through a lot of different
test and examinations along with therapies. Afterwards doctors shifted him to CRP,
Savar rehabilitation Center for better rehab and therapy services. At CRP, he went
for regular physio and occupational therapies and just started to feel better when
he had to leave the treatment in the middle, due to lack of finances and far distance
travel. His left hand and leg was fully paralyzed and life seems to be falling apart
for this 45 years old man. He never thought that he will be facing a disarray
situation like this at this age. Hopes started shattering away with each passing days
and all their savings were running out as well.
Once they went to Harirampur hospital to find any other possible ways to provide
health support and it is than that through a local doctor they heard of a non -
government NGO- DRRA. They were delighted, it’s like a glimpse of hope appeared
after hearing about DRRA’s, PIHRS project which provides free of cost support of
Rehabilitation and therapy services for person with disability. In April 2019 he was
admitted in the center and after proper assessment and diagnosis, was enlisted
with his physical disabilities to start the process.
Now it’s 2019 and Aalal still can’t believe that with regular phy sio and occupational
therapy services now he is capable of doing his regular chores without anyone’s
help, he can write now, walk both steps properly. It has been a great achievement
for Aalal so far, as he never thought of seeing this day in reality again . His wife was
also given training on therapy and exercises; so that she can provide him the
services at home.
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“After getting a walker, now Yasin wants to go to school like other
children”
Yasin is only 8 years old and has been diagnosed with C.P Spasti city
(Paraplesia).They live in the outskirts of Sobrothia Gaji village in Dopotim upozila
at Nagorpur, Tangail District. In hope for a son yasin’s parents serially tried but as
all 3 were daughters, the dream of having a son was left aside after a while. A n
unplanned pregnancy came along bringing yasin to them as a dream coming true.
The family was very excited as now they have a full family as they hoped earlier. As
time went along gracefully everything went well. Although no one ever thought that
their dreams would shatter soon in time.
Once while visiting his grandparents’ house, it was at night that yasin fell down
from the bed and was severely injured. However nothing was noticed right away
but soon they realized that yasin’s behavior and movement aren’t normal like usual.
In disarray they went to lot of doctors and specialist but there wasn’t any
improvement in his physical situation. Then they took him to Dhaka, Savar where
they consulted a specialist and after through tests and scans they identified that 3
percent of his body’s water has dried up and only 1 percent is left and though a lot
of medicine was given but it all went in vain as his mental situation started
deteriorating. Then they took him to Sibaloy children Therapy center, where he was
provided with therapy for a while.
It is around that time that they came to know about a non-government organization
DRRA’s for the 1 st time from locals. Without wasting any time further they went to
Daulatpur and met DRRA’s, PIHRS Project representatives an d other OT, APT
personals. They were delighted, it’s like a glimpse of hope appeared in their faces.
Knowing that it provides free of cost support for Rehabilitation and therapy services
for person with disability it made them confident that they have come to a right
place. He was admitted in the center on May 2017 and after proper assessment and
diagnosis, was enlisted with various physically problems like - less strength in legs
to walk or stand, difficulty in cross sitting, TA tightness etc. Then a short and long
term treatment was planned and thus yasin started his regular services since then.
Now Yasin has a Walker for support and he is improving each day. He is capable of
doing his regular chores with some help; he can write now, walk both steps with th e help of
walker and he is going to school now regularly. It has been a great achievement for him and his
family, as he never thought of seeing this day in reality.
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“Riya’s improvement has eased the life of her parents now”
Riya’s mother’s name is Laily and she is a housewife and her father Md. Ripon
works at a grill workshop. They live a very simple life in a Sibari village of
Borodhiya at Ghior, Manikgong District and were unaware of the problems that
will come along with their 1 st born daughter.
According to riya’s mother it’s been 8 months since May 2019 now that they are
bringing riya to DRRA’s Manikgong premises for Physiotherapy. They bring her
thrice every week for the therapy. Her mother Laily got married at a very tender
age of only 14 years and conceived riya just after a year of their marriage.
According to her father there were no complications before or after her birth. And
it was a normal delivery in their house just around 10 months of conceiving. But
at around the age of 7 months she had Pneumonia and was admitted to local
hospital for a day for treatment. Laila says that they had no idea that her child has
Cerebral Palsy and after her birth she was acting normal for a while but just after
the pneumonia she started having problem with her legs and shoulder. They were
unaware about DRRA’s, PIHRS Project that from 2015 they are providing all these
kind of support and treatment for free at Shibaloy Upozila hospital. It was his
workshop owner, who informed him about the Shibaloy health complex that
DRRA’s PIHRS project provides all the physiotherapy and occupation therapies and
helps disabled people and children with medicine and all other sorts of surgery
and intervention support.
Since then he is taking his daughter Riya for all necess ary therapy supports and
after so many months of therapy they can see the changes in her clearly. Before
she couldn’t walk properly her steps were always inward now she can put proper
steps. Her words are getting clearer then before and she had no control of her
shoulder but now she is getting her strength back in her shoulder for movement.
Riya’s parents are at ease now with the support of DRRA’S PIHRS PROJECTS’S
contribution.
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References:
1. https://www.hurights.or.jp/archives/focus/section1/2009/03/ Bangladesh and Persons with
Disabilities
2. Convention on the Rights of Persons with Disabilities: some facts about disability. New York,
United Nations, 2006(www.un.org/disabilities/convention/facts.shtml, accessed 18 June 2010).
3. Disability, poverty and development. UK, Department for International Development, 2000
(www.make-development-inclusive.org/docsen/DFIDdisabilityPovertyDev.pdf, accessed 18
June 2010).
4. Declaration of Human Rights. United Nations, 1948
(www.un.org/en/documents/udhr/index.shtml, accessed 18 June 2010).
5. DRRA-Health study Rights are still left behind report
6. DRRA-Evaluation Report of PIHRS-PHASE-1
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Thank You..
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