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Indian Journal of Community Medicine

Continuing Medical Education - Community Based Rehabilitation in Primary Health Care

Author(s): A.K. Sharma, Praveen Vashist

Vol. 27, No. 3 (2002-07 - 2002-09)

Deptt. of Community Medicine, Lady Hardinge Medical College, New Delhi

Community Based Rehabilitation (CBR) strategy was developed by the WHO after 1978. Alma Ata declaration, which stated that comprehensive primary health care, should include promotive, preventive, curative and rehabilitative care. The major objective of CBR is to ensure that people with disabilities (PWD) are able to maximize their physical and mental abilities, have access to regular services and opportunities and achieve full social integration within their communities. CBR is a comprehensive approach, which encompasses disability prevention and rehabilitation in primary health care activities and integration of disabled children in ordinary school and provision of opportunities for the gainful economic activities for disabled adults. Medical Council of India in the "Regulation on graduate medical education, 1997" has emphasized that medical graduate be competent to practice preventive, curative and rehabilitative medicine. It has recommended that clinical posting in Orthopedics should include exposure to Rehabilitation and Physiotherapy. An elective posting of fifteen days is also recommended in Physical Medicine and Rehabilitation during internship.

The Person with Disability Act (PWD Act) 1995:

The PWD Act was implemented in 1995. It envisages equal opportunities, protection of right and full participation of people with disability. Prevention and early detection of disabilities is the most important component of the Act.

The various measures given under the Act for the prevention and early detection of disabilities are:

  1. To undertake surveys, investigation and research concerning the cause of disabilities.
  2. To promote various methods of preventing disabilities.
  3. To screen all the children at least once in a year for the purpose of identifying at risk and cause of disability.
  4. To provide facilities for training to the staff at the primary health centre.
  5. To sponsor awareness campaigns and disseminate information for general hygiene.
  6. To take measures for prenatal, perinatal and postnatal care of the mother and child.
  7. To educate the public through the preschools, schools and primary health centres with the help of village level workers and Anganwadi workers.
  8. To create awareness amongst the masses through television, radio and other mass media on the causes of disabilities and preventive measures to be adopted.

Situational analysis of disabilities:

The implementation of people with disabilities act 1995 is being vigorously perused by the Ministry of Social Welfare and all other concerned ministries. Therefore, it is appropriate time to take stock of the situation of disabled population in the country, their needs and services available, both in urban and rural sector. It is also essential for the policy formulators and implementers to know present and future trends of various diseases and disorders causing morbidity and disability.

The estimated number of physically disabled persons in India are 16.154 million (1991 census) which include 8.939 million people of locomotor disability, 4.005 million visually disabled, 3.242 million hearing disabled and 1.966 million speech disabled. 78.32% (12.65 million) of physically disabled people are living in rural area. The proportion of males is higher (58.93%) than females.

Age-wise distribution of physically disabled people reveals that out of every 1,000 disabled, 398 are in 60+ age group, 425 in 15-59 age and 150 are in less than 14 years age. Visual and hearing disabilities are more common in 60+ age group. Out of every 1,000 visually disabled, 717 are in 60+ age group. Five hundred and twenty six out of 1,000 hearing disabled are in 60+ age group. Out of every 1,000 people with locomotor disability, 487 are in 15-59 age group, 251 are in less than 14 age group and 240 are in 60+ age group. Five hundred and thirty nine out of 1,000 speech disabled are in 15-59 age group and 197 are in 60+ age group (NSSO, 1991).

The incidence of all kinds of physical disabilities increases after 45 years and it is very high after 60 years of age. Out of every 1,000 people with physical disability, 278 have onset in 45-59 age, whereas, 511 have onset after 60 years of age.

As per population data provided by UNFPA Geneva 1995, the prevalence of severe and moderate disability in India is estimated as 4.6% and the predicted prevalence by 2020 is 5.25%.

Proposed programme for rehabilitation of the disabled in the ninth five-year plan:

  1. At the Gram Panchayat level the local panchayat committee will manage the CBR programme. Preferably, Two CBR workers one male and one female, for about 5,000 population, may be employed and suitably trained at the Gram Panchayat level.
  2. At the PHC level 2 Multi Rehabilitation Workers (MRWs) for about 30,000 population will be responsible to provide services to the persons with disabilities. They will provide information to community leaders, to the persons with disabilities and their families about disability. They will also provide services and opportunities using already available resources. The MRW will co-operate with PHC, education, Labour, NGOs and other persons, which will make services available and open opportunities for PWDs. They will also make appropriate referral of cases to the District Rehabilitation Centre (DRC).
  3. At the district level DRC will be headed by District Rehabilitation Officer who will monitor and guide the work carried out at peripheral levels. Functionaries of the department of rural development, social welfare, labour and employment and women and child development will also provide specialist services at the district level.
  4. At the state level, an apex level institution will be set up to serve as resource centre in the field of disability prevention and rehabilitation. This institute will train the functionaries of DRCs, PHCs and CHCs. The institute will also undertake long and short term training programme to develop the manpower required in the state for the delivery of rehabilitation services. It will also establish linkages with the existing medical professionals, training and employment infrastructure and also promote and conduct research in the area of disability prevention and rehabilitation.
  5. At the national level, it is proposed that there should be a national centre for disability rehabilitation under the national programme of rehabilitation.

Role of Primary Health Centres for Disability Rehabilitation:

Various services for persons with disabilities in India are very short in supply and do not cover more than even one percent of the entire disabled population. In order to face the challenges of increased population and the lack of proper services to match the needs and expectations of the persons with disability, their family members and the society as a whole, a suitable framework having wide coverage has to be developed in the country for effective management of the disabled. It is in view of these primary and basic needs, the primary health centre (PHC) network in India assumes great importance. A PHC is the only existing minimum necessary infrastructure to provide various disability prevention and rehabilitation services. By sensitizing the medical officers and health teams in PHCs on some of the important aspects of disability prevention, early identification, referral and rehabilitation, valuable services could be rendered to people with disabilities in the rural areas.

Primary health care in India is provided by a network of primary health centres and its subcentres in rural areas and health posts in urban areas. Health workers at subcentres get help from village health guides (VHGs), traditional birth attendants (TBAs) and anganwadi workers in their functioning. This huge manpower can help in identification of disabled along with CBR workers and community level functionaries of DRC with the help of training packages developed by WHO.

Multi Rehabilitation Workers (MRWs) at PHC with the help of Medical Officer will attend to referred disabled and help in training of personnel engaged at subcentre and village level. Vocational rehabilitation centres will provide support in relation to generating various occupational opportunities for disabled along with NGOs and other concerned personnel at district level.

Model method of Implementation of CBR using Primary Health Centres:

  1. Community level functionaries (CLF) at village and subcentre level for a population of 5000. The Village Rehabilitation Committee (VRC) of the Panchayat members will manage the activities.

(a) Manpower

-Person with disabilities
-Family trainee
-Community rehabilitation worker
-MPHW male and female
-VHG, TBA and anganwadi worker
-NGOs, teachers and volunteers

(b) Functions:

-Micromanagement
-Community preparation
-Resources
-Monitoring

(c)Tasks:

-Locate and Identify PWD
-Referral
-Assess functions and activities
-Select training material and trainees
-Teach and motivate family training
-Increased acceptance by family
-Facilitate school admission
-Refer to social and vocational organization
-Assess record and report results to VRC
-Stimulate awareness of community about disability.
-Continuing education for CLF and teach them about health care needs of disabled persons.

  1. At PHC and CHC level for a population of 30,000 to 1 lakh. The Medical Officer-in-charge of PHC and CHC will manage the activities.

(a) Manpower

-Multi rehabilitation worker (MRW)
-Health assistant male and female

(b) Functions

-Provide technical training, supervision and support of CBR programme
-Report on effectiveness of CBR centre
-Provide first level referral advice and refer to higher level if required
-Interact with middle level personnel in other sectors like social, education and labour and co-ordinate supports to community.

Orientation of Medical Officers working in Primary Health Centres to disability management:

Rehabilitation council of India has launched the National Programme on Orientation of Medical Officers working in Primary Health Centres to Disability Management on 15th July 1999, with a view that the Medical Officers of PHCs could be trained in various disability issues, PHC is the only health infrastructure, which is spread over the country. Training the Medical Officers in Disability Prevention & Rehabilitation can bring significant benefits to the persons with disabilities. Most of the disable people live in the rural areas with very poor infrastructure for providing rehabilitation services. In view of such gross neglect of rural areas, this programme has been designed for rural disabled.

The programme is being implemented in two stages. In the first stage, a master training programme is imparted in each state to a team of medical practitioners/ rehabilitation professionals working in the institutions selected to conduct the master training programme. In the second stage, the trained Master Trainer's Services are utilized for taking up the training of the Medical Officers working in the PHCs. The ingenuity of programme is the utilization of the rehabilitation professionals taken from all the disability areas for the training of Medical Officers. This has been consciously done with a view to add thrust to programme by way of transferring the rich knowledge and experience of these professionals to the Medical Officers regarding various intricate disability issues. Another notable feature of the programme is the selection of Institutions, which have rich experience and possess laboratories in one or more areas of disability. This not only gives an opportunity to the doctors to observe themselves the various facets of disability and also allow them to gain practical insight into managing the problems in the locality covered under their PHCs.

Expected benefits of the programme:

  1. The programme is expected to generate in the country, the following benefits in the short as well as in the long run:
  2. Large scale direct benefit of various services like prevention, early identification, referral and rehabilitation to the rural population.
  3. Wide and improved service network for the persons with disabilities even in the remotest corners of the country.
  4. Decrease in the severity and extent of disability in millions of cases.
  5. Increase in the GDP, as the impact of disability prevalence will be less.
  6. Awareness generation among the Health Workers through the PHC Medical Officers which will percolate to the lowest level as the lower level health workers function within the community.
  7. Social and economic empowerment of the persons with disability.
  8. Leadership building in the PHC Medical Officers to help create better sensitization at the grass root level which will ultimately ensure better implementation of the Persons with Disabilities Act, 1995.

Suggested readings:

  1. The Persons With Disabilities (equal opportunities, protection of rights and full participation) Act 1995 - Ministry of Law, Justice and Company affairs.
  2. Proceedings of workshop on Community Based Rehabilitation WHO sponsored - department of Physical Medicine and Rehabilitation, Safdarjang Hospital, New Delhi, 1997.
  3. Disability prevention and rehabilitation in Primary Health Care - A guide for district health and rehabilitation managers. Rehabilitation, WHO, 1995.
  4. National programme on orientation of Medical Officers working in Primary Health Centres to disability management - status of implementation 2001, Rehabilitation Council of India.
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