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ISPO An Asian Prosthetics and Orthotics Workshop '98 in Japan Final Report

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THE ROLE OF EDUCATION AND EDUCATIONAL INSTITUTIONS IN THE DEVELOPMENT OF PROSTHETIC/ORTHOTIC SERVICES

Sepp Helm

The late 19th century marked the take-over by the German State of the professional Education System in Germany and the ensuing recognition of the degree accorded to graduates resulted in a stabilisation of the various professions. The understanding that well trained professionals are needed for further development especially in an industrialised environment had a strong influence on the development of the various professions. This is also the case for the orthopaedic technician where professional acceptance took shape only after 1880, when professional education was regulated by law. For years there has been no doubt about the necessity for an extensive and specially structured training process that could be integrated within the specific conditions of different countries. There is the understanding that in the process of developing a profession, there is a need for a professional base. Only after the introduction of a structured training and education programme for orthopaedic technicians, who were at the time known as orthopaedic mechanics, did technical orthopaedics become attractive as a profession in Germany in terms of career and personal development.

Looking at low income countries; the same basic premise must be accepted and implemented, even if nowadays better methods and preconditions exist. Countries in need of orthopaedic treatment but offering no potential for professional development or career orientation have no possibility to build a necessary treatment structure which can be sustained over the long term. Short term assistance efforts, such as dispatching experts, donating workshop facilities and/or materials etc. generally work as long as the external supporters continue to stand behind these efforts, guaranteeing financial support as well as technical and professional backing. This means, that even in unique response situations involving prosthetics and orthotics, such as emergency situations, the goal of long-term development should be kept in mind. Although one does not necessarily exclude the other, nevertheless prosthetic and orthotic training processes could be improved in such a way as to ensure an acceptable on-the job learning process that could lead to the development of a structured training programme at a later date. Therefore it is necessary, of course, that procedures and contents of the structured training process are realised and are taken into consideration in the manpower selection process and in the contents of the short-term training. To quote Prof. Sethi from India: "not less, but more science and knowledge is necessary to solve the problems of developing countries. Simply transferring sophisticated technology from the industrialised world is no solution. But nor is it an advantage for development and looking ahead at the future to romanticise too simple technologies and to present peg legs for an example, using new materials or a new coat of paint as the latest and most realistic solution".

Goals in the development process are:

  • to provide knowledge for implementing simple concepts based on the most up to date theories of kinesiology, locomotion, gait analysis and ergonomics;
  • to develop appliances within the limits imposed by national economic conditions by utilising local materials and indigenous technologies;
  • to incorporate a blend of newly acquired knowledge mixed with traditional techniques to achieve optimal results.

These elements do not lead to narrowly educated experts but rather to experts trained in all facets of the profession, whereby no circumstances, such as the social position, and the personal goals of the individual must be left out of consideration. Only knowledge about the social and economic situation in the living and working environment gives enough background for realistic prosthetic and orthotic development.

Social acceptance and subsequently professional acceptance within the clinical treatment team, are in addition to personal income enhancement, at least equally important factors which must be considered in training specialised professionals and, if possible, should be guaranteed. The clinical treatment team is one of the most needed platforms for adequate and indicated treatment.

Without long-range perspectives oriented toward the future, and without a greater value being placed upon the need for development in the region, only personnel with short term orientations can be obtained. The training of professionals required within the social environment of the developing country is, in itself, an urgently desired outcome.

Over a long period of time, through events such as:

  • Holte, Denmark, 1968
  • Education study week in Glasgow, Scotland, 1974
  • Workshop focused on Training in Developing Countries, Moshi, Tanzania, 1984
  • Training workshop Toronto, 1984
  • World Health Organisation consultation Alexandria, Egypt, 1990

an international understanding was reached towards the creation of a Category II professional in prosthetics and orthotics to address the needs and realities of developing countries, - as a transitory measure.

The Category II professional or "Orthopaedic Technologist" is a compromise where relatively highly trained professionals cannot be provided. As members of the treatment team, they are able to take responsibilities for the various work procedures in the absence of a prosthetist/orthotist or meister, who is classified as a Category I professional. By proceeding in this way, the fully trained professional is not eliminated, but rather, in areas where there is no potential for higher training, better paying jobs are available, and this solution seems to be a practical intermediate one. The following illustration outlines the different categories of classification, as a reminder for better understanding.

Category I Prosthetist/Orthotist or equivalent
Education prerequisite: Secondary school graduation or equivalent
Professional Education: Formal Education with University degree or equivalent


Category II Orthopaedic Technologist or equivalent
Education prerequisite: "0" level (British) or equivalent
Professional Education: 3 years of formal structured training, below a degree level

The training and education required to become a Category II professional in prosthetics and orthotics currently involves completion of a three-year formal, structured study programme with internationally approved curriculum contents.

The ISPO programme for evaluating schools according to established criteria gives a tool:

  • to compare their level against established international standards
  • to include items like cost calculation, social structures and checking quality of training
  • to guarantee an ongoing achievement of the school for regional development.

Especially the last point is strengthened through a school and training recognition by the ISPO and is an important factor of investment into the future. ISPO certification of examinations made possible by the standardisation of the subject matter and the training procedures, gives the individual school leaver a possibility of international registration.

Here is another important tool for the development of the profession, through the professional stabilisation of individuals.

I believe that these two elements are important instruments which will improve the level, quality and international scope of these studies. In this way, the trained professional will have a much better opportunity to prove his level of acquired skill.

The professional profiles for Category I and Category II professionals provide the framework for training and education as exists in industrialised countries, as well as providing a guideline for the level of performance expected from, as well as the duties and rights of the prosthetic and orthotic professional. They provide all parties with a basis for professional understanding, acquisition of social status and the possibility of putting this knowledge to use.

The professional profile is the definitive framework for further development of the profession and the provision of treatment in the country.

The professional profile should be issued for the whole territory by the responsible Ministry before commencing the education programme. It is therefore strongly connected to the Education and Educational Programmes.

The two items discussed: the professional profile and the contents of the training programme must be adapted to fit the local, regional, cultural, social and technological goals. If the local system or Ministry of Education requires that an excessive amount of "Cultural Education" components be included, the length of time required for the actual training must be increased. Generally, since the particular country and the ministry involved is interested in international recognition for the educational programme, compromises are possible.

If, due to the size of the country, regional training is planned to maximise use of its resources, the element of international recognition becomes an absolute need.

But these training related elements are not enough for stabilised professional development in the region.

Consideration must be given to the following:

  • legislation frame
  • care systems
  • cost calculation
  • quality issues

as integral parts of development duties - consultancy duties - of educational institutions.

A conference in Wuhan / China in 1996 ended with a so called "Wuhan Declaration" which gives an overview of these ideas and takes the development into consideration. I would like to express it in a short form:

Wuhan Declaration on Orthopaedic Technology
- Summary -

The overall objective of interventions in the field of orthopaedic technological services should be to contribute to the re-integration of sick and disabled people into family, community and working life. The main target is the poor population, with special consideration for women and children as particularly vulnerable groups. In order to achieve this objective, interventions in developing countries should emphasise the following aims:

1) Integration of rehabilitation and orthopaedic services into the health care system

  • Governments should integrate orthopaedic services into the national health care plan and develop a national policy with relevant guidelines to ensure the delivery of adequate rehabilitation services
  • Basic orthotic and prosthetic services should be linked to Primary Health Care and Community Based Rehabilitation
  • Relevant administrative and service systems should be structured in such a way as to allow for a team approach among all health workers involved.

2) Strengthening of education and training in orthopaedic technology

  • The ISPO classification of prosthetics and orthotics professionals should be adopted with an immediate focus on Category II. Formal training programmes should meet international standards and seek ISPO recognition.
  • The training should not only contain the technological subjects, but also subjects such as clinical management of patients, quality assurance, staff and financial management.
  • Training schemes for continuing professional development should be made available.

3) Appropriate methods and technologies which provide proper fit and alignment based on principles which suit the needs of the individual at affordable costs should be sought

  • Priority should be given to providing appliances which are made from locally produced or available products
  • New technologies, such as CAD-CAM, may be advantageous for developing economies and should be further investigated
  • Standards should be applied and the use of quality management and performance indicators in the production of prosthetic and orthotic components should be adopted

4) Conditions should be created where a sustainable funding of orthopaedic care can be achieved.

  • From the start of planning prosthetics and orthotic services in a country, suitable funding mechanisms leading to the development of a sustainable system should be identified. Sources of funding include national or regional government, national (national health care funding) and international organisations, individuals and patient contributions.
  • There should be a system in place for costing, auditing and budgeting of all aspects of prosthetic and orthotic care, including costs incurred by patients
  • Encouragement should be given to the establishment of private sector workshops, taking account of economic and social factors prevalent. Private services should be a part of the overall service concept and co-ordinated with the public sector.

All these points are necessary for development and progress and should be recognised as such by educational institutions.

Why? -- These institutions are in fact the nucleus of professional growth and the place where most of the interested experts are available.

I would now like to explain the principles using three examples:

  • The regional school, TATCOT in Moshi, Tanzania;
  • The national school, CHICOT in Wuhan, People's Republic of China and
  • The VIETCOT school in Hanoi, Vietnam

The prosthetic and orthotic facility in Moshi was set up as a regional training unit from the beginning. The decision to proceed in this way was reached as a result of a feasibility study that was conducted by a group of experts, whose findings were accepted by the local authorities.

The government in Dar es Salaam, Tanzania originally wished to introduce a national prosthetic and orthotic education system for the country. Only four fitting centres existed throughout the entire country, and all were experiencing the same problems with materials, technology and skilled manpower. Continued financing was especially problematic due to the lack of a state budget, and a decline in the amount of donations from church groups.

The number of trained and skilled professionals needed to serve the estimated number of handicapped persons in the country was quite high. However:

  • There was no budget for creation of an increased number of jobs.
  • There was no funding to invest in facility development.
  • There were only a few available means of transportation and it was necessary for many patients to travel in order to get fitted with appliances.
  • There were limited possibilities to secure an adequate budget for the school.

Since the basic problems occurring in Tanzania were the same as in all other African countries, under the proposed localisation scheme, Moshi offered the best conditions required to set up a regional training centre for East African English-speaking countries. If through regional training, the number of trained personnel for each country was reduced, it meant that they:

  • could be absorbed into the system and their employability was ensured;
  • were an asset for the goal of long term improvement of the quality of the treatment system

Tanzania itself benefited from a number of advantages:

  • The school was financed largely through foreign scholarships. With a ratio of one Tanzanian for every two foreign students, the Tanzanian students were trained at almost no cost.
  • The presence of long-term Category I experts from the outside, provided stimulation for the prosthetic and orthotic field;
  • The country as a whole benefited in the end, since training for a group of professional teachers had been externally financed, and these indigenous Category I experts later took over the jobs of the expatriates and could therefore guarantee further development of the profession within the country.

From its inception, TATCOT was planned as a programme that could be integrated into a University training programme, offering an internationally recognised final diploma. The faculty of Dar es Salaam University (610 km from Moshi) sets up the contents of the education and training programme as well as the different stages of training and examinations and they are also responsible for issuing the final diplomas. It must be stressed that the curriculum offered is in conformity with the international specifications of the Category II professional.

Clinical studies comprise part of the third year of training and guarantees an additional income for the school and an realistic approach to current problems of clients and patients.

In addition to the regular class work, TATCOT offers:

  • national and international upgrading seminars,
  • modular seminars geared to the three-year teaching programme and integrated into the entire training,
  • advisory services to the government health administration and national government officials working in this area regarding setting up treatment facilities and clinical activities,
  • teachers who are delegated to other centres for support and improvement of local facilities.

In the area of practical work TATCOT has:

  • adapted a large number of European fitting techniques to the country
  • tested the polio orthosis mounted on wooden clogs,
  • tested and taught the direct stump lamination technique,
  • enhanced the treatment for leprosy patients using methods from West Africa that were improved.

Since 1981, approximately 195 students from 19 English-speaking and 2 French-speaking African countries have been awarded diplomas and have returned to their respective native countries. As far as we know, more than 80% continue to work in the profession and some of them hold impressive positions.

This education project has completely met its original objectives and has contributed toward a strong development not only within its own country but also to the entire East African Region.

Recently in 1996, the German Agency for International Development (DSE) financed a study about TATCOT leavers and their outcome. Professor Neff carried out the evaluation study. Some final statements of this study will close this section about TATCOT:

The development during recent years in the visited four East African countries seems to be a very important step forward, compared to the situation 15 or 20 years ago. This would never have been possible without the three-year training programme at TATCOT on high level, appropriate to the local needs, however. The evaluation revealed, that besides a few problems in human relationships and between generations of quite differently trained professionals, the critical input to improve the prosthetic and orthotic supply was and is still due to the activities of TATCOT trained professionals.

Now let us examine the second example, CHICOT in Wuhan, People's Republic of China, which has, in 1997, moved to a new location near Beijing. With its new politics, which are oriented to the outside world, in the area of Orthopaedics, China took an opportunity to stimulate and make a connection to international treatment status. In comparison to Tanzania, in this case it was not a question of eventually absorbing the number of skilled professionals needed and later offering them adequate jobs at treatment facilities.

Official statistics show 7.55 million handicapped persons exist in China, but only about 25% may be in a position to obtain necessary orthopaedic appliances. In general, there is one central prosthetic factory per province, a staggering statistic when you note that some provinces have more than 60 million inhabitants and extend in some instances for several hundred kilometres in diameter.

Out of several thousand employees in the various factories, only about 1,100 are directly involved in the field of prosthetics and orthotics, and out of this number, only approximately 10% are trained in such a way that they could be recognised as Category II prosthetic and orthotic professionals; all other staff have received very limited training in some areas. None of these employees has received structured school training. Rather, they are all trained on-the-job and are later upgraded by means of different seminars.

Due to this structure, almost all fittings performed up to this point have been prosthetic. The lack of a social security system which could serve as a cost bearer resulted in the fact that only state employees, for example, police, military and ministry employees were eligible to be treated with guaranteed cost coverage. Work related accidents are covered by the work unit through its profits and are therefore very different from those mentioned above and are not always available. In 1992, the central Orthopaedic Training School for Orthopaedic Technologists had been set up in Wuhan, Hubei Province in order to train sufficient leadership personnel to an internationally recognised level.

  • A professional profile has been defined and finalised.
  • The education is based on the international three year programme.
  • A fourth year was added in order to accommodate additional national requirements.
  • External international examination observers have been approved.
  • The yearly intake is 20 students.
  • The school is integrated into the secondary level II within the national education system

Training and education at the school so far.

From early beginning this installation served as an important instrument of professional policy set by the applicable ministry, in conjunction with the Prosthetic Research Centre in Beijing, and as such performs a number of special tasks.

This school is the first of its kind in the field of orthopaedic education for China as a whole, and even for a number of neighbouring Asian countries. As a result, there is a greater acceptance of the prosthetic and orthotic profession and a noticeable improvement of the quality of fitting in the orthopaedic treatment of handicapped persons.

Because of the physically central location of CHICOT within China, and the large population within the area, a number of professional and policy oriented functions have been assigned to the school, over and above its regular teaching functions.

To put this in perspective, the school was located in Wuhan, with a population of 6.5 million, the capital of Hubei province which itself has a population of 62 million.

The key additional functions of the school have been:

  • The creation and introduction of a modular seminar programme offering those receiving on-the-job training the opportunity to attain the same level through continuous upgrade training as those who complete the formal training programme.

Besides improving professional quality, this development paved the way for the central administration to make the school diploma or its equivalent a condition for the installation of private fitting service providers and future positions of leadership.

  • An important responsibility of the school to the central government was to offer proposals and advice on how to standardise orthopaedic appliances and treatment procedures. The 22 prosthetic factories in the Chinese provinces are thus able to base their quality control and cost calculation on this data.

These tools are vital to the central government, considering the increased privatisation of industry in general, and specifically in the field of orthopaedic supply. Actually, there are already a great number of privately owned facilities in China, and this tendency is increasing. This data is also important in the experimental stages of the introduction of health insurance and credit unions so that support for the costs of orthopaedic appliances may be available in the future.

  • The Orthopaedic School should provide impetus for the development of low cost treatment for the rural population. With no insurance available to this point, the rural population, with few exceptions, does not have the luxury of being fitted with a prosthesis, and certainly has no possibility of orthotic treatment. In addition the actual cost for all types of regular appliances, even using a very basic cost calculation, is not affordable to the average handicapped person on a privately funded basis. It must also be mentioned that the cost structure does not allow for a price reduction from the supplier side. The only way to reduce costs is to simplify the production process or to minimise the additional costs for patients who are procuring the needed appliances.

In this instance, using a CAD-CAM system, the school developed a programme that reduces the production process and lowers its costs. A remote fitting system was tested in co-operation with three other provincial prosthetic factories, and this brought, in addition to the above mentioned advantages, key quality improvements in the actual prosthetic socket fit.

Following an analysis of 40 test fittings, this has been heralded as a success and could lead to an increase in the remote or centralised prosthetic supply system in China. An 80% reduction in the additional costs for the patients, such as travel and incidental expenses, which are often several times higher than the cost of the prosthesis alone, represents the removal of an extreme social burden for those affected.

An additional focal point in the role of the school is to serve as a consulting body for state and private treatment centres. Pilot seminars on new techniques in fitting and production technology for provincial treatment centres were developed at the school through special consultations.

Increasingly, the different facilities are subjected to competitive pressure combined with the increased expectations of the handicapped persons themselves. The centres have an urgent need to offer a wider range of services, to lower costs of factory management and to modernise equipment and work procedures. In this area, the school is able to profit from its modern equipment by using it for demonstration purposes.

In the meantime a number of larger facilities have already modernised in these areas.

CHICOT, the school for Orthopaedic Technology, became an important instrument of the Ministry for Civil Affairs to promote improvement in fabrication and supply of orthopaedic appliances in terms of quality and quantity throughout the People's Republic of China.

The Training Centre for Orthopaedic Technologists, opened in 1997 in Hanoi, Vietnam, has already fulfilled a number of additional duties of overriding importance:

  • By influence and consultancy it transpired that the Ministry of Labour, Invalids and Social Affairs created a National Steering Body
    a) to work out a frame for development of a national care system
    b) to come to a national cost understanding for orthopaedic appliances
  • Appropriate technologies were tested, in order to advise the national body on implementation procedures
  • Polio treatment and associated CBR activities were reviewed
  • Co-ordination and co-operation of the different NGOs working in the prosthetics/orthotics field within in the country were improved.

Of course the aforementioned understanding of social work, implementation of professional profile etc. was necessary to the implementation of training and education in this country.

These three training centres, TATCOT in Tanzania, CHICOT in China and Hanoi may serve as examples of the processes involved in setting up professional schools in developing countries.

It is my hope that through these examples, I have illustrated both the need for, and the advantages of, these establishments.


Commemorating the Mid-Point of Asia and Pacific Decade of Disabled Persons
ISPO An Asian Prosthetics and Orthotics Workshop '98 in Japan Final Report
- Papers : The Role of Educatonal Institutions in the Development of Prosthetic/Orthotic Service -

Editors:
Eiji Tazawa
Brendan McHugh