ISPO An Asian Prosthetics and Orthotics Workshop '98 in Japan Final Report
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PROSTHETICS AND ORTHOTICS SERVICES AND THE IMPLEMENTATION OF COMMUNITY BASED REHABILITATION PROGRAMME IN INDONESIA (a Study in 17 CBR Pilot Project Villages)
Handojo Tjandrakusuma
Introduction
Prosthetics and Orthotics service is one of the most important aspects in medical rehabilitation services. However, in Indonesia, it is relatively less developed than the other medical rehabilitation services, such as physiotherapy.
Central Java province consists of 35 districts with the total population 32 million people. At present, in every district, there is already a physiotherapy service. But there are only two cities that happen to be the biggest cities in Central Java which have prosthetics and orthotics services. Those are Semarang, the capital city of Central Java province and Solo city.
There are several reasons why the development of prosthetics and orthotics services is not as significant as that of the other services. One of them is that the information on prosthetics and orthotics service is not distributed well which, in turn, leads to a lack of awareness of the service in the community. In such cases, the CBR programme can act as a bridge in the dissemination of information to the community. However, the problem in the provision of prosthetics and orthotics services is not that simple. It involves complex technical skills and production equipment which is not cheap. As a result, the implementation of prosthetics and orthotics services and its development become more difficult. This paper will discuss some problems in the provision of prosthetics and orthotics services in a village, based on the experience of the CBR Development and Training Centre (CBR-DTC) in carrying out a CBR pilot project in 17 villages in Central Java.
CBR Pilot Project in Central Java
Central Java is one of the most populous provinces in Indonesia. Its population is estimated to be 32 million. The transportation in this province, in general, is fairly good. There is sometimes a slight problem in certain mountainous areas, but it is solved by the availability of traditional transportation, such as horse carts. There are two big cities in the province where almost all businesses are carried out and available. They are Semarang, the capital city of the province and Solo City. In respect to the prosthetics and orthotics service, only those two cities provide the services. They are organised by Government institutions and private enterprises.
The Community Based Rehabilitation programme carried out by the CBR-DTC consists of:
- promoting community awareness of disability issues
- organising rehabilitation intervention
- providing rehabilitation services
- promoting income generating projects for people with disabilities (PWDs) and family
- promoting integrated education system;
In carrying out the programme, CBR-DTC sent trained field workers to the villages. They were to facilitate the local community in discovering their problems in disability issues and finding out how to solve them using the available resources within the village as well as outside. They did community awareness promotion including distributing information on rehabilitation services. They had to co-operate with both Government Organisations such as the Health Centre and Hospital, and Non-Governmental Organisations which had similar concerns to the CBR-DTC. These networks were then introduced by the field workers to the local community so that by the end of the project, the community would be able to carry out the CBR project using The networks.
The Pilot Project was carried out in 17 villages. The total number of people covered by the project was 93,902 people. According to the information from the community, there were 598 people with disabilities (PWDs). Among them, 317 people were reported to have physical disabilities and 68 of them were referred to a physiotherapist who was a member of CBR-DTC staff, by the field workers. Based on the examination, there were about 6 people who needed orthopaedic shoes, two people needing braces, and one person needing a splint.
CBR and Prosthetics and Orthotics Practices
Prosthetic and Orthotic services can be divided into three aspects:
- needs
- delivery
- maintenance.
Needs
In general, we can say that the community is ignorant of their need for prosthetics and orthotics services. This is mainly because they do not realise the usefulness of the service and more than that, they do not know where to access the information nor how to get the prosthetics and orthotics service. The existence of a CBR project in itself helped the community to be more aware of their disability problems. Furthermore, they knew better what to do to solve the problems, according to the field workers. As community awareness increased, their need for rehabilitation services including the prosthetics and orthotics services also rose. However, there were several problems:
Delivery
Prosthetic and orthotic provision needs intensive work from the professionals and equipment for the production of the devices. Within Central Java, there are only two cities that provide prosthetics and orthotics services. The delivery of prosthetics and orthotics services is the work of professional rather than of community. Therefore, a CBR programme cannot help much.
Maintenance
In this respect, there are two factors involved. They are patients and professionals. Both have an immense role. The patients supported by their community have to have awareness of the importance of maintenance. In addition, the professionals have to technically maintain the devices they have given. For example, the patient has to know when his prosthesis is to be sent back to the prosthetic/orthotic workshop for checking and repair, whereas the professional has to provide the service. Because there is a limited number of prosthetic/orthotic workshops the maintenance services, such as repairing, become difficult to provide.
Discussion
Based on the experience of the CBR-DTC in implementing its CBR Pilot Project, there are four major problems which occurred in the provision of prosthetics and orthotics services:
1. Funding
The Pilot Project was carried out in a rural agricultural community which was relatively poor. The capacity of people to fund their own prosthetic and orthotic needs was somewhat low. The CBR programme provided an alternative solution to solving the problem. It raised funds through:
- local community;
- NGOs;
- government services
However, to raise funds the community needs to understand the importance of the services and also know how to do the activity. For instance, they need to know which institutions provide help or funds for rehabilitation services. The CBR programme can function as a resource in providing information and skills in raising funds.
2. Socio-cultural aspects
Most communities have their own culture and beliefs, including in disability issues. These beliefs are difficult to change. It is difficult for them, especially the older people, to accept new knowledge or a new concept. For example, they are reluctant to use a prosthetic or orthotic device because in their opinion, it is a strange instrument. Of course, there are other reasons, such as the geographical environment that prevents them from using the devices comfortably. Related with socio-cultural aspects, the CBR programme can act as an agent of change.
3. Availability of Prosthetics and Orthotics Services Centre
As mentioned before prosthetics and orthotics services are provided in two cities only in Central Java. This limitation resulted from:
- the high cost of equipment for prosthetic and orthotic production;
- the limited supply of skilled manpower in prosthetic and orthotic services.
To improve their skills, the prosthetic/orthotic technicians have to take short courses organised by the Government Hospital. There is no school of prosthetics and orthotics in Indonesia. As a result there is no significant development in the prosthetics and orthotics services due to the lack of professionalism in the fields of prosthetics and orthotics.
4. Need
The real need in prosthetic/orthotics services has never been studied. The available data are provided by non-prosthetic/orthotic professionals, either from community or from the field workers. To have more accurate data on the need for prosthetic/orthotic services, intensive research is needed. The basic data resulting from the research would be of considerable use in developing prosthetic/orthotic services.
Recommendation And Conclusion
A Community Based Rehabilitation programme has an immense role in increasing the community awareness of prosthetic/orthotic services. But there is one problem which CBR cannot solve. It concerns the availability of professionals in prosthetic/orthotic services and the availability of equipment for prosthetic/orthotic production.
There are some models that could be developed to solve the problem in the provision of prosthetic/orthotic services. Those are:
- Setting up prosthetic/orthotic sub-centres
- Organising a mobile prosthetic/orthotic service
However, considering the limited information and experience available, a research study on prosthetic/orthotic services needs to be carried out beforehand.
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 : Community Based Rehabilitation Programme in Indonesia for Prosthetics and Orthotics -
Editors:
Eiji Tazawa
Brendan McHugh