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

Papers

STATUS OF WAR VICTIMS AND ACTUAL TREATMENT AND PROSTHETICS IN CAMBODIA.

Carson Harte

Cambodia holds a unique place geographically and historically in Asia. As a result of war and then genocide the country was decimated in terms of economy and infrastructure and most importantly human resources. Philosophically the government has changed its role model five times in the last thirty years leading to confusion and loss of morale.

Development had stopped completely for fifteen years and during that time a further twenty years of regression was experienced. It is reasonable to say that Cambodia was thirty or more years behind Thailand or Malaysia in terms of infrastructure and income at the end of the 1980s. Low gross national product and small tax base make the economy heavily dependent on international funding. The national budget this year is in the region of USD 430 million.

It is against this backdrop that a picture must be painted of a country in deep recession. While Phnom Penh is bustling and lively the country districts are extremely poor. Recent surveys suggest an average family income of less than two hundred dollars per annum. There are virtually no social services or socialised medical system. Free medical treatment for small numbers of patients is available at two hospitals in Phnom Penh but nowhere else.

The road system is poor in general with no public transport available. The population depends on private motor cars and bus services and consequently travel is extremely expensive. The population at the last census was just below 10 million with more than two-thirds female and half under 16 years old. Life expectancy is 47 years and infant mortality in the first three years is in the region of 147 per thousand.

The Disabled Population.

The number of people with disability has been said to be the highest per capita in the world. This may or may not be true. It is true to say however that the greatest cause of disability in Cambodia has been the effects of war. The prime focus has been the landmine victims, mostly lower limb amputees. The other significant group is the polio patients. War and lack of infrastructure has meant that the country has only recently managed to conduct immunisation programmes for the first time since 1967. Polio cases are routinely under diagnosed and reported. Indeed it is felt that many polio patients simply did not survive the acute stage of the disease to become disabled by it.

It must be said that the exact number of disabled people in Cambodia is unknown. Some basic data was gathered in 1992 by the ICRC and American Red Cross. This information came from two distinct areas of Cambodia, both of which have a reputation for high incidence of landmines. Best estimates have been made by comparing the population in those areas with the disabled population and then extrapolating the ratio country-wide. This is at best a guideline and at worst a misleading figure.

It is accepted in Cambodia that amputees from landmine injuries and other war related causes number around 30,000. No official statistics are in existence except for veterans and demobilised soldiers. To date these figures have not been made available to us by the Government. It is thought that they may never have been collated. The picture is confused in the Rehabilitation Centres since often the same patient will attend several centres. No centralised control or registration is yet in place.

The number of other disabilities apart from those of the amputees is also difficult to ascertain. Field studies have shown that local enumerators are unreliable when counting non-amputee disabled people. Work carried out by AFSC in 1995 suggests that the underreporting may be as high as 300%.

Blindness remains one of Cambodia's most important disabilities. It is often caused by trauma but is more likely to be caused by poor nutrition, or poor medical treatment. It is suspected that there are as many as 90,000 profoundly blind people in Cambodia. Once again the lack of a formal survey is limiting the usefulness of this data.

Amputation Levels.

The distribution of amputation levels is again unknown. The vast majority (around 60%) are trans-tibial amputees. The statistics collated by the agencies have as yet given no clear picture of amputee distribution. We are certain that 8,000 new prostheses are produced every year but we have little idea whether these are for new patients or are repeat prescriptions. The Agencies are currently installing a common database to collate such data.

More than 90% of the work carried out in Cambodia is lower limb prosthetics. It was only in 1996 that locally manufactured components became available for upper limb work. This allowed services to be started for the first time. Take up is increasing but once more it is difficult to say just how many need to have services. Most of the lower limb amputees are trans-tibial on a ratio of 2:1 with trans-femoral.

One detail is certain. The capacity to produce prostheses and orthoses in Cambodia is certainly too small. All centres where there is a high quality product with well trained staff are busy and active. Some provincial centres are less than fully occupied. This may be for a variety of reasons such as poor accessibility, poverty, or poor quality product. Low activity level may be a result of the patients simply not knowing about the services.

Facilities.

Cambodia has a system of provincial hospitals, district hospitals and referral hospitals. There is, on paper, a free medical service. However, it is so under-resourced that free service is unheard of. The exceptions are two fully NGO operated hospitals in the capital. There is one university affiliated hospital in Phnom Perth. There are 15 rehabilitation centres around the country. They operate almost entirely on NGO support but are linked to the Ministry of Social Affairs, Labour and Veterans Affairs. They primarily function as prosthetics service providers to a greater or lesser extent. It is the plan in the next few months to develop things further.

Medical Personnel.

There are no doctors trained as rehabilitation specialists in Cambodia. There are general surgeons and physicians who act as such. No rehabilitation centre has a full time medical person attached to it. Orthopaedics is embryonic and only successfully carried out in NGO supported facilities.

Allied Health Professionals.

The Phnom Penh School of Physiotherapy has produced some 80 graduates. There are no local occupational therapists or speech therapists. There are in the region of 150 social workers in the form of community based rehabilitation workers. In 1994 the Cambodian School of Prosthetics and Orthotics (CSPO) was set up to train prosthetists and orthotists.

To date, 18 graduates have completed the course. There are a further 32 students in training. The course is in the process of accreditation by ISPO at the level of Category II (Orthopaedic Technologist).

The CSPO replaces a one year limited function prosthetist course which produced more than 100 practitioners. Those practitioners have mostly reverted to being bench workers, or remained as limited function prosthetists. Some have successfully upgraded at CSPO. We intend to have a core group of some 60 graduates at the centre of future rehabilitation work.

Finance.

Cambodia has no insurance or medical cover. Prosthetics and orthotics services provided by NGOs are free at the moment.

Statistics.

Of the 8,000 prostheses produced in Cambodia each year more than 95% are either trans-tibial or trans-femoral in the ratio of 2:1. The number of hip disarticulations, knee disarticulations and others remains small.

Orthotic production remains at very low levels (700 produced in four years) compared to demand. This will increase as agencies prepare orthotic componentry and equipment and begin production. The limiting factor at the present is lack of funds, follow up and surgical capacity. There is no surgical shoe production at all.

Componentry.

A full range of prosthetic and orthotic components is available in Cambodia with the exception of shoulder joints. They are designed and manufactured from polypropylene injection moulded by the ICRC factory in Phnom Penh. They are supplied free of charge as part of interagency collaboration and are of high quality and easy to use. Rubber feet are produced in a small local factory sponsored by Handicap International.

Design.

Trans-femoral prostheses
Sockets are generally of the quadrilateral type, manufactured in polypropylene either by the bubble drape method or more commonly by wrap drape. Some IRC sockets are being produced and some work is being carried out on adaptation of the designs to the local conditions. The structure is modular and endoskeletal. Knee joints are usually the free type with the option of manual lock. The ankle foot assembly is based on the SACH design but made from local rubber. The cost of such a limb is in the region of USD 60.

Trans-tibial p prostheses
The trans-tibial patient is given a modular endoskeletal PTB prosthesis with the option of cuff, supracondylar, or PTS suspension. Sockets are generally pelite lined and made from polypropylene. The foot and ankle are of the SACH type. The cost is generally below USD 40.

KAFOs
Most KAFOs are produced in polypropylene with external side steels although there is growing interest in conventional and simple devices. The knee joints are either drop lock design or posterior off-set. Ankles are rigid, dynamic or plastic jointed.

AFOs
These are generally plastic, made in polypropylene. There axe very numbers of conventional AFOs made in Cambodia.

Education of Prosthetist Orthotists.

In 1994 the Cambodia Trust in collaboration with the American Friends Services Committee set up the Cambodian School of Prosthetics and Orthotics. It has a full three year programme and is currently in the process of accreditation with ISPO. The level is Orthopaedic Technologist (Category II). There are 18 students who have completed the course and 32 in training. All costs are met by the NGOs through external funding. The government provides small salary support to some students. There is no independent certification system but the course is recognised by the Cambodian Government and also should attain ISPO recognition in the near future. Prosthetics and orthotics graduates are recognised by the Government at a level equivalent to the physiotherapists.

Physiotherapy School.

The school is under the auspices of the Ministry of Health with external funds and personnel from the NGO sector. The intake is 18 per annum and there are some 80 graduates. The school began in the early 1990s. There is no external certification system. The school does not apply any external formal standards.

Occupational Therapy.

As yet there is no occupational therapy training nor are there any plans to begin.

Community Based Rehabilitation (CBR) Programmes.

There are no CBR programmes, as such, in Cambodia. The equivalent work has been called "Community work with the disabled"(CWD). There are probably six groups at work. Most organisations use their CWD workers for follow up and patient identification.

However the range of work is widening as staff training and experience is developed. All work is NGO funded. Co-operation between agencies is very good. There is no CBR manufacture of prosthetic or orthotic devices. The workers are sometimes used to teach prosthetic and orthotic use but usually the teaching is done by the prosthetist/orthotist or therapist.

Summary.

It is clear that Cambodia has a long way to go to get service to the disabled person up to an accepted level. Services need to be much further developed. A new national planning and co-ordinating body, the Disability Action Council, has recently been formed and will be responsible for the future direction.

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WHO GUARANTEES THE COST OF PROSTHESES OR ORTHOSES, WHAT IS THE SOCIAL STATUS OF PEOPLE WITH DISABILITY IN VIETNAM

Ha Anh

Who Guarantees the Cost of Prostheses or Orthoses?

Vietnam is a poor country. The budget of the Vietnam Government cannot pay for all disabled people who need prostheses or orthoses to be provided for them. There are many organisations which have provided funding for disabled people in Vietnam including:

1

The Vietnam government funds prostheses and orthoses for war invalids. If these people need artificial limbs they can come to the orthopaedics centres to get prostheses without charge and MOLISA will pay for them; one leg for every 3 years.

2

Since 1990 many of the international organisations have helped Vietnam to provide prosthetic limbs for its amputees (especially the poor people) without charge such as:

• ICRC helped HCNI Orthopaedic Centre in the south of Vietnam to provide polypropylene devices for disabled people. Since 1990 over 10,000 prosthetics limbs and braces have been provided for disabled people in the south of Vietnam
• World Vision have been helping four orthopaedic centres in the middle of Vietnam Quy Nhon, Da Nang, Vinh and Thanh Hoa and 11,000 artificial limbs have been provided for Vietnamese amputees
• VNAH have been helping Can Tho and Thu Duc in the south of Vietnam and provided about 10,000 prosthetic legs and over 1,000 wheelchairs for disabled people
• POF - Seattle, USA helped POC Hanoi to make prostheses using CAD-CAM There were over 7000 AFMA Limbs provided for amputees
• MSAVLC helped Tam Diep centre in the north of Vietnam and provided Jaipur limbs for 1,000 amputees
• HI and VVAF helped in producing artificial limbs and orthoses

3

The Vietnam insurance system pays for disabled people who are government staff or in business if they have paid for social insurance

4

Disabled people must buy their prosthetic limbs or orthoses if there is no organisation paying for them.

With the help of NGOs, about 100,000 Vietnamese amputees have their artificial limbs free of charge.

Now, in Vietnam, MOLISA controls and decides the cost of the orthoses and prostheses. The cost includes the following elements:

• Materials and components 70% to 80% the all of cost
• Salary about 4% to 9 % of the cost
• Insurance (medical, social, retirement, accident) 0.9%-1.2%
• Electricity: 2- 7%
• Management: 6- 12%
• Consumption of fixed capital: 5-7%

Other items not included in this list include transportation, fuel, outreach and building costs. The salary of the technicians is low and to earn enough to live on they must make 10 to 30 devices per month. This is very difficult for them because there are not enough patients.

What is the social status of people with disability?

According to a survey, the disabled in Vietnam constitute about 5 to 7% of the population. The survey was carried out in 21 provinces of Vietnam with a total population of 21,039,000. There are 163,074 disabled people who have received orthoses or prostheses (0.775% of the population). Vietnam has about 500,000 disabled people needing orthoses.

Table 1: Causes of disability: Survey of Ha Tay province (population: 2,217,800)

Most of people in Vietnam are poor or very poor. They cannot earn enough money to live on. Vietnam has had many years of war and many disabled people suffered in the war. Over a million families have suffered from exposure to toxic chemicals. Many families have had 1 to 4 disabled children. They cannot earn. So disabled people and their families are very poor. They cannot buy any orthoses or prostheses so they are dependent on the help or- the government or other organisations.

Table 2: Employment of Disabled people in Ha Tay province

Vietnam insurance systems are small and have operated only for about 5 years - especially the medical and retired insurance. Vietnam is now beginning to create a law for disabled people but we have still some difficulties to deploy the law because we have not sufficient budget for this work. There are many problems we must deal with for disabled people such as helping them to earn, to live, to get treatment, helping their children can go to school like others.

Table 3: The living condition of disabled people

The help of NGOs in providing prostheses and orthoses for disabled people is very important. Employment in Vietnam still difficult, especially for disabled people. They meet many difficulties in learning skills and foreign languages necessary to earn high salaries.

MOLISA Vietnam has a system of training schools for disabled people. They can learn many skills in the training schools such as making radios, repairing motorcycles, electronics and sewing clothes ... but the social status of the disabled is always difficult and they need the help of the community in and out the country.

Table 4: Classification of People with Disability

Table 5: The Price of Orthoses and Prostheses

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SOCIAL STATUS OF PEOPLE WITH DISABILITY IN INDIA AND STATUS OF WAR VICTIMS AND ACTUAL TREATMENT

Chapal Khasnabis

Social status of people with disability in India

In the 1991 census, the National Sample survey organisation reported that people with visual, communication and locomotor disabilities number at least 14.6 million, or 1.9% of the total population of India. This figure only covers people who are profoundly disabled. Available statistics on disability should be interpreted with a degree of caution. On the one hand many families are reluctant to report disability, particularly in view of the prevailing negative attitudes to people with disability in most communities and on the other hand the data collectors had limited knowledge and experience. In the absence of any detailed accurate census report on the disabled population in India, it is estimated that about 50 million people with disability live in India which is about 5% of its total population. About 78% of this population live in rural areas.

Disability is a direct product of poverty, illiteracy and other social evils. The rural poor are particularly at risk from those disabilities, which are associated with malnutrition, poor conditions of environmental sanitation and communicable diseases. Accidents arising out of negligence, poor road safety, ignorance and lack of safety measures at work and community, are also major cause of disability.

Among this population, we have about 9.6 million people with locomotor disabilities who need some kind of mobility aids. Most of these people do not have access to mobility aids, and are not aware of the benefits of rehabilitation aids. Those who are aware of the benefits of appliances have trouble obtaining them. Generally mobility aids are distributed through 'camps' run by charitable organisations or political parties. These camps are usually held in cities and often people have to travel long distances from their villages, besides bearing the costs of their stay in the city. There are usually no facilities for training, follow up or repair, and the appliances are often ill fitting, resulting in their rejection. There are only 700 prosthetic and orthotic workshops in India. Although the majority of the people live in rural areas, eighty percent of the workshops are urban based.

Most rehabilitation efforts in the field of disability have so far been made by medical or paramedical professionals and charitable organisations but they have remained very much urban based. Medical rehabilitation is important but unfortunately concerned professionals forgot to look into social/ developmental aspects. It is estimated that only 5% of the disabled population receive some kind of benefit through Government Organisations (GOs) and Non Governmental Organisations (NGOs). While lack of services and knowledge/technology is a serious constraint, the greatest obstacle to, mainstreaming people with disability is the negative attitude of non-disabled people/community and especially of so-called professionals. Poor rural people with disabilities and their families have little or no access to the opportunities, information, technologies and programmes that are available within India for rehabilitation or participation in the developmental process.

Among people with disabilities women are more marginalised than men. There are about 30 million women with disabilities in India, the majority of whom live with very little control over their lives. In some cases they are regarded with misplaced sympathy as being helpless and unable to do anything for themselves and their families. In other cases they are kept hidden so that they do not damage the marriage prospects of their siblings. There is also a small section of society that regards women with disability as 'bad women'. As compared to men, women with disabilities face the double discrimination of disability and gender. Their chances of marriage are slight and they live as non-productive adjuncts in the household of their birth. The literacy rate of these women is low due to social attitudes, lack of facilities and inaccessibility of schools. As a result, opportunities for women with disabilities to become mobile and achieve economic independence are minimal.

Till last year the annual budget of the Ministry of Welfare Government of India for the welfare of people with disability was only USD 15.4 million (540 million Indian Rupee) per annum which has doubled this year due to a good advocacy programme but still it means only $5 per person with disability per annum. To take care of people with disability, the Government of India has established 5 national level institutes, many district hospitals and district rehabilitation centres, 17 vocational rehabilitation centres (VRCs) and about 40 special employment exchanges. As a result of these, only 5% of children with disability go for education and only 40,000 (not even 0.1 %) of people with disability got a job in the last 50 years through special employment exchange and VRCs.

To measure the social status of people with disability living in India a study was done recently on the basis of UN Standard Rules and the outcome of some important issues was as follows:

1. Very few measures have been taken to ensure a rehabilitation service for people with disabilities in India.
2. People with disability are not assured of access to housing, public/private buildings, means of transport, streets and other outdoor areas.
3. Very few measures have been taken to ensure income, maintenance in the form of pensions and other social security benefits, service/employment, job training, recreation and sports for people with disabilities.
4. Opportunities for marriage, parenthood and respect of personal integrity are also remote.
5. Most of the people with disability have equal opportunity to practice religion and participate in religious life of the community.
6. People with disability are not usually consulted in the general planning and development strategies of the country.
7. Legislation to ensure equal opportunities, protection of rights and full participation of people with disability got passed through Parliament and received the assent of the President of India on 1^st January 1996. However, a chief commissioner to implement the Act has yet to be appointed.
8. The Indian Disability Index (in cities) is around 28 whereas the Disability Index in most of the European countries is more than double this figure.

Who guarantees the cost of orthoses/prostheses?

The Government of India has a unique scheme "If the income of people with disability is less than $30 per month then they would receive any Orthoses/Prostheses free of cost provided the cost of it is less than $128. If the income is between $30-$60 he/she would have to pay half cost of the appliance". Only 2% of the disabled population could be availed of this facility due to problems like lack of outlets, inappropriate aids and appliances, long waiting periods, lack of enough professionals/personnel, bureaucracy, lack of proper planning and coordination and also poor attitude.

Status of war victims and actual treatment

Though India did not take direct part in either of the two world wars, the Second World War, in particular, saw a massive participation of Indian solders and many lest limbs or became paralysed as a result of it. To take care of them, an Artificial Limbs Centre (ALC) was opened in Pune near Bombay in the year 1944. It moved to Sialkot (Pakistan) but soon after independence it moved back to Pune. After the World War, India also had wars with China and Pakistan. This resulted in an increased number of casualties. Besides war, many Indian army personnel lose their limbs due to frostbite.

People with disability, usually amputees and paraplegics, used to get referred to ALC-Pune from forward/base hospitals for rehabilitation. Seeing the need the Centre opened a 190-bedded hospital and a fully fledged rehabilitation centre. So far, about 50,000 people with disability have benefited from treatment at ALC-Pune. It produces about 250 artificial limbs, using wood and plastic, per month - of course free of cost. War Victims are economically better off, in comparison to civilians, due to various welfare schemes, so obviously their social acceptance is better. Amputees, especially the trans-tibial/femoral lead a near normal life but conditions for paraplegics and quadriplegics were not good at all. Even society thought they could be a burden so attitudes towards them were very negative. Most of them, especially the world war victims have died because of secondary infections. The few remaining ones are counting their days in Red Cross Homes. IS THERE ANYBODY TO HELP?

To address above mentioned issues we have created Mobility India and we need your support to achieve our aims and objectives, which are as follows:

MISSION STATEMENT

"The mission of Mobility India is to promote mobility in persons with disability, especially in rural areas, through awareness creation, advocacy, research and development, improved services, and all other activities to promote integration of people with disabilities into society".

OBJECTIVES

• To create awareness of the need for and benefit of, mobility aids and rehabilitation facilities, in those involved in rehabilitation of people with disabilities
• To provide technical support for the creation and strengthening of the rehabilitation aids and appliances facilities primarily in rural areas, through partner organisations
• To carry out research And development to promote appropriate mobility aids and therapeutic interventions
• To develop the right kind of human resources to enable people with disability to become mobile, through training programmes
• To promote appropriate technology in rehabilitation, with focus on community based rehabilitation
• To promote simple therapeutic techniques to prevent or correct deformities, and to avoid unnecessary surgery wherever possible
• To network with government organisations, non-governmental organisations, professionals and non-formally trained rehabilitation workers in the field, in order to provide linkages for the benefit of people with disabilities
• To initiate and participate in advocacy programmes that promote equal rights, opportunities and participation for people with disabilities

Our address is as follows:

Mobility India,
APD Campus, Hennur Road,
Lingarajapuram, Bangalore 560 084
Tel: +(80) 5478863, 5461037
Fax: +(80) 5470390, 3461824
E-Mail: mobility@giasbg01.vsnl.net.in

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PROSTHETIC AND ORTHOTIC REHABILITATION FOR WAR VICTIMS IN MYANMAR

Sai Woon Ma

Abstract

The Union of Myanmar, like many other developing countries, has suffered from the impact of war in striving for independence, national peace and security. Most of the war victims are amputees; and the main tasks for rehabilitation of the amputees are providing functional prostheses or orthoses, vocational training and creating income generating job placement. Only urban dwellers and a small number in rural communities, with amputation, had access to services in the past. Now with the help of Myanmar and the International Red Cross more war victims from rural and remote areas have access to services. There are still many more rural victims who need, and are waiting for, the benefits of amputee rehabilitation services.

Introduction

The Union of Myanmar is situated within the South East Asia region neighbouring with India, Bangladesh, China, Laos, Cambodia, Thailand and Malaysia. Myanmar has approximately 48 millions at present, out of whom 75% are rural and 25% are urban dwellers. The economy of the country is essentially agriculture-based but industrialisation is also expanding through an open market economy system and inviting international investments. There are 14 States and Divisions consisting 350 townships with more than 65,000 villages.

A nation-wide survey to determine the prevalence of disability or magnitude of the problems facing disabled persons has never been attempted. Nevertheless various health programmes have, during the course of their implementation, conducted surveys to determine the prevalence the different types of disability. According to the data of surveys, an estimated 3-5% of the population have disabilities and some 45% of these have physical disability.

In common with most of the other developing countries Myanmar had to struggle for independence followed by peace, tranquillity and security which resulted in both the military and civilian population becoming war victims. Among the injuries resulting from war, amputation of limbs is the most common residual disability which results in various degrees of physical, social, vocational and economic handicap in the case of those who remain alive.

Thus, rehabilitation of the amputee started soon after independence was achieved in 1948 and has continued until today. But the coverage of the services is only the "tip of an iceberg", and with the help of multisectorial and organisational support the rehabilitation of amputee should be carried out energetically to enable war victims to gain equality and full participation in their daily lives so as to restore their self respect and dignity and to improve the quality of their life.

Rehabilitation Services In Myanmar

The services for rehabilitation of persons with disabilities are basic and mostly met by the Department of Health and the Department of Social Welfare. The facilities provided are as follows.

Medical Rehabilitation Services
Medical rehabilitation services are provided under Department of Health by:

1. the National Rehabilitation Hospital in Yangon taking care of all types of physical disability both temporary and permanent irrespective of age, sex and race. It also has a prosthetic and orthotic workshop with full facility to provide a comprehensive prosthetic and orthotic service for the whole country. It now has a capacity of 50 in-patients and an upgrade to 100 patients is planned. It also has out-patient facilities.
2. the Department of Physical Medicine and Rehabilitation in Yangon General Hospital where most of the acute, post-traumatic rheumatological and neurological cases including spinal cord injury patients are accepted for treatment and rehabilitation. Those who need prostheses and orthoses are sent to the National Rehabilitation Hospital. It is also a teaching centre for medical and paramedical students.
3. the Department of Physical Medicine and Rehabilitation in Mandalay General Hospital which has only out-patient facilities for acute and chronic physically disabled and handicapped conditions. It is also responsible for the care and rehabilitation of' patients admitted to the general and specialty wards in the hospital. Pre-prosthetic stump care exercises and post-prosthetic ambulatory gait training are given in this department. It is attached to the prosthetic and orthotic workshop which has a 10 bedded in-patient facility for rehabilitation of amputee civilian war victims.
4. fifty three physiotherapy departments in specialty, divisional and sub-divisional hospitals. The services rendered are mostly for temporary disablement and under the responsibility of respective medical officers.

Community Based Rehabilitation
Using the translated and adapted booklets of the WHO manual "Training in the Community for People with Disability" the basic health staffs and volunteer health workers were trained and placed in about 160 villages in the whole country with the support of WHO, UNDP, MAF and WVI. It covers only a very small population, as it is not included as a priority in the National Health Plan at present.

Vocational and Educational Rehabilitation
Vocational and educational rehabilitation services are under the administration of the Department of Social Welfare. They include:

1. The Vocational Training School offering the following skills training:
   1. photography
   2. radio repair
   3. sewing (tailoring)
   4. carpentry
   5. bookbinding
   6. press printing
   7. textile printing (silk screen printing)
   8. haircutting
   9. massage
   10. shoe and slipper making
   11. knitting
   12. embroidery (tapestry)
   The majority of the trainees are physically handicapped. They also accept persons with visual and hearing disabilities. This institution has the capacity for 100 resident male trainees and about 30 female trainees for whom accommodation is arranged by themselves or by the Women's' Welfare Association
2. The School for Disabled Children provides primary education for physically and mentally disabled children who are not capable of attending normal school. The capacity of the school is 100 day students. Some of the students are able to join normal school after completion at this school.
3. The School for Visually Handicapped in Yangon provides primary school education and vocational training for both children and adults with the capacity to train more than 100 students at a time.
4. The School for Visually Handicapped in Pakoku in central Myamnar has about 60 to 80 residential students at a time. Apart from reading and writing it also has vocational training and other subjects including musical training.
5. The School for Hearing Handicapped in Yangon, which provides primary school education, has over 100 residential and day students. Domestic science and some vocational training are given here.
6. The School for Hearing Handicapped in Mandalay has accommodation for 100 residential and some day students where primary school education and some suitable vocational training are given.

Rehabilitation of Amputees

In Myanmar rehabilitation of persons with amputation of limbs started in 1955 with vocational training for war veterans, a joint programme of the Ministry of Defence and the Ministry of Social Welfare. A hospital for the disabled was established in 1959 under the Ministry of Social Welfare with the capacity to cater for 25 in-patients, but the service was limited to civilian amputees due to war. An orthopaedic workshop with full facilities to produce prostheses and orthoses independently was also established. In 1965 it was transferred to the Ministry of Health and upgraded to 50 in-patient beds with out-patient facilities to provide rehabilitation services to people with physical disabilities from all parts of the country. The hospital is essentially involved with rehabilitation of locomotor system disabilities, for amputees, victims of poliomyelitis and cerebro-vascular accident, cerebral palsies, spinal injuries and other musculo-skeletal and neuro-muscular disorders. Being the only hospital of its kind in the country with comprehensive prosthetic fitting facilities, and situated in the southern part of the country, it is not really accessible to the majority of the disabled, particularly those residing in the rural communities.

An orthopaedic workshop for production of prostheses and orthoses for upper Myanmar was established in 1973 at Mandalay General Hospital but it has to depend on the National Rehabilitation Hospital for the production of some components.

Now in the Union of Myanmar there are three orthopaedic workshops for the production of prostheses and orthoses for the whole country including both military and civilian. The orthopaedic workshop of the Ministry of Defence has full and complete facilities to produce necessary comprehensive prostheses and orthoses for military service persons with amputation from various causes. More than 90% of them are war victims.

The orthopaedic workshop at the National Rehabilitation Hospital, previously known as the Hospital for the Disabled which is planned to be upgraded to a 100 bedded hospital also has full facilities to produce necessary prostheses and orthoses for civilian clients throughout the county.

The Orthopaedic workshop in Mandalay General Hospital is a centre for production of prostheses and orthoses for upper Myanmar relying, for some components, on the National Rehabilitation Hospital workshop. This workshop has produced rehabilitation aids and equipment including prostheses and orthoses regularly since its establishment. However, their services were not accessible for communities in the rural and remote areas where disability due to war is prevalent.

In 1986 the Prosthetic Rehabilitation Joint Programme for Amputee of Mine Injury was started. Myanmar Red Cross Society (MRCS) acted as the host body, while the Ministry of Health and Ministry of Defence acted as implementing agencies. The International Committee of the Red Cross (ICRC) donated resources which are not available in this country.

During the years 1986-89 the major tasks of the programme were upgrading and strengthening of the above workshops with machinery, material and technical support. Training courses on the care of amputee for medical officers nurses and physiotherapists were conducted. Two nine-month training courses on prosthesis and orthosis fabrication were opened to recruit new technicians for all workshops. Both conventional and new techniques of fabrication using polypropylene were taught during the courses. Locally made prosthetic and orthotic knee joints were also introduced into the courses.

From 1990 the programme started to produce and fit prostheses for war victim amputees and this is still in progress. Here, the Myanmar Red Cross Society takes the responsibility of identifying eligible clients and making necessary arrangements for them to come to the respective institution batch by batch. The arrangements were made in co-operation with the local authorities, township medical officers and local Red Cross Association of the rural and remote areas. Pre-prosthetic stump care and exercise; prosthesis fabrication and fitting; and finally prosthetic care and gait training were given by the institutions before they were sent back home. This programme is only for the war victims from the rural areas, and frontier and remote areas where amputation due to mine injury are prevalent. The clients who reside in those areas could not come for limb fitting due to educational, communication and economic barriers. The programme provides all the necessary expenses for transportation, accommodation, daily allowances for the clients and cost of prosthesis including both material and fabrication costs.

Situation of Amputees and Limb Fitting Services

Before 1990 prostheses were supplied for all amputees in military services free of charge by the Ministry of Defence. From 1990 onwards, prostheses have been provided for military services personnel free by the Ministry of Defence with the support of a joint programme project.

Before 1990 prostheses were provided by the Ministry of Health free to those who were government employees, those who were dependent and those who had very low income. Half of the cost of the prosthesis had to be paid by the clients who had income more than 300 kyats per month. The full cost of the prosthesis had to be paid by those who could earn more than 600 kyats. The cost of trans- tibial, trans-femoral, hip disarticulation, and knee disarticulation prostheses were 2600 kyats, 4200 kyats, 8000 kyats and 3000 kyats respectively. Since 1990 the cost of prostheses for the war victim amputees have been covered by the joint programme and another category has been added for those who could pay for prosthesis as private clients. Here the cost of a trans-tibial prosthesis is 9000 kyats and a trans-femoral prosthesis is 18000 kyats and, moreover, accommodation, medical and gait training charges are added.

Regarding socio-economic status in the Ministry of Defence, 30% of the amputees were still in service until the age of retirement. They were transferred to the administrative department. Job replacements were arranged by the government for about 35% of amputees from the Ministry of Defence. Some of them had to undergo vocational training. About 35 % retired from the services and about half of them have some income generation job while the remainder rely on their retirement salary.

In the case of civilian clients, at the time of intake for prosthetic rehabilitation 70% of them were dependent or earning very low income. This statement was not fully correct as regards the provision of free prostheses to that particular group of clients. Of these clients, 20% were government employees and only 10% stated that they were from a reasonably good income group. However, during follow-up of cases from 1990 to 1992, who came back for repair or new prosthesis, 28% were dependent, 25% were cultivators or farmers, 19 % were self employed with a good income generating trade, 13 % were students and 15 % were government employees. In civilian amputees who came for prosthesis fitting only about 7 % underwent vocational training given by the Ministry of Social Welfare. Amputees from the joint programme did not go for vocational training because the majority of them were illiterate and because they wanted to go back to their villages soon after the prosthesis was delivered.

The status of prosthesis and orthosis production in two civilian workshop were as follows:

National Rehabilitation Hospital Workshop

Mandalay General Hospital Workshop

Future Needs in the Country

Prosthesis demands will become greater as accessibility to the prosthetic centre improves. The need for better types of prosthesis is projected in the near future. With the changing health financing system, there will be more and more sharing the cost of prostheses by amputees who can afford to pay and this will reduce the burden on rehabilitation financing and thus will make possible reallocating support for the care of amputees who cannot afford to pay. However, with the cost sharing system, consumers will have more choice from the types of prosthesis available on market nationally and internationally.

Therefore, the prosthetic services at the orthopaedic workshops need to be updated and upgraded both in technical aspects and in materials. This can be accomplished by provision of training as required.

Furthermore, there is a need for expansion of the prosthetic centres in strategic regions throughout the country so as to meet the increasing demand for prosthetic services. Each state and division should have reasonably well equipped workshops. Therefore there should be a good training centre for the country. The National Rehabilitation Hospital is, at the present time, in a position to function as a teaching centre to produce necessary technicians to be deployed to various state and divisional workshops in the country.

The strategy for the future prosthetic and orthotic services:

1. to upgrade the capacity and capability of all the orthopaedic workshops.
2. to expand the prosthetic and orthotic services in the country through the phased establishment of orthopaedic workshop.
3. to train more technicians, to meet future demand, at the National Rehabilitation Hospital.
4. to prepare trained technicians to a sufficient level to meet the technical requirement to handle advanced prosthetic and orthotic systems.
5. to devise a system of outreach prosthetic and orthotic services to support Community Based Rehabilitation.

Conclusion

The Union of Myanmar is projected to need more prosthetic and orthotic centres to cater for the needs of amputees throughout the country. She will need more qualified and competent prosthetic and orthotic technicians to meet future requirement.

Therefore, a proper plan for development of prosthetic and orthotic services and manpower resources is mandatory. A programme for training of technicians locally and abroad is necessary and will be formulated to realise the above mentioned strategy.

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STATUS OF PROSTHETIC/ORTHOTIC SERVICES IN PAKISTAN

Naseer M. Akhtar

Pakistan emerged as an independent country 50 years ago in 1947 with negligible prosthetic/orthotic services and whatever little was available was in the private sector. Although considerable development has taken place in the field of prosthetics/orthotics a lot is left to be desired in the quality as well as general availability.

Pakistan has a population of 140 millions and according to the estimates of disability figures published by the Pakistan Medical Research Council, 4.2 million people are physically disabled. The prosthetic/orthotics services have been developed in the private and public sectors as well as N.G. Social Welfare Organisations in most of the major cities of Pakistan. Orthoses and prostheses are either entirely manufactured in these centres or are based on indigenously made or imported components depending upon the paying capacity of the patient.

Who Guarantees the Cost of Prosthetics or Orthotics?

There is no insurance or any other such system guaranteeing to meet the cost of prosthetic/orthotic treatment in Pakistan. The cost is borne either by the patient or is subsidised fully or partially by various social welfare organisations established in the attached hospitals which in turn get funds from philanthropists or from the Government Zakat Fund. Zakat is a kind of tax (2.5%) which is levied annually on all bank savings. It is deducted by the Government or paid voluntarily by individuals on the wealth and jewellery owned by them. This is a tremendous help in meeting the cost of the prosthetics/orthotics service.

The war victims of the Army, however, get their prostheses and orthoses funded by the Fouji Foundation which provides for the welfare of Army personnel. They have no problem in getting these appliances from the foundation centre which has attached Hospitals and residential facilities also available for them.

Social Status of Disabled People:

People with some disability are usually looked at with pity and sympathy. Some people exploit the disabled, and the sympathy of the others, and force the disabled to become beggars, a curse for any society. Some of the disabled adopt this profession voluntarily finding this to be the easiest way to earn their livelihood.

However, various rehabilitation facilities developed by the Government and NGOs encourage the disabled to become integrated with the general social set up of the country. Special education and vocational centres have been developed for various types of disabilities.

Legislation has been passed for reservation for disabled people of at least 1% employment in all public and private sectors and admission to all teaching institutions. Disabled persons are also allowed to import cars duty free.

It really depends largely on the individuals concerned and their primary economic status to be able to avail themselves of the opportunities available or to fall into the profession of beggary.

Status of War Victims and Actual Treatment.

War victims belong to two categories: the actual army combatants and the civilians who become victims without being part of the war itself. The victims in the first category are usually the "blue-eyed" people who get all the necessary facilities including prostheses and orthoses as well as pensions or employment without much difficulty.

The civilian category is the one which is worst hit if they happen come from a poor socio-economic status in a developing country without any insurance system and have to be dependent on various NGO rehabilitation programmes. On acquiring some education or vocation, they may get employed in the 1 % quota allocated by legislation.

How the Prosthetic/Orthotic Services can be Improved?

i) Training of prosthetic/orthotic workers.
There are, in my opinion, adequate facilities available at present for their training at the centres. One located in Peshawar, and awarding a B.Sc. in Prosthetics and Orthotics, has already produced 80 graduates most of whom are without any jobs.

The other located in Lahore, attached to the institution, at which I work, is non-functioning at the moment because of the relatively poor employment facilities available. These are the people who were trained as technicians to produce prostheses and orthoses. Their training and production without correspondingly establishing the prosthetic/orthotic centres is going to create a lot of problems.

ii) Expansion of Prosthetic/Orthotic Facilities and Improvement of Existing Facilities.
The existing facilities must be expanded to be made available within easy reach of needy disabled persons. Provincial as well as national plans have been prepared and approved in principle by the Government but have been shelved for want of funds. Funds should be provided by international donor agencies to meet the shortage problems. The expansion of these facilities will not only help disabled persons but will also provide opportunities for employment of the personnel trained in this field.

Improvement of Existing Facilities.

Most of these workshops utilise locally available raw materials in manufacturing orthoses as well as prostheses which are usually heavy and not easily accepted by the users. The time taken to manufacture these is also quite long, thus the patients have to wait for a long time before the appliance is made available to them.

In my opinion standard lightweight components should be available, manufactured locally or imported to be assembled when required and supplied to the patients without a long wait.

Establishment of Insurance Systems:

There is no health insurance system in the country so far and funding of the cost of production of the prosthesis or orthosis is a major problem. Although a lot is being done through various social welfare organisations and institution of Zakat, an insurance system is mandatory to provide people health cover including facilities for prosthetic/orthotic treatment.

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DISCUSSION 3

Reported by Brendan McHugh

It was stated that Community Based Rehabilitation (CBR) workers should come from the community, be literate and have sufficient time for the job.

Those who would specialise in prosthetics/orthotics should have education in simple aspects of the subject at least sufficient to be able to refer patients correctly.

It was important to have a sufficient proportion of female CBR workers.

Many people with disabilities could work in CBR.

More information was needed to assess the extent of the need for prosthetics/orthotics CBR workers.

It was important to recognise that CBR workers cannot do everything. For example they cannot be expected to give full prosthetic/orthotic treatment. They needed to know the location of disabled people, be able to assess their disability and make effective referrals to the next higher level. It may also be necessary for the CBR worker to have social welfare skills to help the patient in such matters as finding a suitable job.

There was some feeling that training prosthetics/orthotics CBR workers would not be economically viable and that general CBR workers, with a knowledge of the system for prosthetic/orthotic treatment, could assess the patient and refer him/her to a prosthetics orthotics centre.

It was important not to confuse CBR with the need for trained prosthetics/orthotics professionals.

In some countries people with disability had very poor social status although war victims might fare better socially and have a pension. It was important to strive for independence and equalisation of opportunity for people with disability.

It was necessary to be able to measure the cost of treatment and a unified approach to this was needed if true comparisons were to be made.

The question of patients contributing towards costs was again raised. Patients contributing would improve the sustainability of the service and there was evidence that it could also increase the life of the prosthesis due to improved care by the patient.

It was felt that objective comparisons of prosthesis life would also be useful. However this was complicated by differences in use - for example climate, terrain and activity levels of patients.

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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 : Who Guarantees the Cost of Prosthese or Orthoses, What te Social Status of People with Disability is, Status of War Victims and Actual Treatment and Prosthetics -

Editors:
Eiji Tazawa
Brendan McHugh