Presentation by Ms. Khojaeva Aziza, Head of Child and Adolescent Unit, Department of Mother and Child Health, Ministry of Health, Republic of Tajikistan

Ministry of Health of the Republic of Tajikistan

Community Based Rehabilitation as a model for Central Asia: Experiences from Tajikistan

Context of rehabilitation and abilitation in Tajikistan

National level ( Hospital based care -Matchiton, Karabolo,

etc..)

Regional (PMPC*)

District (PMPC, CBR Support rooms, Day

care Services)

Jamoat and village level (CBR Support Rooms, play

corners, CBR workers and home visiting nurses)

* PMPC – Psychological Medical Pedagogical Consultation Centres

Psychological, Medical and Pedagogical Consultation Centres as referral bodies in the middle

Main functions of the PMPCs are:• Assessment and Diagnosis of children with disabilities:

• Early intervention / rehabilitation: Specialists of the PMPC provide rehabilitation for children with disabilities. Special training and support is also provided to family members for them to better support their children at home;

• Gate-keeping: The PMPCs have the authority to refer/recommend various options for the children with disabilities. They can refer as appropriate to an upper level in the pyramid to community based care. Their mainly aim is inclusion as much as possible.

Joint UN Statement (WHO, UNESCO, UNICEF and ILO)on Community Based Rehabilitation (CBR), Helsinki 2003

CBR is a strategy within general community development for rehabilitation, equalization of opportunities and social inclusion of all children and adults with disabilities.

CBR is implemented through the combined efforts of people with disabilities themselves, their families and communities, and the appropriate health, education, vocational and social services.

CBR Guidelines 2010 (WHO)

CBR: MoH+MLSP+MoE+Local Governments+NGOs/DPOs

Health

Education

Social

Livelihoo

d

CBR

Empowerment

Turning an emergency into an opportunity:CBR and the polio outbreak 2010 - 2011

• Ministry of Health, with support from UNICEF and WHO, immediately responded to contain the virus through mass immunization campaigns

• Issue of rehabilitation and inclusion of those affected was given equal importance from the beginning;

• CBR: A model for Tajikistan to ensure inclusion and to provide for rehabilitation for children affected by polio and other children with physical disabilities;

• Ministry of Health lead to introduce CBR in the 25 most affected districts, in coordination with MLSP and MoE;

• Support from: UNICEF

• As implementing partners:Operation Mercy

Handicap International

Main outcomes

• More than 800 stakeholders received basic knowledge and training on rehabilitation and inclusion:

• Referral system through PMPC strengthened

Health care workers Education staff

Social workers Representatives from DPOs and Association of Parents

Community leaders Volunteers

CBR Working Group established to coordinate efforts and share expertise (UN, INGOs and ministries)

Awareness-raising of the population and parents

Main outcomes21 CBR support rooms established staffed by a mix of

nurses, doctors, social workers who had a basic training in CBR, childhood disabilities, parents’ psychosocial support and inclusive education.

About 350 children received orthotics through the new mobile team of the orthopaedic workshop under the MLSP

18 schools have been provided with ramps for accessibility (more needs to be done for toilettes, and changing mindsets)

DPOs and parents associations for CWD mobilised to support the CBR process

Went much beyond children affected by polio: More than 1,000 children with disabilities were reached in 25 districts and basis for CBR was established.

Real life story 1: GulnoraGulnora was weak on her right

side after polio – there was start of scoliosis. She was

supported to do active exercises to strengthen her

trunk muscles at the support room in Sharinav

Gulnora is now going to regular school in grade 1

She can walk and participate in all activities in her school and

neighbourhood with the help of an orthotic on her leg.

Other CBR models in Tajikistan

CBR projects implemented with support from Operation Mercy

• Geographical Coverage: 3 districts • (Rudaki, Khujand, Babajon Gafurov)

• Partnership with PMPC for: • Cross-referral • Inclusion in schools

• 200 children reached• Local NGOs and DPOs are supported • Activities:

• Early intervention through Day Care and kindergarten • Group based rehabilitation (physical, intellectual, social rehabilitation)• Individual consultations and home visits• Training for parents• Inclusive education programme• Income generation activities• Education (health, parents), prevention

Real life story 2: AzizbekIn fall of 2012, Azizbek could not walk, he was shy. His speech was at the level of a 2 year old and hard to understand.

Soon after he started coming to the CBR room with his mother, he learned songs, colors and to count. He gained self confidence, and become an outgoing child without any fear to try and climb up wherever he can.

When he was introduced a walker his face was shining with pride and joy to finally stand up and “walk”, even though he now needs to learn how to use the walker properly and improve his leg and hip movements.

Azizbek was one of the children who received an orthopedic device through the Orthopedic workshop.

CBR projects implemented with support from Handicap International

• Handicap International started being active in Khatlon region in January 2010

• Provided technical support in strengthening capacities of workers at a local day-care centre

• Currently: 2 CBR projects, extending over 15 districts and covering over 1000 children

• One larger project, performed through:• Local NGOs• Social Assistance at home units

• Another project directly through strengthening support groups at head of districts

• Both working with similar workers/ volunteers and associations, but with different level of input and trainings available

CBR project implemented with support from Caritas Germany (Vahdat, Ghonchi and Konibodom districts)

• CBR project in Ghonchi district, with the support of EU and Caritas Germany

• 20 rehabilitation workers trained

• 28-day initial training to use WHO package on training every day self-care, communication, mobility and learning skills at home and on improving participation in the society.

CBR project implemented with support from Caritas Germany (EU Funded) (Vahdat district): results

• Decrease in dependency by all 130 PWD, from all age groups, who participated in program from 2010-2012

• None of the participating families interrupted their training programs

• All participants had their first experience of rehabilitation

• Sustainability through local social service unit, in cooperation with health and education sectors

At the age of 5, Burkhon could not sit or move, or eat independently.

He was constantly taken care of by his mother, who was not provided with information on know how to help her son to become a more independent individual.

3 months after Burkhon‘s mother started learning `home-based rehabiliation` with a CBR worker, Burkhon learned to: sit, hold his head, and use his hands to play and to eat by himself.

12 months later, Burkhon recieved locally manufactured and state- provided appliances such as seats, standing supports and a wheelchair to help him move outside his home. He started attending school once a week besides recieving home education.

Today, Burkhon is a talented school-boy of 8 . When he grows up he wants to become an English language translator.

Real life story 3: Burkhon

Challenges

Rationale for CBR

• Cost-effectiveness;

• Maximize resources of government and (I) NGOs• Cover both urban and rural areas;

• Family and communities ownership;

• Maximal impact through early identification and intervention

• Not merely rehabilitation provision; strategy for inclusion and community development promoting access to:• Health • Livelihood• Education• Social life and protection• Empowerment!

Vision for future for when CBR strategy is fully implemented

National level

Regional level

District levelCommunity level

Challenges

Challenges

• Institutionalization • Professionalization• Sustainability• Collaboration mechanisms initiated, to be

further developed • government • local NGOs • INGO • DPOs, Parents Associations, and self-help

groups

Opportunities: An inter ministrial working group on CWD has been established with decree of the Commission on Child Rights. • It can be strategically used to promote further development of and scaling up of

CBR

Funding opportunities• Strategic use of the new Ministry of Health – WHO – USAID rehabilitation program to

build on the knowledge gained for scaling and building a rehabilitation program to support CBR implementation in Tajikistan

Physiotherapy and Occupational therapy are included in the list of professions

Cost-effectiveness and impact indicators should be further measured

Interest raised and commitment achieved at the local level

Involvement of Disabled People’s Organisations and Association of Parents with Children with Disabilities at the local level, coalition of Parents Associations and DPOs

Kishti Day service providing support to families and support prevention of institutionalization of CWD

ConclusionCBR has been implemented by INGOs since 2005, but For Tajikistan, 10 years after being certified as polio free , the tragedy of the polio outbreak became a catalyst for introducing at a larger scale CBR as a low cost viable model for reaching out to the most vulnerable and hardest to reach children with disabilities

Thanks to our partners:• UNICEF• WHO• USAID• Operation Mercy• Handicap International• Caritas Germany• Mercy Corps

Operation Mercy (Khujand, Babajon Gafurov, Rudaki), Handicap International Khatlon Region, EU CARITAS (Vahdat, Gonchi, Konibadam) , EU –MLSP, (Hissor, Kurgan Teppa) UNICEF – MOH (in co-operation with, OpMercy and HI, 25 districts in DRD and Khatlon) , ADD MERCY CORPS

CBR PROJECTS