Regulatory mechanism Responsible entity Situation
Gate-keeping mechanisms ministry of Public (information, referral and Health DrD access)
strategies, plans or service delivery schemes, which hinder the development of the physical rehabilitation sector. While a number of NGOs work hard to cover the vast need of physical rehabilitation services, assistive devices and technical aids, there is a need to speed-up the development of physical rehabilitation units and departments within the MoHFW system. In the same sense, the MoSW should put more focus on promoting physical rehabilitation, and the one-stop centres is a step in the right direction.
3.1 Identification and early intervention
of physical impairments
This mapping concludes that there are very few services available at community level for identifying
both children and adults in need of physical rehabilitation. The main support for persons with disabilities, including Community Based Rehabilitation (CBR) programs at this level are implemented by NGOs and charities. It is not clear though how these CBR programs coordinate with local health structures in terms of referral to more specialised care after identification has been done.
Community Based Rehabilitation activities are implemented by, among others, following organisations: CRP, CDD, Bangladesh Protibandhi Kallyan Somity (BPKS), Disabled Rehabilitation and Research Association, Leprosy mission, Lepra international, World Vision, Caritas, Action Aid
and CBM. Examples of work of some of these CBR programs are:
• bangladesh Protibandhi kallyan somity—BPKS is working through two main structures, Persons with Self Initiation to Development centres and Disabled People’s Organisations to Development. They are active in 32 districts with at least one CBR worker per district34.
• Centre for Disability and Development—The CDD and NFOWD program of rolling out CBR in 10 districts in partnership with NFOWD, targeting the lowest level of union councils is planned to strengthening human resource capacity and promoting an inclusive approach to community development. CDD has around 300 partners called Community Based Organisations across Bangladesh. Each of these organisations has a trained community worker, here called Community Handicap and Disability Resource Persons who conducts home visits and Primary Rehabilitation Therapy.
• Centre for the rehabilitation of the Paralysed— CRP is primarily providing specialised physical rehabilitation services in Dhaka, Savar, Chittagong and Barisal and has set-up a CBR network in a number of districts, covering for example reintegration of Rana Plaza victims in Savar, awareness around road safety in Comilla, and access to livelihood in Barishal, Manikgonji and Dhaka, Chittagong and Rajshahi. Around 13 CBR workers are available in these districts.
In Handicap International’s KAP study (2012), persons with disabilities said that information about services was primarily given through neighbours and that the families themselves often made the first identification35. This can delay in many situations
the useful start of rehabilitation, provisions of orthopaedic devices or early stimulation for access to
education, as well as finding, or be reintegrated into livelihood opportunities. .
3.2 Rehabilitation medicine, therapy
and assistive devices
Rehabilitation medicine and therapy span from surgical interventions to acute and long-term therapies such as physiotherapy, occupational therapy or speech therapy. Modifications to the close environment as well as support and counselling is usually also included in physical rehabilitation, and can be important factors for supporting inclusion in daily life activities. Assistive devices, such as prosthetics, orthotics and other mobility aids, are also crucial components of physical rehabilitation and sometimes necessities for going to school or engaging in livelihood activities.
Physical rehabilitation at Upazila/Thana level
The result of the mapping shows that there is no comprehensive rehabilitation program except an identification service, which refers to district and divisional levels and specialised level hospitals at primary health care level within the health system, and that most people have to travel to the nearest district hospital or one-stop centre (also at district level) to access some kind of physical rehabilitation service. There are a few NGOs or charities that provide physical rehabilitation through its CBR programs but during this mapping, such level of details could not be reached.Physical rehabilitation at district level
At secondary health care level, which in Bangladesh covers the level of district hospitals at Zila level, few physical rehabilitation services are available. Health care services have minor surgery provision but more complicated health problems are referred to divisional and national level. These hospitals though do not provide any physiotherapy or P&O services. According to the description of services provided at district hospitals, and the type of staff assigned, physical rehabilitation professionals, such as physiotherapists or occupational therapists are not included.
34 http://www.bpksbd.org
35 Handicap International. KAP survey. Attitudes and awareness
around physical rehabilitation in Afghanistan, Bangladesh, Orissa (India) and Sri Lanka, October 2012.
An interesting development is the project implemented by the MoSW, with funds from the World Bank, where so called Integrated Disability Service Centres (IDSC), also referred to as Jatiya Protibondhi Unnayan Foundation centres (JPUF), have been set-up at district level. The funding with the World Bank on this project will continue until 2016.
At this moment 68 centres are functioning throughout Bangladesh. Each such centre should have the following type of professionals employed and as is described below, the staffing is still in process:
• 1 Centre manager—all centres have one manager in place.
• 1 Consultant senior physiotherapist and 1 clinical physiotherapist—each centre has a senior physiotherapist in place but only 34 centres have a clinical physiotherapist36.
• 1–2 Assistant physiotherapist—120 assistant PTs are currently in place.
• 1 Clinical occupational therapist—only three OTs are currently in place due to lack of trained professionals.
• 1 Clinical speech and language therapist—only one speech and language therapist is employed due to lack of trained professionals.
• 1 technician for hearing test (audiologist)—60 low- level technicians are in place but no audiologists are yet available due to lack of trained professionals.
• 1 technician for vision test (ophthalmologist)—60 low-level technicians are in place but no ophthalmologists are yet available due to lack of trained professionals.
• 1 Accountant—50 accountants are in place and the rest are supposed to be hired based on governmental quota.
• 1 office assistant—68 office assistants are in place. As these centres are at district level it is difficult for persons with disabilities living far from the centres to access the services, both due to their socio-economic situation and inadequate transport facilities. For that reason, the IDSCs plan to start 32 mobile clinics using adapted buses, equipped with therapeutic equipments. Each mobile therapy van will cover two districts and will focus on children with disabilities, referral linkages to district level IDSCs and raising awareness on disability.
Rehabilitation professionals are equally working in a number of NGOs across Bangladesh. Some specialized government hospitals at national level have posts for rehabilitation professional, such as PTs and OTs, but other medical professionals sometimes hold those posts. Table 2 presents a situation where the vast majority of physical rehabilitation professionals are working in the NGO and charity sector and where the governmental services are almost absent in this field.
36 One reason for the lack of recruitment is there is a government quota to have employed in each post 5 % of staff to be freedom fighters
or persons with disability. The availability of this quota to be qualified at many of these posts is limited.
Table 2: Organisations and hospitals providing physical rehabilitation in bangladesh 2013
Name of organisation PT OT P&O SLT*
Action Against Hunger 1
Apollo Hospital 7 1
Autistic well fare foundation 2
Bangladesh Prothbondhi Kollan Somity 1
Bangladesh Medical and Research Council 1
Bondhu Kallan Foundation 1
Beautiful mind (school for children with autism) 1
Bangladesh University of Health Sciences 6
Centre for the Rehabilitation of the Paralysed 98 50 6 12
Centre for Disability in Development 10 2 4
Disabled Rehabilitation and Research Association 7 5
Dream Angel school for autism 1
Endolite Bangladesh 1
Handicap International 8 4
Hope for Life 2
International Centre for Diarrheal Disease Research Bangladesh 1
Integrated Disability Service Centres (working in 64 district) 178 3 1
Jivita Bangladesh 1
BRAC Limb and Brace Centre (Dhaka) 9
Dynamic Limb Centre 5
Save the Children 1
Society for Assistant to Hearing Impaired Children 1
Social Service institute 1
Social Assistance and Rehabilitation for the Physically Vulnerable 1
Tauri foundation (school for children with autism) 1
Christian Medical College and Hospital) 1
Nalta Hospital 1
Danish Bangladesh Leprosy Mission 2
Modern Limb Centre 1
Impact foundation 2
International Committee of the Red Cross 1
Kidzee international school (schools for children with autism) 1 1
LAMB hosptial—Integrated Rural Health and Development 1
Practical Action Bangladesh 1
Proyash (school for children with autism) 3 3
Shishu polli plus (the Sreepur Village Bangladesh) 1
Society for the Welfare of autistic children 1
Sylhet private clinic 1
United Hospital, Dhaka 7
Total 323 83 37 19
SLT—Speech and Language Therapist