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COMMUNITY BASED REHABILITATION (CBR),

A MODERN AND EFFICIENT WAR VICTIMS


REHABILITATION CONCEPT
Autors:
Boo Ljubi,
M.D. Ph.D., Professor, University Hospital Mostar
Nadeda Zjuzin, M.D., Ph.D., Professor, Medical Faculty Sarajevo
Zdravko Troli, M.D., Ph.D., University Hospital Mostar
Goran erkez, M.D., Federal Ministry of Health, B&H

Jan 14, 2016

Community based Rehabilitation


(CBR)

OBJECTIVES OF THE PRESENTATION

Reasons for rehabilitation system reform in F BiH


Community based rehabilitation key component of
the War Victim Rehabilitation project
The role of community based rehabilitation within
the rehabilitation system in general (based on
questions to CBR centers )
Assessment of former rehabilitation programs,
assessment of CBR concept and expectations
(based on questions to disabled and health
professionals in CBR centers)
Strengths and weaknesses
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CBR

MAJOR REASONS FOR THE REFORM OF HEALTH


SYSTEM IN FB&H

Irrationality

and inefficienci of inherited model


Health services inequity regarding acces and
quality
War consequences: Change of epidemiological
pattern(large number of injuried and disabled,
increase of mental disoders, cardiac and
cerebrovascular diseases....), Health facilities and
medical equiment devastated, Flee of medical
professionals, Lack of financial resorces
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CBR

MAJOR AND ADDITIONAL REASONS FOR THE


REFORM OF REHABILITATION SEVICES IN FB%H
PREWAR AND POSWAR( War related) RAHABILITATION
SERVICES
Tertiary level None (Central Rehabilitation Institute in
Sarajevo destroyed in war)
Secundary level None (except departments for phisical
medicine in hospitals and clinical centers)
Primary level None
WAR RELATED INJURIES AND DISORDERS
More than 70.000 need for some form of phisical rehabilitation
due to war caused injuries
More than 20.000 persons have some form of permanent
disability and 5.000 are amputees
More than 15% of the total population suffer from some mental
disorders due to the war

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CBR

WAR VICTIMS REHABILITATION

PROJECT COMPONENTS

1.

2.
3.
4.

Community based rehabilitation /CBR/


centres; 38 for phisical and 38 for mental
rahabilitation
Production of prosthesis and orthoses network
of 6 units
Orthopeadic and reconstructive surgery-all
prewar facilites
Implementation support-scientific snd tehnical

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CBR

COMMUNITY BASED REHABILITATION /CBR/


CENTRES-REASONS

Delivery of services to population in community


(50.000-70.000)
Establish CBR Center within primary health care
level, ensure access to clients (in particular to persons
with disabilities)
Home visit rehabilitation services
Enhance the role of persons with disabilities in the
rehabilitation process
Training role training of teams, family members
and local community
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CBR

B O S N IA A N D H E R Z E G O V IN A
F E D E R A T IO N O F B O S N IA A N D H E R Z E G O V IN A
PR O JE C T M A P

C B R P H IS IC A L R E H A B .
C BR M EN TA L R EH A B

Jan 14, 2016

CBR

B O S N IA A N D H E R Z E G O V IN A
F E D E R A T IO N O F B O S N IA A N D H E R Z E G O V IN A
PR O JEC T M A P

P R O ST H E T IC C E N T E R S

Jan 14, 2016

CBR

B O S N IA A N D H E R Z E G O V IN A
F E D E R A T IO N O F B O S N IA A N D H E R Z E G O V IN A

O & R SU R G E RY

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CBR

COMMUNITY BASED REHABILITATION /CBR/


CENTRE - BASIC REQUIREMENTS

Space (150-200mm2 )
2. Equipment (Physical therapy,
kinesithreapy, software, library, psychosocial support, TV, Cameras...
3. Medical professionals: Physical medicine
and rehabilitation specialist,
physiotherapist, occupational therapist,
nurse, psychologist
1.

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CBR

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Evaluation

COMMUNITY BASED
REHABILITATION /CBR/
CENTRES-FOLLOW UP STUDY
1997-1999 and 1999 - 2001),
Conducted in cooperation with Queens
University,Kingston, Canada
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CBR

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COMMUNITY BASED REHABILITATION /CBR/

Survey conducted in 38 Centers-16 Questions


22 Centers delivered valid data
Total delievered services 166.558

15%

Total number delivered


procedures= 2.617.438

85%
Adult

Average number of procedures


per patient=15

Children

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COMMUNITY BASED REHABILITATION /CBR/


CENTRES- TYPE OF DISORDERS

2.369

17.036
war injuries
other injuries
degenerative diseases
amputees

46.239
26.808

Abaut 50% are patients with war related and oder injures
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COMMUNITY BASED REHABILITATION /CBR/


CENTRES - TEAM COMPOSITION

Average number of team members: 6,5


Minimum=3
Maximum=11
Team composition
1. Physiatrist= all
2. Physiotherapist=all
3. Nurse/technician=all
Other professionals( logoped, psychoterapist...some
centres)
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COMMUNITY BASED REHABILITATION /CBR/ CENTRESVERTICAL/HORIZONTAL COOPERATION

Cooperation with other Centres 82% YES


18% NO
Cooperation with cantonal hospitals, clinical
centres and specialized institutions 100% YES
Hospital referrals percentage:
1. Average
9%
2. Minimum
1%
3. Maximum
30%
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ASSESSMENT OF COMMUNITY BASED REHABILITATION


PROGRAM (PERSONS WITH DISABILITIES n=151 )

Age of persons with disabilities


12%

9%
8%

7%

11%

7%

9%

15%
11%

15-19
20-24
25-29
30-34
35-39
40-44
45-50
51-54
55-59
60+

11%

Majority persons with disabilities (15%) between 45-50


Jan 14, 2016
CBR

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ASSESSMENT OF COMMUNITY BASED


REHABILITATION PROGRAM (PERSONS WITH
DISABILITIES)
Gender of persons with disabilities
54%
Female
Male

46%

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ASSESSMENT OF COMMUNITY BASED REHABILITATION


PROGRAM (PERSONS WITH DISABILITIES) (N=149

Cause of disability
21%

direct war
injury
indirect war
injury

57%
22%

non war
related injuries

43% direct and indirect war related injuries


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ASSESSMENT OF COMMUNITY BASED REHABILITATION


PROGRAM - PERSONS WITH DISABILITIES (N=151)

Level of assistance required by disabled


Functioning level made on the basis of five-grade evaluation
scale

Dependant, unable to participate in activities, fully dependant:

11

(7%)

Maximum physical assistance, able to assist, but needs assistance:

19 (13%)

Minimum physical assistance, needs below full time assistance

65 (43%)

Supervision, needs oral instructions, or some assistance to perform


activities:
and Independent, able to perform activities independently

(6%)

47 (31%)

Most interviewed persons 65(43%) need minimum assistance

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ASSESSMENT OF COMMUNITY BASED REHABILITATION


PROGRAM - PERSONS WITH DISABILITIES (N=151)

Employment and income status

73(48%) unemployed
9(6%) run private business
69(46%) do not work, or do not receive
salary
79% income insufficient to meet the needs

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SATISFACTION LEVEL WITH FORMER REHABILITATION


PROGRAMS-PERSONS WITH DISABILITIES (N=151)-LIKERT
SCALE

Table: Satisfaction with former services


Highly
satisfactory
(n=91)

(29%)

(20%)

(13%)

(26%) (4%)

(* includes clients which did


not respond)
Total satisfactory: 62%
Medium answer:
satisfactory

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(2%)

(6%)

Highly
dissatisfied

(services not delivered n=60)


Total dissatisfactory> 12%

CBR

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FORMER REHABILITATION PROGRAM WEAKNESSESS


IDENTIFIED BY PERSONS WITH DISABILITIES

Response

Number of persons

No comments

Program inappropriately organized,


inappropriate organization

Access, clinics are distant from clients, clients


waste their time to travel to distant clinics,

10

Majority persons complain accessibility to rehabilition centres


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HEALTH PROFESSIONALS SATISFACTION LEVEL WITH


FORMER REHABILITATION PROGRAMS (n=31)-LIKERT SCALE

Table: Satisfaction with services


Highly
satisfactory

1
(23%)

(16%) (39%) (10%) (3%)

6
(6%)

Highly
(3%) dissatisfactory

(n=31); (did not participate in former programs = 21


Total satisfactory: 78%; Total dissatisfactory : 12%

Medium point: Partly satisfied

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FORMER REHABILITATION PROGRAMS WEAKNESSES


IDENTIFIED BY HEALTH PROFESSIONALS(N=24)

Most frequent response

Number of persons

Nothing inappropriate about the former


rehabilitation programs

Financing, lack of economic and social support

Inappropriate organization, program


implementation, lack of plan

Access, clinics are distant from clients, clients


waste their time to travel to distant clinics

14

Most interwied professionals identified access as key weakness


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ASSESSMENT OF COMMUNITY BASED REHABILITATION


PROGRAM BY PERSONS WITH DISABILITIES (N=151)

Requirements for better involvement of persons with


disabilities in the rehabilitation process ?
1. Advocacy-18( most frequent response)

The need for a person, or a body to influence the


Government or protect the rights of disabled
2. Conscience and attitudes -14+11 (second
frequency ranking response)

Change societal attitudes about disabled and


their needs 14

Enhance conscience -11


3. Change system-9
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QUESTIONNAIRE ANALYSIS PERSONS WITH DISABILITIES


AND HEALTH PROFESSINALS

Questions:

About former rehabilitation programs


About attitudes, beliefs and behavior
About general social topics

About CBR expectations

Both groups agred:


CBR will enhance public conscience level on
disabilities issues
CBR will upgrade community services support in the
society
CBR will help to disabled to return to independent
living
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COMMUNITY BASED REHABILITATION


-DISCUSSIONWeaknesses and obstacles
1.
2.

3.
4.

Psycho-social rehabilitation partly in function


Community based mental rehabilitation
concept and infrastructure provided under
the program, but non-functional in practice
Lack of volunteers participation
Lack of participation of persons with
disabilities

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COMMUNITY BASED REHABILITATION


-DISCUSSIONAchievements

Better access to community based


rehabilitation
2. Cost-effectiveness (equal or better
results for less funds)
3. Reduction of hospital referrals
4. Medical rehabilitation aspect provided
in both local community and patients
home
1.

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CONCLUSIONS
Experience gained after six-years implementation and 3years
CBR operation program:

Local community based rehabilitation concept has many


strengths in particular for poor societies and post-conflict
situations
A full success of this rehabilitation model requires reform
changes in both health sector and societal attitudes to
persons with disabilities
It is necessary to continue research on functioning, training
of health professionals, beneficiaries and community
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