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Keep on Rehab

FIRST IMPRESSIONS ON REHABILITATION, Sept 23 2015

It has been two weeks since we arrived in Blantyre and this short period has already been full of experiences. During the last few months, we got in touch with several health practitioners in Blantyre, and everyone was interested in meeting us and talking about rehabilitation care. These first weeks we have visited the main hospitals and health care facilities in Blantyre and we have spoken to several medical professionals.

Malawi
Malawi is a small but densely populated country, that currently has a population of 16 million people. The life expectancy is about 55 years. Lack of education is a major issue, with only 10% of all children attending secondary school and almost 40% of adults is illiterate. Malawi is a poor country with a gross annual net income of approximately 300 USD/year. The reported prevalence of disabilities in Malawi is 4.18%. The major forms are physical disabilities (43%) and sensory impairments (42%). The most common causes are physical illness, congenital problems and accidents. Also a common belief is that witchcraft or other supernatural forces cause disabilities. People with disabilities are experiencing educational problems, due to lack of financial resources, mobility problems, inaccessibility of some schools and lack of teachers trained in special education. 84% of people with disabilities is aware of the availability of health care services and requires these services, but only 64% actually receives these services. In terms of seeking care, mobility and large distances to healthcare services are the major problems experienced by people with disabilities. A study showed that 17% of people with disabilities use assistive devices. 34% were acquired privately, 19% through government services and 17% through non-governmental organisations (NGO).

MAP
There is one rehabilitation center in Blantyre (Kachere), which is run by the organisation Malawi against Physical disabilities (MAP). Kachere has 40 beds and treats mainly patients recovering from stroke or spinal cord injuries. Patients are referred mostly from Queen Elizabeth Central Hospital (QECH), a teaching hospital in Blantyre. Kachere is the only rehabilitation center in the country with inpatient rehabilitation services for adults. Inpatient treatment is free of charge. Outpatient physiotherapy is offered only to those who can pay and are able to come to the center. There are no doctors working at the center. Consequently, if a patient needs medical attention, they will be referred to QECH for evaluation and treatment. Kachere is mainly run by physiotherapists and rehabilitation technicians. Rehabilitation technicians are trained in basic nursing, occupational therapy and physiotherapy skills. There are no occupational and speech therapists working at Kachere, due to the lack of a training program in Malawi. Fortunately, there are plans to start a training program in the near future.
MAP has a workshop that employs technicians who develop assistive devices, such as wheelchairs, crutches and walking devices. Their trademark is building handbikes: it takes one person two weeks to make one from scratch. All the materials are bought locally. The devices are customized and free of charge, but their production depends on funding. Initially MAP was a NGO, supported mainly through public funds. Currently it is supported only by the Malawian government, who provides salaries of staff members. Other costs, such as maintenance, food and materials have to be paid via external funding. Unfortunately, due to lack of funding MAP is now unable to provide a similar level of rehabilitation services as they were able to provide in the past. Until four years ago, MAP ran an extensive outreach program, through which rehabilitation care was provided in the rural communities across Malawi. To compensate for the loss of this program, rehabilitation technicians were sent to treat patients in the rural communities. About five technicians are currently working in district hospitals in the south of Malawi.

In-hospital rehabilitation services are provided at QECH. This teaching hospital contains 1500 beds, although a higher number of patients is admitted and patients often have to share beds. Rehabilitation care is provided by the physiotherapy department. Nine physiotherapists and a small number of rehabilitation technicians is responsible for the treatment of all in- and outpatients. Thirty new interns are expected after their graduation and hopefully, this will contribute to improvement of in-hospital rehabilitation services. Located next to the physiotherapy department is the orthopaedic center. This center provides orthotics and prosthetics, mobility devices and special chairs. Production of devices is limited because of lack of funding, but also hampered by problems like power cuts. The center employs eleven orthopaedic technicians, who were trained abroad due to lack of education facilities in Malawi. At this moment one orthopaedic shoe-maker is working in the center. There is no direct collaboration between the orthopaedic center and the physiotherapy department. This results in for example orthopaedic technicians giving gait training to patients after they received their prosthesis, something usually done by physiotherapists.

Another important health care provider is Beit Cure International Hospital (Cure). Cure is a non-governmental hospital, run by foreign doctors. Cure is famous for its orthopaedic surgeries, such as joint replacements, and is well-known across southern Africa. Adults have to pay for their treatment and part of this income is used to provide free orthopaedic treatment to children. Physiotherapists and (occasionally) occupational therapists are providing postoperative rehabilitation care.

After discharge from hospital a follow-up visit takes place after three to six months. In between, most of the patients do not have access to any form of rehabilitation care at home. Training instructions are given to the family, but these instructions often appear not to be followed up properly.

In the coming weeks we would like to find out more about specific treatments for frequently encountered disorders, such as stroke, cerebral palsy, amputation, spinal cord injury and spina bifida.

Source: A baseline study to map existing documentation related to CBR programs in Malawi, by Alister C. Munthali and Paul Kakhongwe, Center for social research, Zomba. March 2011.

REFLECTIONS, Oct 25 2015

workshop
Over the last weeks we have been given lectures and workshops, with the aim of exchanging knowledge and discuss current rehabilitation care and improvement strategies. We were pleased that professionals from a variety of institutions were attending, making it possible to discuss rehabilitation care from different angles. Professionals pointed out the current problems and challenges in Malawi’s rehabilitation care, and the improvements they would like to see. While evaluating the three workshops we have given, two major topics of improvement were mentioned:

1. Improvement of awareness and knowledge about rehabilitation medicine and existing institutions providing rehabilitation services.
Health care workers in rural areas have insufficient skills and time to provide adequate health education to the communities. Currently, outreach programs sponsored by the government are mostly directed to HIV-prevention and treatment, and to environmental awareness programs. Physical disability is not a main topic of interest for the government, resulting in the need of donor funding to enable outreach programs. MACOHA (MAlawi COuncil of the HAndicapped) is a governmental organisation providing some of these services, but they are limited in their financial resources.
Another issue that was mentioned is that patients admitted in hospitals receive limited information about their diagnosis, prognosis and treatment possibilities. Difficulties seem to be the high workload of medical care practitioners, leading to priority in “emergency” medicine rather than informing patients, and a more paternalistic doctor-patient relationship.
Among professionals, knowledge about the importance of rehabilitation services and the knowledge about existing rehabilitation services is limited. Existing rehabilitation institutions should focus more on putting themselves on the map.

2. Improvement of a network of qualified professionals, resulting in good collaboration and communication between all different health care workers and institutions.
Currently the amount of qualified professionals and knowledge about the tasks and responsibilities of each discipline is limited, resulting in solitary work, instead of teamwork. In turn, this often results in insufficient follow-up of patients. Implementation of a “coordinator” would be desirable, to improve across-discipline collaboration within and between institutions.

During the workshops, it struck us that professionals had difficulties to switch to improvement strategies other than improving finances and increasing the number of qualified staff. We have given several suggestions for improvement, but factors like motivation and hierarchy seem to be important struggles. In the past, there have been several initiatives to improve rehabilitation care, leading to good results. However, as soon as the initiator pulled out, the program collapsed. Reasons that were given for this include “lack of motivation due to low salaries, working attitude, difficulties taking responsibility and the “political system” (hierarchy)”. Unfortunately, our time in Blantyre has been too short to get a full grip on all cultural aspects that may hamper establishment of efficient rehabilitation care in Malawi.

Malawi
So our project is already coming to an end, and it leaves us with mixed feelings. We were pleasantly surprised by the hospitality of different institutions and rehab professionals, making it possible to get a clear picture of rehabilitation services provided in Blantyre and the challenges that are being faced. Giving lectures and organizing workshops has increased our understanding of these issues. Unfortunately, due to limited input concerning ways of improvements during our interaction with rehabilitation professionals, we have not yet been able to come up with a concrete plan for the future.

With respect to the continuation of our project our idea is to return to Blantyre to provide specific “train-the-trainer” projects. However, for this to be successful we will need a local partner to collaborate with and to provide input on the specific subjects and implementation strategies. Our last week in Blantyre we will discuss this idea with some of our contacts and hopefully this will lead to a future collaboration.

Rinske and Maritza

 

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