Processes and approaches to enable sustainable access to quality rehabilitation services

les processus et les approches pour un access perenne aux services de readaptation

Etude comparative des programmes de HI en Albanie, Kosovo et Mozambique2012

In these three countries (out of 28, in 2011) HI was engaged in the development of the rhabilitation sector, thus with a clear systemic approach Despite the differences of the socio-economic, cultural and political contexts, the analysis of the interventions allow us to identify retrospectively factors of succcess in improving the access to services for Pwds via this appraochBut it allows as well the identification of gaps or weaknesses to be more effective .1Profils pays MOZAMBIQUE24 M IDH: 184KOSOVO1,7 mIDH N/AALBANIE 3,2 mIDH: 70Systme de sant organisManque des politiques sectoriellesManque de professionnels Assistance aux Victimes de mines1986-2001HI prsent pendant la guerre civile+reconstruction longue terme2000-2004; crise et reconstruction2006-2011Phase de reconstructionAlbania: initiated at the end of 2005. With the aim of supporting the sector in a comprehensive way, HI adopted a systemic approach, supporting key actors with the aim to develop PMR policies, establish human resource training capacity, pilot new PMR services and facilitate the participation of persons with disabilities at all levels. Kosovo Handicap International was appointed by UNMIK in 1999 as a leading agency for developing Physical Medicine and Rehabilitation services in Kosovo, and from April 2002, HI took a role as consulting agency for PMR and disability issues for the Ministry of Health. In this context, Handicap International assessed the needs for rehabilitation services in Kosovo, and put forward a comprehensive project to improve the Physical Medicine and Rehabilitation sector. The project included actions to support the development of a physiotherapy program, support to the National Ortho-Prosthetic Centre (NOPC) and support to the development of a Community Based Rehabilitation (CBR) network together with local NGOs. Mozambique Handicap International was among the first international organisations in Mozambique opening rehabilitation centres in the 1980s, following the war that affected the country until 1992. For a number of years, Handicap International worked in several regions to support or set-up PMR services, mainly P&O centres, and also to deliver services directly. HI subsequently strengthened its partnerships with national authorities to develop the rehabilitation system in the country, through support to rehabilitation professionals education, services organisation capacity development and lobbying at the ministry level for resource allocation within the rehabilitation sector. In addition, HI set up a CBR project and facilitated the first Disabled Peoples Organisations, as part of a parallel project.

2analyse systemique:QUEL NIVEAU D INTEGRATION D UNE APPROCHE SYSTEMIQUE DANS LES PROGRAMMES?

QUELS TYPES DE PARTENARIATS?

QUELS IMPACTS SUR LES DIMENSIONS CLES Y COMPRIS LA PERENNITE?Methodology: a qualitative and retrospective study, based on project documents review, interviews of partners and organisations and FGD.3APPROCHES: -NIVEAUX DINTERVENTION-montage du projet-affectation des ressources 4

NIVEAUX D INTERVENTION:GOUVERNEMENTAUTORITE LOCALE AUTORITE CENTRALEPERSONNES HANDICAPESIndividusFamilles/OPHPRESTATAIRES Personnel terrain organisationApproches (1)BAILLEURSONGThe interactions between the three types of stakeholders (authorities, services providers and users) and the capacity of each to play their respective roles (regulation, delivery, use and quality control) to ensure a better access to services for persons with disabilities from a systemic point of viewIt is important to note that all the interventions of HI prioritised the support to Ministry of Health and service providers promoting national policies in PMR, training of professionals and development or the strengthening of PMR services. The capacity building and support to the disability movement was implemented differently in the three countries. 5

LES INTERVENTIONS PRIORITAIRES :La promotion des politiques sectoriellesLa formation des professionnels Le dveloppement ou renforcement des services, y compris niveau communautaire ( exception de lAlbanie)

Lappui aux organisations des PH a t mis en place de faon diffrente et en parallle avec les stratgies de radaptation

LE CAS DU KOSOVOInterventions diffrents niveaux ,mais pas coordonnes; interactions entre acteurs limites

Dispositifs de rgulation tels que valuation des besoins locaux, dfinition de critres daccs, standards de qualit, systme de rfrencement et suivi..lacunairesKosovo Handicap International was appointed by UNMIK in 1999 as a leading agency for developing Physical Medicine and Rehabilitation services in Kosovo, and from April 2002, HI took a role as consulting agency for PMR and disability issues for the Ministry of Health. In this context, Handicap International assessed the needs for rehabilitation services in Kosovo, and put forward a comprehensive project to improve the Physical Medicine and Rehabilitation sector. The project included actions to support the development of a physiotherapy program, support to the National Ortho-Prosthetic Centre (NOPC) and support to the development of a Community Based Rehabilitation (CBR) network together with local NGOs. Mozambique Handicap International was among the first international organisations in Mozambique opening rehabilitation centres in the 1980s, following the war that affected the country until 1992. For a number of years, Handicap International worked in several regions to support or set-up PMR services, mainly P&O centres, and also to deliver services directly. HI subsequently strengthened its partnerships with national authorities to develop the rehabilitation system in the country, through support to rehabilitation professionals education, services organisation capacity development and lobbying at the ministry level for resource allocation within the rehabilitation sector. In addition, HI set up a CBR project and facilitated the first Disabled Peoples Organisations, as part of a parallel project.

7Approches (2)MONTAGE DU PROJETBass sur des valuations des besoins, mais plus systmatiques et globales en Albanie et avec la participation des OPH pendant lidation.La participation des OPH en Albanie a continu de faon moins importante pendant la mise ne place

AFFECTATION DES RESSOURCESMozambique et Kosovo: nombreux expatris et personnel national ( du fait de lurgence).Albanie: Peu dexpatris long terme, mais utilisation dexpertises externes courtes, y compris rgionales PROJECT DESIGNProject design were all based on needs assessments , more systematic and comprehensive in Albania.Participation of DPOs in the project design, implementation and monitoring was much higher in Albania if compared to Kosovo. and Moz.

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TYPES DE PARTENArIATA qui est la responsabilit (ownership)Comment prend-on les dcisionsLe rle de chaque acteur dans la planification, la mise en place et le suiviLE CAS DE L ALBANIeDemande officielle de dvelopper les services par les OPH Mise en place dun comit de pilotage rad et dun groupe de travail sur la Mdicine Physique et Radaptation au sein du MinistreAccords crits rgulant chaque interventionForte influence des acteurs locaux dans la prise de dcisionContrle par les acteurs albanais lors du le lancement appui technique assur par des experts extrieurs, provenant de la rgion

Participation des acteurs locaux au suivi qui sest progressivement affaiblie

Modalites de partenariat Leon apprise: lengagement des autorits publiques pour dvelopper le secteur et les politiques est incontournable pour assurer une planification quitable et accessible des services Enjeux: - stratgies de sortie pas assez dveloppe, pas de concertation/ consultation avec les acteurs -manque de stratgies pour la dmarche qualit des services

PartEnariat: le rle the HIMOZAMBIQUE KOSOVOALBANIEPRESTATION DIRECTE DE SERVICEFORMATION

APPUI AUX POLITIQUES

COORDINATION

Impact et perennite:

1 resultats en sante/readaptation2 capacites institutionnelles /politiques3 formation des professionnels4 prestataires de services 5 communaute et capacites des OPH

1 Rehabilitation outcomesLack of data in the three countries to allow comparison and measure of impact and availability of services (either baseline or final data )In Mozambique, services were multiplied and exist with a good geographical cover, but needs of rural areas are not addressed and the quality has deterioratedIn Albania and Kosovo so far few new centres were opened by national authorities, the rest is with the private sector

Capacites institutionelles Le cas du Mozambique

Dveloppement dune politique nationale, avec gestion des centres de radaptation aux niveaux secondaire et tertiaireServices pris en charge par le gouvernement et gratuits pour les PHDispositifs pour le recueil de donnes dans les services (statistiques de base)

2- capacites institutionnelles/politiquesATOUTS dfinition de politiques sectorielles services de readaptation prsents aux niveaux secondaire et tertiaire, gratuits pour les PHFormations en gestion des services au Mozambique

ENJEUXMise en place des politiques limite: manque de financements, manque de capacits de gestion et de suiviLiens trs limits entre les centres et les communauts. Zones rurales sous-desserviesAbsence de dispositifs de rgulation

Too much emphasis given to training and facilities , and not enough to decision making, managerial and monitoring ; relationships between center and periphery underestimated

The nature of national rehabilitation policies has several degrees of complexity that make implementation much more difficult:-long term, interdependent with other sectors, targeting different groups of the population!-skills and resources that have to be built/ mobilized: many!!

Example more easily implementable policy:One agency, clear goals, single objective, simple technical features, marginal chnage, short udration, visible benefits, clear costsNational policies were developed in the three countries (national action plans), but poorly implemented (lack of financing, but also managerial and monitoring capacities) rehab services are included at secondary/tertiary level and free of charge in Moz and Kosovo CBR in Kosovo and Moz are very poorly implemented despite specific actions, with poor links between communities and centerspoor range of services available (PTs) , and concentrated in citiesOnly in Mozambique where HI directly supported capacity building of management of centers , procedures and data collection is possible; other regulatory mechanisms are absent in the three countries

163- FORMATION DES PROFESSIONNELSATOUTS

Formation innovante pour orthoprothsistes en AlbanieProgramme de formation kin dmarr directement avec linstitut des formations paramdicalesAu Kosovo et Moz.les formations par HI ont t reconnues

ENJEUX

Qualit de la formation et de la pratique sur le long terme Pas de reconnaissance des profils communautaires Manque de planification, perte de personnel

In Moz and Kosovo, trainings of P&O and Pts started during the conflict and provided by HI, and were institutionalized laterAlbania: training for PTs started immediately under the national training institute; training of P&O was in-house and innovativeLong-term quality of training and practice is a concern in all the three countries

174- ServicesATOUTS

Tous les ateliers crs par HI sont aujourdhui gers par le gouvernementLe nombre de cabinets de kin a augment (dans les zones urbaines ) avec une bonne couverture au Mozambique ;secteur priv plus actif dans les Balkans

ENJEUX

Cout du matriel pour les ateliers est un problme sur le long termeAccs trs rduit dans les zones rurales

Manque dinterventions de rgulation par le gouvernement central dans les trois pays

P&O workshops are all run by government today, but concern about costs (material)

Increase in PT clinics in the 3 countries, in urban areas and in the private sector in Albania and Kosovo Important gap in the three countries in rural areas, poor linkages and poor accessibility (costs)

18Capacites des communautes et des ophConsultation/participation la cration des politiques trs limitesPlaidoyer et lobbying : rseau efficace seulement au niveau local au Kosovo et en AlbanieParticipation au fonctionnement et lvaluation des services: trs limites, aussi du fait de laccs rduit.

Du projet la perspective locale

Montage participative des projets ;connaissance des organigrammes, des responsabilits et roles ; connaitre les barrires laccs aux services dans la globalit ; faire une analyse des couts

20 Du projet la perspective locale Du projet la perspective locale

RECCOMMENDATIONS-design Relevance of knowing the barriers to access servicesRelevance the deep understanding of role and interactions of stakeholders, including PwDsparticipatory definition of objectives, responsibilities, timeframe is effective for actual engagement in the long terma cost analysis of services, including set up and maintenance, should be based on local capacities and resources to be feasible- Identification of risk factors and definition of monitoring tools since the beginning

Questions:Pour un accs quitable et prenne aux services de radaptation pour les PH, qui devrait contribuer et comment :1 lamlioration de la qualit des services?2 au dveloppement des dispositifs de rgulation?3 au montage et suivi des politiques de radaptation?

For an equitable and sustainable access to REHABILITATION SERVICES for PWDs, who should contribute , and how, to:

The improvement of the quality of services ?The development of regulatory mechanisms? The design and monitoring of rehabilitation policies?

24Reccommendations -implEmentationPromote the participation of PwDs in management of servicesContribute actively in the setting up of regulatory mechanisms : need assessment, gate keeping procedures, quality criteria, monitoring mechanismsEncourage services to develop closer relationships with community actors :

Promote both the competences of local actors for recognition in the community and professionals at the central level for regulation of performances and quality control

networking with DPOs that can provide support for transportation or some financial support, links with local authorities for local financing possibilities, and links to primary health care centres for early referral etc.25Reccommendations-phasing out Define with partners longer term strategies to:-strengthen monitoring mechanisms for actual implementation of policies-develop long term partnerships with external technical resources for training (when necessary)-transfer of knowledge requires to anticipate a lot