ICRC Physical Rehabilitation Programmes - Annual Report 2000

Introduction

The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance.

In 1979 the ICRC set up a unit for the physical rehabilitation of war victims. Since then, 56 projects have been set up in 25 countries. Two-thirds of the projects are carried out in close cooperation with government authorities. The others are run by the ICRC alone or in partnership with local non-governmental organizations or Nati onal Red Cross/Red Crescent Societies.

Since the unit was formed, 145,160 individuals have been fitted with a total of 162,705 prostheses and 62,731 orthoses, while others have received crutches (217,848 pairs), wheelchairs (12,259), physiotherapy, etc.

Programmes in 11 countries (Chad, Colombia, Eritrea, Lebanon, Mozambique, Nicaragua, Pakistan, Rwanda, Syria, Viet Nam and Zimbabwe) have been handed over after an average period of 10 years'full-time ICRC involvement. In some countries (Ethiopia, Myanmar, Sudan and Uganda), the ICRC resumed has its assistance because of extensive unmet needs and the persistence of a conflict situation.

It is essential that handed-over projects continue to provide services for the disabled, whose needs for replacement and repair of orthopaedic appliances are lifelong. After their handover, most of the programmes are monitored and assisted on a smaller scale through the ICRC's Special Fund for the Disabled.

Activities in 2000

For the fourth consecutive year, the ICRC assisted a record number of physically disabled people in 2000, providing mainly prostheses (16,442) but also orthoses (11,005). This was especially the case in Afghanistan, where the production of orthoses exceeded that of prostheses. Seven additional projects were initiated in 2000, in Ethiopia (Addis Ababa, Mekele, Harar and Desse), Myanmar (Yenanthar) and Uganda (Gulu and Mbarara). This increased the total number of prosthetic/orthotic centres receiving assistance to 37, in 14 different countries. The projects in Ethiopia (except Desse) had previously been handed over but required renewed ICRC involvement.

The 20% increase in projects receiving assistance brought about a corresponding increase in staffing. By the end of the year, 41 expatriate specialists were employed in 37 field projects, assisting 1,049 local staff. The three specialist staff from headquarters spent 176 days on assignments in the field during 2000. All physical rehabilitation country programmes were visited except those in Georgia, Tajikistan and Uganda.

The three main objectives for 2000–2005 are the following:

• To develop, together with the partner, project guidelines for the treatment of amputees .

General project and treatment guidelines for prosthetic/orthotic programmes already exist. During the year, examples of such guidelines used in specific projects were collected and distributed to the staff of other projects for information purposes and where possible for application. Follow-up will be handled at a round table meeting in 2001, which may ultimately result in the adoption of an ICRC Orthopaedic Reference Manual providing p roject guidelines.

• To define a standard level of training and develop a teaching package for local staff .

Six teaching manuals on prosthetics and two on orthotics have been completed. They have been used in the southern Caucasus training course (Georgia and Azerbaijan) and are now available for distribution to other projects. Representatives of the International Society of Prosthetics and Orthotics (ISPO) and the French Ministry of Education have carried out an on-site evaluation of the southern Caucasus training course, and the course contents and syllabus are being modified to obtain ISPO Category II recognition. In 2001, when this is completed, a working group will examine the possibility of basing the ICRC in-house standard training course on this model. In a related development, two teaching manuals on physiotherapy were produced in Iraq and Tajikistan.

• To improve and standardize affordable raw materials, including prosthetic components .

The development and production of low-cost components at CR-Equipements (Coppet, Switzerland) continued on schedule. The introduction in February 2000 of knee and foot components from CR-Equipements in 80% of all assisted projects raised the quality of polypropylene prostheses significantly. The lifespan of these components cannot yet be determined, but it is expected to be longer than that of most locally made components. In the course of next year, components from CR-Equipements will also be made available at cost to other humanitarian organizations assisting projects in low-income countries. This will depend on stock levels and will be subject to the condition that local staff be trained in the use of the components. The regional training centre of the Special Fund for the Disabled in Addis Ababa, Ethiopia, organi zes one-month training courses. The ICRC-assisted component factory in Phnom Penh, Cambodia, which has achieved a high degree of technical and managerial self-sufficiency, will continue to provide components for the national market.

An external evaluation of the ICRC's physical rehabilitation programmes was completed in 2000. It was carried out by Mr Sepp Heim, president-elect of the ISPO and Senior expert of the technical orthopaedic programmes of the German Technical Cooperation (GTZ) and former director of the German School of Technical Orthopaedics in Dortmund, and by Dr. Bernhard Miethe, a private consultant in economics and technology for the GTZ, in particular for its technical orthopaedic programmes. Extensive and useful discussions held during the evaluation visits had an immediate result on the approaches used in some of the physical rehabilitation programmes concerned. Although the complete evaluation report is not yet available, some of its main recommendations can already be mentioned:

• The quality of prosthetic and orthotic fitting should be the main focus for projects that come under the auspices of the ICRC. The production of components in orthopaedic workshops is neither efficient nor necessary.

• There should be a move away from the current policy of free delivery of orthopaedic appliances towards direct payment per patient to the producer of these appliances. This should be seen as a tool to create sustainability.

• Existing or planned facilities in host countries must be fully respected in ICRC programme planning.

• The image of polypropylene technology as a second-rate solution should be improved by demonstrating the advantages of this approach. To that end, better communication is needed within and outside the ICRC.

• Proper cost calculation and data collection are required in all workshop activities. This is mandatory for reaching the target of sustainability. A standard method for drawing up cost estimates should be developed and tested.

• Fitting the disabled is perceived as a humanitarian activity, rather than one associated with gainful employment. Nevertheless, projects in this sector do include an important development aspect which must become an integral part of the ICRC's strategy, e.g. through calling upon the expertise of the Special Fund for the Disabled at an early stage.

Activities per country programme

Afghanistan: Kabul, Herat, Mazar-i-Sharif, Jalalabad, Gulbahar ,1987-2000

Background

Despite the pressing need for physical rehabilitation services in Afghanistan, existing health-care facilities lack resources and professional skills. In 1981, the ICRC started assisting physically disabled Afghans in facilities just across the border in Pakistan. The organization has been present in Afghanistan since 1987 and has set up prosthetic/orthotic centres in Kabul, Herat, Mazar-i-Sharif, Jalalabad and Gulbahar. The ICRC programme has developed steadily to meet the needs of amputees, and has also made significant progress in addressing the physical needs of non-amputees such as paraplegic patients, polio victims and others. The return to society of many physically disabled people has been facilitated by their inclusion in the workforce of the pros thetic/orthotic centres and other programmes. Small-scale projects providing education, vocational training and micro credit for the disabled have also helped. The ICRC physical rehabilitation programme in Afghanistan has the highest number of beneficiaries of any of the ICRC-assisted country programmes.

Achievements 1987–1999

• Physical rehabilitation services were provided for patients, who received 30,435 prostheses and 15,747 orthoses.

• The premises were renovated and new equipment was installed.

• Support units were set up for paraplegic patients in three prosthetic/orthotic centres, together with an extensive home-visiting programme.

• Some 700 disabled people took part in micro-credit programmes set up on the private initiative of the project leader.

• Continued training was provided for technical staff.

Achievements 2000

• Physical rehabilitation services were provided for patients, including the supply of 4,600 prostheses and 6,360 orthoses. Nearly 2,000 new amputees were registered and treated, 75% of whom were mine victims. Access to care was facilitated by the decentralization of services and by making use of the Afghan Red Crescent Society where possible. Separate treatment areas were available for male and female patients. Some of the disabled attended school, others were given help finding work or encouraged to start small business es. Several hundred ICRC-produced components were supplied to centres assisted by the Swedish Committee for Afghanistan's Comprehensive Disabled Afghan Project (SCA-CDAP) in Ghazni, Taloqan and Kandahar for the fitting of amputees.

• Over 4,000 new non-amputees were registered and treated, including 1,005 additional polio victims and 333 additional paraplegic patients. All proshetic/orthotic centres except the one in Jalalabad have small paraplegic wards for basic care. The home-care team project in Kabul offers multiple-approach (medical, economic, social and psychological) treatment to paraplegic patients in their home environments with the constant involvement of the patient’s family.

• Two national workshops on physiotherapy and orthopaedic technology were organized to ensure better information and coordination among those working in physical rehabilitation. In-house courses adapted to local training needs were organized at all ICRC centres. Workers from SCA-CDAP centres received training in the use of polypropylene technology for prostheses. Two disabled employees were attending a two-year extramural course in physiotherapy organized by the International Assistance Mission in Kabul.

• More management responsibility was given to local employees in the centres.

Angola: Luanda, Huambo, Kuito, 1979–2000

Background

The long-standing conflict in Angola has claimed many victims. More than 80% of the amputees in the country were injured by mines. The ICRC has cooperat ed since 1979 with the Ministry of Health in providing technical and material support for prosthetic/orthotic centres in Luanda, Huambo and Kuito. Appropriate technology has been introduced, including prosthetic components that have also been provided for centres assisted by other organizations. Flare-ups in the conflict have sometimes been accompanied by looting, famine and a general lack of security that have interrupted services. The longest period of standstill was between 1992 and 1994, following which, in 1995, the ICRC renovated the Huambo centre and rebuilt the Kuito centre from scratch. Recently, the focus has been on improving patient services, including making centres more accessible and achieving a better quality of fit and longer durability of prostheses. In 2000, at the request of the European Union, a new five-year plan for physical rehabilitation was adopted by the national authorities.

Achievements 1979–1999

• Physical rehabilitation services were provided for patients, who received 19,905 prostheses and 128 orthoses.

• Prosthetic components were delivered to seven centres assisted by other humanitarian organizations.

• Renovation or construction work was carried out on the premises, new equipment was installed and a patient dormitory was set up.

• Continued training was provided for 60 technical staff.

Achievements 2000

• Physical rehabilitation services were provided for patients, who received 2,366 prostheses and 24 orthoses (80% of the fitted amputees were mine victims). Access to the centre in Luanda was improved by providing transportation for 99 amputees from Malange and by covering part of the travel costs of 350 other patients. Two thousand posters were distributed in the main provi nces.

• Seven centres, including four assisted by Veterans International, Handicap International, German Technical Cooperation (GTZ) and Intersos, received components for 3,500 prostheses free of charge from the ICRC. The feet were provided free of charge by Handicap International of Belgium.

• The production of prosthetic components in Huambo was phased out and replaced by low-cost imported components that are of better quality and have a longer lifespan.

• Continued on-the-job training was provided for 55 technicians, including 14 physiotherapy staff.

Azerbaijan: Baku, 1994–2000

Background

Physical rehabilitation services have suffered since the collapse of the former USSR while needs have increased owing to the conflict in Nagorny Karabakh. Since 1994, the ICRC has been providing assistance for a prosthetic/orthotic centre in Baku which is managed by the Ministry of Labour and Social Protection (MOLASP) and where patients are assisted free of charge. There is an additional, larger government centre for paying patients in Baku, also run by MOLASP, while small centres in Nakhichevan and Ganja are facing major problems due to a shortage of raw materials and manpower. According to the findings of a combined government/ICRC survey conducted in 1996, there are about 2,000 amputees in need of prostheses.

Achievements 1994–1999

• A survey of needs was conducted nation-wide.

• Physical rehabilitation services were provided for patients, who received 1,713 prostheses (amputees) and 307 orthoses (other beneficiaries).

• The premises were renovated, new equipment was installed and a patient dormitory was set up.

• Continued training was provided for 17 technical staff.

Achievements 2000

• Physical rehabilitation services were provided for patients, who received 477 prostheses and 51 orthoses (22% of the fitted amputees were mine victims).

• After simultaneously working and taking part in a training course for nearly two years, seven students were awarded the ICRC Certificate of Professional Competency in Prosthetics in September 2000. The ICRC/MOLASP certificate is also recognized by the Ministry of Education. A new salary scale was introduced to take the certificate into account, thereby showing strong backing for the programme by the authorities. Seven students who had already graduated continued the course for a supplementary third year with the aim of obtaining an ISPO Category II-level diploma. During the year, two visits were paid to the programme by external training consultants. The course could become a model for other programmes, wherever conditions allow.

• The accessibility and quality of rehabilitation services was improved through two outreach programmes in the Mingachevir and Lenkoran districts.

• After several meetings with the authorities, a new cooperation agreement was signed in November which included details of the future handover. As a first step, the partner accepted greater responsibility for managi ng prosthesis production and the dormitory.

• A database was introduced that facilitated patient management and follow-up.

Cambodia: Phnom Penh, Battambang, 1991-2000

Background

Cambodia has a very high number of mine victims. Since 1991, the ICRC has had an agreement with the Ministry of Social Affairs, Labour, Vocational Training and Youth Rehabilitation (MOSALVY) to assist the disabled population through a prosthetic/orthotic centre in Battambang and a national prosthetic/orthotic component production centre in Phnom Penh. These two programmes contribute significantly to the overall national effort in the area of physical rehabilitation, both in terms of the total number of patients they assist and by providing prosthetic/orthotic components free of charge to other centres.

Achievements 1991-1999

Phnom Penh:

• Prosthetic/orthotic components were manufactured and delivered free of charge to 15 non-ICRC centres assisted by such organizations as Veterans International, Handicap International, the American Red Cross, the Cambodia Trust and the Cambodia School of Prosthetics. During the year, the Phnom Penh workshop supplied these centres with some 5,000 prostheses, 2,000 orthoses and 4,000 pairs of crutches.

• Prosthetic/orthotic components were manufactured and delivered free of charge to the ICRC-assisted centre in Battambang. During the year, the Phnom Penh workshop supplied this centre with some 1,500 prostheses, 500 orthoses and 3,000 pairs of crutches.

• Renovation work was carried out on the premises, equipment was installed and a local production line developed.

• Continued training was provided for 28 technical staff.

• A high degree of self-sufficiency was achieved by the prosthetic/orthotic component production centre in Phnom Penh.

Battambang:

• hysical rehabilitation services were provided for patients, who received 11,082 prostheses and 642 orthoses.

• Construction work was carried out, new equipment was installed and a patient dormitory set up.

• Continued training was provided for 26 technical staff.

Achievements 2000

Phnom Penh:

• Component production was made more efficient by the manufacture of complete trans-femoral and trans-tibial prosthetic kits rather than separate components.

• Owing to a temporary lack of production capacity elsewhere, prosthetic kits were exported to five ICRC-assisted projects in Myanmar, Sri Lanka, Tajikistan, Sudan and Kenya and to another project in Laos.

• The national factory manager took over the responsibility for production planning and for MOSALVY staff management.

Battambang:

• Physical rehabilitation services were provided for patients, who received 1,295 prostheses and 480 orthoses (over 90% of the fitted amputees were mine victims). A fitting programme was started up in the last Khmer Rouge stronghold, Along Veng, where 361 amputees were seen by the ICRC and 316 were fitted. Since the conflict e nded in 1998, mine injuries have become less frequent but have by no means ceased. Between January and October 2000, 686 mine casualties were reported (26% were amputees), representing a 25% decline as compared with the same period in 1999. The northern and north-western parts of the country, including Battambang, remain the areas most affected by mine injuries.

• Twenty-one repair trips to the field were organized in Battambang province and two in Samrong province, resulting in 730 prosthetic repairs and 9 wheelchair repairs carried out on site. These repair trips are much appreciated by the patients (they travel less and repair time is shorter) and the Battambang staff (the service is more cost effective). Another improvement was the assignment of a prosthetist to the physiotherapy service on a weekly rotational basis, to assist staff in checking socket fits and alignment devices and in carrying out assessments.

• The MOSALVY was restructuring the physical rehabilitation services at national level and new statutes were prepared for the Battambang prosthetic/orthotic centre, which could may on a regional role in the future.

• Since 1994, the ICRC has sent six students to the Cambodia School for Prosthetics and Orthotics (CSPO), which is managed and operated by the British non-governmental organization Cambodia Trust, for a three-year formal training course. All have now successfully passed the exams and have returned to the prosthetic/orthotic centre.

Democratic Republic of the Congo: Kinshasa, 1998–2000

Background

The only functioning prosthetic/orthotic facility in Kinshasa capable of producing prostheses in significant numbers is the centre run by the Red Cross Society of the Democratic Republic of the Congo. During the year, the centre became more efficient following modifications to the main building, the installation of equipment, and the streamlining of patient intake and treatment. The centre has registered 500 amputees, of whom nearly 300 have received prostheses. Transportation was a problem both for patients in town and for those from surrounding areas. At the end of the year the focus was on improving patient care and upgrading the quality of the prostheses.

Achievements 1998–1999

• Physical rehabilitation services were provided for patients, who received 159 prostheses and two orthoses.

• The premises were renovated and new equipment was installed.

• Continued training was provided for technical staff.

Achievements 2000

• Physical rehabilitation services were provided for patients, who received 245 prostheses and 19 orthoses.

• Continued training was provided for five technical staff.

Ethiopia: Addis Ababa, Mekele, Harar, Desse, 1979–1995 and 2000

Background

Since 1979, the ICRC has helped set up and provided assistance for prosthetic/orthotic centres in Debre Zeit, Addis Ababa, Harar and Mekele. The assistance programme ended in 1995 with the stabilization of the social and political situation, although monitoring of the centres continued. The centres also still received some assistance from the ICRC’s Special Fund for the Disabled, which maintained its presence in Addis Ababa with a regional prosthetic/orthotic training and follow-up centre. Following the outbreak of war between Ethiopia and Eritrea, facilities were overwhelmed by patients requiring health services, including physical rehabilitation. As a result, the ICRC resumed its assistance programme for the prosthetic/orthotic centres. Working through a patient services support system, the ICRC partially subsidizes running costs while the centres retain managerial and operational control. The costs for services provided to patients, such as the provision of orthopaedic appliances, physiotherapy, transportation, accommodation and food, are partly reimbursed by the ICRC, which monitors the quality of those services, technical instructions and the patient filing system.

Achievements 1979-1995

• Physical rehabilitation services were provided for patients, who received 7,366 prostheses (amputees) and 2,756 orthoses (other beneficiaries).

• The premises were renovated and new equipment was installed.

• Continued training was provided for technical staff

Achievements 2000

• Physical rehabilitation services were provided for patients, who received 1,252 prostheses and 1,100 orthoses (50% of the fitted amputees were mine victims).

• During the year, successive patient support service agreements were prepared and signed with different partners in Mekele, Addis Ababa, Desse and Harar. Monthly monitoring visits were paid to the different centres and on-the-job refresher courses provided. Plans were made to send technicians on a three-year orthopaedic training course in Moshi, Tanzania, to improve the quality of the services provided. These plans await government approval.

• The production of prosthetic components in Addis Ababa was progressively scaled back and replaced by imported standard quality CR-Equipements components.

Georgia: Tbilisi, Gagra , 1995-2000

Background

Owing to a lack of financial investment, in-depth reforms and proper training for medical staff, the health-care system has been rapidly disintegrating. In cooperation with the local authorities, the ICRC has provided assistance for the disabled through two prosthetic/orthotic centres in Tbilisi and Gagra, Abkhazia, since 1995. These are the only centres available to treat those in need of physical rehabi litation. Given the financial difficulties faced by the partner and the patients, their running costs are largely subsidized by the ICRC.

Two main activities are carried out at the centres: treatment for the physically disabled (amputees and others) and a training programme lasting several years for technical staff.

Achievements 1995-1999

• Physical rehabilitation services were provided for patients, who received 2,639 prostheses (amputees) and 433 orthoses (other beneficiaries).

• The premises were renovated, new equipment was installed and a patient dormitory was set up.

• Continued training was provided for 25 technical staff.

Achievements 2000

• Physical rehabilitation services were provided for patients, who received 558 prostheses and 320 orthoses (20% of the fitted amputees were mine victims). The introduction in February of knee and foot components from CR-Equipements significantly raised the perceived quality of polypropylene prostheses but it was too early to draw any conclusions regarding increased lifespan. Upper-limb prostheses were manufactured with Russian components combined with polypropylene technology. Access to treatment improved for patients in the Gali region thanks to the outreach programme based in Gagra. Seventeen amputees were fitted with prostheses.

• After attending a training course for nearly two years , eight students in Tbilisi and six students in Gagra successfully passed the exams leading to the ICRC Certificate of Professional Competency. The ICRC/Ministry of Health (MOH) certificate is recognized by the MOH. Six graduate students in Tbilisi continued the course for a complementary third year leading to the ISPO Category II level diploma. In 2000, the programme received two visits by external training consultants. Wherever conditions allow, the course could become a model for other programmes.

• The centre's national director, a medical doctor, attended a four-week physical rehabilitation course organized by the Rehabilitation Department of the University Hospital in Groningen, Netherlands.

• A summary report on the previous five years of activities was drawn up and led to in-depth discussions with the Georgian authorities and the signing of a new cooperation agreement. Soon afterwards, technical and managerial responsibilities at the Gagra centre were handed over to the local partner.

Iraq: Baghdad (MOH), Baghdad (MOD), Basra, Najef, Mosul, Arbil, 1993-2000

Background

Unlike the majority of ICRC-assisted countries, in the past Iraq was a wealthy nation with a well-funded health-care system that included prosthetic/orthotic services. A decade of sanctions has had severe consequences. The ICRC’s programme in the country, begun in 1993, aims to provide the technology necessary to continue providin g prosthetic care. It supports six prosthetic/orthotic centres (two in Baghdad and one each in Basra, Najef, Mosul and Arbil) and the Baghdad Prosthetic/Orthotic School. These projects involve agreements with five different partners. The ICRC also supervises a local component production facility.

Achievements 1993-1999

• Physical rehabilitation services were provided for patients, who received 10,595 prostheses (amputees) and 6,410 orthoses (other beneficiaries).

• The premises were renovated and new equipment was installed.

• Continued training was provided for 150 technical staff

Achievements 2000

• Physical rehabilitation services were provided for patients, who received 2,807 prostheses and 1,446 orthoses (53% of the fitted amputees were mine victims). In 2000 the government managed to import some prosthetic/orthotic components from Europe under the oil-for-food programme. These are being used in a number of centres in addition to the ICRC’s polypropylene components (criteria for use are being developed). However, time-consuming government import procedures make it difficult to ensure a reliable supply.

• Physiotherapy facilities and gait-training areas were set up or upgraded in all assisted centres with a view to improving the quality of the clinical services provided. A travelling physiotherapist visited all the centres to provide follow-up training and or ganizational advice. A physiotherapy handbook, including basic treatment guidelines for projects, was compiled.

• Four national seminars were conducted jointly with the Ministry of Higher Education. These dealt with physiotherapy for lower-limb prostheses, partial foot prostheses, Symes prostheses and cast-taking and fitting techniques for short stumps. A meeting for the directors of all the prosthetic/orthotic centres was organized to allow for an exchange information and discussion of quality control.

• Two expatriate positions were taken over by local staff and two local staff were sent abroad to attend a one-week congress on physical rehabilitation.

• A constructive relationship could be built up with a number of newly appointed contacts at the MOH. The Under-Secretary of Health visited one of the assisted centres in Baghdad and a Steering Group for Prosthetic/Orthotic Services was set up to establish quality guidelines and address other issues.

Kenya: Lokichokio, 1992-2000

Background

Amputees and other disabled people from the rebel-held areas in southern Sudan have been undergoing physical rehabilitation since 1992 at the ICRC’s hospital in Lopiding and its sister prosthetic/orthotic centre across the Kenyan border in Lokichokio. As it mainly serves patients from across the border, the centre is fully run and managed by the ICRC. The expatriate prosthetist working there was withdrawn in 1998 but returned after a few months to deal with irregularities and malfunctioning.

Achievements 1992-1999

• Physical rehabilitation services were provided for patients, who received 2,107 prostheses for (amputees) and 1,257 orthoses (other beneficiaries).

• New premises were built and equipment installed.

• Continued training of eight technical staff

Achievements 2000

• Physical rehabilitation services were provided for patients, who received 348 prostheses and 160 orthoses (22% of the fitted amputees were mine victims). The number of patients fitted in 2000 decreased owing to an outbreak of the Ebola virus in northern Uganda, which limited travel.

• In August two technicians followed a one-month course in prosthetics at the regional centre of the Special Fund for the Disabled in Addis Ababa, Ethiopia.

• Four technicians from southern Sudan received training in prosthetic repairs at Lokichokio and were given tool boxes and raw materials. Feedback from decentralized repair centres remains problematic.

• Weekly two-hour interactive training sessions were provided for eight technical staff.

Myanmar: Yangon (2x), Mandalay, Maymyo, Yenanthar, 1986-1995 and 1999-2000

Background

There are many mine victims and other amputees in Myanmar. Conservative estimates put their number at 6,000. The majority live in border areas and most cannot afford to travel to existing workshops.

The ICRC started its physical rehabilitation assistance programme in Myanmar in 1986, together with the Ministry of Health (MOH). The following year it began to cooperate with the Ministry of Defense (MOD). In 1990, a joint programme was set up with the Myanmar Red Cross Society (MRCS) to identify and provide transportation for patients. In 1995, the ICRC withdrew its full-time staff but kept on monitoring the situation through periodic technical follow-up visits from Cambodia. The fitting of amputees continued through the joint programme, but on a smaller scale. Under the programme, the MRCS identifies and refers amputees while the ICRC funds transportation, lodging and food for them during the time needed for fitting. The ICRC resumed its assistance programme with a full-time expatriate prosthetist in June 1999 so as to increase the quality of care and the number of patients being treated.

Achievements 1986-1995 and 1999

• Physical rehabilitation services were provided for patients, who received 10,511 prostheses and 2,624 orthoses.

• The premises were renovated, new equipment was installed and a patient dormitory was set up.

• Continued training was provided for technical staff.

Achievements 2000

• Physical rehabilitation services and prosthetic/orthotic appliances were provided for 907 amputees (55% of whom were mine victims). During the year, the number of patients referred increased and production more than doubled compared with the previous year (1999: 385 prostheses). However, there is still room for improvement in terms of the quality of prosthetic fitting.

• Four candidates were selected and sponsored for the three-year CSPO training course in Phnom Penh and two technicians attended a one-month training course in Addis Ababa. On-the-job training continued and a covered training area was built.

• A hydraulic injection press was installed and adapted for the local production of elbow crutches (production will start next year).

Sri Lanka: Jaffna, 1999-2000

Background

The long-standing conflict in Sri Lanka has left many people disabled, most of them mine victims. In 1998 the ICRC carried out an assessment of needs and the following year it started up an assistance programme for the Friends in Need Society Centre in Jaffna, the only existing prosthetic/orthotic facility on the peninsula. Delays of 6-9 months in the supply of materials owing to the security situation hampered the initial stages of the programme.

Achievements 1999

• Physical rehabilitation services were provided for patients, who received 141 prostheses and 19 orthoses.

• The premises were renovated and new equipment installed.

• Continued training was provided for technical staff.

Achievements 2000

• Physical rehabilitation services were provided for patients, who received 207 prostheses and 19 orthoses (58% of the fitted amputees were mine victims). There were several interruptions in production and the centre had to be moved twice during the year because of heavy fighting. Training in polypropylene prosthetic production continued for two technicians. The majority of prostheses were made using traditional aluminium technology. The Jaipur foot was experimentally joined with a polypropylene prosthesis, but the technique required improvements.

Sudan: Khartoum 1990-1996 and 1999-2000

Background

The ICRC, which supported the government prosthetic/orthotic centre in Khartoum from 1990 to mid-1996, resumed its assistance in early 1999. During the interval of two and a half years , the centre received periodic follow-up visits under the Special Fund for the Disabled programme. Early on, the visits demonstrated the need for full-time ICRC involvement in the centre to offset a rapid deterioration in the quality of patient care, prosthetic fitting and orthopaedic components. This was partly owing to the departure of half the ICRC-trained technicians. In addition, the building and the layout of the different sections were in need of improvement.

Achievements 1990-1996 and 1999

• Physical rehabilitation services were provided for patients, who received 6,585 prostheses and 1,485 orthoses.

• The premises were renovated and new equipment installed.

• Continued training was provided for 43 technical staff.

Achievements 2000

• Physical rehabilitation services were provided for patients, who received 767 prostheses and 513 orthoses. This represents an increase of 44% (amputees) and 204% (other disabled patients) as compared with 1999, an increase that is attributable to better organization following the completion of renovations to the premises and the introduction of an incentive system for local staff. By the end of the year, arrangements had been made to transport patients from Wau (southern Sudan) to Khartoum for fitting.

• Two-week training courses, one in the production of trans-femoral prostheses and the other in physiotherapy, were organized for local staff in the prosthetic/orthotic centre in Juba. This centre is assisted by an NGO, the Norwegian Association for the Disabled, and receives prosthetic components from the centre in Khartoum.

• Continued on-the-job training, especially in the field of orthotics, was provided for 43 local staff. Physiotherapy treatment improved thanks to weekly training sessions for the local staff in Khartoum.

• Renovation work on the premises was completed in April.

• A new three-year cooperation agreement was signed with the authorities in April.

Tajikistan: Dushanbe, 1997-2000

Background

Following the breaking apart of the USSR, the existing prosthetic workshops in Dushanbe and Khojent were deprived of the materials and financial means they required to go on functioning. After initial surveys conducted by the ICRC in 1997 revealed substantial unmet needs (concerning an estimated 3,000 amputees, including 500 war-wounded), a tripartite agreement was signed in March 1998 between the Ministry of Social Protection (MSP), the Red Crescent Society of Tajikistan (RCST) and the ICRC. As with similar projects, the long-term aims are twofold: to provide correct fitting of prostheses for all amputees so as to facilitate their reintegration into normal life and to ensure the future autonomy of the centre under the management of the local authorities. The project was delegated to the Canadian Red Cross.

Achievements 1997-1999

• Physical rehabilitation services were provided for patients, who received 200 prostheses.

• Training workshops focusing on dissemination and the registration of amputees were organized together with the RCST.

• The premises were renovated, new equipment was installed and a patient dormitory was set up.

• Continued training was provided for technical staff.

Achievements 2000

• Physical rehabilitation services were provided for patients, who received 397 prostheses. Six orthopaedic seminars attended by 208 participants were organized together with the RCST and the Ministry of Social Protection (MSP) on the subject of patient data collection (criteria, listing, referral, follow-up). Of an estimated maximum of 3,000 amputees, 728 are listed in the centre’s database. All patients were provided with one free meal a day at the centre by the TRCS and patients from outside Dushanbe were accommodated by the MSP. Limited material assistance was extended to peripheral centres in Khojent, Kulob and Khorog for the repair and maintenance of prostheses made with traditional Russian technology.

• A physiotherapy room with indoor and outdoor treatment facilities was set up, training was provided and a study manual was handed out.

• Continued technical training was given to the centre’s staff and staff from peripheral centres (in prosthetic repairs and maintenance).

Uganda: Fort Portal, Gulu, Mbarara, 1988-1990 and 1998-2000

Background

Between 1988 and 1990, the Mulago centre in Kampala was supported by the ICRC. In consultation with the Ministry of Health (MOH), and following a survey at the end of 1997, the ICRC resumed its assistance programme in Uganda in the smaller MOH prosthetic/orthotic centre in Fort Portal in January 1998. An agreement was signed with the Ministry of Health in July 1998 to provide assistance for the disabled population of the western region, using appropriate technology. ICRC support was gradually extended to other MOH prosthetic/orthotic centres like Gulu and Mbarara.

Achievements 1988-1990 and 1998-1999

• Physical rehabilitation services were provided for patients, who received 402 prostheses and 537 orthoses.

• The premises were renovated and new equipment installed.

• Continued training was provided for 15 technical staff

Achievements 2000

• Physical rehabilitation services were pr ovided for patients, who received 217 prostheses and 119 orthoses (36% of the fitted amputees were mine victims). The number of assisted patients was lower than expected, partly because of an outbreak of the Ebola virus in September. Monitoring was carried out to check the quality of production in prosthetic/orthotic centres in Fort Portal, Mbarara and Gulu. The centre in Gulu is assisted by an Italian NGO, AVSI, which has special expertise in physiotherapy services.

• The authorities provided accommodation in Mbarara for amputees during their fitting.

• The MOH Disability and Rehabilitation Office organized a national orthopaedic workshop/seminar.

• An increase in military patients at the Fort Portal centre prompted the MOD to study the possibility of setting up a separate military prosthetic/orthotic centre elsewhere (possibly in Mubende).

• Two staff of the Mbarara prosthetic/orthotic centre received training in polypropylene prosthetic production methods at the Fort Portal centre and on-the-spot training was provided for other technical staff in Mbarara. Polypropylene production started in March.

Annexes

Annexe 1

Geographical distribution 2000

Annexe 2

Annexe 3

Annexe 4