Comments of the community-based rehabilitation Africa network regarding the special report from the international rehabilitation forum
Sally Hartley, Siphokazi Gcaza, Barbara Batesaki , Peter Ngomwa, Zamo Soumana, Phitalis Were, Daniel Tsengu, Peter Obeng Asamoa, Andre Zinga Nkula, Joan Okune, Grace Musoke
We would like to comment on the paper by Haig et al. (1) on behalf of the Community Based Rehabilitation Africa Network (CAN). We are the Executive Committee of that organization and are from 7 different sub-Saharan African countries. We currently represent 281 community-based rehabilitation (CBR) programmes from 27 countries in Africa.
We agree wholeheartedly that services and support for people with disabilities and their families in Africa need more resources and provision, and that services and support are best rendered by multi-disciplinary teams. We would, however, argue that these teams should have a much wider membership than indicated in Haig et al.’s article and, importantly, that they should always respectfully include disabled people and their family members as major players. There are a number of other issues in this article that also raise our concern, as follows:
• The article uses a narrow and outdated conceptualization of disability, which focuses on “impaired body structure and functioning” (2) and reflects a charity/medical model
approach rather than the rights-based approach of the United Nations Convention on the Rights of Disabled Persons (UNCRPD) (3).
• Linked to this is an equally limited view and understanding of CBR, which seems to ignore the extensive body of work that exists about the nature and development of CBR (4, 5) and fails to make the distinction between physical medicine and the various different rehabilitation specialisms. Contrary to the perceptions communicated in this article, CBR does not seek to deliver specialist “physical medicine” services, but rather to facilitate referral to such services when appropriate and lobby for them where they do not exist. CBR also seeks to promote access to existing mainstream services such as education, employment, and mainstream health services, and to exercise positive influence on the social and contextual aspects of disablement (6).
• We cannot see anything to be gained by comparing people with disabilities in Africa to penguins in other parts of the world.
• It may be true that there are very few physiatrists in Africa, but this does not mean that 78 million people with disabilities in sub-Saharan Africa are un-served; there are other stakeholders in this multi-disciplinary endeavour who are working together to make a difference. For example, many African governments have ratified the UNCRPD and have policies in place to support provision of service development for disabled persons. In Malawi, for example, disability has been recognized as a cross-cutting issue and a special “Ministry
of Social Development and People with Disabilities” has been created, through which the national policy on the equalization of opportunities for people with disabilities is administered. Malawi runs a national CBR programme with 5 components: health, education, social, livelihood and empowerment. This is because Malawi looks at people with disabilities holistically and not just from the health perspective alone (http://www.fedoma.org/). Kenya has a Disability Act that waives the pay-as-you-earn (PAYE) tax for some disabled groups, requires 5% of employment opportunities to be offered to disabled people, and has a National Disability Fund of 200 million shillings per annum to support people with disabilities who cannot work (http://www.nfdk.or.ke/).
• Given the above evidence we would like to suggest that the low response to the survey reported in this paper is more likely to be an indication that this method of data collection was inappropriate for the task, rather than evidence that there is nothing happening to improve disabled people’s lives.
• We recognize and appreciate the advanced technical ability and power of physiatry as a potentially major player in seeking to improve disabled people’s lives, but we are concerned that the article does not reflect respect and understanding for the value of other roles; an understanding that no one group can have all the answers to the multi-dimensional and dynamic challenges faced by people with disabilities (7). If the aim of the article was only to examine physiatry then it would have been wise to omit rehabilitation from the title and aims.
• The fact that physiatry is practised and takes a leading rehabilitation role in other parts of the world is not, in our view, a convincing argument for doing something similar in African countries, where the cultural context is so different, and when no evidence-base exists to support such action.
• We acknowledge that multi-disciplinary teams need leaders, but we are not convinced that this role would be best taken by physiatrists. It is our view that the leader of such a group needs to understand and appreciate the role and value of all the players. We do not find this understanding demonstrated in this paper.
• It is our perception that people in Africa have adopted CBR because of its appropriateness to local cultural conditions and situations. It is not true that CBR has been adopted because of lack of funds. CBR is not cheap, but rather a potentially cost-effective way of assisting the majority of disabled persons (8, 9).
We would like publically to support the World Health Organization (WHO) policy of CBR as we feel that this
approach embraces the diverse nature of disability and promotes a strategy that is democratic and empowering. We
acknowledge that much work still needs to be done to improve CBR training, implementation and evaluation, but would like to invite physiatrists and other interested parties reading this to become active members of the Community Based Rehabilitation Africa Network (CAN) (www.afri-can.org), so that with their additional expertise we have more chance of achieving this.
We encourage interested parties to facilitate the development of the multi-disciplinary and multi-sectorial teams required to make sure that we all come together with disabled people and their families to help make better lives for us all, lives lived amongst people who offer respect, understanding and inclusive practices, where opportunities are provided for promoting productive lives that are appreciated, valued and have less pain and suffering.