FINAL REPORT
Assessment of the Project
‘Setting up a Community Based Rehabilitation model for children and adults
affected by the polio outbreak and other children with physical disabilities’ in
Tajikistan
Submitted by Sue Mackey
UNICEF, Tajikistan
November 2011
1
This report has been commissioned by UNICEF Tajikistan to Sue Mackey, and individual consultant
on disabilities.
(REF. NO.SSA/TADA/2011/00000943)
The opinions expressed in this report are those of the author and do not necessarily reflect the policies
or views of UNICEF or its partners. The text has not been edited to official publication standards and
UNICEF accepts no responsibility for errors.
Extracts from this report may be freely reproduced with due acknowledgement.
For more information, please contact dushanbe@unicef.org
Cover Illustration: This picture hangs in the Kishti Early Years Centre at Baby Home 1 in Dushanbe.
The Kishti Centre is run by Ishtirok (Disabled Women’s League) in partnership with HealthProm.
2
Table of contents
Summary of Findings
3
1) Introduction/ background
7
2) Methodology
7
3) Findings
8
4) Effectiveness, Efficiency, Sustainability
23
5) Conclusions
27
6) Recommendations
27
7) Annexes
31
1.
2.
3.
4.
5.
6.
List of persons interviewed
List of documents reviewed
Final timetables
Topic guides used for data collection
Consent Form
CBR Project Log Frame
Acronyms and Terms
UNICEF - United Nations Children’s Fund
CBR
- Community Based Rehabilitation
PMPCC - Psychological Medical Pedagogical Consultation Centre
MoH
- Ministry of Health
MoE
- Ministry of Education
MLSP - Ministry of Social Protection and Labour
INGOs - International Non-Governmental Organisations
HI
- Handicap International
OpM - Operation Mercy
OPM
- Oxford Policy Management
NOC
- National Orthopaedic Centre
WHO - World Health Organization
WASH - Water, Sanitation and Hygiene
CWD
- Children with disability
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Summary of Findings
Introduction:
Following the Polio Outbreak of 2010, UNICEF in partnership with the Ministry of Health
and together with Operation Mercy and Handicap International initiated a Community Based
Rehabilitation Project for those affected by the polio outbreak and other children with
physical disabilities in the 24 most afflicted districts. The project had two main objectives: 1)
Persons affected by polio paralysis get quality physical rehabilitation services to decrease the
disabling outcome of the disease and are accepted into mainstream society; 2) Polio
rehabilitation is used as an example for inclusive community-based development of services
for people with disabilities; reducing barriers to access to local education, social and health
care for all children with disabilities.
The project has been led by the Ministry of Health (MoH) from the Government side, with the
involvement of the Ministry of Labour and Social Protection (MoLSP) as well as Ministry of
Education (MoE). The project has been implemented since June 2010, and will end on 31
December 2011.
Methods:
The methodology for collecting and analysing data for the research was mainly qualitative but
also included quantitative information from the progress reports, monitoring-mentoring data
and from the records of the concerned parties implementing the project. Qualitative
approaches included semi-structured interviews, focus group discussions and observations
made during the filed site visits.
Conclusions on the Findings:
The requested format for presenting the findings was to use the ‘Planned Results and
Activities’ structure of the project log frame (see Appendix 6). Thus the ‘Expected Results’
are highlighted in numerical sequence, together with the findings and lessons learnt from the
evaluation reported under each section.
The overall conclusion of the findings was that a considerable amount of work has been
accomplished in the short 15 months duration of this project to achieve the expected results
and activities to a large degree. The project was ambitious in scope and in the number of
target groups it sought to reach, across different sectors. A number of significant
achievements have been made in reaching the majority of affected children and young adults
with polio needing rehabilitation and assistive devices, as well as other children with physical
disabilities.
The intended number of trainings and educational material were completed and most of the
Support Rooms established and equipped. A weaker aspect has been in the adaptation and
inclusion work in schools. Entrance ramps were constructed just in Khatlon at the time of this
assessment, whilst other environmental barriers remained throughout the target schools. There
are mixed results in fitting the relevant orthotics and mobility aids. Although most of the
children with polio listed did receive their orthosis eventually, the delay had caused
contractures to develop or children had already grown out of them. The system for referral
and provision of other mobility aids such as wheelchairs, walkers and crutches did not always
work effectively, and much work needs to be done together with Government departments to
improve the referral process.
4
Although a large number of mid-level Government health, education and social workers
attended up to three training workshops, their level of skills is not sufficient at this stage to
deliver quality rehabilitation services. They lack the necessary training, skilled supervision
and the programme stayed mainly at district level. More work needs to be done to increase
coverage to reach families at village level. There was universal appreciation and enthusiasm
from all sections of the Government, from ministerial to district levels about the work
accomplished by the CBR project. It has raised awareness and encouraged inter-sectorial
approaches, which is quite an achievement in such a short space of time.
The project activities had targeted three of the five main areas of CBR, namely; health,
education and social sectors in response to an emergency polio outbreak. Areas of livelihoods
and empowerment were beyond the scope of this project. The possibilities and potential of
CBR has been demonstrated and a window has been opened. It is important now to build on
this and not to lose the momentum that has been reached.
Recommendations
(abridged – see full version in the relevant 'Recommendations section at the end of the report)
1. Capacity building of rehabilitation professionals:
a) More qualified professionals such as; physiotherapists, occupational therapists,
orthotists, preferably with paediatric experience are needed to work alongside
Government workers, until these professions are upgraded within Tajikistan, to include
community paediatric rehabilitation skills.
b) The type of training required varies from degree level therapists, to a 6-12 month model
of child developmental therapist training,1 to a 3 month CBR mid-level worker training
model.
c) Exchanges within country to good models of child therapy practice would be very helpful
as well as exchanges to other countries in the region from policy makers to CBR project
workers.
2. Strengthening Rehabilitation systems:
a) Home visits are currently not sufficient to reach villages and the majority of parents
do not manage to attend support rooms regularly. A more systematic, coordinated
approach between the different sectors would help to cover the gaps more.
b) National Orthopaedic Workshop is a crucial resource for physical rehabilitation but
needs strengthening at all levels, including management as well as technical skills. An
overseas orthotic expert will continue to be needed periodically.
c) A system for referral, fitting, distribution and review of assistive devices should be
drawn up by all parties involved in these processes, with simple flow charts.
1
Child developmental therapy is a practical course, that entails aspects of occupational, physiotherapy, speech
and language, early development and play therapy, designed in a number of places in India to bridge the
paediatric skill gap, especially for working with chronic disabilities such as cerebral palsy children.
5
d) Ideally the four regional orthopaedic workshops could be strengthened to become
more autonomous and better serve the population in the districts.
e) The mobile clinic should have increased capacity to cover more districts and where
necessary stay longer to complete fitting as well as measurements.
f) Wheel chair supply is inadequate and does not meet the needs of younger children.
Changes are needed in the type of wheelchairs currently imported, together with
trained staff who know how to assess and measure children correctly. An alternative
method of assembling wheelchairs in country could help to alleviate the problem.
3. Community Outreach
a) Support room staff need further paediatric training so the rooms could start to
function more on a child development model, with group activities where parents
have greater involvement in their child’s rehabilitation.
b) More children with other types of disability should be identified and encouraged to
attend. The majority of these conditions are likely to be cerebral palsy and intellectual
delay, with long term chronic and complex needs, so staff will need specific training
on how to work with these type of children.
c) Community support needs to be strengthened as most families are not receiving
services at village level. In the short term, this could be provided by the CBR Support
Groups, but a longer term project would be to strengthen and develop more parents’
self-help groups.
4. Inclusion and Schools
a) School adaptation – more than a ramp. In future, sufficient funding should be
available to make at least target schools properly accessible and adapt not just the
front entrance ramp but other areas in schools like classrooms, doorways and toilets
etc.
b) The sanitation in both the schools and health centres we visited in the project sites was
very poor. WASH projects are desperately needed across the project areas and
probably the whole country.
c) Inclusive Education resources are freely available from the internet and these could
be downloaded and distributed to bridge the gap until more training is available to
teachers. As most are in English, they would need translating and some adaptation
first.
5. POVERTY was the most common problem cited for families of children with
disability and large numbers require social assistance, so the role of social workers
should be recognised more in CBR programmes
6. Involvement of DPOs in future initiatives is important to alleviate poverty in the long
term, if they can be empowered to foster community development and include parents
of children with disabilities.
6
7. A National Rehabilitation Plan and Joint Working Groups for rehabilitation
across sectors are essential for future cohesive development, involving the three key
Government sectors of health, education and social protection, as well as UN agencies
and INGOS.
8. CBR Network to be strengthened nationally so that the various CBR actors in
Tajikistan coordinate their efforts and share expertise more. In the longer term, this
CBR network could expand to include national stakeholders such as local NGOs,
DPOs, and Associations of Parents who have children with disabilities, as well as
government agencies in order to promote wider community development.
……………………………………………………
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1) Introduction/ Background
Following the Polio Outbreak of 2010, UNICEF in partnership with the Ministry of Health
and together with Operation Mercy and Handicap International initiated a Community Based
Rehabilitation Project for those affected by the polio outbreak and other children with
physical disabilities in the 24 most afflicted districts. The project had two main objectives: 1)
Persons affected by polio paralysis get quality physical rehabilitation services to decrease the
disabling outcome of the disease and are accepted into mainstream society; 2) Polio
rehabilitation is used as an example for inclusive community-based development of services
for people with disabilities; reducing barriers to access to local education, social and health
care for all children with disabilities.
The project has been led by the Ministry of Health (MoH) from the Government side, with the
involvement of the Ministry of Labour and Social Protection (MoLSP) as well as Ministry of
Education (MoE). The project has been implemented since June 2010, and will end on 31
December 2011.
The project partners wanted to document the experience gained, learn from the achievements
and shortcomings, understand the reasons behind them, and to build on them to ensure
sustainability and future scale up of the model. This external assessment was foreseen from
the beginning of the project to feed into the policy dialogue towards a national CBR plan with
the Ministry of Health and the Ministry of Labour and Social Protection as well as
contributing to a lesser degree to the implementation of the new Inclusive Education policy by
the Ministry of Education.
2) Methodology
The method for collecting and analysing data for the research was mainly qualitative but also
included quantitative information from the progress reports, monitoring-mentoring data and
from the records of the concerned parties implementing the project.
Data collection methods included:

Desk research: An analysis of available information: Project proposal, results
framework, publications made during the project, progress and monitoring-mentoring
reports, etc. (see list of documents reviewed in Annex 2)

Field observations: Site visits were made to selected locations in the two CBR
project target regions, where two different INGOs were the implementing agencies:
Operation mercy in the DRD and Handicap International Federation in Khatlon. In
addition, since the DRD and Khatlon Regions differ in their governance structure, and
the availability of various resources, two sites from each region were chosen.

Interviews and focus group discussion with key informants: A combination of semistructured interviews and focus group discussion were held with key informants in
collaboration with UNICEF and its implementing partners. Five Topic Guides were
designed for the separate groups of: Government Ministries, INGOs, CBR project
workers, parents, children (see Annex 4). The main groups covered are listed below:
8
o Key informants from relevant agencies/partners
o Government Ministries; Health, Education, MLSP at both national & district
levels
o Project management staff from UNICEF, Operation Mercy, Handicap
International
o Project field staff & CBR activities.
o Rehabilitation centres - support rooms, orthotic workshops
o Children and families
o Community stakeholders – DPOs, social networks
o School staff & children where children have been included

A consent form was drawn up and translated into Tajik so that respondents could be
informed of the project purpose, confidentiality and their withdrawal at any stage
without adverse effects to their services. Written consent was obtained before focus
group discussions and for permission to take photographs (see Annex 5).

Interviews were held with focal persons from the three line Ministries (MoH, MoE,
MLSP), local authorities, selected staff of the support groups and selected participants
at the trainings. To ensure voices of the beneficiaries were heard, parents and children
were also interviewed whenever possible, either in a focus group setting or
individually. (see list of persons interviewed in Annex 1)

Sampling: Some randomisation where possible was planned to take into account
balance of: gender, geographical location (urban / rural), age bands, length of time
services initiated. However, given the natural field setting, time frame and logistics,
for the most part the sampling was opportunistic and purposeful, but did take into
account all of the criteria planned.

Observations: took place in the following settings:
o Support rooms
o Family homes
o Schools
o Orthotic workshop-Dushanbe
3) Findings
Following the evaluation feedback session at UNICEF, the requested format for presenting
the findings was to use the ‘Planned Results and Activities’ structure of the project log frame
(see Appendix 6). Thus the ‘Expected Results’ will be highlighted in numerical sequence,
together with the findings and lessons learnt from the evaluation reported under each.
9
Result 1: The general population, and especially parents of children affected by polio or
AFP (acute flaccid paralysis), have access to correct information on the long-term effects
of polio and the correct rehabilitation
The activities carried out to meet this goal were to design a media/TV campaign and
educational materials. The scripts for the TV media campaign were completed some time ago
but gaining full agreements and permission from the various parties has delayed production.
Nevertheless, it is planned to broadcast the programme by the end of December this year.
The educational materials have been successfully developed with 50 posters and 6,000
brochures on managing polio distributed. These have been well received, with strong approval
expressed from the Ministry of Health (MoH).
The parents we met or visited appeared to understand how polio had affected their child and
had received the relevant information. This finding correlates with the summary of the first
Operation Mercy Monitoring and Mentoring report;
‘Overall parents and families effected by polio, the majority know the facts about polio and
work on physical exercise with their child” (dated April-June 2011).
However, not all parents had received the brochures and it was apparent that a number still
thought their child would regain normal muscle strength and fully recover again, hence there
was reluctance in some cases to accept orthoses or apply for a disability card. Although
parents had been taught exercises, it was questionable that they always understood and knew
how to apply them effectively, especially where techniques were new to project staff too.
The combined monitoring statistics from both Operation Mercy and Handicap International
collected over a period from March-June 2011, show that a large number of the general
population were targeted in the information campaign (see Table 1). However, the figures
included just 5 social workers. In addition, the knowledge of some of the community leaders
and teachers on general issues related to polio was said to be lacking.
Table 1 Combined Operation Mercy & Handicap International monitoring data
Population Group
Parents of child with disability
Health care workers
Community leaders
Parents of non-disabled children
School staff
Non-disabled children
Social workers
Total number
reached
329
291
196
788
484
3,152
5
The combined 1st and 2nd round monitoring report figures from Handicap International states
that in total 5,696 received information about polio. A comparison between the 1st and 2nd
rounds is made in the report stating;
10
“The comparison of data show that nearly the same percentage of parents in both monitoring periods
regularly doing exercises with their children, but their knowledge on polio and its sequels increased.
As a result parents and…. relatives less rely on taking medicine, injection or visiting local healer,
instead they prefer doing exercises and massage. Only 8% mentioned taking medicine as main
treatment for polio”.
Result 2: Acute level health workers directly dealing with affected families have basic
knowledge about CBR principles and range-of-movement exercises and can train others
Service providers had been trained and received information on polio and rehabilitation. They
were aware of basic rehabilitation techniques, particularly range of movement (ROM)
exercises and parents also had some idea too when asked to show us. In general, it still tended
to be passive treatments, massage and wax that was favoured by staff as they feel comfortable
and used to these. Rarely was there evidence of active, functional activities, except in the
Khatlon (Psychological, Medical, and Pedagogical Consultation Centres (PMPCC) visit,
where a VSO volunteer funded and placed there by UNICEF had been working alongside the
Centre staff for a year. Knowledge of correct orthoses was patchy and both health care
workers and some parents were not familiar with their use.
It was encouraging that health care workers were aware that CBR principles not only
involved medical treatments but that school and inclusion in the community in general were
important. That this message had been transmitted was apparent during interviews at all
levels, from Government officials to nurses in the support rooms.
Training in the community: Those relevant staff involved in the CBR project across health,
social protection and education sectors were all asked about undertaking this aspect and the
majority strongly replied in the affirmative. There was great variability in the process and
extent of training undertaken by them in the community, as it ranged from informally at
community events, during normal community work i.e. family doctors or nurses visiting
families, to formal training sessions at health facilities or school PTA meetings. Thus it is not
possible to give a definitive answer to the total number trained, but certainly the seeds of
increased CBR, disability knowledge and awareness had been sown in the community.
Result 3: Mid-level, district and community health workers, district and community
social workers, teachers and school directors, as well as Red Crescent volunteers2 gain
good knowledge of CBR principles and rehabilitation techniques to use with people
affected by polio
This training was completed by June 2011 with the district community training sessions and
two ‘training of trainers’ workshops (TOT 1 & TOT 2). The 45 two day seminars that were
planned and held, often needed to be shortened to 1 day for logistical and attendance factors.
However, the partner INGOs realised overall that the training was not enough, particularly
for social workers (staff of Social Assistance at Home Units), who were not reached in the
first year and many were not prepared for their new role of now working with children instead
of the elderly at home, which they started doing only since 2010. There is a great need for
2
The Red Crescent organisation pulled out of the project early on.
11
increased coverage as well as more training sessions, as the workshops were only 1-2 days
and participants largely did not come from a rehabilitation background.
The CBR project was strengthened through the Operation Mercy Tool Kit initiative, (flip
chart, posters, leaflets, doll etc.), which were successfully produced & distributed after
approval from the MoH and translation into Tajik. It was well accepted and proved to be very
useful. In addition, the WHO mid-level manual on working with cerebral palsy children was
translated into Tajik and shared with the support room CBR project workers.
The monitoring and mentoring aspects of this section of the project proved to be a complex
and challenging undertaking. It involved chiefly the district doctor-trainers who had attended
the TOT workshops. Seven districts were covered in DRD, whilst in Khatlon, this activity
was carried out in 15 districts by 15 district trainers, with the support of HI project manager
and a VSO physiotherapist, visiting 54 villages. An important issue is the subsequent
management of this data by the Government, how it will be collected, analysed and acted
upon in the future.
Most of the children live in remote areas where there is poor transportation, so that often only
two or three children could be visited in a day, or an overnight stay was needed. Consequently
it could take more than one visit to complete the process and frequently there might only be
one child listed in a village. Sometimes parents were not available or had refused to give
phone numbers (one person in DRD district thought he would be bothered every day). So it
proved to be a time consuming process, with the length of the monitoring depending on the
number of staff who could be utilised.
Although a MoH Regional Director noted that this monitoring work was part of the doctor’s
responsibility, and in theory there was a hospital ambulance or local authority vehicle that
could be made available, this was not generally the case on the ground. Therefore a budget
had to be set aside from the project to cover these costs. This could prove to be a barrier in the
future after the CBR project ends in December 2011.
Result 4: Creation of a structure of Mid-level disability, health and education workers –
family support.
The aim was to establish a child disability Support Room in each district, where staff from
health, education and social sectors could function as ‘mid-level’ disability, health and
education workers. Support Groups of key stakeholders would then be formed, usually of a
nurse, family doctor, social worker, teacher and parents. The support rooms would be
supplied with basic and locally available, child development equipment by Operation Mercy,
and provide a focus of support for families who had a child with disability. Mostly they were
situated in a health facility but other locations such as a special school for the hearing
impaired were also sought.
To a great extent these goals were achieved and the majority of those rooms and support staff
are in place. Space had been made available and Government staff allocated to support the
children who come. The intention was also to carry out home visits as it was mostly just the
parents living nearby or within an hour away who were attending.
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Part of the terms of reference for the project assessment field site visits was to make
observations and report notes on particular aspects relating to the Support Rooms related to
Expected Result (4). Hence in the following section, these aspects will be listed in turn with
the points to check in blue, together with the findings.
SUPPORT ROOMS
Have the support rooms been established? What are their functioning capacities?
Establishment of the support rooms is not quite 100% but as mentioned above, the majority
are established and equipped, with a varied functioning capacity. It is still early days as on the
DRD field visit, support rooms only started from July 2011 and in Khatlon, from around Oct
2011, where in Rumi, they had only ran on three Saturday mornings.
 Number of support rooms established
In DRD, 7/9 have been set up with the site location finalised in Rudaki, but one site further
North yet to be decided. In Khatlon, 11/13 district support rooms are established and two
other districts have a PMPCC structure which can function as a child development centre.
These have more rooms and child specialists, with more sophisticated equipment, already
supplied by UNICEF.
Alijon 2 years with polio attends Sharinav support room

Overall condition of rooms
Nice child friendly space, clean and appropriate,
well-chosen equipment. Some are quite small
which limits both number of children who can
attend as well as the range of activities.

Accessibility:
Most not accessible from outside as there are often
steep hospital steps and a long distance from the
front gate, but once on floor level the surface is level. The implementing INGOs and health
staff are aware of this issue, but as a first initiative only these spaces were available. Both
the Operation Mercy country director and some hospital doctors noted that in future they
hope that a more accessible place will be found. Toilets are usually situated far away and not
in good condition, though this is the case in most of the health facilities we visited.
 Available Equipment:
As noted above, basic, appropriate and useful equipment was purchased by Operation Mercy
e.g. (mat, therapy rolls, balls, table, chairs, toys, dolls etc.). Parents really liked the support
room and appreciated the space and equipment. Staff at all levels were also very enthusiastic
about the support rooms. It was a new concept for health centres/hospitals and the need for
families to have such a facility was recognised. They would like more equipment and the
suggestions ranged from basic drawing materials to computers and more sophisticated
rehabilitation machines.
13
 Operating hours, days and months, of the centres, etc.
This varied according to where the support rooms had been set up and the type of staff
involved e.g. in Guliston (Tues 8-5 & Sat 8-2), Sharinav (Weds 1-3 & Sat 11-1), Khuruzon
(Tues 8-5), Rumi was only open Saturday mornings, as the support room had only just
opened and people such as social workers, a nurse, two teachers and parents worked there on
a voluntary basis. In both Khatlon locations visited, the doctors also said parents “can come
any day of the week” but the VSO programme officer had noted during an interview in
Dushanbe, that this had caused problems at the PMPCC when no designated day or a
particular person were given.
 Availability for a long term CBR structure:
All support room centre staff and hospital authorities had no hesitation in endorsing the
continuation of the support rooms, so space should be available in the long term for CBR.
However, the momentum needs to be kept up in order to demonstrate the usefulness of such a
resource and the continuation of the service.
Staff usually covered the support room within their working week, and hospital managers and
Ministry officials did not see this as an issue. However, these staff, particularly nurses have
very low salaries and working at the support room may prevent them from earning money in
other practice. The increased participation of parents who are present anyway as a support
room resource could be explored and was already being used in Khatlon, Rumi.
 Allocated staff and children action plan:
There was some variability in the staff allocated and how they worked. A common pattern
(DRD) is a main doctor-trainer, a higher level paediatrician plus one or two nurses. In
Khatlon, Khurozon support room, there was a doctor-trainer, one paediatrician and two
nurses. When pressed to give an estimate of the time he spends there, the doctor thought
approximately 17% for the CBR project, although he often saw children at other times. The
nurses spend one whole day (Tuesday) of their three day working week for the support room.
The Rumi support room workers were; one nurse, three social workers, two teachers but as
mentioned, they worked only Saturday morning on a voluntary basis. However, the doctortrainer is very involved and active, also carrying out many home visits himself despite many
other duties.
Those doctor-trainers and nurses not attached to a designated support room, e.g. Rudaki may
face more difficulty monitoring or following up the children. On our visit, nurses were not
present at midday and the locations of the polio affected children were not known. Later
however we found the competent paediatrican who had originally completed the Polio
Assessment forms, who knew the families and visited with us. It appears that regular home
visits are not being carried out and the parents we visited were not aware of any educational
materials and one of the children was in need of orthoses.
Child Action Plan: This was not generally well defined or the concept understood. The Polio
Assessment forms were available but not always fully completed or accurate. There are
sections with comment boxes which were sometimes used on the second page, but usually
with only vague descriptions of ‘improved’, but without specific objectives or concrete
14
measurements. Other doctors used an exercise book or child health records to write comments
but they were not specific to rehabilitation treatment.
 Number of children and parents they reach, the cost of setting up and maintaining
each room, etc.
Commonly about five children with disabilities were seen weekly and on our visits in DRD
there were around three children present. The majority have polio but there were also other
children with neurological conditions such as cerebral palsy (CP). The number of children
benefiting from this resource is low at present when the same children are seen on a one to
one basis, especially on shorter days. There would be capacity for more children if staff learnt
how to manage active group sessions, with the involvement of parents/carers too. Numbers
are likely to increase when more parents become aware of the support room facility.
In Khurozon district the doctor stated that a total of 14 children with polio who were told to
come on Tuesdays, plus others (CP, trauma, paralysis) who came, so in total approximately
25 children. However, the support room was quite small so it is unlikely that they are seen
each week. In Khatlon many more families turned up but mainly because they were mustered
for our visit – in Rumi it was first time for most families to come to the support room.
A large number of families came
during our visit to Rumi support
room.
In terms of home visits, sometimes only
doctors do home visiting, other times
nurses. However, some of the parents we
talked to during focus group discussions or
at home, said they had not received home
visits. Those that had, appreciated being
shown how to do the exercises and the
support shown to them.
On questioning it was hard to determine exactly how frequently community visits are carried
out and there is high variability.
Cost & maintenance: Mostly absorbed by hospital or social welfare departments as space and
staff allocated from existing resources.
Colourful equipment provided by
UNICEF at the PMPCC in Khatlon,
Kurghonteppa. The Centre staff were
trained by the VSO volunteer (funded
by UNICEF) working there.
15
 Support Groups:
Around 20 support groups have been formed, with another to come in the DRD. A support
group meeting was not included in the DRD field site itinerary but during the Khatlon field
visit, two meetings with support group members were held. Two day training workshops have
been held for the Khatlon support groups with more in-depth and holistic training for
rehabilitation and child development topics.
There were three social workers, one nurse and 1 teacher present at the Rumi focus group
discussion and they were also the people carrying out the support room activities on
Saturdays. They felt the CBR project had helped with re-integration, play with others and
prevented children being sent to institutions.
At present they were only able to see children with polio at the centre as there was no time or
transport funds to enable them to do home visits. They stated there were many other children
with disabilities out in the community but they covered a population of 180,000 in Rumi
district and many more staff were needed. Ideally they felt that satellite services should be
more available at village level as parents were too poor to pay the transport to town. They
tried to help families with registration for disability cards as many faced bureaucratic
obstacles and charges to obtain one.
Poverty is the overriding problem for the majority of families and the original plan in Khatlon
was to form a large number of support groups following the district CBR training sessions
who would compile Social Support Pans. Definitive data on the number of support groups
formed was not available but it was reported that 63 were listed at the end of the training.
However, one to two day training sessions was a short amount of time to consolidate
knowledge on such a wide topic as CBR, so most did not continue to function as a group.
However, individuals such as a medical point doctor we met in a village near Rumi had
continued to disseminate information about polio and inclusion messages for children to
attend school, within his daily work.
A report from the Handicap International Monitoring & Mentoring of March/April 2011
documents the problems in this extract below:
Only 14 village Support group from the 63 (support group formed in villages during the Polio
seminars) send their Social Plan to District Trainers. Besides, even though nurses, teachers claim
that they disseminate information on Polio and social support, the quality of it is not reflected on the
data (getting Disability card and orthotics). Social group are not working as a group but rather
individually, without coordination.
 Capacity of rehabilitation and mid-level CBR project workers
It was reported during an INGO group discussion that the ability and motivation of support
room staff did vary across the districts. During the field site visits, the doctor-trainers
expressed a keen interest and willingness towards the CBR work. All staff noted how they did
not have such a support space for families before and it was something new they liked.
A positive aspect noted by the OpM country director during our visits to the support rooms,
was the number of children without polio who had previously not had disability registration
but had now started the process or received the disability card. This was a useful side effect
16
anticipated in the project proposal, that the CBR programme had helped to identify children
with disabilities that are currently not in the government system and statistics. The example
case study 1 below illustrates such a family.
Case study 1 – Abdullah 5 years with cerebral palsy
This young boy is being cared for by his grandmother and
aunt, who have brought him to the Sharinav support room
every week for three months, despite having to carry him
for one hour. Although he tires easily they feel the
exercises are helpful as he has progressed slowly and can
stand with support.
He attends the NOC workshop for special shoes every two
months and has had very positive experiences there,
receiving the shoes free of charge, since they have been
registered for the disability card.
__________________________________________________________________________________
However, many of the support room staff do not have enough training and skills to fully
function in the role of rehabilitation and orthotic prescription. Children with polio are
relatively straight forward to rehabilitate, but the clinical reasoning required to plan effective,
function rehabilitation plans and assess children for orthotics and mobility aids, would need
trained rehabilitation personnel, at least to supervise and monitor outcomes for the children.
The short case study below illustrates some of the problems encountered.
________________________________________________________________________
Case study 2 – Support Room Guliston
Firoza comes weekly to the Guliston support
room for exercises with the health centre
staff (Dr, nurse + paediatrician).
Dr has referred her for both disability card
and orthoses but the parents have not
wanted to take up these options. Mother says
“We usually don’t go out of the house”,
despite orthopaedic workshop being only 10
minutes away. A ‘medical’ neighbour offered to
take measurements to the orthopaedic workshop
but charged approx. $100 and never came back.
Firoza, 4 yrs old girl with polio
from Uzbek family attending
support room since Aug 2011
17
Both legs of Furoza are affected and now both TAs (Achilles tendons) are contracted –
she did not receive any night splints or brochure showing passive stretchings. Now
serial plasters or ETAs (mild surgery) to both ankles are required before she can stand
with flat feet for walking. As her hips are also affected, she is likely to need a HKAFO
(hip, knee, ankle orthoses).
The initial assessment chart was only partially and not correctly completed by the
paediatrician, who did not tick the orthotic referral box when mother said they didn’t
need any. Has apparently been prescribed a wheelchair but if this is given before
proper orthotic rehabilitation, there is a chance Firoza will never learn to walk when it
should definitely be a possibility.
_________________________________________________________________
Lessons learnt from this site visit:

There are gaps both in the communication and system procedures for provision of
orthotics and mobility aids.

Monitoring system from support rooms is not adequate for the community visits, referrals
or documentation

The CBR workers do not yet have adequate training or rehabilitation skills to deliver a
comprehensive rehabilitation service.

Ideally, trained paediatric therapists are needed to provide the appropriate supervision and
capacity building needed to improve the staff skills and service delivery, particularly
when working with more complex neurological conditions such as cerebral palsy.

Lack of coordination between MoH, CBR project staff at Support Room, MLSP and the
orthopaedic workshop

Families may need accompaniment to reach clinics, even when close by.

Record keeping is not adequate enough to make informed decisions on treatment.

In some places home visits are either not happening or not effective to meet rehabilitation
needs.

Guidelines, using simple flow charts at every clinic on procedures and documentation are
required, it would be helpful for staff and parents.
-------------------------------------------------------------
Result 5: Affected children and adults are fitted with the relevant orthotic and mobility
devices
Most of those listed with polio and requiring orthoses were fitted (approx. 250).However,
there were definitely children missed off that list, as noted in both the MoH Monitoring report
18
of August 2011, and during our first field visit where there were three children who lacked an
orthosis or crutches. Sometimes parents had refused the orthotic, still hoping their child was
going to fully recover, whilst others did not have the personal ability or funds to travel to
Dushanbe for the orthopaedic workshop fitting. It is apparent that some families need
psychosocial support to cope with their child’s disability. This has been recognised during the
project implementation and the revised MoH monitoring form now has sections to pick up on
psychosocial issues (see the example below taken from the relevant section of the new form).
If family is under stress due to disability and needs family psychosocial support ( ) Yes ( ) No
If YES: What kind of psychosocial support would they would they like:
a. ( ) parents group
b. ( ) meet with psychologist
c. ( ) meet with social worker
A positive case study example of rehabilitation with orthotic and mobility provision in
Sharinav district is illustrated below:
Case Study 3 – Gulinara 8 years with polio
This young girl has polio that affected her right side arm and leg, also causing some
curvature of her spine. Her mother had been taught exercises to help her recover and
she attended both the Macheton government rehabilitation centre as well as the CBR
support room.
We were able to examine her completed polio assessment chart, where she was
referred to the NOC workshop and followed up. She was measured and fitted with a
long leg hip orthosis there, which does have a knee joint. Despite her reluctance to wear
an orthosis, Gulinara admitted that it was to easier to walk with it. Gulinara has
successfully re-integrated back at her old school, she says without problems and her
favourite lesson is drawing – see below
Gulinara with therapy ball at the Sahrinav support room and one of her drawings
Provision of assistive devices was variable though, whether in the acute phase night braces or
permanent orthotics. There are clearly gaps across the referral, measurement, fitting and
replacement systems, which is compounded by the involvement of two different and separate
19
line ministries (MoH and MLSP). Most children have been seen only once, so since that time
children have grown and some orthoses are already too small or were not functional in the
home/community setting. There was also a lack of suitable crutches – axillary crutches are
ordered from Iran and not always in stock, while elbow crutches are only available in two
sizes and not appropriate for small children. Some children will be equipped with walkers but
this material is currently not provided by the MLSP or pharmacists. It could be made locally
out of wood for a modest price and the HI orthotist trainer noted that this has been suggested.
 Correct prescription, measurement & fitting of orthoses and mobility aids is an issue
Provision of Wheelchairs: This has been very problematic for the project teams as the
current system whereby the MLSP buy a quota of 700 general wheelchairs annually, is not
meeting the needs of younger children. Again the shortfall is further complicated by different
Government authorities having responsibility for children at different ages, also depending on
whether they have disabilities or grew up in a state institution such as a Baby Home.
On the field site visits we observed children who needed mobility aids such as crutches or
walkers, having to walk behind an old discarded wheelchair or neighbour’s adult walker
instead. These children have now been assessed for wheelchairs within the CBR project but
two of them could be assessed for orthoses and crutches providing their arms were now strong
enough. This would give them greater mobility in the Tajikistan context, which is not
generally accessible for wheelchairs and make negotiating the school environment easier
too.
The following extract form the Handicap International March/April 2011MonitoringMentoring report highlights some of the issues regarding orthotics :
The situation with orthotics did not change from previous visit. The number of children who have
orthotics is low and the reasons remains still the same:
- Trainers, doctors and nurses and Support group members are not able to identify children who
needed orthotics.
- Most of the parents, who were asked to go to Dushanbe to get orthotics, refused to go and
explained that they need considerable sums to go.
- Most CWD leave in remote areas and are limited in receiving accurate information about
orthotics and other mobile aids. Only 36% of Parents know what are they for and the majority
do not realize the importance of having orthotics. This can be the main reason why parents do
not go for orthotics.
Community awareness about importance of orthotics can change the situation. Trainers need to work
more closely with districts health workers and support groups and ask them to held discussion on
these topics among the community members.
The National Orthopaedic Workshop: One brief site visit was made with the Handicap
International orthotic trainer, Mr Pritpal Singh, who has completed two separate, two month
training visits this year. Unfortunately, the workshop Director and physiotherapist were not
present at the time, but we were able to hold an informal group discussion with nine
technicians and assistant technicians and the workshop coordinator.
The response from the technicians was that all the children with polio who were on the list
given to them as needing orthoses, now have them. There had been some delay in this list
20
reaching the orthopaedic workshop but in last 10 months figures were given of 253 orthoses
made for 243 cases (some need > 1 orthosis). There were shortages of appropriate crutches
and other materials which affected the quality of service delivery at times.
The training from the overseas visiting orthotists, Mr Singh was greatly appreciated as big
improvements were seen in a short time frame. Now they are able to make jointed ankle foot
orthoses (AFOs) and even more complex Hip, Knee, Ankle Foot orthoses (HKAFOs),
whereas previously the focus was more limited to amputee prosthetics. A comprehensive
manual had been given to the technicians but they still feel they need an expert to supervise
for more complex cases. They also request training for orthopaedic shoes and cerebral palsy
developmental aids, as well as further training & exchanges overseas.
The Orthotic trainer with technicians at the
Orthopaedic workshop
HKAFO now produced at the
National Orthopaedic workshop
Mobile Clinic: The Orthotic trainer and technicians say this works well, particularly for those
outside Dushanbe affected by polio, covering nine districts. It is an appropriate, functional
model which is much needed and appreciated by parents and project staff. Technicians feel it
helps the families and spreads knowledge about orthoses too. However, limitations were
experienced in that the team (1 technician,1 assistant, 1 physiotherapist and the coordinator)
can only go out one day in two weeks. At present the trainer feels there is not the capacity to
do more than 26 visits per year. Families still have to travel to Dushanbe for the fitting. It
would be more efficient if the team could stay overnight in districts both to measure and fit
previous batches, and save families the journey to Dushanbe, but at present there is no
allocated budget for this.
In order to avoid the loss of this valuable service when the project ends in December,
Operation Mercy have made provision for another year, negotiating an MoU with the
Government workshop, so orthotic requisition can be completed and the service doesn’t
suddenly collapse. Overall though, having just one fully functioning national orthopaedic
workshop for the entire country is not sufficient. A recent UNICEF report3 noted that
although there are four branches of the national orthopaedic workshop in the regional centres
of Kurgan-Tyube, Kuliab, Khorog, and Khudjand, which can take measurements and fit
orthotics, their capacity is very limited.
3
UNICEF Country Assessment of Essential Commodities in Tajikistan, Lilly Langbehn, July 2011
21
Result 6: Affected children and people are able to participate in education and other
normal, age-appropriate activities in their community with minimal stigma or
discrimination
The message of the importance of participation and inclusion in school and community for
children and others with disability had definitely been transmitted. The project workers we
met from across health, education and social sectors, had been made aware of these
fundamental CBR principles. Many children had returned to school but we still heard of a
number that had not, sometimes through fear of either parents or child. They usually received
a Home Tutor instead until they were able to return to school.
However, we made a school and home visit to
one bright 12 year old girl, Anisa from
Sharinav, who did not even have a home
school tutor – the head teacher stated that the
household was too poor and unsuitable. The
mother was having to cope on her own with
an additive husband and very little money.
She had been forced to rent a very poor
dwelling with appalling accessibility issues
and did not have suitable mobility aids to reintegrate back into school. She faced a
multitude of social problems and was not able
Anisa at home carried by her brother
to cope with the barriers of registering for a
disability card and social assistance. Clearly,
despite being known to the school and Support Group, the intended Result 6 activities of
family and community based solutions had not worked for this child.
Many other parents noted difficulties with obtaining a disability card, sometimes being asked
for money or sent back without the right documentation. More families were helped with
social assistance in the CBR project sites visited in Kahtlon region, where there was more
involvement of social workers coming from Social Protection Units (SAHU) who were used
to this type of work.
School Inclusion: One of the aspects to assess in the ToRs was whether schools have been
adjusted to allow accessibility for children with disabilities. Here, there were mixed results
with the seven entrance ramps completed in Khatlon but not yet finished in the DRD and now
delayed due to bad weather. The original Result 6 Activities had also included adaptations for
classrooms and toilets but there was insufficient funds budgeted to manage this in the end.
The CBR project school entrance
ramp Vahksh
In all the schools we visited, toilets,
other stairs, classrooms and playing
fields all needed major attention. Within
schools most corridors are wide and
there is generally level space to move
22
around but classes may often be on the second floor unless there was a change in curriculum.
School head teachers did express a willingness to do this.
School Toilets: due to budgetary constraints none had been made accessible and they were in
a very poor state, both at schools and within health facilities, often located far away. They can
be more of a barrier to inclusion than stairs, where fellow pupils or teachers are often willing
to assist. The ones we observed could not have been easily adapted and needed rather a
complete new construction for the benefit of the whole school.
Vahksh school toilet - no water supply so
previous UNICEF built ones unusable
Entrance and inside current toilet not
accessible or user-friendly
Most schools did try to welcome children with disabilities but resources for inclusion were
not present i.e. no special teacher training, equipment or classroom materials/adaptations. The
children attending school that we met at the support rooms or talked to in schools said they
were managing well there and happy with friends, noting only slight difficulties with stairs,
toilets, classrooms or playing fields (most did not engage in sports lessons). However, these
children had only mild impairments, whilst the ones we met on home visits, with greater
mobility challenges, requiring wheelchairs or walkers had not yet re-integrated.
One of the head teachers we met had followed up this issue after the TOT training by holding
PTA (parent teacher association) meetings to talk about the issues raised. However, most
teachers had not attended the CBR awareness training or any other special education courses
for inclusion. Mr Amirov, the focal person at the Ministry of Education had noted that the
CBR training on inclusion had been useful for increasing awareness amongst teachers and
parents, but also acknowledged the huge task ahead of bringing inclusive education practices
across schools in Tajikistan. Recently there has been a Government decree and a strategy on
inclusive education was adopted, so this should provide a favourable climate for greater
inclusion in the future.
Result 7: Evaluation and documentation for future direction: Tajikistan specific
knowledge on community-based approaches, disability and Inclusive Education (IE) at
government and district levels
To meet the objective of Result 7, the jointly developed terms of reference for the current
consultancy were designed to make an assessment of the process of the work undertaken
within the 15 month short duration of the CBR project. It was to review what has been
achieved to date and the lessons learnt, and given that CBR is a relatively new concept in
Tajikistan, it was to provide information to guide future interventions of UNICEF and its
23
partners. Thus, the final section of the findings will look at the questions of effectiveness,
efficiency and sustainability, followed by a conclusion with recommendations for taking the
project forward in the future.
4) Effectiveness, Efficiency, Sustainability
The effectiveness of the project has been considered in terms of the extent to which the
project achieved the expected results and all initially planned activities. These aspects have
been discussed in detail under each of the Results 1-7 in the previous section. To give an
overview, the information campaign was achieved to a large extent with all the brochures,
posters and educational materials printed and well accepted. The awareness and TOT training
sessions were successfully completed as planned. Even though there were some gaps in not
being able to reach all the target group populations, this is understandable given the nature of
an emergency response and short time frame. Due to administrative agreement delays, the
TV/media campaign is yet to be completed but is expected to be broadcast in December
before the end of the project.
The training and knowledge of rehabilitation and CBR principles targeted at mid-level,
district and community health, education and social sector workers was carried out as planned
with 100% of the trainings completed. The training tool kit (flip chart, posters, doll etc.) was
produced and distributed, approved by the MoH and translated into Tajik. However,
rehabilitation and CBR are vast subjects to learn and to gain a full understanding of them
would normally take years. The INGOs themselves who delivered the training recognise that
the training was not enough for project workers to be able to carry out their expected roles
effectively to deliver a comprehensive quality service. There is a need both for increased
coverage of target groups as well as more depth of practical knowledge concerning
rehabilitation skills and good inclusive practices for schools.
Provision of assistive devices was specified under Result 5 and included acute phase braces,
permanent orthoses and other mobility aids such as wheelchairs, crutches and walkers. These
have been produced and distributed to the majority of polio children listed and wheelchairs
are on order and expected to arrive by December. As discussed in the ‘Findings’ section
previously, there were serious problems in the referral, prescription and fitting systems. The
list of children needing orthoses was delayed in reaching the orthopaedic workshop, which
meant that muscle contractures developed and children’s progress in regaining mobility was
adversely affected, slowing their re-integration into society. A number of children have not
gone back to school because they lack the wheelchairs, walkers, crutches and orthotic devices
which would enable them to do so.
For certain there are children requiring orthoses who have been missed off as they fall
between the system of CBR project workers who lack the requisite skills to know when or
which type of orthosis is needed, the inadequate referral process with the NOC, which is
compounded by the lack of coordination between different ministerial departments. Bringing
in an expert orthotics trainer for a total of four months this year and establishing the mobile
clinic were very important and effective steps towards improving the orthotics service and
ones which should make a lasting impact.
24
Participation and education were the target areas of Result 6 and here there were mixed
results in terms of project effectiveness. Many children had returned to school but these were
largely the ones who had made a full recovery or who had only mild impairments, which
meant they could function within the normal school environment. During the field site visits,
the children we met with more challenging mobility or social issues had not successfully
returned to school, nor were able to move around and participate so freely in the community.
Apart from seven school entrance ramps in Khatlon oblast, little adaptation or increased
accessibility could be observed at home or in the schools. It is helpful as a temporary measure
that there is a system of ‘home tutoring’ for children, but this can also hinder their reintegration if it becomes a substitute for real inclusion along with their peers in school.
Constructing an entrance ramp at school can be just a symbol of accessibility if the rest of the
school retains environmental barriers. On all our visits to school we noted that other barriers
to accessibility remained; additional sets of steep stairs, unsuitable toilets, out of reach play
areas, classrooms upstairs etc. It would be too ambitious to expect to overcome all
accessibility barriers within the short time frame and available funds of this CBR project. At
least now accessibility issues have been raised and the relevant staff and community members
are more aware of the barriers than before, which is already an achievement in itself. It would
be helpful if cross sector funding could be raised to initially create ‘model’ schools of
accessibility, which would be of benefit to all. Then hopefully this example would influence
future universal design of school and public building.
Other questions to consider for effectiveness concerns whether the methodology/tools were
appropriate for the project objectives and whether they addressed the needs of all target
groups. The methodological approach and tools (education materials, tool kits, mobile
orthopaedic clinic, inter-sectorial approach, CBR principles etc.) can be said to have been
appropriate and effective to meet project objectives. However, there is a need to build on the
initial results achieved to reach more families at village level, with quality rehabilitation
services.
Regarding efficiency is the question of whether the results achieved can be considered
adequate for the budget spent, and whether the allocation of resources among different aspects
of the project was appropriate or not. The funds were raised from a partnership between
UNICEF, Operation Mercy and Handicap International and it can be judged that there was
definitely value in the results achieved for monies spent. In addition, there was a substantial
contribution made by the Government in term of the extensive allocation of staff made
available to support the CBR project, as well as provision of space in buildings in which to
hold the activities, particularly the designated support rooms.
Overall the different allocation of funds between; medical services, rehabilitation, equipment,
training, CBR inclusion, awareness, accessibility in schools was appropriate and well used.
However as has been noted, there were insufficient funds for all the necessary school
adaptations. It had also been stated by orthopaedic technicians that there were insufficient
funds for the mobile clinic to stay more than part of one day in each location. However, part
of that issue is that current capacity at the NOC would not allow increased time away for the
mobile clinic, without adversely affecting services at the main orthopaedic workshop.
25
Sustainability is a multi-faceted concept and was considered in this assessment from the
following set of questions:
o
Is the project methodology appropriate to local, cultural context?
o
What is the level of sustainability in the results achieved to date? are they of long, medium or
short term nature?
o
Can they continue to influence for lives of:
a) children/families with disabilities,
b) implementing partners
c) other partners & stakeholders at district, provincial and national levels.
o
Will the services, rehabilitation, CBR approaches, support groups etc. be maintained at the
end of project support?
o
What is the degree of longer term commitment and involvement of all parties, such as the three
Government Ministries, implementing partners, community support groups and other
stakeholders?
UNICEF and the project implementing partners have been working in Tajikistan for some
time and already had good working relationships with the three key line ministries, as well as
considerable experience of successful work on the ground. CBR is an appropriate
methodology for resource poor settings, particularly where the majority of the
population live in rural areas. However, it is a relatively new concept for Tajikistan and
requires a shift from institution based services to the CBR concept of grass roots action and
voluntary contribution, which were not necessarily part of the culture before.
People are used to a model of large, well-resourced rehabilitation institutes, with sophisticated
therapy machines and where everything is provided for them, without requiring much active
participation from their clients. Wherever we went on the field site visits, project workers and
families all referred to the rehabilitation centres of Chorbogh, Macheton or the Republican
Centres for child health. Most families had spent at least one stay there of up to four weeks
and continued to return for treatment, even though acknowledging that their child with polio
was no longer making progress since the initial recovery of muscle strength.
Most people still valued the more passive treatment modalities of electrotherapy, wax,
massage etc. and expensive, sophisticated machines were highly praised and desired. Medical
staff in general tended to favour that type of model for the CBR programme support rooms,
rather than taking therapy to the villages with home visits, even whilst realising that most
families were not able to travel often to such centres. The concept of tailoring interventions
to the reality of home settings and functional daily life activities, and the mismatch of ‘high
tech’ environments to everyday needs was not appreciated.
Thus for CBR to be sustainable requires far more assimilation of the principles and proof that
low cost, rural alternative forms of rehabilitation and community mobilisation can be
successful. It is early days yet, after just 15 months of implementation in what was an
emergency response to a polio outbreak. Even so, for longer term sustainability of more
active, family-centred rehabilitation, it would be beneficial to try and integrate these
principles within Government rehabilitation structures, so that an appreciation of
community outreach could become part of their work.
26
The level of sustainability in the results achieved to date are likely to have a range of short,
medium and longer term effects. In the short term, many families have been helped with
rehabilitation and assistive devices and informed about their child’s disability, available
services and social provision such as disability cards. In the medium term, a substantial
number of health, education and social sector workers have been sensitised about CBR
principles, not just of rehabilitation techniques but increased awareness of disability and the
importance of participation and inclusion in society. Their capacity has been increased and
their frequent requests for further training demonstrates an appreciation for what has been
achieved.
A key factor for longer term sustainability for the CBR project was that it was embedded
within Government structures and personnel, from ministerial to district levels. All three
Government Ministries expressed strong approval of the project actions and for continuing to
expand CBR across the country. The Head of Mother and Child services at the MoH declared
during our interview that they intended to establish a joint cross sector National
Rehabilitation Framework by the end of 2012, and that CBR should be used as a vehicle for
delivering it. Two WHO visits from the VIP/DAR (Disability & Rehabilitation) unit during
the polio outbreak had highlighted the need for a National Rehabilitation Plan and role of a
national CBR network, which reinforces the position and approach of the CBR polio project
work.
The question of whether services will continue after the project ends this December 2011 was
asked during interviews with all three central Ministry representatives, as well as in the
district offices and health facilities. Each time, officials were convinced that they would
continue, even if the project support did stop. This was despite acknowledging that they
needed the technical and ideally financial input from the UN and NGO sectors. Assessment
and monitoring tools had been jointly developed and approved by the MoH, who stated that it
would not be difficult for them to train their staff and analyse the data at the Ministry. One
round of monitoring of this CBR project had already been done by a department official.
The fact that permanent space and staff were allocated to the Support Rooms and Support
Groups demonstrated a strong commitment on the part of the Government. It will be
important that these much appreciated child-centred spaces continue to thrive and be used by
a growing number of children with other disabilities, now that the polio outbreak has abated.
The inter-sectorial approach adopted in the project has been another useful aspect which could
have major long term implications. All three Ministries stated their conviction in cross
ministry initiatives, despite the difficulties of doing so in the current longitudinal
structure of separate administrations. The need for joint working was stressed by them,
with the suggestion that UNICEF might take up the lead coordinating role for children’s
services as they are positioned between Government, the UN and NGOs. Some
Government cross ministry forums and round tables had been initiated already at high level.
However, there is a the need for inter-sectorial, task force working groups to be established in
27
order to ensure effective implementation. To this end, UNICEF is advocating and negotiating
for a cross ministerial advisory group to be formed.
5) Conclusions
A considerable amount of work has been accomplished in the short 15 months duration of this
project to achieve the expected results and activities to a large degree. The project was
ambitious in scope and in the number of target groups it sought to reach, across different
sectors. A number of significant achievements have been made in reaching the majority of
affected children and young adults with polio needing rehabilitation and assistive devices, as
well as other children with disabilities.
The intended number of trainings and educational material were completed and most of the
Support Rooms established and equipped. A weaker aspect has been in the adaptation and
inclusion work in schools. Entrance ramps were constructed just in Khatlon at the time of this
assessment, whilst other environmental barriers remained throughout the target schools. There
are mixed results in fitting the relevant orthotics and mobility aids. Although most of the
children with polio listed did receive their orthosis eventually, the delay had caused
contractures to develop or children had already grown out of them.
The system for referral and provision of other mobility aids such as wheelchairs, walkers and
crutches did not always work effectively, and much work needs to be done together with
Government departments to improve the referral process. There is a lack of mobility aids
generally in the country and interventions that would support local production could alleviate
the situation.
Although a large number of mid-level Government health, education and social workers
attended up to three training workshops, their level of skills is not sufficient at this stage to
deliver quality rehabilitation services. They lack training, skilled supervision and coverage to
reach families at village level. There was universal appreciation and enthusiasm from all
sections of the Government, from ministerial to district levels about the work accomplished
by the CBR project. It has raised awareness and encouraged inter-sectorial approaches, which
is quite an achievement in such a short space of time.
The project activities had targeted three of the five main areas of CBR, namely; health,
education and social sectors in response to an emergency polio outbreak. Areas of livelihoods
and empowerment were beyond the scope of this project. The possibilities and potential of
CBR has been demonstrated and a window has been opened. It is important now to build on
this and not to lose the momentum that has been reached.
6) Recommendations
1. Capacity building of rehabilitation professionals:
a) More qualified professionals such as; physiotherapists, occupational therapists,
orthotists, preferably with paediatric experience are needed to work alongside
Government workers, until these professions are upgraded within Tajikistan, to include
community paediatric rehabilitation skills.
28
b) The type of training required varies from degree level therapists, to a 6-12 month model
of child developmental therapist training,4 found in India (Mumbai, Delhi, Chennai,
often at former Spastic Societies of India institutes). There are also 3 month CBR worker
training models for example at CDD in Bangladesh www.cdd.org.bd/
c) Currently the OPM, workforce development initiative, funded by the EU is holding
accredited associate degree level training
in Tajikistan for occupational and
physiotherapy, as well as mid-level courses for CBR. Some of the staff at Ishtiroc are
enrolled on this course and others have done child development placements in Mumbai.
d) Exchanges within country to good models of child therapy practice would be very
helpful e.g. to Ishtiroc child development Centre or the Operation Mercy ‘All About
Children’ project in Khojand region.
e) Exchanges to other countries in the region from policy makers to CBR project workers
can be very effective in bringing about change and was frequently suggested by
government staff involved with the project. Again India and Nepal have a wide range of
CBR organisations, with long experience of working at grass roots level.
2. Strengthening Rehabilitation systems:
a) Home visits are currently not sufficient to reach villages and the majority of parents do
not manage to attend support rooms regularly. A more systematic, coordinated
approach between the different sectors would help to cover the gaps more.
b) National Orthopaedic Workshop is a crucial resource for physical rehabilitation but
needs strengthening at all levels, including management as well as technical skills. An
overseas orthotic expert will continue to be needed periodically.
c) A system for referral, fitting, distribution and review should be drawn up by all
parties involved in these processes, so that there is joint ownership and agreement.
Guidelines and flow charts of the systems and documentation required can then be
disseminated
d) Ideally the four regional orthopaedic workshops could be strengthened to become
more autonomous and better serve the population in the districts. In the meantime, the
mobile clinic should have increased capacity to cover more districts and where
necessary stay longer to complete fitting as well as measurements, to save families the
cost and effort of travelling to Dushanbe – many families don’t make it and children
suffer.
e) Wheel chair supply is inadequate and does not meet the needs of younger children.
The issues have been discussed and are well known by the implementing partners.
Operation Mercy now has plans to adopt an ‘assembly model’ based on the operations
of a UK based INGO called Motivation , which has extensive experience of providing
wheelchairs in low income settings. www.motivation.org.uk
4
Child developmental therapy is a practical course, that entails aspects of occupational, physiotherapy, speech
and language, early development and play therapy, designed in a number of places in India to bridge the
paediatric skill gap, especially for working with chronic disabilities such as cerebral palsy children.
29
3. Community Outreach
a) Support room staff need further paediatric training so the rooms could start to
function more on a child development model, with group activities where parents
have greater involvement in their child’s rehabilitation with active therapy groups,
developmental activities for learning and daily living task training. Parents could have
greater involvement in their child’s rehabilitation by helping their child in groups or
assisting staff in running other learning or fun activities.
b) More children with other types of disability should be identified and encouraged to
attend. The majority of these conditions are likely to be cerebral palsy and intellectual
delay, with long term chronic and complex needs. Staff need specific training on how
to work with this type of child and additional, low cost ‘Conductive Education’ type
furniture would be invaluable, such as, stools of varying height and ladder back chairs
so children can learn to grip, balance and pull themselves to stand for functional tasks
such as dressing and toileting.
c) Conductive education is a system of rehabilitation developed in Hungary at the Peto
Institute and is now widely acclaimed across the world. It was designed as a practical
method to achieve ‘orthofunction’ whereby children learnt to walk or at least move
themselves independently so they could attend school. It is particularly suitable for
large institutions where there are sufficient numbers of children to form groups of
similar ability. It would be an appropriate model to encourage for the Tajikistan
rehabilitation Centres as it promotes a more functional and active approach to achieve
greater independence. http://www.youtube.com/watch?v=iaSoM68r7Io&feature=related
d) Community support needs to be strengthened as most families are not receiving
services at village level and cannot afford to travel to the district Support Rooms.
Many parents need accompaniment to attend more distant centres like the orthopaedic
workshop in Dushanbe or help to overcome the obstacles of obtaining social
assistance and disability cards. In the short term, this could be provided by the support
groups but a longer term project would be to develop parents self-help groups
4. Inclusion and Schools
a) School adaptation – more than a ramp. In future, sufficient funding should be
available to make at least target schools properly accessible and adapt not just the
front entrance ramp but other areas in schools like classrooms, doorways and toilets
etc. Universal design benefits everybody and there are low cost options – Handicap
International noted at the assessment feedback session, that they hold a blueprint
design for a six toilet block for schools which has one with access for wheelchairs
whilst the rest are normal size for pupils.
b) The sanitation in both the schools and health centres we visited in the project sites
was very poor for all. WASH projects are desperately needed across the project areas
and probably the whole country. There are resources freely available on the internet
which describe how to mainstream water and sanitation areas at relatively low cost.
See Water Aid www.wateraid.org and the internet resource book entitled ‘Water and
Sanitation for Disabled People and other vulnerable groups by Hazel Jones of
30
Loughborough University http://www.wedcknowledge.org/wedcopac/opacreq.dll/fullnf?Search_link=AAAA:M:553655366978
See also UNESCO - New toolkit on hygiene, sanitation and water in
schools. UNICEF has a WASH program which could target the schools in the areas
where the CBR project is implemented.
d) Inclusive Education resources are freely available for the internet and these could
be downloaded and distributed to bridge the gap until more training is available to
teachers. As most are in English, they would need translating and some adaptation
first. See UNESCO ‘Education for All’ tool kit, http://www.ictinedtoolkit.org,
Embracing Diversity tool kit, http://icfe.teachereducation.net.pk, Save the Children
‘Making Schools Inclusive’ brochure www.savethechildren.org.uk
5. POVERTY was the most common problem cited for families of children with
disability and it prevented some from attending the support groups or Orthopaedic
workshop. The NGO monitoring reports show large numbers requiring social
assistance, but they need greater support to access Social Protection benefits. The
role of social workers should be recognised more in CBR programmes and the
fact that some families need more support and accompaniment to access these
resources.
6. Involvement of DPOs and parents of children associations in future initiatives
is important to alleviate poverty in the long term, if they can be empowered to
foster community development and include parents of children with disabilities.
Ishtiroc have seen the results of empowering families through self-help approaches
with parents groups. There are numerous examples of strong DPO development in
Asia and the PSID approach of BPKS in Bangladesh has proved to be an
appropriate and very successful model - http://www.bpksbd.org
7. A National Rehabilitation Plan and Joint Working Groups for rehabilitation
across sectors are essential for future cohesive development, involving the three
key Government sectors of health, education and social protection, as well as UN
agencies and INGOS. It has been suggested by key stakeholders that UNICEF take
the lead in facilitating the coordinated development of children’s services.
8. CBR Network5 to be strengthened nationally so that the various CBR actors
(Operation Mercy, Handicap International, Caritas, OPM/EU) in Tajikistan
coordinate their efforts and share expertise more. In the longer term, this CBR
network could expand to include national stakeholders such as local NGOS,
DPOs, Associations of parents who have children with disabilities, as well as
government agencies in order to promote wider community development.
5
These last more global initiatives of National Rehabilitation Plan and enhanced CBR network
nationally are also listed as recommendations in the WHO visit made by Mr Chapal Khasnabis
recently this November 2011.
31
Annex 1: List of key persons interviewed
UNICEF
Operation Mercy
Handicap International
MoH
Laylee Moshiri
Siyma Barkin Kuzmin
Salohiddin Shamsiddinov
Andrea Vogt
Sobirjon Safarov
Dilorom Nazimova
Cecile Rolland
Hilma Razkaoul
Ryan Calaour
Zafar Dorgabekov
Pritpal Singh Sidhu
Mr Rahmatulloev
Ms Aziza Khojaeva
MoE
MoSLP
Mr Amirov
Ms Soima Muhabbatova
National Orthopaedic
Jumilla Yusufi
(coordinator) + 9
technicians & assistants
Dr Shorev Director,Head
nurse and 2 children with
polio
Macheton
Rehabilitation Centre
WHO
Gulistan Support Room
Guliston School
Rudaki health centre &
2 x home visits
Sharinav site visit
Support Room
Home visit
School & home visits
Khatlon
Support Room
Home visit Khorasson
Support Group
PMPCC
Khurganteppa
MLSP
Vahksh School 56
Khurganteppa
MoH
Dr Stephen Chacko
Doctor-trainer +
paediatrican + 2 nurses
Mr Omirov + pupil CWD
Doctor trainer
Mahmud & Josebar CWD
Doctor-trainers x 2 (also
Turzonsoda) +
paediatrician + nurses
Families with CWDs
Gulinara & Sharaf CWDs
Head teacher & home
visit Anisa’s home
Polyclinic manager
Dr Mashraf + Padiatrician
+ nurses
FGD: parents & children
Parents & Farhod 12
years CP
FGD:3 x social workers +
1 teacher + 1 nurse
Dr Davlatova Manzura +
nurses
Mr Nazarov IzatulloDeputy Minister
Head teacher
Deputy regional Director
Mr Shonazarovah
Rumi Support
Room
Doctor-trainer & manager
of Polyclinic -Dr Saidov
Khurram
FGD: 16 children with
families.
Rumi Support
Group
FGD: 3 x SWs + 1 nurse +
1 teacher
Village in Rumi
committee
member
Home visit
Kishti Centre
& HealthProm
Doctor at village medical
point
Ishtiroc
DPO meeting with Saida of
the Disabled Women’s
League, Ishtiroc at Kishti
Centre
OPM/ EUCBR
Vlodymyr Kuzminsky &
Erik Van Dissel
Rumi district
Sabrina & family
Rachel Tainsh & staff
32
Annex 2: List of documents reviewed:
9. ToR polio evaluation October UNICEF
10. PCA format proposal for CBR Operation Mercy for assessment
11. CBR Results & Activities log frame
12. Operation Mercy Tajikistan 2010 Annual Report
13. Operation Mercy Report on Monitoring-Mentoring April-June 2011
14. Operation Mercy Semi-Annual Project Updates x 2 (July & November 2011)
15. Handicap International Monitoring -Mentoring Report March-April 2011
16. Handicap International Project Manager Khatlon documents on:

Support Group Structure
Course Curriculum for Support Groups in Khatlon
End of Training reports
Level of Functional Mobility of PWPs in Khatlon
Client database for 2nd Quarter
Second & third quarterly reports
Assistive devices Excel databases
Orthopaedic workshop Expert Trainer’s reports:
- First final report on P&O training in Tajikistan Feb-April 2011
- Curriculum for P&O training
- Excel database of assistive devices
17. Monitoring report concerning organization of medical services to children with
disabilities in Districts of Republican Subordination, August 2011.
18. MoH Revised Monitoring form 201l
19. VSO Volunteer Reports 1st June – 29th August 2011
20. Tajikistan Monthly Update on Polio August 2011
21. Low cost options to move pilot projects to a national system of child protection,
2009 David Tobias
22. Travel Report Summaries, Chapal Khasnabis , June 2010 & November 2011
VIP/DAR Unit, WHO, Geneva.
23. UNICEF Country assessment of essential commodities in Tajikistan, Lilly
Langbehn, July 2011
33
Annex 3: Final Itineraries: DRD & Khatlon
Dushanbe & DRD region Itinerary – Sue Mackey
Date
November 16, 2011
Wednesday
November 17, 2011
Time
10:00
Activity
Arrival in Dushanbe Airport via Almaty
Comments
UNICEF car
12:00 -13:30
Lunch and orientation with UNICEF team
Finalization of the schedule & site visits.
Further documentation/ records review
Meeting with CP team for detailed planning
Security briefing, UNDSS
Briefing with UNICEF Representative
Meeting with Operation Mercy and
Handicap International followed by lunch
including orthotic trainer from HI
Visit the orthopedic workshop
UNICEF Office
14:30- 15:30
16:00- 17:00
09:00- 12:00
13:30 -14:30
14:30- 17:00
November 18, 2011
08:40- 09:50
10:00- 11:20
14:00- 15:00
16:30- 17:30
November 19, 2011
08:00- 17:00
November 20, 2011
08:00- 17:00
November 21, 2011
08:00- 12:00
13:00- 17:00
Visiting Macheton Centre in Vahdat District
Possible first visit to Guliston Jamoat CBR
Room, discussion with the local support
room staff
Meeting with MOH, Mr Rahmatulloev, Head
of MCH of the MOH, 221 77 69
Meeting with the MOE, Mr. Amirov, Head
of BS and AE Centres, 227 84 82
Meeting with the MLSP- Ms. Muhabbatova
Soima, Head of Rendering Social services
for children and families, 236 68 88
Meeting with Stephen Chacko, Dr Stephen
Chacko, Consultant, WHO, Tajikistan,
907 78 01 43
Travel to DRD to Gulistan, Rudaki with
Operation Mercy – meet local project Support
Room staff, school visit. Conduct interviews
with key local authorities/ beneficiaries/
implementers.
Review documentation & finalize the
methodology and sampling, finalize
arrangements for interviews/focus groups
logistics, etc.
Travel to DRD to Shahrinav district with
Operation Mercy – meet local project Support
Room staff, conduct interviews with key local
authorities/ beneficiaries/ implementers
Visit the school access for CWD
Meet project trainer-doctor from Turzonsoda
district . Home & school visits , conduct
interviews with key local authorities/
UNDSS
UNICEF
In Operation
Mercy Office
OPM/ MLSP,
Operation Mercy
Operation Mercy
In MOE
MLSP
WHO
Operation Mercy
Operation Mercy
Operation Mercy
34
November 22, 2011
08:00 17:00
November 23, 2011
08:00 17:00
November 24, 2011
09:00 – 10:30
11:00- 12:30
13:30- 14:30
November Fri 25,
2011
10:00-11.00
11.30-12.30
13.30 - 1600
16:00 -19:00
beneficiaries/implementers
Travel to Khatlon oblast with Handicap
International , visit the project sites in
Khorassan District, conduct interviews with
key local authorities/ beneficiaries/
implementers. Travel to Kurghonteppa
Visit to PMPC KT +other sites (accompanied
by VSO)
Stay overnight in Kurghonteppa
Visit the project site in Jaloliddin Rumi
District of Khatlon oblast with Handicap
International , visit the project site in district,
conduct interviews with key local authorities/
beneficiaries/ implementers
Visit the school with access for CWD
Return Dushanbe
UNICEF office – progress update
Meeting Rachel Tanish of HealthProm at
Kishti Centre
Meeting with VSO Tajikistan – Mr
Khuvaydo, Programme Manager
Meeting with OPM/ EUCBR team leaders
Vlodymyr Kuzminsky & Erik Van Dissel
DPO meeting with Saida of the Disabled
Women’s League, Ishtiroc at Kishti Centre
Analysis & preparation for feedback session
November 26-27th
08:00 17:00
De- briefing with UNICEF and implementing
partners regarding the main findings,
recommendations etc.
Drafting of the report
November 28, 2011
05:10 am
Departure from Dushanbe to Istanbul
Handicap
International
Handicap
International
Operation Mercy
OPM/ MLSP
In UNICEF
UNICEF
Itinerary for Sue Mackey- Khatlon Oblast - November 22 and 23, 2011
Day 1 - November 22, Khurozon District
8:15 to 8:30 – Arrival and courtesy call with manager of Polyclinic
8:31 to 9:00 – One-on-one with doctor-trainer (Dr Abdulloev Mashraf); brief look at support
group room
9:00 to 9:15 – Travel to home of child with disability 1
9:15 to 9:45 – Interview with child with disability 1 and parents
9:46 to 10:00 – Travel back to Polyclinic
10-01 to 10:45 – Discussion with parents of CWDs
10:46 to 11:15 – Discussion with children with disability
11:16 to 12:00 – Discussion with support group
35
12:01 to 12:45 – Lunch with doctor trainer
12:46 to 1:30 – Travel to KT
1:31 to 2:15 – Visit at PMPC (Manager – Davlatova)
2:16 to 2:30 – Travel to MLSP
2:30 to 3:00 – Visit at MLSP (Mr Nazarov Izatullo-Deputy Minister)
3:01 to 3:30 – Travel to Vahksh
3:31 to 4:00 – Visit at School No. 56
4:01 to 4:30 – Travel back to KT
4:31 to 5:00 – Meeting with Ryan at the Ramz
Day 2 - November 23, Rumi District
8:30 to 9:15 – Visit at MoH (Deputy regional Director - Shonazarovah)
9:16 to 9:50 – Travel to Rumi
9:51 to 10:00 – Arrival and courtesy call with manager of Polyclinic (Dr Saidov Khurram)
10:01 – 10:30 – One-on-one with doctor-trainer
10:31 to 11:15 – Meeting with parents and children with disability
11:16 to 12:00 – Meeting with support group
12:01 to 12:45 – Lunch
12:46 to 1:00 – Travel to village
1:01 to 1:45 – Interview with village health workers / community members
1:46 to 2:15 – Travel to home of child with disability
2:16 to 2:45 – Interview with child with disability and parents
2:46 to 3:15 – Travel to KT
3:16 to 3:30 – Wrapping up with Ryan
3:45 to 5:30 – Travel back to Dushanbe
36
Annex 4: Topic guides used for data collection
Topic Guide 1: NGOs (OPM/ HI/ VSO)
1) Their understanding and views on how project is working to date
2) Inter-sectorial approach – experience of:
o Advantages
o Disadvantages
3) What kind of CBR approach they envision?
- medical/ rehabilitation
- social/ comprehensive model
- DPO/ SHGs
- participation extent
4)
5)
6)
7)
What works well? - specific examples of
Challenges / constraints?
Which aspects do they feel need changing?
Future directions / scaling up / costings?
Topic Guide 2 – Project workers
1) What kind of work are you doing with the children targeted in the project?
- Rehabilitation
- School inclusion
2) How is the situation for the family ?
- what kind of difficulties are the children facing?
- what do you think are their greatest needs?
3) What helps the families most?
- Could you give any examples ?
- Any changes you noticed in the children
4) How was experience of working with the CBR polio project?
- Training workshops & support afterwards
- Number of children seen
- Assistive devices
5) What things did not work so well?
6) Which aspects should be included in any future programmes?
Topic Guide 3 – Families of children with disabilities
1) Opening questions on where they come from and how far travelled?
2) What kind of difficulties do their children have?
- In the community
- In school – teasing?
- Moving around – any mobility aids
3) What kind of problems did / do you still face in caring for your child?
4)
-
What kind of project activities happen at the centre or at home?
How many times seen the rehabilitation project workers?
Did you go to any other places for treatment?
In what way has it helped your child or not?
37
-
What doesn’t work so well?
5) What kind of activities would help you most in any future?
6) Are you aware of any parent support group or disabled persons organisation?
Topic Guide 4 – Children with disabilities
1) Opening questions: do you live nearby?
How did you get here?
2) What kind of things do you like doing in general?
- Play
- Household chores
- School – any problems there?
3) Do you have any difficulties doing those things? – what makes it difficult
4) How is it for those of you at school?
- Moving around
- Classmates welcoming or teasing
- Teachers
- Playground / toilets/ lessons
- What about those of you old enough but not going to school?
5) What kind of exercises or other activities do you do at the centre or at home?
- In what way has it helped you or not?
6) What things would you like to be able to do in the future?
- What would help you most to do them
[*specific questions adapted according to which Ministry]
Topic Guide 5 : Ministries (MoH, MoE, MLSP)
1)
-
Their understanding and views on how project is working to date
CBR focal point
Aspects needed for quality approach
Coordination
2) Inter-sectorial approach – experience of:
o Advantages
o Disadvantages
3)
-
What kind of CBR approach they envision?
medical/ rehabilitation
social/ comprehensive model
National CBR framework
4)
5)
6)
-
What works well? - specific examples of
Where Government capacity strengthened?
Challenges / constraints?
Which aspects do they feel need changing?
Which could be managed by themselves without UN/NGO support?
Monitoring & evaluation
7) Future directions / scaling up / costings?
38
Annex 5: Consent Form
Logos UNICEF/Operation Mercy/ Handicap International
Consent Form: Families & Community members
Assessment of: ‘Setting up a community based rehabilitation model for
children and adults affected by the polio outbreak and other children with
physical disabilities’ in the Republic of Tajikistan
Following the Polio Outbreak of 2010, UNICEF together with Operation Mercy and
Handicap International have been running a Community Based Rehabilitation (CBR) project,
since September last year in the 24 most afflicted districts, for those affected by polio as well
as other children with physical disabilities.
The aim of the project is to help these children receive physical rehabilitation services, in
order to decrease the disabling outcomes and help them to integrate back into mainstream
society.
This first 15 month phase is finishing in December and UNICEF and the partner
organisations would like to make an assessment, in order to learn from you what things
worked well, if there were any difficulties, and what you think is needed to improve the
situation for these children and families. We can then build on this learning to propose
developments for the project in the future.
Therefore we are requesting your permission to ask questions about your experiences, to talk
also with some of the children and to make a report of our findings. We will keep all the
information confidential and not use any names. Your participation is completely voluntary,
you can withdraw at any time and it will not affect you receiving medical services.
------------------------------------------------------------------------------------------------------------Participant Form
I have given this consent after being informed on the above mentioned issues. I am also
giving permission for photographs taken to be used for the project purpose
Signature of the participant:
Name of the participant:
Date:
39
Annex 6: CBR Project Log Frame
Planned Results and Activities for Community Based Rehabilitation for Polio Affected Children
June 2010 to December 2011
Result
Activities
1.The general population, and
especially parents of children affected
by polio or AFP, have access to correct
information on the long-term effects
of polio and the correct rehabilitation
Develop, print and start to distribute brochure
(5000 copies), develop and print posters (50)
2.Acute level health workers directly
dealing with affected families have
basic knowledge about CBR principles
and range-of-movement exercises and
can train others
3.Mid-level, district and community
health workers, district and
community social workers, teachers
and school directors, as well as Red
Crescent volunteers gain good
knowledge of CBR principles and
rehabilitation techniques to use with
people affected by polio
Implementing Partner
Time line
Status/Comments
Operation Mercy, UNICEF, WHO
June , July 2010
Media / TV campaign
Operation Mercy, UNICEF,
broadcast 2011
Brochures printed
and distributed to
xx places by Ops
Mercy
To be implemented
in 2011
One day or two half day trainings on cause,
pathology and rehabilitation of acute post
polio syndrome, practical lessons on range of
movement and prevention of deformities,
basic introduction to CBR (approx. 100
participants from Matcheton, Kurgan Teppa,
Karaboli, and policlinic’s family doctors and
nurses)
Tool kit developed and available in Tajik and
approved by MOH
Operation Mercy , MOH
June, July
Completed activity
by Operation Mercy
xxx health workers
received training in
xx districts in
months of xx
Operation Mercy in cooperation
with other NGOs, MOH, MLSP, MOE
July, October
TOT seminar for partner organisation on usage
of the tool kit
WHO, MOH
September
In process to be
completed by end
of September
TOT for 10
participants already
took place with
expertise provided
by Operation Mercy
Operation Mercy and Handicapped
International, UNICEF, MOH
45 two-day seminars for this target group in
their locations (if possible) using the tool kit
lessons, case studies form real life situations
and practical mentoring of the participants
Operation Mercy Dushanbe City
Planned for 29th
Sep – 1st of Oct.
In addition doctors
Start October 2010 ongoing
Operation Mercy RRJ
Soughd (if needed
40
by Operation
Mercy SogdBranch
VSO volunteer Khatlon, KT and
and
Vahsh valley –
Handicapped International
(depending on fund availability),
4.Creation of a structure of Mid level
disability, health and education
workers – family support
5.Affected children and adults are
fitted with the relevant orthotic and
mobility devises
Monitoring and mentoring of district and
community level trainees and implementation
of learned lessons
Approx. 20 support groups location identified
with in 30 min public transport travelling
distance from affected communities (e.g.
PMPC, day care centres, village or district
clinics, social protection or child rights offices),
team members identified, news about
information and rehab hub announced in the
relevant communities, basic equipment
provided if not yet existing (balls, mats, toys)
Refresher seminar for all the members of the
20 support groups in spring 2011
Acute care phase fitting with short term braces
(e.g Kramer to prevent deformities in the
recovery phase)
People are aware of the important role of
orthotics in polio rehab, the referral process is
clear, workshop is receiving patients,
improved cooperation with the workshop
mobile team visiting regions for fittings 24 trips
to all affected districts
specialists from HI and Operation Mercy, team
has the goal to assess and cast children for
orthotics but also to raise community
awareness on CBR – support the families (the
mobile ortho teams could possibly work
Supported by Tajik Red Crescent,
and district offices of MoH, MLSP
and MoE
See above
After first trainings
are completed
See above
As first rounds of
training are
conducted
WHO, ICRC
June, July, August
HI, Operation Mercy, MLSP,
orthopaedic workshop
ongoing
Orthopaedic workshop,
Handicapped International,
Operation Mercy, Ortho workshop,
MLSP, ICRC?
September - ongoing
Done
Searching for funds
for purchasing of a
car if not OpMercy,
minibus (Gazell) will
be utilised
41
simultaneously to the CBR training team in
Result 3)
6.Affected children and people are
able to participate in education and
other normal, age-appropriate
activities in their community with
minimal stigma or discrimination
7. Evaluation and documentation for
future direction:
Tajikistan specific knowledge on
community-based approaches,
disability and Inclusive Education (IE)
at government and district levels –
Severe cases are assessed and fitted with
wheelchair, walker or other mobility devices, if
needed imported from abroad
Children continue or first time included on
school or preschool (where it exists);
prevention of stigmatisation of families; family
and community based solutions and support,
children equipped with mobility aids (Result 5)
and classrooms, toilettes etc adapted for
accessibility.
After TOT main responsibility with hubs –
follow up and monitoring by district CBR
training teams (Result 3)
MLSP?
September
see result 3 – MOE, MLSP, PMPC
To be started in
spring of 2011 for
inclusion of children
in 2011-2012 school
year
Need for working
on case to case
situations as
community
seminars are he
Evaluation and monitoring feedback on CBR
approaches with government partners and
rehabilitation cluster
Possibly independent University
researcher – MOH, MLSP, MOE
2011
Terms of reference
to be developed
jointly in 2011
support:
CARITAS Switzerland Dushanbe city:
Operation Mercy
RRJ
Handicapped International Khatlon
Approved: _____________________________________, Ministry of ________________________________________
Date: _____, July 2010
42