Ministry of Health and Sanitation

National Strategy
for the Development of
Prosthetics & Orthotics Services

Ministry of Health and Sanitation

Government of Sierra Leone

March 2002

Foreword

The rehabilitation of persons with disabilities has to date not been fully addressed in Sierra Leone. There are many people in the country who could benefit from rehabilitation and the use of orthopaedic devices but who have not, because of various constraints, had the chance to be assisted. While it is obvious that many war-victims could need prostheses and orthoses, we must also have in mind that there are many other persons, such as polio victims and people with disabilities due to accidents or congenital deformities, who could need the same type of service.

The Government of Sierra Leone is much appreciative of the timely intervention of international non-governmental organizations, such as the German Leprosy Relief Association, Handicap International, World Hope International, Mercy Ships, and of the Red Cross Movement, CARITAS, T. Choithram Charity Trust and others who stepped in very quickly during the war to provide much needed rehabilitation services for persons with disabilities.

However, the types of prosthetics and orthotics services that are offered vary considerably since they are geared and designed to meet the assisting organisations' mandates. The use of different technologies and approaches makes it difficult to manage the services and, in the absence of national guidelines and proper coordination, the international support may not at the end give the desired long-lasting result.

The Ministry of Health and Sanitation therefore saw the need for developing a National Strategy that can provide guidance on the development of prosthetics and orthotics services, both to the Ministry itself and to anyone organization or agency interested in supporting the services.

The present strategy is the result of the joint efforts of some 30 local and international organizations, associations and agencies. Without their contribution and collaboration, it would have been impossible to carry out this work in a successful way. The strategy aims at ensuring that the best possible result can be achieved of the resources that are presently available and the support to this sector that can be provided in the future by national authorities as well as by local and international organizations and agencies. It aims at guiding the development of the services so that they become sustainable, affordable and accessible to the users.

Owned by the people of Sierra Leone and with the Ministry of Health and Sanitation as Focal Ministry for its implementation, it is believed that the strategy will be an important tool for the creation of awareness of disability issues in the society as a whole, and an important step on the way to empower people with disabilities.

Dr Ibrahim I. Tejan Jalloh

Minister of Health and Sanitation

Government of Sierra Leone

Call for support:

This strategy may serve as reference for anyone planning a programme in the disability field in Sierra Leone. With this document, the Government of Sierra Leone invites any organization or agency interested in supporting the development of prosthetics and orthotics services in the country to contribute to the implementation of one or several activities as described on the following pages. No individual organization needs to feel obliged to provide multi-disciplinary services, or even to cover the whole prosthetics and orthotics field, but may focus its efforts and resources on those activities in which the organization has expertise and particular interest.

Acronyms used in this document:

CBRCommunity-Based Rehabilitation

DPODisabled Peoples' Organization

ISPOInternational Society for Prosthetics and Orthotics

NGONon-Governmental Organization

P&OProsthetics and Orthotics

TATCOTTanzania Training Centre for Orthopaedic Technologists

Table of contents

Page

Foreword ...... 3

Background ...... 6

The preparation of this strategy ...... 7

General ...... 8

The overall aim of this strategy ...... 8

Main objectives for the development of prosthetics and orthotics services ... 8

General actions needed ...... 8

The implementation of this strategy ...... 9

1.Sensitisation ...... 10

2.Need Analysis ...... 11

3.Service Distribution ...... 12

4.Personnel ...... 13

5.Training of Personnel ...... 14

6.Technology ...... 15

7.Raw Materials and Components ...... 16

8.Maintenance and Repairs ...... 17

9.Quality Management ...... 18

10.Costing of Prosthetics and Orthotics Services ...... 19

11.Financing Prosthetics and Orthotics Services ...... 20

12.Networking/Collaboration ...... 21

13.Prosthetics and Orthotics Services and Community-Based Rehabilitation (CBR) 22

14.External Support ...... 23

15.Committees and Working Groups ...... 24

1. National Committee for Rehabilitation ...... 24

2. National Technical Committee for Prosthetics and Orthotics Services ... 25

3. Working Groups ...... 26

16.Stakeholders ...... 27

17.Preliminary Implementation Schedule and Responsibilities .... 30

Background

Much work still remains to be done in the area of rehabilitation and reintegration of persons with disabilities in Sierra Leone. In the past years, some charitable national and international non-governmental organizations have provided, supported and maintained institutional facilities for medical, educational and vocational rehabilitation. Though these efforts have been important, they have not fully satisfied the needs of disabled persons.

The war led to a rise in the number of persons with disabilities and made the need for prosthetics and orthotics (P&O) services very obvious; people with amputations and persons affected by polio due to difficulties in carrying out immunization programmes are among those needing orthopaedic devices. The war also led to the destruction of the facilities that normally could have assisted these persons, i.e. the services that had been in place since long to assist people who need orthopaedic devices and rehabilitation because of diseases and injuries that are not war-related.

War added displacement and migration, destruction of family structure and hardship, and it led to poverty, which may be seen as the greatest disease of all in Sierra Leone. Eventually, it led to a situation where disabled persons are among those people at the corners of the streets who are begging for their daily bread.

This is a situation that could be avoided, however. Disability is not inability. People with disabilities have the capacity to contribute to the society and to the nation as a whole like any other citizen if provided the opportunity. The provision of a prosthesis or orthosis, together with other relevant rehabilitation measures, can prevent disabled people from go begging in the streets and bring back their hopes and status and make them contributing members of their communities. By focusing on their abilities, while providing needed rehabilitation to minimize the impact of their disabilities, opportunities may be given to persons with disabilities to earn their own income and lead a normal life without being dependent on others. In this context, it is important to point out the need for raising awareness about disability and rehabilitation issues since, in fact, the problem faced by the attitude of the general public is often far greater than the problem of the disability itself.

Before May 1997, there were only two centres in Sierra Leone providing prosthetics and orthotics services, one in Murray Town (Freetown), which was Government-owned and funded, and the other in Makeni, owned and funded by the German Leprosy Relief Association (GLRA). With the total destruction of the latter workshop in 1998, only the facility at Murray Town, which was at the time ill equipped, poorly funded and understaffed, was in existence. With the increased incidence of amputations and lacerations, it was evident that the services offered could not meet the demands for P&O services in the country.

It was therefore laudable that international non-governmental organizations (NGOs) like the GLRA, the Adventist Development and Relief Agency (ADRA), Handicap International, World Hope International, New Steps (Mercy Ships), the Red Cross Movement, CARITAS, T. Choithram Charity Trust and others stepped in to provide services in an effort to cater for the needs of the disabled population.

The precarious security situation, however, limited the scope of activity of these organizations, which were not able to reach a larger number of persons needing P&O services as their activities were mostly localized in the relatively safe Western Area. With peace in Sierra Leone, it is hoped that rehabilitation centres can be set up in other areas to offer services to people with disabilities closer to their communities. With the country leaving the emergency phase and entering a development period, time has also come to end the use of technologies for relief situations and introduce working methods that are more permanent and sustainable in the long-term.

The P&O services offered by the various organizations (national and international) differ according to the agency's policies. Moreover, it is evident that these organizations cannot stay to render service in Sierra Leone indefinitely and that their support, if not coordinated and properly directed, may not result in a sustainable system for service provision. It was therefore seen as a matter of urgency for Sierra Leone to create a National Strategy that sets the direction for the development of P&O services. The plan should be owned by the people of Sierra Leone, with a future goal of being able to function with or without external technical and financial input. The formulation of a National Strategy for the Development of Prosthetics and Orthotics Services would ensure standardization of methods and facilities, affordability, accessibility to rehabilitation centres and, where possible, the use of materials that are locally available. To sustain P&O Services, staff must be trained, certified and motivated to ensure that continued services are provided after the international organizations have left.

With the Ministry of Health and Sanitation as the focal ministry actively collaborating with local and international NGOs and with the other line ministries – the Ministry of Social Welfare, Gender and Children’s Affairs, the Ministry of Education, Youth and Sports, the Ministry of Information and Broadcasting – and with the support of the Ministry of Finance, the Ministry of Development and Economic Planning and the National Commission for Social Action, armed with a National Strategy for the Development of Prosthetics and Orthotics Services and a similar Strategy for Community-Based Rehabilitation, great strides may be taken in meeting the needs of peoples with disabilities in Sierra Leone. This work will be done, not by putting up institutions to keep persons with disabilities isolated in one place, but by making sure that rehabilitation happens within the community, and by ensuring that crucial links are established with referral services, such as P&O services, and with organisations and agencies working in education, skills training, employment and other developmental activities.

The preparation of this strategy

The preparation of this strategy started with the Brainstorming Session on Prosthetics and Orthotics Services, held 19 March 2001 at the WHO Country Office in Freetown, followed by the Workshop on Development of a National Policy on Prosthetics & Orthotics Services in Sierra Leone, held 22-25 May 2001, also in Freetown, organized by the Ministry of Health and Sanitation. The latter meeting had 70 participants representing national and international NGOs, local authorities, service providers and, most important, the users of orthopaedic services. On the basis of the proceedings from the workshop, a draft strategy was prepared and then distributed for review to the groups represented in the meeting. Comments on the draft were collected and discussed in individual meetings with each group and changes were made accordingly in the revision of the strategy. The final document, the National Strategy for the Development of Prosthetics and Orthotics Services, was officially launched by the Minister of Health and Sanitation, Dr Ibrahim I. Tejan Jalloh, on 8 March 2002.

The workshop and the preparation of the strategy was carried out with financial support of USAID’s Patrick Leahy War Victim’s Fund and the technical assistance of the WHO Country Office in Freetown and the Disability and Rehabilitation (DAR) Team and the Emergency and Humanitarian (EHA) Department of WHO Headquarters in Geneva. The process was facilitated and coordinated by Mr Anders Eklund and Mr Chapal Khasnabis, WHO Consultants.

The following organizations, agencies and individuals were consulted in the preparation of this document:

The Amputee Group in Murray Town, the Baptist Convention Sierra Leone (BCSL), CARITAS, CAUSE Canada, the CBR Steering Committee, Children Associated with the War (CAW), Choithram Trust, CHRISTAG, Community Chiefs of Kissy, Kroobay, Krootown Road and Portor Levuma, Community Help Evangelism Programme (CHEP), Disability Rights Movement (DRIM) in Bo and Bonthe, German Leprosy Relief Association (GLRA), Handicap International (HI), Handicapped Youth Development Association, International Committee of the Red Cross (ICRC), the Leprosy and Tuberculosis Control Programme, Mercy Ships (New Steps), Ministry of Health and Sanitation, Ministry of Social Welfare, Gender and Children’s Affairs, Norwegian Refugee Council (NRC), Organization for the Homeless, Disabled and Rural Development (OHDRAD), Polio Victims Association (PVA), Sierra Leone Red Cross Society (SLRCS), Sierra Leone Stroke Victims Association, Sierra Leone Union of Polio Persons (SLUPP), Sierra Leone Union on Disability Issues (SLUDI), UN Office for the Coordination of Humanitarian Affairs (UNOCHA), United States' Agency for International Development (USAID), World Health Organization (WHO), World Hope International (WHI) and the World Rehabilitation Fund (WRF).

General

The overall aim of this strategy

This strategy aims at supporting persons with disabilities. It aims at ensuring that, through the provision of appropriate prosthetics and orthotics services, conditions can be created to enable disabled people to enjoy full participation in the ordinary life of the community. By the provision of orthopaedic devices, people with amputations, paralysed limbs or other impairments should be enabled to take their place side by side with their fellow members of society, in education, employment, recreation and all aspects of social life. This strategy, therefore, acknowledges that the provision of rehabilitation services must be based on the principles of human rights, social justice and equity.

Main objectives for the development of prosthetics and orthotics services

This strategy has been prepared with the conviction that the development of prosthetics and orthotics services in Sierra Leone, like in any other country, should at all its stages aim at fulfilling the following long-term objectives:

The services should meet the country's total need for prostheses and orthoses (meaning that no one person with disability should have to travel abroad to receive proper services).

The services should be available to all people who need orthopaedic devices, irrespective of the cause of disability.

The devices that are supplied should be of acceptable quality and affordable.

The services should be decentralized so that they are available in the areas where the potential beneficiaries actually are.

The services should be permanent so that they are available at any time they are needed.

The services should be sustainable, with or without external support.

The services should be regarded as an integral part of health and medical services.

The services should give the same importance to orthotics as to prosthetics.

General actions needed

To achieve the long-term objectives as described above, immediate actions are needed to:

• prepare detailed plans, set realistic goals and implement the programme in phases
• mobilize all possible resources: governmental and non-governmental; national and international; short-term as well as long-term
• collaborate, and coordinate every activity, with all Government agencies/institutions and NGOs
• move from an emergency relief mentality to a development approach
• plan for the inevitable decrease of external support and prepare the services for self-sufficiency
• involve service users, including those in rural areas, at every stage of planning and implementation

The present strategy aims at giving directions for the steps needed to carry out this work.

The implementation of this strategy

The implementation of this strategy is synonymous with the development of appropriate, long-term, sustainable prosthetics and orthotics services in Sierra Leone.

The strategy, therefore, should not be seen as a new plan for a separate project in the prosthetics an orthotics field. Its implementation should instead build on and continue the development work that has already been carried out by service providers in the country, and aim at providing means and directions for further strengthening these efforts.

Collaboration with the non-governmental sector

As stated in the UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities (UN 1993), it is the State's responsibility to ensure that rehabilitation and support services, such as those for prosthetics and orthotics, are provided. The Government of Sierra Leone assumes this responsibility by organizing, coordinating, monitoring and financing work related to the implementation of this strategy, as well as by providing direct services. It is clear, however, that the provision of proper nation-wide services requires the combined efforts of the Government and the non-governmental sector. The implementation of this strategy, therefore, calls for close collaboration between service providers and between government and non-governmental sectors, and also with other rehabilitation services, with health and medical services, and – not least important – with people with disabilities and their organizations.

Development of specific plans and sub-strategies

The nature of prosthetics and orthotics services requires that they be developed with the use of a flexible approach. While important guidelines can be provided at the initial stage, and are presented in this document, much planning needs to be done gradually. This strategy, therefore, outlines the main direction to be taken by pointing out a number of specific plans and sub-strategies that need to be developed and implemented, such as the following: