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Abstract

To provide an update on rehabilitation in Madagascar by using local knowledge to outline the potential barriers and facilitators for implementation of the World Health Organization (WHO) Disability Action Plan (DAP). A 14-day extensive workshop programme (September-October 2014) was held at the University Hospital Antananarivo and Antsirabe, with the Department of Health Madagascar, by rehabilitation staff from Royal Melbourne Hospital, Australia. Attendees were rehabilitation professionals (n=29) from 3 main rehabilitation facilities in Madagascar, who identified various challenges faced in service provision, education and attitudes/approaches to people with disabilities. Their responses and suggested barriers/facilitators were recorded following consensus agreement, using objectives listed in the DAP. The barriers and facilitators outlined by participants in implementing the DAP objectives include: engagement of health professionals and institutions using a multi-sectoral approach, new partnerships, strategic collaboration, provision of technical assistance, future policy directions, and research and development. Other challenges for many basic policies included: access to rehabilitation services, geographical coverage, shortage of skilled work-force, limited info-technology systems; lack of care-models and facility/staff accreditation standards; limited health services infrastructure and "disconnect" between acute and community-based rehabilitation. The DAP summary actions were useful planning tools to improve access, strengthen rehabilitation services and community-based rehabilitation, and collate data for outcome research.
SPECIAL REPORT
J Rehabil Med 2015 Preview
J Rehabil Med 47
© 2015 The Authors. doi: 10.2340/16501977-1995
Journal Compilation © 2015 Foundation of Rehabilitation Information. ISSN 1650-1977
Objective: To provide an update on rehabilitation in Mada-
gascar by using local knowledge to outline the potential
barriers and facilitators for implementation of the World
Health Organization (WHO) Disability Action Plan (DAP).
Methods: A 14-day extensive workshop programme (Sep-
tember–October 2014) was held at the University Hospital
Antananarivo and Antsirabe, with the Department of Health
Madagascar, by rehabilitation staff from Royal Melbourne
Hospital, Australia. Attendees were rehabilitation profes-
sionals (n=29) from 3 main rehabilitation facilities in Mad-
agascar, who identied various challenges faced in service
provision, education and attitudes/approaches to people
with disabilities. Their responses and suggested barriers/
facilitators were recorded following consensus agreement,
using objectives listed in the DAP.
Results: The barriers and facilitators outlined by partici-
pants in implementing the DAP objectives include: engage-
ment of health professionals and institutions using a multi-
sectoral approach, new partnerships, strategic collaboration,
provision of technical assistance, future policy directions,
and research and development. Other challenges for many
basic policies included: access to rehabilitation services, geo-
graphical coverage, shortage of skilled work-force, limited
info-technology systems; lack of care-models and facility/
staff accreditation standards; limited health services infra-
structure and “disconnect” between acute and community-
based rehabilitation.
Conclusion: The DAP summary actions were useful plan-
ning tools to improve access, strengthen rehabilitation ser-
vices and community-based rehabilitation, and collate data
for outcome research.
Key words: disability; rehabilitation; Madagascar; World Health
Organization.
J Rehabil Med 2015; 00: 00–00
Correspondence address: Fary Khan, Department of Reha-
bilitation Medicine, Royal Melbourne Hospital, 34-54 Poplar
Road Parkville, Melbourne VIC 3052, Australia. E-mail: fary.
khan@mh.org.au
Accepted May 12, 2015; Epub ahead of print XXX ?, 2015
INTRODUCTION
There are an estimated 1 billion people with disabilities (PwD)
worldwide, of whom 110–190 million have signicant dif-
culties and 80% reside in low-income countries (1, 2). The
United Nations (UN) Convention on the Rights of Persons
with Disabilities (CRPD), through international standards and
a normative framework for disability, provides for a paradigm
shift in attitudes and approaches to PwD, viewing them as
active contributing members of society with equal rights (3).
Although a number of UN member countries signed the con-
vention, there remain signicant gaps in service provision for
PwD in terms of implementation of rehabilitation policies and
legislation, funding and access to services (4), especially in the
developing world. The World Health Organization (WHO) esti-
mates that in 2011 only 3% of individuals worldwide received
adequate rehabilitation requirements (1) and, in developing
countries alone, 0.5% of the population was unable to obtain
the prostheses or orthotics they needed (5, 6).
Madagascar, the fourth largest island in the world (area
587,041 km2), situated in the Indian Ocean has more than 22.2
million inhabitants (4, 5). The WHO ranks it in the low-income
group, with gross national income per capita (2012) of US$930
(6), placing it 155th on the World Bank Human Development
Index (7). Only 33% of Malagasy people live in urban areas,
and an estimated 92% of the total population live on less than
$2 per day. The median age of the population is 18.3 years, with
a life expectancy of only 52 years (6). The literacy rate among
adults aged 15 years and above is 64% (1). Overall spending
on healthcare by the Malagasy Government is signicantly
lower than that of the average African region. In 2012, total
expenditure on health per capita was US$40, which equates to
4.1% of total expenditure (6). The majority of PwD in Mada-
gascar, as in many developing countries (8, 9), are economically
deprived and experience difculties in accessing basic health
services, including rehabilitation services. Furthermore, similar
to other sub-Saharan African countries, much effort has gone
into improving the acute care sector. The post-acute care system,
including rehabilitation, is undeveloped at many levels (10–14).
REHABILITATION IN MADAGASCAR: CHALLENGES IN IMPLEMENTING
THE WORLD HEALTH ORGANIZATION DISABILITY ACTION PLAN
Fary Khan, MBBS, MD, FAFRM (RACP)1,2,3,4*, Bhasker Amatya, MD, MPH1, Hasheem Mannan,
BSc (Stats), MSc, PhD5, Frederick M. Burkle, Jr, MD, MPH, DTM6,7 and Mary P. Galea, PhD,
BAppSci (Physio), BA, Grad Dip Physio, Grad Dip Neurosci1,2
From the 1Department of Rehabilitation Medicine, Royal Melbourne Hospital, 2Department of Medicine (Royal Mel-
bourne Hospital), The University of Melbourne, Parkville, Victoria, 3School of Public Health and Preventive Medicine,
Melbourne, Monash University, Victoria, Australia, 4Lead Task Force for the Committee for Rehabilitation Disaster Relief
(CRDR), International Society of Physical and Rehabilitation Medicine (ISPRM), Geneva, Switzerland, 5Nossal Institute
for Global Health, The University of Melbourne, Parkville, Victoria, Australia, 6Harvard Humanitarian Initiative, Harvard
School of Public Health, Cambridge, MA, USA and 7Medical School, Monash University, Melbourne, Victoria, Australia
2F. Khan et al.
Table I compares the data on common disabilities, disability
legislation, non-governmental agencies (NGOs), community-
based rehabilitation programmes (CBR) and support services of
Madagascar with that of 4 sub-Saharan African countries (14).
The objective of this paper is to provide an update on rehabili-
tation efforts and plans in Madagascar based on implementation
of the WHO’s Disability Action Plan (DAP) of 2014–2021 and
endorsed by the world’s health ministers to improve health
for all people with disability. The authors utilized interactive
feedback from rehabilitation professionals from Madagascar
attending an organized workshop programme and recorded
both the realistic challenges and strengths the attendees found
in meeting the established objectives listed in the DAP.
METHODS
The authors (FK, MG) were invited as independent experts (Septem-
ber–October 2014) by the Madagascar Department of Health (Antana-
narivo) in association with the UK-based charity Overseas Partnering
and Training Initiative (OPT IN) and the University of Leeds, to assist
in improving education and training of rehabilitation staff in the newly
formed Malagasy Rehabilitation Society. The focus was on taking the
DAP guidelines and building capacity in the workforce, developing
standards and key performance indicators; and up-skilling in specic
areas, such as rehabilitation services operational set-up, infrastructure
for horizontal health systems, development from acute through to
community, referral management, consumer involvement, research
methodology, including data collection, and setting up a rehabilitation
registry based on the Australian experience. This exercise was approved
by the Malagasy Health Department and the Royal Melbourne Hospital.
Non-communicable diseases (NCDs) and rehabilitation have re-
cently been prioritized by the Malagasy Health Department. There
are 6 regions in Madagascar with 3 established rehabilitation centres
in Antananarivo, Antsirabe, and the Mahajanga region. In addition,
there are 4 smaller regional facilities that provide supportive rehabili-
tation including CBR programmes. As yet, there are no operational
National CBR Programs in Madagascar and existing programmes are
run mainly by NGOs (14). Over a 14-day period, the authors also as-
sumed a facilitator role in conducting extensive teaching programmes,
including workshops and consensus meetings based on the DAP in the
Department of Rehabilitation, University Hospital Antananarivo and in
the Antsirabe Hospital. In addition, participants from the more remote
Mahajanga Rehabilitation Hospital also attended additional workshops
held at the University Hospital Antananarivo. A total of 29 healthcare
professionals attended these workshops and meetings, which included
approximately 9 rehabilitation physicians (including a representative
from the Department of Health), 2 surgeons, 4 nurses, 3 prosthetists,
3 occupational therapists, 7 physiotherapists and 1 speech pathologist
from various rehabilitation centres. The authors also met with a number
Table I. Summary of current health systems/resources for disability in some Sub-Saharan African countries
Country Madagascar Mozambique Senegal Ethiopia Congo-Brazzaville
Demographics
Population
22.9 mil*; PwD:7–8%
(2000)
25.8 mil*; PwD: 5.9%
(2000)
14.1 mil*; PwD: 10%
(1998)
91.7 mil*; PwD: 1.8%
(1998)
4.4 mil*; PwD: no
data
Cause of disabilities
(mobility, self-care,
vision)
Stroke; cerebral palsy;
infectious diseases (polio,
leprosy); drug and alcohol
use
Infectious diseases
(polio, malaria,
meningitis); war;
landmines
Diabetes; infectious
diseases (polio,
onchocerciasis); road
accidents and landmines
Infectious diseases
(polio, leprosy);
road accidents;
malnutrition
Infectious diseases
(polio, leprosy,
malaria)
Legislation of
disability for
PwD
1998: Law for equal rights,
2007: CRPD ratied; 2003:
National Decade of
Disabled persons;
Action Plan: 2007–2012
1990: Constitution to
support PwDs;
1999: Disability-
specic policy
National policy, but no
explicit laws, for disabi-
lity; 1984: education for
disabled children
1994: Employment
rights of the disabled
1996: Social welfare
policy
1992: Law on
protection and
education of PWDs
National Health Plan
not implemented for
disability
Human resources
(healthcare)
Physicians: 0.16/1000
people;
(in 2007); 3,150 doctors,
5,661 nurses, 385
community health workers
Physicians: 0.03/1000
people (2008); no
data on rehabilitation
personnel
Physicians: 0.06/1000
people (2008); no data on
rehabilitation personnel
Physicians:
0.03/1,000 people
(2008); no data
on rehabilitation
personnel
Physicians:
0.2/1,000 people
(2006); no data
on rehabilitation
personnel
NGOs and DPOs Many (religious, cultural,
sporting associations);
Handicap International;
Union des Associations
d’Handicapés de Madagascar
11 organizations
provide government
with technical
support, none indepen-
dent
8 NGOs, all in advisory
roles in policy and
technical support
11 NGOs; most focus
their services in urban
areas with limited
coverage
No information
available
National CBR
programmes
None, most funded by NGOs 1993: CBR by Ministry
of Social Welfare for
2000 PwDs
None, 1 CBR in 1988
by the Red Cross – now
suspended due to nancial
constraints
1983: CBR initiated
in 2 provinces by
NGOs with the
government but only
in urban areas
National programme
in 1999–2001
covering 11 regions
of the country
Research and
evaluation
Some research on clubfoot;
member of ISPRM
None; no inter-country
collaboration
None; member African
Rehabilitation Institute
None; member
African Rehabilitation
Institute and afliate
Rehabilitation
International
None
(Main sources: WHO Country Prole; Regional Ofce for Africa WHO; WHO Health Statistics 2011; WHO Disability and rehabilitation status 2004 (14)).
*Population in millions in 2013.
CBR: community-based rehabilitation; DPO: disabled people’s organizations, ISPRM: International Society of Physical and Rehabilitation Medicine;
NGO: non-governmental organization; PwD: persons with disability.
J Rehabil Med 47
3
Rehabilitation in Madagascar
of independent NGOs working in Anatanarivo, including OTs involved
in CBR programmes and those involved in assisting the University
of Antananarivo in developing training courses in Occupational and
Physical Therapy programmes. However, because there are various
levels of trained allied health staff, visiting NGOs, medical and other
volunteers in Madagascar the exact number of fully accredited reha-
bilitation professionals is unclear. Participants in these workshops
were invited by the Department of Health along with the University
of Antananarivo and comprised approximately 60% of the academic
and rehabilitation leadership teams across the country.
Prior to the detailed workshops, the host hospital’s lead medical and
allied health team provided presentations on their health services, includ-
ing specic challenges faced by their rehabilitation staff under the DAP.
All this volunteered information was supplemented with more specic
and recorded data during the workshop settings. The teaching programme
and workshops included basic principles of rehabilitation, disability care
planning, linking information technology (IT), data and health record
systems with acute hospital referrers and those in the community; CBR
and capacity building; and leadership skills development, etc. Based on
earlier presentations by lead local rehabilitation staff about issues they
faced in service delivery, the participants were then asked to work out
and discuss their views and perspectives of the various problems that
were highlighted relating to service provision, attitudes/approaches
to PwD, gaps in service provision, education, related challenges and
potential barriers and solutions designed to tackle these issues. At all
times the 2014–2021 DAP was used as a blueprint for discussion and
allowed the authors to educate the audience, many of whom were not
familiar with the document’s specics. In addition, a simplied overview
of the DAP worded for the French-speaking audience was used, using an
interpreter provided by the Malagasy Department of Health. This was
followed by a formal iterative decision-making and consensus process
tabulating potential challenges and facilitators in the implementation
of the DAP. Throughout the workshops, the author-facilitators recorded
all information provided by the participants in writing, as there was
limited access to computers or internet. In addition, they conducted a
desktop literature search of academic and grey literature using available
internet search engines and websites for relevant publications (including
academic articles, reports, related website contents, etc.) and discussed
relevant information with the participants. Known experts in this eld
were also contacted for further information on disability-related policies
and legislations. A formal presentation of all results from this exercise
was made by the authors to both the Malagasy Department of Health
and all workshop attendees on 7 October 2014.
RESULTS
Based on the above-stated multi-pronged avenues to obtain
data, an overview of current rehabilitation status and associ-
ated challenges in implementation of the WHO’s DAP was
summarized in 3 major sections: (i) burden of disability, (ii)
current developments, and (iii) WHO Global Disability Action
Plan, as follows.
Burden of disability
In Madagascar there is no epidemiological data on disability,
and limited data on disability-related burden. Based on the
worldwide disability prevalence rate-estimation of 15% (or
1 in 7 people) from the World Report on Disability (1), there
are an estimated 2.8 million PwD in Madagascar. NCDs are a
noteworthy cause of overall burden of disease in Madagascar,
contributing an estimated 29% of overall disability-adjusted life
years (DALYs) in 2004, followed by injuries (8% DALYs) (1).
Amongst NCDs, DALYs attributed to cancer are estimated at
12.1, for neuropsychiatric conditions 2.3, and for cardiovascular
diseases (CVDs) 2% (15). Communicable diseases are still the
main cause of mortality; however, NCDs contribute to 39%
of overall mortality, with 18% due to CVDs alone. The age-
standardized death rate due to cerebrovascular diseases (such as
stroke) is 134.9 per 100,000 (4). Consistent with other countries
in Africa (13), the prevalence of disability in Madagascar is
escalating due to an ageing population, a rise in chronic condi-
tions, political instability and economic down-turn. Despite
the lack of conclusive data on the economic and social costs of
disability for Madagascar, these costs are signicant for PwD
(their families), the community and the nation (1).
Disability policies and legislation. In 1997, the Malagasy
Government initiated the Law on Disability (Act No. 97-
044), to promote equal social rights and freedoms for PwD,
as for other citizens (16). The law advocates rights of PwD
for access to medical and rehabilitation services, education,
employment and social participation (4). In 2002, Madagascar
ratied the National Decade of Disabled Persons 2003–2013 in
accordance with the Continental Plan of Action of the African
Decade of Disabled Persons, and with the UN CRPD in 2007
(15). Madagascar has an operational multi-sectoral national
policy, strategy or action plan that integrates several NCDs
and shared-risk factors, and has some evidence-based national
guidelines/protocols for the management of major NCDs, us-
ing a primary care approach. The collaboration between acute
and rehabilitation facilities and various NGOs, who provide
social care for PwD, has improved in the last few years. More
work, however, is needed to implement these policies; and
surveillance and/or monitoring systems to enable reporting of
healthcare data are yet to be established. Compliance with the
UN standards, such as disabled access to buildings, parking,
transportation, etc., can be improved. The PwD have limited
access to advocacy, provision of assistive devices, aids, coun-
selling and community integration assistance. In general, the
public are unaware of the economic and social implications
for PwD. However, there is some progress, as Madagascar
subscribed to the International Health Partnership and related
initiatives (IHP+) in 2008, which aligns development partners
with a single national strategy, a monitoring and evaluation
framework and a joint review process to improve harmoniza-
tion and accountability for achieving the health-related Millen-
nium Development Goals (17). In the same year the Ministry of
Health also signed up to the guiding principles of a sector-wide
approach along with the 22 development partners to address
the challenges facing the health sector; however, it is unknown
if this contains rehabilitation medicine (17).
Human resources. Overall, there are an estimated 3,150 doc-
tors, 5,661 nurses and 385 community health workers currently
registered in Madagascar (15). However, there is a shortage of
trained and available healthcare professionals, and inequitable
distribution of staff across rural areas (particularly in the re-
habilitation sector). There are an estimated 1.6 physicians per
10,000 population in Madagascar, which is signicantly lower
than the regional average of 2.6 (14, 15). The Department of
J Rehabil Med 47
4F. Khan et al.
Health, in conjunction with a UK-based charity (OPT IN), com-
menced a mid-level diploma programme at the University of
Antananarivo approximately 4 years ago. This capacity-building
initiative is now being supported by the Royal Melbourne
Hospital, Australia. There are 10 rehabilitation specialists in
the country, including 8 new graduates. There is less than one
physiotherapist and nurse per 10,000 people (18), and no accu-
rate data are available regarding other rehabilitation personnel,
such as occupational therapists or speech pathologists, social
workers or psychologists. Importantly, the Malagasy Society of
Rehabilitation Medicine and allied health staff in rehabilitation
settings are focussing on building multidisciplinary teamwork,
communication and decision-making processes to operate as a
cohesive team. However, the lack of IT systems limits participa-
tion in web-based international teaching initiatives.
Service delivery. The Malagasy health system has been strug-
gling for some years, due to poverty, political uncertainty and
a decrease in international aid. Rehabilitation services are
still minimal for the general population, especially for PwD
and those living in rural areas. The few existing rehabilitation
services are not integrated with acute health services, and are
based in urban areas, mainly in the capital. There are, on aver-
age, 3 hospital beds per 10,000 population and 6 improved
rehabilitation services (4). The hospital infrastructure lacks
computers/fax and other administrative equipment. There are
no healthcare models or systems in place (e.g. patient referrals
from acute to rehabilitation services, follow-up after discharge
from acute care, timely access to medical records, etc.), which
results in fragmented care. There are no hydrotherapy facilities
or well-equipped gymnasiums for patients in hospitals or in the
community. Existing equipment is often in disrepair. The most
common physical therapy treatment provided in rehabilitation
facilities is massage, in line with the cultural expectation of re-
ceiving treatment. There are limited occupational therapy and no
speech pathology or psychology services at tertiary rehabilitation
facilities. Although the focus is on developing CBR; access to
qualied staff, lack of infrastructure and funding are the main
barriers for provision of customized programmes, patient educa-
tion and provision of appropriate equipment. At the community
level, care of PwD (including CBR) is predominantly funded
by NGOs and charitable organizations, such as the National
Collective of Organizations Working for Disabled Persons,
Handicap International, Christian Blind Mission, International
Red Crescent, etc. There are, however, operational NCD Depart-
ments within the Ministry of Health and Population.
Current developments
Like most sub-Saharan countries, current disability manage-
ment and supports in Madagascar are inequitable, under-
funded, fragmented, inefcient and often inaccessible (11).
Despite these barriers, overall health services show a trend
towards improvement over the past 2 decades (19), mainly in
the control and prevention of communicable diseases. In the
last 5 years, there has been some development in the reha-
bilitation eld. For example, Madagascar is one of few sub-
Saharan African countries with an established rehabilitation
network. The Society of Physical and Rehabilitation Medicine
was established in 2013, and since 2014 has been a member
of the International Society of Physical and Rehabilitation
Medicine (20). It has an active website to communicate with
its members and recently hosted its rst National Congress on
Cerebral Palsy (in March 2014). The Malagasy Rehabilitation
Society is currently outlining its standards and key performance
indicators and setting up data collection procedures to form a
national rehabilitation data-set.
More recently, there has been much interest amongst physi-
cians in postgraduate training in rehabilitation at the Univer-
sity of Antananarivo. Rehabilitation for specic conditions
requiring multidisciplinary input, such as spinal cord injury,
will commence in one tertiary facility in the capital in 2015.
There are measures to improve communication between health
professionals in rehabilitation services and the acute care sector
for improved patient referral procedures. While there is some
coordination between the government and NGOs (and charitable
organizations) for funded conferences/ workshops, education
and training opportunities must be expanded and sustained.
WHO Global Disability Action Plan
The DAP provides encouragement for all national and in-
ternational partners to enhance the quality of life of people
around the world (21). The WHO species all Member States
to promote this development and adapt it as a key national
priority. The main goals of the DAP are:
to remove barriers and improve access to health services
and programmes,
to strengthen and extend rehabilitation, assistive technology
and support services, and community-based rehabilitation,
to strengthen disability data collection for international
comparability, and to support research.
As stated above, similar to other developing countries,
Madagascar faces various challenges and barriers for im-
plementation of the core objectives of the DAP. Healthcare
priority is still primarily focused on acute care (19); sub-acute
care and rehabilitation services get less attention. The PwD are
amongst the most marginalized in Madagascar and are unaware
of their rights and benet entitlements. There are limited data
on the needs and unmet needs of PwD, impeding planning for
service delivery in rehabilitation. In general, there is lack of
awareness amongst citizens with regard to disability, which
is perceived as a curse and/or a contagious disease in many
parts of the country. This results in stigma and discrimination
against PwD, limiting their societal participation. Furthermore,
medical rehabilitation, including PwD, is not recognized by
citizens and their families and many prefer traditional or native
healers, especially in rural areas.
Based on participant feedback, consensus agreement and
using a bottom-up approach in developing recommendations
for the future, some of the potential facilitators and challenges
in implementation of the proposed standard actions in the DAP
for rehabilitation are summarized in Table II.
J Rehabil Med 47
5
Rehabilitation in Madagascar
Table II. Potential challenges and facilitators in implementation of the World Health Organization (WHO) Disability Action Plan 2014–21 in Madagascar (n=29)
Actions Current state Potential challenges/barriers Potential facilitators/enablers in the next 5–6 years
Objective 1: Remove barriers and improve access to health services and programmes
1.1 Develop and/or reform
health and disability laws,
policies, strategies and plans
Law on Disability (Act No. 97-044) 1997;
CRPD ratied: 2007; National Decade of
Disabled Persons (2003), The Madagascar
Action Plan 2007–12;
International Health Partnership and related
initiatives 2008
Health priority more driven towards acute sector and
communicable disease
Unstable political and economic situation
Poor past political commitment
Existing policies underfunded
Lack of coordination/collaboration among different
government sectors and ministries
Lag in implementation of existing policies
Lack of consensus on who is responsible for enforcing
and/or funding new legislations/policies
Health Ministry to develop health policies from coordination to implementation;
sectoral approach for alignment in disability care
Strengthen management capacity through legislation and regulation
Implement health nancing strategies for equity and social protection
International cooperation and WHO support
Knowledge management capacity-building initiatives
Strengthen National Health Information systems
Guidelines for public-private partnerships in healthcare
Review pharmaceutical policy documentation and surveillance systems
Establish a secondary level body for implementation and evaluation at the community
level
Involve PwD and community organization in policy development
Linkage with regional organizations, e.g. South Africa, Mauritius
1.2 Develop leadership and
governance for disability-
inclusive health
National coordination/funding: Ministry of
Health and Population
No central body for developing governance
Lack of coordination/ collaboration among different
government sectors, hospitals and CBRs
No disability-rehabilitation standards or key performance
indicators
No specic accreditation standards or criteria for
rehabilitation facilities and for staff
Limited workforce leadership development programmes
Ministry of Health – central capacity building body for health professionals and
management for operational effectiveness of regional health departments and quality
of services
Capacity-building for educators for health work-force
Implement plan for quality control and health inputs
Coordinate and link various government and NGOs with hospitals
More active role of National Association of Rehabilitation Medicine in facilitating
leadership skills and governance
Improve web-based access to evidence-based guidelines/protocols and outcome
measures for disability
Provide Key Performance Indicators and Standards of Care
Development of accreditation criteria for staff and rehabilitation facilities
1.3 Remove barriers to
nancing and affordability
for PwD
Per capita health expenditure $40 (2012);
Health expenditure as % of GDP 4.1 (2012);
Government health spending 15.3% (2012);
70% of total spending on health- 30%
contributed international donors and private
sources
Budget decit
Decreased international aid
Out-of-pocket payment for services
Lack of government/private insurance
Lack of legislation or national policy for employment/
education/health
Increased health budget expenditure in line with the African neighbours
More international nancial assistance
Training and educational programme for PwD – build workforce
Improvement of social welfare, livelihood and benets
Development of national social/governmental insurance coverage for PwD
1.4 Remove barriers to
service delivery
Approximately 3 hospital beds per 10,000
people
Lack of infrastructure
Non-disability friendly public places and transport
Geographical location – isolation
Lack of rehabilitation for specic conditions such as
stroke, spinal cord injuries, etc.
Lack of adequate referral system
Lack of multidisciplinary team approach and systems/
models of care
Lack of integration with acute hospitals
Development of infrastructure and awareness of existing services
Structured standard referral systems: acute to sub-acute
Promotion of community-based rehabilitation
Development of Mobile Units to deliver care in remote areas
Telerehabilitation and local technology
Provision of disability friendly public facilities and transportation
Public awareness and educational programmes
Public-private sector partnership for service provision
1.5 Overcome specic
challenges to the quality
of healthcare experienced
by PwD
Total death: NCDs: 39%; cerebrovascular
diseases: female 6.4% (age standardized death
rate: 134.9/100,000 population)
Poverty
High illiteracy
Discrimination and stigma
Poor awareness of health services
Misconception and cultural belief about disability
Belief in traditional or native healers
Limited access to disability services
Ministry of Health-central body to implement national health promotion policy
Minimization of cultural stigma through public campaigns
Skill training and educational programmes for healthcare staff
Development of consumer organizations for advocacy (including PwD at national and
local level)
Identify needs to develop initiatives for unmet needs of PwD
Development of strategies for engagement of staff and patients
J Rehabil Med 47
6F. Khan et al.
Table II. Contd.
1.6 Meet the specic needs
of PwD in health emergency
risk management
No information Lack of emergency assistance programmes for PwD
Lack of ambulance availability and transportation
Minimal collaboration and/or referrals between
emergency staff and rehabilitation personnel in tertiary
facilities
Rapid assessment and evaluation to identify needs to mobilize resources
Coordination of interventions
Build local capacity
Improve communication systems and collaboration between acute and rehabilitation
staff; International cooperation in humanitarian crises
Objective 2: To strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation
2.1 Provide leadership
for developing policies,
strategies and plans
Same as 1.1 above Same as 1.1 above Same as 1.1
More active role of Malagasy National Association of Rehabilitation Medicine
2.2 Provide adequate
nancial resources
No data available for welfare or support for
PwD and their families
Same as 1.2 Same as 1.2
Improvement of social welfare and livelihood
2.3 Develop and maintain a
sustainable workforce
PRM: 10 Physicians or 1.6/10,000 people;
(in 2010); total of 3150 doctors, 5661 nurses,
385 community health workers
PT:<1/10,0000 people
Department of Health commenced mid-level
Diploma course at University of Antananarivo
Interdisciplinary workforce – limited skill base
No educational standards or key performance indicators
(KPIs) for rehabilitation or continuous medical education
evaluation
No staff development or appraisal systems in hospitals or
community settings
Limited access to education or IT-based learning
Limited opportunity to train in new equipment for therapy
delivery or hydrotherapy
Inadequate distribution of healthcare professionals –
mostly urban setting
Limited infrastructures and professional courses/training
programmes in academic institution
Poor awareness amongst healthcare professionals about
workforce development
Demoralized workforce
Ministry of Health – develop a strategic workforce development plan
Establishment of national observatory for human resources
More funding and opportunity to develop a skilled workforce
More courses on disability in academic institutions and hospitals
Development of strategies for empowerment and staff engagement
Develop teaching models, using interactive problem-based learning
Increase clinical capacity through organized educational activities, e.g. journal clubs,
grand rounds, etc.
Motivation of clinical staff
Promotion of interdisciplinary teaching and interaction
Commence OT training using international links within region
Establish workforce management and retention programmes
Collaboration with international partners for staff training overseas
2.4 Expand and strengthen
rehabilitation services
ensuring integration, across
the continuum of care
Improve rehabilitation services No accreditation standards or key performance indicators
for rehabilitation
Rehabilitation services included with other general
hospital services not well integrated nor identied for
attention
Lack of structured standard referral systems from acute to
sub-acute care to community
Lack of healthcare delivery models for Rehabilitation
services
Minimal integration of community based programmes
with acute services
Poor follow-up after discharge from acute facility and
rehabilitation hospitals
Ministry of Health to establish clear accreditation standards for rehabilitation facilities
and key performance indicators
Develop rehabilitation services within the existing health infrastructure
Improved prole of rehabilitation services in acute hospitals
More community-based rehabilitation services linked with main hospital networks
Incentives and mechanisms for retaining healthcare personnel especially in rural and
remote areas
Use of IT systems, telemedicine and web-based services for improving awareness and
access
Provision of equipment and technology for therapy in rehabilitation
2.5 Make available
appropriate assistive
technologies
No information Lack of government services and health insurance
Private insurance does not include cover for rehabilitation
mobility aids (wheelchairs, cane, and walker), or those
for activities of daily living, orthotics, or prosthetic
devices.
Advocacy for assistive technology funding – Government and NGOs
Inclusion of PwD and consumer organizations to raise awareness about technology
Expansion of assistive technologies to rural areas
Development of Mobile Units
2.6 Promote access to a
range of assistance and
support services
No information Minimal information available to public about access to
rehabilitation services
Lack of insurance/ government support for accessing
rehabilitation services
Health Department to develop web-based campaign for support involving consumer
organizations and NGOs – promote awareness
Develop Mobile Units to deliver care in remote areas
Expansion of community-based rehabilitation through capacity-building
J Rehabil Med 47
7
Rehabilitation in Madagascar
DISCUSSION
Similar to other low-resource countries (13, 22, 23),
Madagascar faces many challenges in improving its
healthcare systems. The Malagasy people have con-
centrated on improving the acute-care sector given the
high prevalence of communicable diseases. The focus
on disability and provision of rehabilitative services,
however, is well below that of its African neighbours.
The concept of longer-term rehabilitation service de-
livery or lifetime care is not well established. Data for
disability are not disaggregated from general health
data, so the need for developing rehabilitation services,
outcome assessments and minimal key performance
indicators for the sector is unknown. Despite political
commitment to improving care and support for PwD,
the implementation of many basic policies remains
limited in terms of access to rehabilitation services,
geographical coverage, skilled work-force shortages,
limited IT systems and infrastructure; and lack of care-
models, and facility and staff accreditation standards
for rehabilitation. Although the prole of rehabilitation
medicine in the Madagascar health system has im-
proved in recent years, it remains poorly integrated with
acute healthcare systems. Rehabilitation participants
report low morale and a poor sense of achievement. The
patient referral mechanisms are unclear between acute
health services, rehabilitation and longer-term commu-
nity services. The lack of a central coordination body
and limited health services infrastructure compounds
the problem of comprehensive management of PwD,
as most healthcare services are based in urban areas.
Undesirable cultural stigma and poor awareness about
disability and rehabilitation amongst general citizens,
impedes access and service delivery.
The DAP provides comprehensive summary actions
for disability and offers the Malagasy Government,
policymakers, and other relevant stakeholders a blue-
print for implementing the recommendations of the
World Disability Report and CRPD. The Malagasy
people now have an opportunity and imperative to
improve and build on existing care programmes for
comprehensive care for PwD. Based on feedback and
consensus from participants in this report, there is need
for strong leadership for providing standards for reha-
bilitative care and key performance indicators for re-
habilitation facilities and staff involved. It is important
to engage and up-skill staff, provide infrastructure and
IT support, and assist in the integration of all relevant
sectors including NGOs and consumer groups (24). The
existing rehabilitation facilities require a skilled work-
force and access to equipment for therapy provision.
They need to be supplemented by local CBR centres,
especially in rural areas, with establishment of regional
hubs for improved access and broader-based services.
Given that the existing CBR staff (funded mainly by
NGOs), often have well-developed programmes, there
Table II. Contd.
2.7 Engage, support and
build capacity of PwD and
caregivers
No information No inclusion of caregivers of PwD in rehabilitation
Poverty
High illiteracy
Misconception and cultural belief about disability
Belief in traditional or native healers
Pursuit of social support by PwD – rather than being
independent and productive
Involvement and education of caregivers in rehabilitation settings
Improve awareness of existing services/benets for PwD/carers
Development of consumer support organizations for PwD at national and local level
Skill training for carers
Expansion of community-based rehabilitation through inclusion of carers in decision-
making processes.
Objective 3: To strengthen collection of relevant and internationally comparable data on disability and support research on disability and related services
3.1 Improve disability data
collection (survey)
Limited national data; Based on WHO Report
on Disability, estimated PwD 2.8 mil (15% of
total population)
Lack of reporting and information-gathering systems
Unreliable timely access to patient medical records
Rehabilitation workforce minimally trained in research
methodology including data collection
Promotion of operational research in disability and health systems
Set a minimal data-set for rehabilitation
Improve processes relating to clinical documentation
Commence medical staff training in research methodologies using audit tools
Establish hospital-based IT systems for data entry
Disability-specic registries in the future
3.2 Reform national data
collection systems based on
the ICF
No national data collection system; concept of
ICF not well understood
Lack of standard data collection systems
Minimal awareness and no incentive for hospitals or staff
to participate
Limited staff training and support for ICF usage
Implementation and training in ICF model
Develop standard data collection systems
Mandatory data collection across all sectors – acute and community
Linkage of performance indicators to health outcomes
3.3 Strengthen research on
priority issues in disability
Limited research in disability/rehabilitation Research not identied as a priority for rehabilitation
Limited support and IT available for research
Limited staff capacity and training for research
Lack of available research professionals
Little funding for research
Involve government and academic institutions to conduct research on disability issues
Train research professionals
Improve access to IT and web-based programmes
Build research capacity in rehabilitation
Cooperation with international partners in research and development
(Sources: WHO Country Cooperation Strategy at a Glance: Madagascar May 2014; WHO Country Prole; Regional Ofce for Africa WHO; WHO Health Statistics 2011; WHO Global Infobase; WHO
Bulletin; UN Human Development Report 2014). CRPD: Convention on the Rights of Persons with Disabilities; GDP: Gross Domestic Product; ICF: International Classication of Functioning, Disability
and Health; IT: information technology; NGO: non-governmental organization; PwD: persons with disability; WHO: World Health Organization.
J Rehabil Med 47
8F. Khan et al.
is opportunity for professionals in physical and rehabilitation
medicine and CBR to come together for improved clinical
practice and service delivery; as well as training and education.
A collaborative, coordinated and pro-active lobbying effort by
the Malagasy Society of Rehabilitation Medicine, consumer
organizations and NGOs will prioritize challenges that need
to be addressed for implementation of the DAP. The responses
and suggestions about specic items in the DAP framework
for action are listed in Table II.
This study has some potential limitations. Firstly, this is a
cross-sectional study and bulk of data were derived from the
interactive feedback from the healthcare professionals attend-
ing an organized workshop programme, rather than from a de-
tailed examination of certain hypotheses or through systematic
analysis. This study was intended as a preliminary descriptive
study, with the aim of updating knowledge about rehabilitation
efforts and plans in Madagascar based on implementation of
the DAP and identifying realistic challenges and strengths
from the participants’ perspective. Secondly, the study cohort
is made up of health professionals selected by the Malagasy
Health Department, which may limit the generalizability and
validity of these ndings. The authors were not involved in
any participant selection process, and this was also beyond
their remit. The study cohort, however, covers rehabilitation
professionals from a wide geographical population in Mada-
gascar, and represents the wider sample currently operational
in the community. The authors believe the ndings reect the
current issues/problems faced in the country at large. They are
unaware of any similar study conducted in Madagascar or any
sub-Saharan country that addresses this issue.
In summary, there was consensus amongst all Malagasy
participants in the workshops that further steps required to
develop rehabilitation medical services in Madagascar should
include the following:
develop and tailor DAP recommendations to suit the lo-
cal environment, for accessibility to mainstream services,
policymakers and administrators
improve infrastructure for disabled access to transport and
buildings; as well as benets and social support systems
establish and sustain leadership from the Ministry of Health
for setting rehabilitation standards for accreditation and key
performance indicators
establish collaborative integrated models of care and service
delivery supported by infrastructure, IT and evidence-based
rehabilitative care
up-skill, educate and develop the rehabilitation workforce
using technology and web-based systems
engage the workforce, consumers (their caregivers) and
NGOs for lobbying and improved awareness of disability
services and the social and economic impact of disability
develop systematic data-collection methods to inform reha-
bilitation outcomes and research capacity in rehabilitation.
In conclusion, the DAP summary actions were useful plan-
ning tools to improve access and strengthen rehabilitation
services and CBR, and collate data for outcome research and
benchmarking. The process was culturally sensitive and ap-
preciated by all participants including the Ministry of Health.
This is the rst narrative report of participants contributing
local knowledge to the actions recommended by the DAP to
achieve various objectives in the real world using a bottom-up
approach in the Malagasy setting. A similar follow-up confer-
ence designed around education and training, in which the DAP
is constantly reviewed under improved data acquisition and
analysis, is recommended.
ACKNOWLEDGEMENTS
This article was supported from internal resources of the Rehabilitation
Department, Royal Melbourne Hospital, Royal Park Campus, Melbourne,
Australia. No external funding was available. No commercial party hav-
ing a direct nancial interest supporting this article has or will confer a
benet on the authors or on any organization with which the authors are
associated.
We are grateful to all participants attending the interactive work-
shops. We particularly wish to thank Drs Rakakotonirainy J. J. Renaud
(Ambatomaro-Antananarivo Centre) and Bona (Antsirabe Rehabilitation
Centre), and Ms Anri-Louise Oosthuizen (University of Antananarivo),
Mrs L. Amatya (CBM) and M. Marella (Nossal Institute of Global Health),
for their assistance in preparation of this manuscript. We acknowledge
M. A. Chamberlain, OPTin and S. Andrianabela, Ministry of Health,
Madagascar for their invitation to the authors to visit major rehabilitation
centres in Madagascar.
The authors declare no conicts of interest.
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J Rehabil Med 47
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... A few papers mentioned community health/disability workers as well as physiotherapist (PT)/OT assistants whose job scopes were not clearly described. 7,11,19 In some instances, family physicians took on the role of rehabilitation doctors, 15,21 and much of the job scope was shared among available rehabilitation workers in various capacities (task shifting). Support and training initiatives toward capacity building came from international as well as national agencies, government as well as NGOs. ...
... Support and training initiatives toward capacity building came from international as well as national agencies, government as well as NGOs. 6,[10][11][12][14][15][16]18,19,21,25 Barriers Human resources and training A shortage of rehabilitation physicians and allied health workers, lack of training programs for their professional development, absent or variable credentials, and/or licensing and lack of paid positions were among the challenges. ...
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