COMMUNITY BASED REHABILITATION (CBR),

A MODERN AND EFFICIENT WAR VICTIMS

REHABILITATION CONCEPT
Autors:
Boo Ljubi,
M.D. Ph.D., Professor, University Hospital Mostar
Nadeda Zjuzin, M.D., Ph.D., Professor, Medical Faculty Sarajevo
Zdravko Troli, M.D., Ph.D., University Hospital Mostar
Goran erkez, M.D., Federal Ministry of Health, B&H

Jan 14, 2016

Community based Rehabilitation

(CBR)

OBJECTIVES OF THE PRESENTATION

Reasons for rehabilitation system reform in F BiH

Community based rehabilitation key component of
the War Victim Rehabilitation project
The role of community based rehabilitation within
the rehabilitation system in general (based on
questions to CBR centers )
Assessment of former rehabilitation programs,
assessment of CBR concept and expectations
(based on questions to disabled and health
professionals in CBR centers)
Strengths and weaknesses
Jan 14, 2016

CBR

MAJOR REASONS FOR THE REFORM OF HEALTH

SYSTEM IN FB&H

Irrationality

and inefficienci of inherited model

Health services inequity regarding acces and
quality
War consequences: Change of epidemiological
pattern(large number of injuried and disabled,
increase of mental disoders, cardiac and
cerebrovascular diseases....), Health facilities and
medical equiment devastated, Flee of medical
professionals, Lack of financial resorces
Jan 14, 2016

CBR

MAJOR AND ADDITIONAL REASONS FOR THE

REFORM OF REHABILITATION SEVICES IN FB%H
PREWAR AND POSWAR( War related) RAHABILITATION
SERVICES
Tertiary level None (Central Rehabilitation Institute in
Sarajevo destroyed in war)
Secundary level None (except departments for phisical
medicine in hospitals and clinical centers)
Primary level None
WAR RELATED INJURIES AND DISORDERS
More than 70.000 need for some form of phisical rehabilitation
due to war caused injuries
More than 20.000 persons have some form of permanent
disability and 5.000 are amputees
More than 15% of the total population suffer from some mental
disorders due to the war

Jan 14, 2016

CBR

WAR VICTIMS REHABILITATION

PROJECT COMPONENTS

1.

2.
3.
4.

Community based rehabilitation /CBR/

centres; 38 for phisical and 38 for mental
rahabilitation
Production of prosthesis and orthoses network
of 6 units
Orthopeadic and reconstructive surgery-all
prewar facilites
Implementation support-scientific snd tehnical

Jan 14, 2016

CBR

COMMUNITY BASED REHABILITATION /CBR/

CENTRES-REASONS

Delivery of services to population in community

(50.000-70.000)
Establish CBR Center within primary health care
level, ensure access to clients (in particular to persons
with disabilities)
Home visit rehabilitation services
Enhance the role of persons with disabilities in the
rehabilitation process
Training role training of teams, family members
and local community
Jan 14, 2016

CBR

B O S N IA A N D H E R Z E G O V IN A
F E D E R A T IO N O F B O S N IA A N D H E R Z E G O V IN A
PR O JE C T M A P

C B R P H IS IC A L R E H A B .
C BR M EN TA L R EH A B

Jan 14, 2016

CBR

B O S N IA A N D H E R Z E G O V IN A
F E D E R A T IO N O F B O S N IA A N D H E R Z E G O V IN A
PR O JEC T M A P

P R O ST H E T IC C E N T E R S

Jan 14, 2016

CBR

B O S N IA A N D H E R Z E G O V IN A
F E D E R A T IO N O F B O S N IA A N D H E R Z E G O V IN A

O & R SU R G E RY

Jan 14, 2016

CBR

COMMUNITY BASED REHABILITATION /CBR/

CENTRE - BASIC REQUIREMENTS

Space (150-200mm2 )
2. Equipment (Physical therapy,
kinesithreapy, software, library, psychosocial support, TV, Cameras...
3. Medical professionals: Physical medicine
and rehabilitation specialist,
physiotherapist, occupational therapist,
nurse, psychologist
1.

Jan 14, 2016

CBR

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Evaluation

COMMUNITY BASED
REHABILITATION /CBR/
CENTRES-FOLLOW UP STUDY
1997-1999 and 1999 - 2001),
Conducted in cooperation with Queens
University,Kingston, Canada
Jan 14, 2016

CBR

11

COMMUNITY BASED REHABILITATION /CBR/

Survey conducted in 38 Centers-16 Questions

22 Centers delivered valid data
Total delievered services 166.558

15%

Total number delivered

procedures= 2.617.438

85%
Adult

Average number of procedures

per patient=15

Children

Jan 14, 2016

CBR

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COMMUNITY BASED REHABILITATION /CBR/

CENTRES- TYPE OF DISORDERS

2.369

17.036
war injuries
other injuries
degenerative diseases
amputees

46.239
26.808

Abaut 50% are patients with war related and oder injures
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CBR

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COMMUNITY BASED REHABILITATION /CBR/

CENTRES - TEAM COMPOSITION

Average number of team members: 6,5

Minimum=3
Maximum=11
Team composition
1. Physiatrist= all
2. Physiotherapist=all
3. Nurse/technician=all
Other professionals( logoped, psychoterapist...some
centres)
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CBR

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COMMUNITY BASED REHABILITATION /CBR/ CENTRESVERTICAL/HORIZONTAL COOPERATION

Cooperation with other Centres 82% YES

18% NO
Cooperation with cantonal hospitals, clinical
centres and specialized institutions 100% YES
Hospital referrals percentage:
1. Average
9%
2. Minimum
1%
3. Maximum
30%
Jan 14, 2016

CBR

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ASSESSMENT OF COMMUNITY BASED REHABILITATION

PROGRAM (PERSONS WITH DISABILITIES n=151 )

Age of persons with disabilities

12%

9%
8%

7%

11%

7%

9%

15%
11%

15-19
20-24
25-29
30-34
35-39
40-44
45-50
51-54
55-59
60+

11%

Majority persons with disabilities (15%) between 45-50

Jan 14, 2016
CBR

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ASSESSMENT OF COMMUNITY BASED

REHABILITATION PROGRAM (PERSONS WITH
DISABILITIES)
Gender of persons with disabilities
54%
Female
Male

46%

Jan 14, 2016

CBR

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ASSESSMENT OF COMMUNITY BASED REHABILITATION

PROGRAM (PERSONS WITH DISABILITIES) (N=149

Cause of disability
21%

direct war
injury
indirect war
injury

57%
22%

non war
related injuries

43% direct and indirect war related injuries

Jan 14, 2016

CBR

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ASSESSMENT OF COMMUNITY BASED REHABILITATION

PROGRAM - PERSONS WITH DISABILITIES (N=151)

Level of assistance required by disabled

Functioning level made on the basis of five-grade evaluation
scale

Dependant, unable to participate in activities, fully dependant:

11

(7%)

Maximum physical assistance, able to assist, but needs assistance:

19 (13%)

Minimum physical assistance, needs below full time assistance

65 (43%)

Supervision, needs oral instructions, or some assistance to perform

activities:
and Independent, able to perform activities independently

(6%)

47 (31%)

Most interviewed persons 65(43%) need minimum assistance

Jan 14, 2016

CBR

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ASSESSMENT OF COMMUNITY BASED REHABILITATION

PROGRAM - PERSONS WITH DISABILITIES (N=151)

Employment and income status

73(48%) unemployed
9(6%) run private business
69(46%) do not work, or do not receive
salary
79% income insufficient to meet the needs

Jan 14, 2016

CBR

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SATISFACTION LEVEL WITH FORMER REHABILITATION

PROGRAMS-PERSONS WITH DISABILITIES (N=151)-LIKERT
SCALE

Table: Satisfaction with former services

Highly
satisfactory
(n=91)

(29%)

(20%)

(13%)

(26%) (4%)

(* includes clients which did

not respond)
Total satisfactory: 62%
Medium answer:
satisfactory

Jan 14, 2016

(2%)

(6%)

Highly
dissatisfied

(services not delivered n=60)

Total dissatisfactory> 12%

CBR

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FORMER REHABILITATION PROGRAM WEAKNESSESS

IDENTIFIED BY PERSONS WITH DISABILITIES

Response

Number of persons

No comments

Program inappropriately organized,

inappropriate organization

Access, clinics are distant from clients, clients

waste their time to travel to distant clinics,

10

Majority persons complain accessibility to rehabilition centres

Jan 14, 2016

CBR

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HEALTH PROFESSIONALS SATISFACTION LEVEL WITH

FORMER REHABILITATION PROGRAMS (n=31)-LIKERT SCALE

Table: Satisfaction with services

Highly
satisfactory

1
(23%)

(16%) (39%) (10%) (3%)

6
(6%)

Highly
(3%) dissatisfactory

(n=31); (did not participate in former programs = 21

Total satisfactory: 78%; Total dissatisfactory : 12%

Medium point: Partly satisfied

Jan 14, 2016

CBR

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FORMER REHABILITATION PROGRAMS WEAKNESSES

IDENTIFIED BY HEALTH PROFESSIONALS(N=24)

Most frequent response

Number of persons

Nothing inappropriate about the former

rehabilitation programs

Financing, lack of economic and social support

Inappropriate organization, program

implementation, lack of plan

Access, clinics are distant from clients, clients

waste their time to travel to distant clinics

14

Most interwied professionals identified access as key weakness

Jan 14, 2016

CBR

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ASSESSMENT OF COMMUNITY BASED REHABILITATION

PROGRAM BY PERSONS WITH DISABILITIES (N=151)

Requirements for better involvement of persons with

disabilities in the rehabilitation process ?
1. Advocacy-18( most frequent response)

The need for a person, or a body to influence the

Government or protect the rights of disabled
2. Conscience and attitudes -14+11 (second
frequency ranking response)

Change societal attitudes about disabled and

their needs 14

Enhance conscience -11

3. Change system-9
Jan 14, 2016

CBR

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QUESTIONNAIRE ANALYSIS PERSONS WITH DISABILITIES

AND HEALTH PROFESSINALS

Questions:

About former rehabilitation programs

About attitudes, beliefs and behavior
About general social topics

About CBR expectations

Both groups agred:

CBR will enhance public conscience level on
disabilities issues
CBR will upgrade community services support in the
society
CBR will help to disabled to return to independent
living
Jan 14, 2016

CBR

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COMMUNITY BASED REHABILITATION

-DISCUSSIONWeaknesses and obstacles
1.
2.

3.
4.

Psycho-social rehabilitation partly in function

Community based mental rehabilitation
concept and infrastructure provided under
the program, but non-functional in practice
Lack of volunteers participation
Lack of participation of persons with
disabilities

Jan 14, 2016

CBR

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COMMUNITY BASED REHABILITATION

-DISCUSSIONAchievements

Better access to community based

rehabilitation
2. Cost-effectiveness (equal or better
results for less funds)
3. Reduction of hospital referrals
4. Medical rehabilitation aspect provided
in both local community and patients
home
1.

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CONCLUSIONS
Experience gained after six-years implementation and 3years
CBR operation program:

Local community based rehabilitation concept has many

strengths in particular for poor societies and post-conflict
situations
A full success of this rehabilitation model requires reform
changes in both health sector and societal attitudes to
persons with disabilities
It is necessary to continue research on functioning, training
of health professionals, beneficiaries and community
Jan 14, 2016

CBR

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