The rehabilitation response in Haiti: a systems evaluation approach

The response to the earthquake in Haiti in January 2010 was rapid and multi-sectoral, bringing together UN agencies, international military forces and government and non-governmental actors. Physical rehabilitation (primarily physiotherapy, occupational therapy and prosthetics and orthotics) provided vital assistance to the large numbers of people injured during the earthquake. The Convention on the Rights of Persons with Disabilities (CRPD) adopted in 2008 requires states to ensure that people with disabilities have access to mobility devices, and to ensure the protection and safety of disabled people in situations of risk, including armed conflict, humanitarian emergencies and natural disasters. This article discusses the results of a study carried out by the London School of Hygiene and Tropical Medicine, with funding from the Christoffel Blinden Mission (CBM), to assess the impact of the emergency physical rehabilitation response after the earthquake.

What is physical rehabilitation?

Rehabilitation is defined as a set of measures that assist individuals who experience disability to achieve and maintain optimal functioning in interaction with their environment. Rehabilitation reduces the impact of a broad range of health conditions and can involve single or multiple interventions. Some rehabilitation interventions can involve lifelong care. Prosthesis and orthesis services require lifelong services to repair and replace orthopaedic devices. Rehabilitation is much more than the provision of orthopaedic devices. It requires a continuum of care ranging from hospital care to rehabilitation in the community. It aims to improve the health status of the population, reduce disability and improve quality of life. Rehabilitation outcomes are the functioning capacities of an individual over time. However, the ultimate objective of rehabilitation combined with other interventions (education, social work, psychology, employment) is to ensure the social inclusion of people with disabilities.

The International Society for Prosthetics and Orthotics (ISPO) and the World Health Organisation (WHO) estimate that 0.5% of the population need prostheses or ortheses and related services, such as physiotherapy. Several factors have increased the need for rehabilitation services, including an ageing population, chronic conditions like cerebral palsy and club foot, malnutrition, diabetes, domestic violence, road traffic accidents, domestic and occupational injuries, armed conflicts and landmines and causes often related to poverty. The growing need for rehabilitation services can also be attributed to the collapse of health systems in post-conflict or post-disaster countries, where vaccination and health services are not fully operational or fail to cover the whole population.

Main findings

The study began in January 2011 with London-based preparatory work. Fieldwork in Haiti was conducted through the course of three visits: an exploratory visit in March 2011; a second visit in May–June 2011, when most of the data was collected; and a final visit in October 2011 to share preliminary results with stakeholders and clarify outstanding questions before final publication of the report. Data was collected using a variety of qualitative methods, including in-depth interviews, observation of rehabilitation sites in Haiti, a review of organisational documents and statistics and social network analysis.

Context

Prior to the 2010 earthquake, data regarding the scale of rehabilitation needs in Haiti was not available. Rehabilitation services were scarce. Prosthetic and orthotic services were very weak, as were in-patient rehabilitation services, and no treatment for spinal cord injuries existed. Before the earthquake, the government did not recognise the importance of rehabilitation as part of health care services and consequently did not provide any support to service providers. As a result, rehabilitation services were financed and administered by external donors and organisations, many of them affiliated to churches. No standardised physiotherapy training was available; although training initiatives were in place there was no consensus on a standardised national training model. To qualify as physiotherapists, occupational therapists or orthotists, students have to travel to the Dominican Republic or elsewhere in Central and North America. The low demand for these types of services prior to 2010 did not encourage Haitian professionals trained internationally to return to Haiti to practice, and most stayed abroad where business was better.

Coordination

The creation within the Health Cluster of the Injury, Rehabilitation and Disability Group, co-chaired by the national authorities and two international NGOs, CBM and Handicap International, had a positive impact on the coordination of the emergency response in the rehabilitation sector by involving a wide range of national and international stakeholders. Compared to the health sector, the rehabilitation sector was very quick to bring Haitian actors on board and give the lead to national actors (i.e. national authorities and local non-governmental organisations). However, as in other sectors of the response national actors rarely attended cluster coordination meetings as they were usually conducted in English instead of Creole or French, and because travelling to and from the heavily secured UN compound outside of the city was time-consuming and expensive.

Relations with national authorities

CBM and Handicap International made considerable efforts to ensure that the national authorities remained at the centre of the rehabilitation response, and that responsibility for the coordination of rehabilitation services was shared. Despite this, national involvement was hindered by political instability within the government and the unclear division of responsibilities between the Ministry of Social Affairs and the Ministry of Health. High staff turnover made it difficult for the national authorities to build relations with partners, adopt and maintain consistent approaches to capacity- building and plan and implement joint activities.

The social network of the rehabilitation sector

According to the social network analysis carried out by the study, the rehabilitation sector comprised 125 actors. They varied in nature (international, local, hybrid, apolitical, Christian), size (budget, number of personnel) and role (service delivery, donor, technical support, advocacy). Most of the links between actors were generated by CBM and Handicap International. While the ‘connector’ role played by these two organisations was positive, the ‘system’ created through these connections is unlikely to be sustained if CBM and Handicap International leave.

From emergency to development

Rehabilitation goes beyond the delivery of one-time treatments. It requires follow up and continued care over months and even years. For example, a prosthesis needs to be replaced every year or two years. This means that rehabilitation actors need to start building the foundations of the future rehabilitation sector from the early stages of the emergency. Four months after the earthquake, more than half of the people accessing rehabilitation services were not earthquake victims, an indication of both the high level of rehabilitation needs and the lack of services prior to the earthquake.

Service delivery

The short-term contracts of many medical and rehabilitation teams delivering care in the first six months after the earthquake and the lack of systematic recording of users made it difficult to generate good data on service delivery. The high turnover and short-term presence of many emergency medical teams between January and October had a negative effect on the morale of Haitian staff and disrupted efforts to build local capacity. The free or subsidised medical care provided by international medical teams also undermined private sector service providers. Both of these factors contributed to the out-migration of Haitian professionals and damaged the quality of clinical and rehabilitation care. Many of the smaller organisations that intervened in the rehabilitation sector in Haiti did not have experience in humanitarian settings and were not familiar with international guidelines concerning the delivery of services in low-income settings (e.g. Sphere or the International Society for Prosthetics and Orthotics (ISPO) guidelines).

Conclusion

One of the key features of the humanitarian response in Haiti after the earthquake was the large influx of actors with little or no experience of humanitarian response. This was also apparent in the rehabilitation sector. The findings from this study highlight the need for internationally agreed standards to guide humanitarian actors in providing rehabilitation services post-disaster. Currently, the only rehabilitation-specific guidelines are the WHO’s Guidelines on the Provision of Manual Wheelchairs in Less-Resourced Settings and the Guidelines for Training Personnel in Developing Countries for prosthetics and orthotics services. These provide minimum standards for orthopaedic devices and place the user at the centre of the rehabilitation process. There are no explicit guidelines for physiotherapy/occupational therapy in post-disaster settings, including spinal cord injuries, the most prevalent injuries in the Haiti earthquake.

National and international rehabilitation professionals who responded to the disaster in Haiti recommended the elaboration and promotion of international guidelines for the provision of rehabilitation services in emergency settings (including standards of practice for rehabilitation medicine, physiotherapy and occupational therapy). The lack of standards was strongly felt in the rehabilitation sector because of the influx of international actors with no previous experience in disaster response, and the lack of government capacity to regulate the sector. Efforts are underway in Haiti to augment and standardise the training of local rehabilitation professionals, which should improve services in the country in the future. Although the Cluster coordination mechanism created links between the various actors involved in the rehabilitation sector, greater effort is required to build a vision of the future rehabilitation sector for the country. The elaboration of international standards in physical rehabilitation, similar to the Sphere standards, will help make professionals aware of their responsibilities towards local populations.

Karl Blanchet and Myroslava Tataryn, International Centre for Evidence on Disability and Public Health in Humanitarian Crises Group, London School of Hygiene and Tropical Medicine.