Implementation of Community Based Rehabilitation (CBR) for Children with Disabilities in Tajikistan, lessons learned and steps forward From 4th Child Protection Forum in Tajikistan, 2013.

1. Ministry of Health of the Republic of Tajikistan

2. National level ( Hospital
based care -Matchiton, Karabolo, etc..)
Regional (PMPC*)
District (PMPC,
CBR Support
rooms, Day
care Services)
Jamoat and
village
level (CBR
Support Rooms, play
corners, CBR
workers and home
visiting nurses)
* PMPC – Psychological Medical
Pedagogical Consultation Centres

3. Main functions of the PMPCs are:
• Assessment and Diagnosis of children with disabilities:
• Early intervention / rehabilitation: Specialists of the PMPC provide
rehabilitation for children with disabilities. Special training and support is also
provided to family members for them to better support their children at home;
• Gate-keeping: The PMPCs have the authority to refer/recommend various
options for the children with disabilities. They can refer as appropriate to an
upper level in the pyramid to community based care. Their mainly aim is
inclusion as much as possible.

4. CBR is a strategy within general community
development for rehabilitation, equalization of
opportunities and social inclusion of all children and
adults with disabilities.
CBR is implemented through the combined efforts of
people with disabilities themselves, their families and
communities, and the appropriate health, education,
vocational and social services.

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CBR
Empowerment

7. • Ministry of Health, with support from UNICEF and WHO,
immediately responded to contain the virus through mass
immunization campaigns
• Issue of rehabilitation and inclusion of those affected was given
equal importance from the beginning;
• CBR: A model for Tajikistan to ensure inclusion and to
provide for rehabilitation for children affected by polio and
other children with physical disabilities;
• Ministry of Health lead to introduce CBR in the 25 most affected
districts, in coordination with MLSP and MoE;
• Support from:
UNICEF
• As implementing partners:
Operation Mercy
Handicap International

8. • More than 800 stakeholders received basic knowledge and
training on rehabilitation and inclusion:
• Referral system through PMPC strengthened
Health care workers Education staff
Social workers Representatives from DPOs
and Association of Parents
Community leaders Volunteers
CBR Working Group established to
coordinate efforts and share expertise
(UN, INGOs and ministries)
Awareness-raising of the population
and parents

9.  21 CBR support rooms established staffed by a mix of
nurses, doctors, social workers who had a basic training in
CBR, childhood disabilities, parents‟ psychosocial support
and inclusive education.
 About 350 children received orthotics through the new mobile
team of the orthopaedic workshop under the MLSP
 18 schools have been provided with ramps for accessibility
(more needs to be done for toilettes, and changing mindsets)
 DPOs and parents associations for CWD mobilised to
support the CBR process
 Went much beyond children affected by polio: More than
1,000 children with disabilities were reached in 25
districts and basis for CBR was established.

10. Gulnora was weak on her right
side after polio – there was start
of scoliosis. She was supported
to do active exercises to
strengthen her trunk muscles at
the support room in Sharinav
Gulnora is now going to regular
school in grade 1
She can walk and participate in
all activities in her school and
neighbourhood with the help of
an orthotic on her leg.

12. • Geographical Coverage: 3 districts
• (Rudaki, Khujand, Babajon Gafurov)
• Partnership with PMPC for:
• Cross-referral
• Inclusion in schools
• 200 children reached
• Local NGOs and DPOs are supported
• Activities:
• Early intervention through Day Care and kindergarten
• Group based rehabilitation (physical, intellectual, social rehabilitation)
• Individual consultations and home visits
• Training for parents
• Inclusive education programme
• Income generation activities
• Education (health, parents), prevention

13. In fall of 2012, Azizbek could not walk, he was shy.
His speech was at the level of a 2 year old and hard
to understand.
Soon after he started coming to the CBR room with
his mother, he learned songs, colors and to count.
He gained self confidence, and become an outgoing
child without any fear to try and climb up wherever
he can.
When he was introduced a walker his face was
shining with pride and joy to finally stand up and
“walk”, even though he now needs to learn how to
use the walker properly and improve his leg and hip
movements.
Azizbek was one of the children who received an
orthopedic device through the Orthopedic workshop.

14. • Handicap International started being
active in Khatlon region in January 2010
• Provided technical support in
strengthening capacities of workers at a
local day-care centre
• Currently: 2 CBR projects, extending
over 15 districts and covering over 1000
children
• One larger project, performed through:
• Local NGOs
• Social Assistance at home units
• Another project directly through
strengthening support groups at head of
districts
• Both working with similar workers/
volunteers and associations, but with
different level of input and trainings

15. • CBR project in Ghonchi
district, with the support
of EU and Caritas
Germany
• 20 rehabilitation workers
trained
• 28-day initial training to
use WHO package on
training every day self-
care, communication,
mobility and learning
skills at home and on

16. • Decrease in dependency by all 130
PWD, from all age groups, who
participated in program from 2010-
2012
• None of the participating families
interrupted their training programs
• All participants had their first
experience of rehabilitation
• Sustainability through local social
service unit, in cooperation with
health and education sectors

17. At the age of 5, Burkhon could not sit
or move, or eat independently.
He was constantly taken care of by his
mother, who was not provided with
information on know how to help her
son to become a more independent
individual.
3 months after Burkhon„s mother
started learning `home-based
rehabiliation` with a CBR worker,
Burkhon learned to: sit, hold his head,
and use his hands to play and to eat by
himself.
12 months later, Burkhon recieved locally manufactured and state- provided
appliances such as seats, standing supports and a wheelchair to help him
move outside his home. He started attending school once a week besides
recieving home education.
Today, Burkhon is a talented school-boy of 8 . When he grows up he
wants to become an English language translator.
Real life story 3: Burkhon

19. • Cost-effectiveness;
• Maximize resources of government and (I) NGOs
• Cover both urban and rural areas;
• Family and communities ownership;
• Maximal impact through early identification and intervention
• Not merely rehabilitation provision; strategy for inclusion
and community development promoting access to:
• Health
• Livelihood
• Education
• Social life and protection
• Empowerment!

20. National
level
Regional
level
District level
Community level

22. • Institutionalization
• Professionalization
• Sustainability
• Collaboration mechanisms initiated, to be
further developed
• government
• local NGOs
• INGO
• DPOs, Parents Associations, and self-help
groups

23. An inter ministrial working group on CWD has been established with
decree of the Commission on Child Rights.
• It can be strategically used to promote further development of and scaling up
of CBR
Funding opportunities
• Strategic use of the new Ministry of Health – WHO – USAID rehabilitation
program to build on the knowledge gained for scaling and building a
rehabilitation program to support CBR implementation in Tajikistan
Physiotherapy and Occupational therapy are included in the list of
professions
Cost-effectiveness and impact indicators should be further measured
Interest raised and commitment achieved at the local level
Involvement of Disabled People‟s Organisations and Association of
Parents with Children with Disabilities at the local level, coalition of
Parents Associations and DPOs
Kishti Day service providing support to families and support prevention

27. CBR has been implemented by INGOs since
2005, but
For Tajikistan, 10 years after being certified
as polio free , the tragedy of the polio
outbreak became a catalyst for introducing
at a larger scale CBR as a low cost viable
model for reaching out to the most
vulnerable and hardest to reach children
with disabilities

28. • UNICEF
• WHO
• USAID
• Operation Mercy
• Handicap International
• Caritas Germany
• Mercy Corps

29. Operation Mercy (Khujand, Babajon Gafurov, Rudaki), Handicap
International Khatlon Region, EU CARITAS (Vahdat, Gonchi,
Konibadam) , EU –MLSP, (Hissor, Kurgan Teppa) UNICEF – MOH
(in co-operation with, OpMercy and HI, 25 districts in DRD and
Khatlon) , ADD MERCY CORPS