DEVELOPMENT OF NEPALESE ACADEMY OF PHYSICAL MEDICINE REHABILITATION

DEVELOPMENT OF NEPALESE ACADEMY OF PHYSICAL MEDICINE & REHABILITATION

BACKGROUND: Small, developing, land-locked country with Himalayas in the north. Life Expectancy at birth 69. 2 years (2013) Per capital income USD 730 (2014) People below poverty line 25. 2% (2010) Doctor: Patient Ratio 1 doctor/5 -6, 000 population • Disability: – ~ 2% of the total population (estimation 7 -10%). – Number of hospitals and allied health professionals working for the people with disability is very limited. – Number of physiatrists is ZERO!!! 2

Objectives: 1. To describe (Background): a) Disability: social attitude b) History of rehab medicine c) Epidemiology of disability d) Legal provisions for disability e) PM&R specialty in Nepal. f) Post-earthquake status 2. To describe (NAPM&R): a) Initiation efforts b) Current scenario c) Mission, Policies & Objectives d) The constitution e) Future plans and goals f) Challenges g) Activities. 3

METHOD: • Description of situation of rehabilitation medicine in Nepal and the formation of NAPM&R. 4

RESULTS: 1. With >500, 000 people with disability, ~90% of them living in the rural areas & very few rehab hospital & health care professionals, the condition of PM&R specialty in Nepal was found to be in very early stages of development. 2. Existing laws are almost adequate but the implementation is ineffective. 3. Multiple in-person meetings & telecommunications between 7 Nepali physicians related to PM&R around the world led to the formation of NAPM&R, urged by the deadly earthquakes of 2015. 5

1, a: Disability: social attitude • Cursed: sin of previous life! Sign of bad omen! Fate! Gone prestige! • Chained: may cause harm to themselves or others! • Curbed: from attending traditional & religious events! • Inconvenient: unfriendly infrastructure (access to government services, transport, education, recreation, etc. )! Positive: changing attitude Negative: but not enough 6

1, b: History of rehab medicine, NEPAL • Rehab patients: – Warfare (religious scriptures, unification of Nepal, war with British, Gorkhalis at war, Maoist war); – Natural calamities (Earthquakes, flooding, landslides, avalanche, etc. ) – Mountain climbing: 7

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• Rehabilitation history of Nepal: – Religious scriptures: Lord Ganesh and moksha; patuka – lumbar corset – Charitable organizations (international, government & local societies): – 1969: 1 st organization - Nepal Disabled & Blind Association. – 1977: Social Service National Coordination Council Ministry for Social Welfare, Legislation for Rights & Welfare of Disabled, Establishment of Social Welfare Council, etc. ) – Since 1992: December 3 rd is celebrated as International Day of the Disabled persons. 9

• What impacted the changes in Nepal: 1975: UN Declaration of Rights for Disabled People. 1981: UN Declaration of the IYDP. 1983 -1992: UN Decade of Disabled Persons. 1982: UN World Program of Action Concerning Disabled People. 1990: UN Education for All �meeting basic learning needs. � 1994: UN world conference on � Special Needs Education. 1997: Dhaka Declaration - � all Governmental and NGOs working in this region recognize that handicap and disability are development issues. – 2003 -12: Asian and Pacific Decade of Disabled Persons. – Nepal has ratified 7 international conventions & including UNCRPD. – – – – 10

1, c: Epidemiology: disability • Historical surveys: – House counting: before modern Nepal, counting for warfare activities. – National Census: 1 st 1911, disability included in 1971 – Sample Survey of Disabled Persons in Nepal (1980), – National Survey of Blindness (1981), Mental Retardation (1989), Prevalence of Deafness & Ear Disease (1991), – Situation analysis of disability by NPC (2001) etc. 11

• 2001: 0. 46 % PWD a/t national census, NPC reported 1. 63%, and in 1995 UNICEF estimated 10%. (1 -13%). • 2001 vs. 2011 12

• 2011 National Census – 1. 94% of the total population has disability (36% has physical disability) – More than one third of the PWDs are less than 30 years old, illiterates have 3 times higher chances to have some form of disability; M: F ratio = 1. 2: 1; Rural: Nearly 90% • Female: – 54%: health problem due to her disability – 45%: Reproductive health issues like UTI, Abortion, vaginal discharge. – More violence, discrimination, illiteracy, inaccessibility to health care. – 2010 Supreme Court: focus on reproductive rights, not implemented. 13

• Children: – children with disabilities are not identified as a distinct disadvantaged group. – overall school enrolment of children with a disability ~ 1%. • Elderly: – Population of elderly is increasing – one-fourth of PWD are aged 60 years or more. 14

• • 15% of PWDs are treated for their disability. >50% disability arise before age of 5 years. 68% are literate 80% aware of rights but unable to access them 80% unemployed Minority population, poor, women are more affected Less than 1% have a lavatory with a flush 1% have access to vocational training 15

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1, d: Legal provisions: disability Disability rights has depended on the democratic rights. • 1 st legislation: Disabled Protection and Welfare Act (1982). Education, Health, Employment, Transport, Social Welfare, etc. The rules to implement was completed only in 1994. • Special Education Policy (1997); Education Act (2000); Social Welfare Act and Child Protection Act (1992); Protection and Welfare of the Disabled Persons Rules (1994); Local Self. Government Act (1999) 17

• Interim constitution 2007: provision of disability ID cards as per categories, social protection allowance for multiple disability/severe disability, allocation of small budget at local government, etc. • National Disabled Children Mx Policy (2008); Disabled ID Distribution Directory (2009); Government scholarship program implementation (2014) • New constitution of 2015: similar to interim constitution: basic rights equality, national inclusion committee, local level jurisdiction, etc. • Out of 601 MPs, 1 is PWD. 18

• Definition of disability by NG: – “Disability is the condition of difficulty in carrying out daily activities normally and in taking part in social life due to problems in parts of the body and the physical system as well as obstacles created by the physical, social, cultural environment and by communication”. • Types of disability by NG: 2011 census followed this • Classification of disability based on the degree of severity: complete, severe, moderate, mild 19

• l. OOKS GOOD (on paper)! • main problem is i. MPLEMENTATION! 20

1, e: Need of PM&R specialty We already have a rough idea about: • History • Current situation • Legislation and its implementation • Statistics • Future scenario and need 21

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Country National Organization Established year Bangladesh BAPMR 1995 China CARM, and CSPMR 1983, 1985 India IAPMR 1972 Japan JARM 1963 Philippines PARM 1960 Korea KARM 1972 Malaysia MARM 2004 Thailand RCPT 1998 NEPAL NAPM&R 2015/16 28

2, f: Post-earthquake status • Preparing for implementation of a national health sector strategy for the next 5 years and the health system is being restructured. • Right time to address needs of PWD by strengthening the health system and operationalizing community based rehabilitation. • Need of a standard database and monitoring system to regularly assess social inclusion of people with disability. • 2015 earthquakes (killed 8, 000 deaths & 21, 000 injured) has stimulated the initiation of PM&R specialty in Nepal and improvement in overall attitude towards disability. 29

2, a: NAPM&R -Initiation efforts • Post-earthquake volunteering: 7 Nepali physicians’ story • Local support: • International support: 30

2, b: NAPM&R - Current scenario 2 residents currently in training in Bangladesh Few medical students interested in PM&R residency Limited number of rehab departments and hospitals Limited number of allied health professionals related to rehab medicine • NAPM&R not yet registered with government • Limited funding & resources • • 31

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2, c: NAPM&R – Mission, Policies & Objectives • Mission: To initiate and establish PM&R specialty in Nepal and make Nepal a friendly country for PWD. • Policies: Non-governmental, not-for-profit, professional and scientific organization to work for and be responsible for PM&R specialty in Nepal. Work towards protecting the professional rights, supporting its members and enhancing the services provided. Not to be involved in any form of politics. Function within the limits of the existing laws and order of Government of Nepal. 38

• Objectives: 1. To support Nepal in the development of PM&R specialty according to the need of the country. 2. To work for professional benefit and to uplift professional status of the members. 3. To work for improving the professional skills of its members and maintain the standard of the services provided. 4. To encourage scientific and research activities in the field of PM&R. 5. To publish newsletters and journals in the field of PM&R. 6. To organize workshops, seminars, training and conferences. 7. To establish scholarships and awards in the field of PM&R. 8. To increase awareness about PM&R. 9. To establish relations with international PM&R societies as needed. 10. To make Nepal a friendly nation for PWD. 39

2, d: NAPM&R - Constitution 40

• Preamble: • Chapters: 15 1. 2. 3. 4. 5. 6. 7. Preliminary Definitions Policy and Objectives Source of funding Membership and Power, Functions and Duties of the Members Limitations Management of the Academy 8. Provisions relating to general assembly and functions 9. Executive body 10. Power, Functions and Duties of Executive body members. 11. Election procedures 12. Motion of no-confidence 13. Constitution amendment 14. Financial regulations 15. Additional articles 41

2, e: NAPM&R - Future plan & goals • • Rehab hospitals Rehab manpower Rehab research Rehab technology Rehab awareness: local, national National and International collaborations Action plan: next 2 years 5 year strategic plan 42

2, f: NAPM&R - Challenges • Societal challenges: Fear, lack of knowledge, disregard and superstition in society. Lack of awareness. • Many good programs and policies, but disability is still not recognized as a development agenda in Nepal. • Good legal provisions, but not well-implemented and within the provisions there are discriminatory practices. • Limited infrastructures, technology and manpower. • Geographical & financial challenges. • Organizational structure of NAPM&R. 43

2, g: NAPM&R - Activities • The PM&R symposium: 14 th ASCo. N Nepal conference, Dec 2015 • International presentations – 1 st oral presentation about NAPM&R, at Joint Congress of 5 th AOCPRM and 26 th Annual Convention of PARM, Cebu, Philippines, Feb 2016. • Ongoing and near future activities: – Introduction lectures in medical schools, persuasion to include rehab medicine in the medical school curriculum. – Discussion with NA, NG & universities about PM&R department, residency training program and development of PM&R in Nepal. – Establish official relationship with ISPRM, AOSPRM, etc. 44

Rehab hospitals in Nepal • Nepal Disabled Association Khagendra New Life Centre (NDAKNLC) was established in 1969 as Nepal Disabled and Blind Association. • HRDC: 1997 • Green Pasture: 1997 • SIRC: 2001 45

Allied health groups in rehabilitation: • • • Rehab nurses: NEPTA: 2002 POS Nepal: ANOT: 2008 SLP: Psychosocial counselor: Peer counselor: Dietitian: Recreational therapist: Vocational education trainer: 46

Opportunities in Nepal: • On top of opportunity to initiate and establish PM&R specialty and to make Nepal a friendly nation for PWD, there are unique opportunities in Nepal in the field of rehab medicine: i. High altitude rehab ii. Disaster rehab iii. Adventure sports for rehab iv. Research activities v. Integrated rehab medicine with Ayurveda and yoga. 47

CONCLUSIONS: 1. Medical specialty of PM&R is an immediate need for Nepal. 2. Construction of a national rehabilitation hospital and local production of physiatrists and allied health professionals related to rehab medicine should be a top priority. 3. NAPM&R should take a lead to establish this specialty in Nepal. 48

REFERENCES: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 2013 World Bank Data 2013 Human Resources for Health, Country Profile Nepal; 2001 and 2011 National Population and Housing Census of Nepal (National Report) Panthi MR. The Disability Situation in Nepal. Disability World. Issue no. 24. June-August 2004. Chomba Wa Munyi. Past and Present Perceptions Towards Disability: A Historical Perspective. Disability Studies Quarterly. Vol 32, No 2 (2012) Joshi SK. Disability in Nepal. Kathmandu University Medical Journal (2004) Vol. 2, No. 1 pp 1 -5 Panthi MR. The Disability Situation in Nepal. Disability World. Issue no. 24 June-August 2004. New Era's (Sponsored By: National Planning Commission (NPC)/HMG, Nepal and Unicef/Nepal. September 2000) survey. Thakur SC. A situation analysis of disability in Nepal. Tribhuvan University Journal. Vol. XXV, No. 1, 2005 page: 19. National Disabled Women’s Association, 2007 survey. Population monograph of Nepal 2014. UNICEF Disability Report 2008 -2010 Flash I Report 2011 by the Ministry of Education 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. Nepal Disability 2011 by UNRCHC, Nepal Policy paper on Nepal Disability by DHRC 2006 Am. J Phy. Med and Rehabil Vol. 86 No. 5 (2007) The Disability Movement in Nepal article by Shudarson Subedi President, DHRC Nepal UN Convention on the Rights of Persons with Disabilities 2006 Paudel YR, Dariang M, Keeling SJ, and Mehata S. Addressing the needs of people with disability in Nepal: The urgent need. Disability and Health Journal. In press. Jan 2016. http: //www. sanatan. org/english/wpcontent/uploads/sites/4/2015/05/1413904410_shivfamily. jpg (image) http: //media. spundge. com. s 3. amazonaws. com/users/fe 8 ca 52 4163 c 11 e 3 adb 112313 d 2 b 58 c 5. jpg (image) https: //pbs. twimg. com/media/CFH 8 p 79 VEAA 3 fk 6. jpg (image) http: //c 8. alamy. com/comp/D 12 FF 1/epa 03494832 -a-nepalesedisable-man-tries-to-navigate-his-way-through-D 12 FF 1. jp (image) https: //c 1. staticflickr. com/5/4113/5440037532_ca 8 c 63 d 885_ b. jpg (image) Photographs from SIRC, Nepal (images) NAPM&R Proposed Constitution, 2016 Dhakal R, Poudel MK. Nepalese Academy of Physical Medicine and Rehabilitation – An overview. Presented at ASCo. N Nepal conference. Dec 2015. NEPTA, ANOT, POS Nepal’s websites. 49

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