Rehabilitation services for visually impaired persons in West Africa, the challenges of integration

International Congress Series 1282 (2005) 50 – 54 www.ics-elsevier.com Rehabilitation services for visually impaired persons in West Africa, the challenges of integration Simon Bush*, David N. Botwey Sight Savers International, West Africa Regional Office, P.O. Box KIA 18190, Accra, Ghana Abstract. The World Health Organisation estimates that not more than 2% of the disabled people have access to any form of rehabilitation services in the developing world. The emergence of community-based rehabilitation (CBR) as a community development strategy for increasing coverage of rehabilitation services to disabled people generally with the involvement of communities and families in the delivery processes seem to be catching on fast with many donors and implementing agencies in almost every country in West Africa. Target beneficiaries in our CBR programmes are predominantly irreversibly visually impaired persons, their families and the local communities as primary stakeholders. Low vision services for both adults and children are yet to go beyond the provision of affordable glasses. Programmes are managed within a comprehensive eye service set up. Local governments and mainstream service providers currently participate in the rehabilitation process as secondary stakeholders. The main frontline personnel are trained and resourced volunteers, while core technical staff co-ordinate service delivery that range from psychological, social and economic services. In response to key recommendations of a recent evaluation of the CBR projects in the Gambia and Ghana, Sight Savers is embarking on a review process that will shift greater participatory roles to visually impaired people, their organisations and local governments as key stakeholders in the design, implementation, monitoring and evaluation of CBR from a programme structure and perspective. D 2005 Elsevier B.V. All rights reserved. Keywords: Rehabilitation; West Africa; Service; Integration; Visually impaired 1. Introduction West Africa has been experiencing challenging trends in the development of rehabilitation services for visually impaired persons for over 50 years. The beginning of the 21st century witnessed initiatives targeted at individual visually impaired persons mainly * Corresponding author. Tel.: +233 21 774210/768935; fax: +233 21 774209. E-mail address: sbush@sightsavers.org.gh (S. Bush). 0531-5131/ D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.ics.2005.04.016 S. Bush, D.N. Botwey / International Congress Series 1282 (2005) 50–54 51 in the homes of the early missionaries. Post-World War II ushered in the work of NGOs and state organized interventions. Existing programmes aimed at rehabilitating visually impaired people in the West Africa sub-region include; segregated residential rehabilitation centres, outreach rehabilitation projects and Community-based rehabilitation projects. This paper presents an overview of rehabilitation programmes and service for visually impaired persons in West Africa, supported by Sight savers International (SSI), and the challenges and learning that have informed the trend in developing rights based rehabilitation services. 2. The issue and need West Africa covers a vast area of Africa from Senegal and the deserts of Mali to the lush virgin rain forests of Nigeria and Cameroon. It takes in countries with stable democratic governments to those that are autocratic and at war with themselves or just getting out of war. Some countries have oil and agricultural wealth while others are at the bottom of the UNDP Human Development Index and average percentage capita of less than $1.00 per day. About 90% of the world’s 45 million blind and visually impaired live in developing countries (WHO), out of which about 3 million live in West Africa. 80% of blindness is avoidable, 60% treatable and 20% preventable. Only about 2% of disabled people in the developing world have access to any form of formal rehabilitation services (WHO). The needs of blind people vary according to their individual circumstances and location. Most countries in the sub-region are at the parliamentary reading stage of the passage of the disability rights bills. In West Africa, Sight Savers International has set itself a high target of promoting the Comprehensive Eye Service concept, whereby the provision of integration of Eye Care, Inclusive/Integrated Education and CBR services in a given location is the focal direction of our work. 3. Blindness in West Africa Cataract, glaucoma, trachoma, vitamin dAT deficiency and injuries through accidents and civil conflict are major causes of blindness in West Africa. The situation is compounded by River Blindness, a devastating disease. River blindness is found mainly in West and Central Africa. It is endemic in 30 countries in Africa, a few in Latin America and in Yemen. The disease is caused by parasitic worms, spread by the bite of the black simulium fly. It causes years of suffering, including severe itching, before invading the eye and leading to permanent blindness. The disease is now under control in many areas of Africa, but the effects of the disease can be felt in every community where there are large numbers of irreversibly blind people. There is a need, however, to ensure that rehabilitation services are available to those blinded by River Blindness and from other causes of blindness. 4. Overview of SSI CBR policy The Sight Savers policy of 1992 on Rehabilitation provided operating guidelines for the introduction of the concept of Community Integrated Rehabilitation for the Blind (CIRB) or Community Based Rehabilitation of the Blind. The policy considers that rehabilitation programmes should be needs based, goal-orientated and time-limited. 52 S. Bush, D.N. Botwey / International Congress Series 1282 (2005) 50–54 A new SSI Policy on CBR, which is soon to be completed, will seek to encourage appropriate interventions at three operational levels of advocacy, partnership development or capacity building and direct intervention from a rights-based perspective. 5. Needs-based approach to rehabilitation services for the blind Based on the CBR policy of 1992, SSI support for rehabilitation service delivery to irreversibly blind and visually impaired people in West Africa boarded mainly on needs based approach. This approach was implemented in Nigeria, the Gambia and Ghana, in the form of projects that were dubbed Community Integrated Rehabilitation of the Blind (CIRB). Characteristic feature of the CIRB approach were as follows: ! A dominant NGO, usually a Church, was the legal partner. ! The projects coverage was based on the local Government areas of jurisdiction. ! There was a district rehabilitation manager committee, and a Unit or Community rehabilitation management committee. Visually impaired people were nominated, along gender balance, to serve on the various committees. ! Local volunteers were recruited through the URCs and trained to provide front-line services mainly in awareness raising, case finding and referrals. ! The projects were manned by a full-time manager with the support of at most two technical (CBR) field workers. ! The CIRB projects had strong networking relationship with existing social service agencies, especially the Eye Care project and Inclusive Education programme. 6. Rehabilitation services in the CBR projects Rehabilitation services provided by the CIRB projects were mainly psycho-social and economic services for irreversibly blind and visually impaired people while building a context within the family and the community. The projects’ beneficiaries had an intrinsic role to play in achieving this, as advocates for their own needs, supported by lobbying and advocacy by the projects at the district level. The range of core rehabilitation related activities undertaken included: ! Case finding (identification), referral for medical screening, treatment and follow ups. ! Providing counseling and basic training in Orientation and Mobility (O and M), and Daily Living skills (DLS). ! Providing social and economic rehabilitation and micro-credit through mainly referrals to specialized collaborating agencies. ! Working with local societies of the blind to provide empowerment training. ! Raising awareness of blindness issues within the communities and supporting advocacy for disability rights. 7. The rehabilitation development programme As part of measures to meet the needs in rehabilitation services in the region, Sight Savers International (SSI) introduced the Rehabilitation Development S. Bush, D.N. Botwey / International Congress Series 1282 (2005) 50–54 53 Programme (RDP) within the West Africa Regional Office in March 2001, with the primary objectives to provide training to rehabilitation personnel in SSI supported CIRB projects and facilitate the efficient management and expansion of rehabilitation projects in a manner that will facilitate inclusion within family and community circles. Towards this drive, SSI now supports an 18-month diploma Programme for rehabilitation field workers in the University of Winneba in Ghana to provide accreditation for the trainees. The rational was to provide rehabilitation field workers in West Africa with a means for job security, a career path and occupational progression. 8. Key learning from CIBR evaluation in Ghana and the Gambia Two major evaluations were carried out in October 2003 and November 2004 into the CBR projects in Ghana and the Gambia and the Rehabilitation Development Programme (RDP) respectively. The key learning points from the CIRB evaluations were: ! That the CBR concept should be promoted for uniformity with allied projects worldwide. ! That rehabilitation services should be mainstreamed within the decentralization structures of the Local Government Authorities from a programme perspective. ! That the sector Ministry for Social Welfare, Health and Education should be encouraged to play key roles. ! That the role of the organizations of visually impaired persons should feature throughout the structures and operations of the project. ! That the ratio of field worker to volunteer to beneficiaries should be more realistic and sustainable. ! That clear bench marks for minimum level of service intervention had to be set. ! That advocacy must be central in the projects’ activities. ! That feedback from field monitoring must reflect in review and personnel training. 9. Key learning from the RDP evaluation ! That shorter training workshops for CBR workers, e.g. Orientation and Mobility, on the ground should be reintroduced. ! That shorter modular course on specific subjects, e.g. micro-credit, etc., should be introduced and outsourced. ! That learning from field monitoring and quality control measures had to be related to training and refresher training. ! That research, documentation of best practices and dissemination of learning had to be improved. 10. Using learning from the two evaluations in project design Learning from the evaluations of the Ghana and the Gambia CBR projects and the RDP have greatly influenced the design of new CBR projects in Sierra Leone and the latest project being planned in Cameroon. The following are core elements in the 54 S. Bush, D.N. Botwey / International Congress Series 1282 (2005) 50–54 Sierra Leone project that seeks to articulate the shift towards the rights based approach: ! The Sierra Leone Association of the Blind (SLAB) and the Ministry of Social Welfare, Gender and Children’s Affairs (MSWGCA) are joint partners. ! The management structure of the project synchronizes with the current Local Government structure. ! The design and implementation of the project are mainstreamed within the MSWGCA administrative and operational systems. ! The implementation of a SLAB membership development as a parallel project. ! The introduction of Participatory Action Learning methodologies for gathering baseline impact indicators, project monitoring, evaluation and assessment. 11. Conclusion Disability led CBR projects in most parts of the world have shown remarkable successes, and we mean to succeed with our attempts in Sierra Leone and other parts of the region, where organizations of visually impaired persons are being encouraged and supported to play a central role in the implementation of national CBR Programmes. The service domains of low vision, recreation and advanced orientation and mobility training are yet to be exploited fully. We have over the years come to the realization that the use of participatory practices in the roll out of rehabilitation services for visually impaired person in West Africa can be effective for promoting social inclusion. Thank you.