Sunday, February 23, 2014

Ecosystem and its link with physiotherapy

In very simple form, ecosystem can be defined as the interaction between organism and their environment. Here the interaction refers to exchange of energy between organism and environment to keep them living and sustainable. In scientific term, organisms are called the biotic component and nonliving goods are called abiotic component, both components are interrelated. Human being falls under the biotic component of ecosystem having dominant control on whole system. The ecosystem are life support system from where organism receives the food, water shelter and others basics. Over population and increasing industrialization is the main factor that compromises the synergistic relationship with both biotic and abiotic component. The disturbance on ecosystem directly compromises the health and livelihood of human beings as they also depends on other component within the same system.

Let’s discuss how the human beings are affected with the change in ecosystem services. 

Food: Damage to ecosystem reduces the production of food which is basic need for every living creature. Decrease supply of food results malnutrition that may predispose the population to developmental delays (in children) leading to the disability. Under nutrition also downsizes the responsiveness of body immune system which predisposes creatures to diseases and finally to the death(if not managed properly). The state of children report published by UNICEF-2013 highlighted malnutrition as one of the leading causative factors for disability. Developmental delays and cerebral palsy are the common disability marked when there is a poor or under nutrition. These sort of disability are often associated with problem in eating and swallowing due to the weakness or impairment in body parts like hands, trunk and swallowing mechanism. The problem in posture after the cerebral palsy or the developmental delays is also one of the factor that hamper the adequate nutrition  (even though availability of food is sufficient) thus predisposing them for the further impairment. The further impairment on such populations makes them weak and more sedentary which reduces their contributions to the ecosystem.

The physiotherapist has major roles to support people with disability to make their life more functional and mobile. Exercises and the facilitation to improve the hand, trunk function and posture are designed by physiotherapist. For some people with disability, only exercises may not assist to be more independent on feeding, at such instances prescriptions of assistive devices could be done. Only prescription of devices without the follow up may not work, the physiotherapist has role to train on how to have the proper and wise use of such devices. United nation convention for the rights of people with disability article 20 also focuses on the user and family training after the prescription of any devices- proper training directs towards the proper use of devices without the harm.

Water and sanitation: Some findings of global ecosystem assessment suggests that about 1 billion people in the world lack the access to safe water supply, while 2.6 billion lack access to sanitation. Globally it is often said and postulated that investment on the safe drinking water and improvement in sanitation directly relates to promotion of human health and ecosystem productivity. Let’s link the discussion with the physiotherapy and disability.  According to the world report of disability 15% of the world population comprises the people with disability. Similarly, WHO guideline on the provision of manual wheelchairs says that 1.5% of the total population needs the wheelchair services. Likewise, World report on the disability says 0.5 % of the total populations need prosthetic/ orthotic devices. WHO also states that out of the total needy population with disability, only 5-15% of the populations have access to the rehabilitation services that includes physiotherapy, assistive devices and other specialized services.

The physiotherapy facilitated by qualified physiotherapist to the person with disability before and after getting the assistive devices increase the mobility of person with disability. The increased mobility facilitates the increased access to water resources and toilet. Access to toilet promotes its usage. Proper use of toilet reduces the possibility of spreading the infections originating from the fecal maters. Experts say that Nepal has still 96% of the rehabilitation needs that is to be addressed. The physiotherapy and the provision of the assistive devices is also one of the major activities that falls under the rehabilitation need. But the physical accessibility of the water resources and toilet is also one of the factors that could obstruct the access even after receiving the physiotherapy and mobility aids. The ministry of women children and social welfare has already developed the accessibility guideline. The proper implementation of this guideline while constructing the water resources and toilets would simply wonders a lot.

Participation: Participation is also one of the facilitating factors to promote the access to the services like health, education, livelihood, empowerment, social opportunity ( as suggested by WHO CBR guideline). The increased mobility and the participation promote the social contribution of people with disability. For example afforestation could be one of the attempts to protect the environment where the person with disability also participate directly if she or he has adequate mobility.

As stated above people with the disability constitute the 15% of the world population. The ecosystem conservation and strengthening initiative will not be participative and complete if this huge group is missed. The increased participation due to increased mobility after the rehabilitation (for the people who need it) promotes their contribution for the ecosystem. The physiotherapist has the very dominant role on facilitating the activity of the daily living and mobility of the person with disability to or closest to the independent level.

Monday, November 18, 2013

Make it inclusive, practical and mutisectorial- Thought for international toilet day

Proper use of toilet is still secondary on many parts of the country. In some of the part construction of toilet is taken as the burden to their economy status even that is affordable and in some places people do not afford to make it. In many stances, the constructed toilets are not disability inclusive due to the accessibility issue. Salute to ODF campaigning for promoting the use of toilets and make an area free of open defecation Zone (ODF) in many parts of country. According to the national census, about 1.94% of people in Nepal are with different type of disability which is more than 5,13,321. It’s very important to ensure that these many populations have proper access to toilet as UNCRPD also obligates state party to ensure right to health for the person with disability. Infections which are supposed to be spread after not using toilet simply due to the poor accessibility could be dangerous and alarming public health issue and nonetheless this may tarnish the aim of making Nepal an open defecation free zone. Therefore, it’s very important for the ODF campaigners to ensure the disability inclusiveness during the implementation.

Thanks to one who are involved in ODF campaigning and declaring the VDCs and district an open defecation free zone. When I go to the different districts, I see a sign board on the VDCs that’s telling," This particular VDC is an open defection free zone". It’s really praiseworthy that at least right holders, decision makers and service providers of these places aimed and decided to make their area an open defecation free zone. But declaration is work that is done in table and the very vital thing is the real implementation. Inculcating the habit of wisely using the toilet is a long term process where the routine follow up and re-sensitization is very important to sustain the real implementation of the ODF campaigning. Routine follow is a time consuming process hence the campaigning should be done in close collaboration with the local groups and authority. FCHVs and social mobilizers of VDCs are volunteers who are in constant touch with the local people and who have the information about the real scenario of the VDC. Therefore, they can be the potential human resource could be trained and deployed for the follow up in the community as the part of their regular work.

Let us link the ODF campaigning with the government of Nepal published accessibility guideline that obligates state and non-state actors to ensure the accessible environment (for the person with disability) in the public places. Hence philosophy of this guideline needs to be well incorporated during the implementation and follow up process of making Nepal an ODF free zone. International rehabilitation experts says that only 4% of the total rehabilitation needs are being addressed in Nepal. Still Nepal has 96% of the rehabilitation needs that has to be fulfilled. The rehabilitation needs could be physiotherapy, assistive devices, corrective surgeries and other specialized services. The rehabilitation services are directly linked with the mobility of the person with disability. Increase mobility of the person with disability increases the access to toilets and other sanitation measures.  Therefore, multi sectorial collaboration is something very desirable at the implementation level.  Multi sectorial collaboration for the inclusive ODF campaigning could  be resulted by distributing the resources and responsibility among right holder-person with disability, decision makers-state party/ministries/DDC/VDC and service providers to the person with disability- rehabilitation center located in each regions of Nepal.

Since today is international toilet day, let’s rejuvenate ourselves s to make Nepal an ODF free zone. Let’s have a positive hope that the newly elected leaders will lead and make this campaign a very success setting an outstanding example in this world.

Tuesday, October 15, 2013

Wheelchairs should be a sequential & human right based approach of the service delivery

Oh! My god, “what I did before could have been better done”. I think, in most of the stances health professionals could be thinking as I thought on the first sentence. Sometime things humiliate us in such a way that gaps and the challenges that have been executed unknowingly in the past are realized after some period of the time. In fact, I should not term them as a gap and challenge rather I should say it as a lesson learnt and obviously I am going to replicate and disseminate the lesson learnt in the mass of people who need it.

As we all know that medical modalities or intervention is followed based on the weightage of the evidences behind it. The practice at present in comparison to the past couple of decades is of high difference. With the passage of time, medical interventions and approaches goes on upgrading and updating day by day. One should not term the previous practice a mistake as that could be the best evidence based practice of that particular period of time. But it’s very mandatory to be updated on the new findings and start incorporating it in supervision and then finally autonomously.
Now I would like to correlate my above thoughts into real life incident that has been faced recently. World Health Organization (WHO) has developed the basic wheelchair service training targeted for the people who work in wheelchair service provision. Let’s go little before, in 2008, WHO had produced a guideline on, “Provision of manual wheelchair in less resource setting”.  This guideline was targeted to all technical and non-technical workforce involved or to be involved on the wheelchair services. Based on this guideline, the WHO has made the basic level training specially targeted for the technical work force involved or to be involved in wheelchair service provision. Physiotherapists are one of the core technical workforces required for the proper wheelchair service provision. Thanks to organizers and my organization for providing me this golden to be the part of this training in June 2013.

The training content presented the wheelchair service as the human right based approach of the service delivery. It correlates the wheelchair service with the article 20 of UNCRPD-Personal mobility( In fact the concept is beautiful and should be respected too. We as a physiotherapist have a most often tendency of looking or judging the world from the angle medical sciences only but there are the lots of dormant psychosocial factors that is directly or indirectly affecting the activity of daily living and social participation of the person. We should be proud of our profession as we are delivering the services which are directly related to supporting our beneficiaries for the achievement of their rights & benefits and equalization of the opportunities. Not only on the wheelchair service delivery, we should be equally elaborative on considering the bio psycho-social   and human right based approach of service delivery to all our beneficiaries.

Let’s come again on the WHO made wheelchair service training. It consists of 8 thorough steps right from the referral/appointment to the follow up /repair. It’s very important to follow the entire step in a sequence otherwise it attributes to the violation of human right based approach, obviously harming and this is also against the oath that we have taken at our graduation day. Delivering the wheelchair for the new user may take more than 3 days following this approach. Any one may think that it’s too time consuming process, but what I think is, this is a team work. That’s why people in a team need to know this and implement it based on the individual job responsibility. One of the step of this package is user training, where a user and family member need to know how to handle and maintain wheelchair in different circumstances. Remember the time when you started learning riding the bicycle. I bet, it takes a time and practice and also think that your body parts were mobile that adjuncts the fast learning of bicycle riding. But the person with disability may not have all body parts mobile. Proper user training limits the chances of wheelchair accident and prevent person from injury or impairment (which again can result the disability). Similarly the user training supports family member and user on maintaining the wheelchair making it more durable and long lasting (the cost of wheelchair commonly used in Nepalese community ranges from 13000-35000)
The WHO recently made service training package has been uploaded in a website- It’s very important for all to be familiar with this package. It’s not too complex, it’s a beautiful collection of the simple interventions which are easy to learn and replicate. In the much part of the country, still wheelchairs are distributed in a charity basis in a mass without proper assessment, prescription, fitting, user training and follow up.  It is equal to giving medicine without doctor assessment and prescription and this can be fatal. Distribution of wheelchair without following the proper sequence violates the principle of no harm and is the wastage of resources in less resource set up like ours.
Though the government of Nepal has a provision of free health services to poor/impoverished person with disability, still delivery of the physical rehabilitation including the proper wheelchair services has not been sighted. The recent announcement of government of Nepal on financially supporting the person with spinal cord injury should be applauded but again the rehabilitation and provision of proper wheelchair service after the medical management should also be equally realized and implemented. The accessibility guideline prepared by government of Nepal is definitely a praiseworthy step which has definitely provided the glimpse of increasing accountability takeover by state party for the equalization of rights and benefits of the person with disability.

We should also appreciate the distribution of wheelchairs through local clubs and NGOs to the person with disability. Being an important person (physiotherapist) of the wheelchair service provision, we should never step back on supporting and strengthening those clubs or NGOs by educating or providing our technical expertise.

Sunil Pokhrel

Monday, May 13, 2013

Accessibility guideline imposes government of Nepal for defining the physiotherapist quotas at least at the district level

Salute to the right holders, state and non-state actors, who have actually played a very dominant role to roll out  the Government of Nepal(GON) validated accessibility guideline. This should be considered as one of the big initiative to include person with disability in developmental process. One should also realize this achievement as the assurance by state parties towards the equalization of rights, benefits and opportunities of the people with disability.

 No doubt, infrastructure can be certainly made maximum accessible during the re-innovation and reconstruction phase which takes place routinely for physical infrastructure on public places. The chief public places where people with disability often need to attend for their basic rights like health, education , employment should be completely accessible right from the beginning.  Inaccessible environment on these places makes the person deprived on attaining basic human rights. Deprivation from  basic rights tarnishes an idea of the including the people with disability as the potential contributor of the developing Nepal. Therefore, from million angles, the decision of making the public places an accessible place sounds perfect. On other hand, implementation of this guideline from GON obligates state parties and non-state parties to assure the things as directed on this guideline.

Now the government of Nepal has already finalized guideline. The next big challenge behind is the real implementation. I see two major parts on the implementation, one is reconstruction and another is making old inaccessible infrastructures into accessible one. Seems there is a need of huge financial resources on both to be constructed and to be reconstructed/re-innovated infrastructure,  to make them accessible as per the definition in guideline. Now, begins the countdown of crucial time for state and non-state actors to plan and implement directions incited by guideline through appropriate and vigilant utilization of the resources.

Making  infrastructure accessible requires qualified human resources around the country. One may just think that government of Nepal has enough engineers to make those things done at central and districts level. Yes, of course, it's the engineers who have lots to with the constructions. But if we see from another angle, disability is sector where the other technical human resources like physical therapists have to do a lot. Physical therapist assess and manage to improve the functional activity of person with any disability who have complains on performing the independent activity of daily livings and ambulation. This may also include the prescription of assistive and other orthopedic devices. Hence, physiotherapists are one of the major goal owners’ who facilitate the physical rehabilitation of the person with disability to make them independent enough for the activity of daily living.

Accessibility is also one of the area where there is the vital role of physical therapist. It’s very important to involve physical therapist while making the infrastructure accessible as physiotherapist has a lot to do for  mobility of the person with disability. After the finalization of accessibility guideline, indirect obligations `to the GON of Nepal to allocate physiotherapist quotas (at least at each district level) is imposed. But  it will not come into main agendas/ action plans until and unless this hidden imposition is highlighted by Nepalese physiotherapist themselves. 

Saturday, March 2, 2013

Let us think about prevention also.

This is the photograph of the private local mill in Baitadi district of Nepal which is on the way to Darchula district. This is the place where generally women from nearby and adjacent community usually come to grind their wheat, paddy and maize. You can see a  belt exposed near by the funnel shaped input section (from where grain is poured for the grinding). Luckily I meet with the operator of this mill and had few exchange of words with him. At the course of exchange, I request him to share any incidence of work related accident that he came across there. He told that in last 10 years of time he had seen three women whose hand was totally crushed while pouring grains. He also told that Nepalese women generally wear Dothi ( it’s similar to sari)  in village, the ending free portion of the Dothi usually hangs at the back side of the shoulder level. Therefore, sometimes running belt suddenly catches the hanged portion of the Dothi pulling the upper extremity under the machine. He also told that women who faced the incidence were Amputed later. After returning back from the trip, i requested my mother to share whether she knows similar tragic incidence of the people when she used to be at village 10 years back. She also revealed that she closely knows four people who were the injured on such mill. Out of four, one woman unfortunately loosed her life as her long hair( Nepalese women usually prefer having long hairs) was caught by the running belt of the mill and remaining 3 were Amputed. Similarly she also shared that except these 4 incidences, she had heard many like such.

We can see this type of mills on every community of the country and there is no option for the people other than these mills for the grinding of their grains. But what strikes on my mind is at least those women  could have been prevented from being disable or losing the precious life if they were aware about the precautionary measures to be taken. I do not have exact figures of such incidence on the other part of the country but i can say this is as the hidden prevalence which should be further explored for the design of some pertinent precautionary measures.

Therefore, it’s my humble request to all the readers, to consider this fact seriously (who knows we or our family members or relative can be a victim one day of such incidence) and  explore the nature of similar prevalence in your community. Please share your findings and then it’s we who should start for what we can contribute to prevent unwanted traumas and deaths in our community.

My observation and derived feelings


Sorry for the delay updates. As a part of my usual work, i have been deadly busy visiting the several districts around the country. Kanchanpur, Dadeldhura, Baitadi, Darchula, Banke, Morang, Sunsari, Sarlahai, Bara, Dang, Salyan and Rukum are the district that i have visited on last 6 months. Though hectic, it was a absolutely golden opportunity for me to accomplish the mission assigned as a part of my usual work in one perspective while on another part it was an exposure for me to understand the living situation, topography, health system and challenges of the population residing at these districts. I have meet and accompanied by the several physiotherapist in these visits which was a plus point for me to better understand and analyze the situation from the window of physical therapy.

Speaking from the physical therapy perspective, every human being needs to work to secure earnings to run their life. For this, they need to do activities throughout the life course. None of the work or activities is simple or stress less. Stress can be physical, mental or both. What i see is most of the population in Nepal faces the physical stress at the course of commencing activities to secure their earning. In my observation what i found is mostly the female population of the country more prone for the work related physical stress. Some of the typical examples of daily activities that i observed on the women are over attainment of continuous squatting posture for all household work like cooking, cleaning, washing and so on. Similarly strenuous work like chopping the firewood with an axe, carrying heavy loads of firewood from jungle, carrying heavy loads of grains on back uphill and downhill, pushing a local grinding instrument called DIKKI and JATHO and so on are few of the usual daily activities of Nepalese women. Yes, no doubt, without these activities, it’s hard to run the families as these activities are directly related to the income or food and which is a prime need of a life. If we look from other perspective, the male dominant society of Nepal can be one of the factor among several that women are considered as the sole goal owner of stressful household activities and men remain out of the house for earning. The solution for this inequality is never ending until and unless the the population is jointly quenched with some important prerequisites of development like education, health, employments and good governance at least. Though there are attempts of securing the development by both state and non-state actors, what i observed is lack of coordinated joint sequential approach. For example, for the general population, it becomes very difficult to understand about how to take care of their health without basic education at the beginning. Population can’t follow the health instructions if they do not know how to read or write. Similarly, vocational training without the proper visibility of the employment is also a very futile example. Here, what i want to express is that the development is a sequential process of its prerequisites; hence it should be followed by both state and non-state actors’ one by one. Similarly  it's very important to include the ideas from community right from the planning phase of the developmental intervention.Otherwise a huge funding being utilized in this sector may act just like just pouring water on sand.

Again speaking from the physical therapy perspective, i see huge number of the population prone for the physical distress. It can be one of the reason why population living in rural Nepal are more diagnosed with early degenerative joint diseases, pelvic organ prolapse , ultimately leading to chronic disability. There is a tendency of the most of Nepalese population to seek treatment at the last or chronic stage of the diseases and by that time diseases leads to the non affordability of higher medical intervention as most of the chronic condition is not addressed on the community level health service providers. So the best step here can be the prevention, but the physical therapist who are the sole goal owners for the prevention or limitation of degenerative condition, pelvic organ prolapse and other chronic disabling condition are not available on primary health care system of Nepal. Exercises and activity modification (activities done on correct postures) are very simple and easy ways that physical therapist can teach the population in community. 

As the number of physical therapist are very less in country, what i think is, state should start mobilizing at least one physiotherapist in a district at first followed by mobilization of physiotherapist in each primary health care center as the number goes up gradually. The simple physical therapy screening and follow up skills should be transferred to female community health volunteer available in each community of Nepal who can address the minor issue in community itself and refer the major cases to the physiotherapist at the institutional level. Above mentioned health issues only provides the glimpse where physiotherapist has a major role. There are many other public health issues in Nepal where there is an important role of physiotherapist, especially on the prevention part.

Saturday, August 11, 2012

Collaborative Practice

Collaborative practice is the key area to be ensured for the quality and sustainable health services in the globe. Hence, it should be taken into accounts by all the health workers and relevant stake holders of the country. In any context, human should not be deprived of the health, education, employment, livelihood and empowerment opportunities. Hence, system of the collaboration among different service providers could make these opportunities accessible for the beneficiaries. Please log in into,””, for the further update regarding the need of collaborative practice around the globe.