Innovations in community physiotherapy

Abstract


Introduction
Bangladesh has a population of 143.8 million, living in about 147 570 square kilometers and growing at the rate of 1.48% per annum.About 70% of the population lives in the rural areas.Administratively, the country is divided into 6 divisions, 64 districts, 507 upazilas and 4533 unions, each one inhabited by a population of about 22 million, 2 million, 255 thousand and 29 thousand, respectively (https://www.cia.gov/library/publications/Correspondence to: M. Ellangovin (mani mpt@hotmail.com)the-world-factbook/geos/bg.html).Each union is divided into 9 wards.
In the last three decades, there has been remarkable improvement in the healthcare provided to the people of Bangladesh.
The average life expectancy at birth in Bangladesh has increased to over 65 years (National Health Policy (NHP), 2008).While progress in modern medicine has led to the prevention of many diseases and the mortality rate of aged and disabled people has dropped significantly, such people are now in need of more advanced care and rehabilitation than in the past.

M. Ellangovin: Innovations in community physiotherapy
In Bangladesh, many reputable physicians unfortunately have little regard for accountability; consultation time with patients is limited and often a diagnosis is made even before the patient has finished explaining his/her problem.Unfortunately when expected result do not follow with the speed of a doctor's prescription writing, patients tend to lose faith in their physicians and keep switching to different "experts" in search of someone better!Given this confusion, what role does a physiotherapist play?Unfortunately in the Bangladesh healthcare profession, they are regarded as intruders and are assumed to be ineffective in providing a proper treatment to patients.Due to this, physicians often refrain from referring patients to physiotherapists, even if therapy is the required treatment option.
The physiotherapy profession is s self-regulated health care profession.Physiotherapists work with their patients to plan and carry out individually designed physical treatment programs for the purpose of restoring function and preventing disability from disease, trauma or injury (Canadian Alliance of Physiotherapy Regulators & the Canadian Physiotherapy Association, 2002).In Bangladesh, physiotherapy as a profession is not yet popular at the national level.There are no physiotherapists in government run hospitals or at any primary health care centers in Bangladesh!So physiotherapists in Bangladesh cater only to an elite clientele of patients who have some knowledge about the benefits of therapy.
In May 2002, the physiotherapy department of Gono Bishwabidyalay arranged camps at remote villages in Savar.When reviewing the medical history of a patient with neck pain, the patient produced an old prescription.The physician had prescribed Ibuprofen capsule (a pain killer), Ranitidine tablet (ulcer healing drug) and Physiotherapy for two weeks.Looking at the prescription, one intern inquired whether the patient was following the prescription properly.In reply, the patient answered promptly, "I went to all the local pharmacies in the area but none of them had the physiotherapy tablet.So I was able to take only two medicines instead of three.My neck pain did not go away".That made us realize how little rural people are aware of physiotherapy as a treatment option.

Gonoshasthaya Kendra
The 480-bedded makeshift hospital which was built during the Liberation War of Bangladesh in 1971 to serve the freedom fighters and refugees from Bangladesh, later emerged as Gonoshasthaya Kendra (GK) in the newly liberated Bangladesh in 1972 (Bose, 2004).GK's innovative work had earned a place in "The Lancet" editorial (3 January 1976, 1(7949), 26-7).Today GK is the largest health care providing organization, second to the Ministry of Health and Family Welfare in Bangladesh (The World Bank Office, Dhaka, 2007).
World Health Organization's "Health for All" programs' core activities started in GK from its very inception (Haque, 2003).The World Health Organization sited GK as an example in the declaration of the principles of "Health for All" in Alma Ata in 1978.Subsequently; GK extended and developed these programs by institutionalizing them."Health for All" is accepted as principle and a vision by GK.All projects are interwoven with this basic aim.Concentrating on the poor, GK began by providing preventive and primary health care for the surrounding villages where access to health services was almost non-existent.GK provides Primary Health Care (PHC) to a rural population of over 1.08 million across 20 Upazila's, 629 villages (Gonoshasthaya Kendra, 2008).It has 13-project offices and 18 sub-centers to monitor the programs (Table 1).
In Bangladesh, "Paramedics" are well trained and a dedicated health workforce similar to health extension workers in Ethiopia and lady health workers and lady health visitors of Pakistan (WHO, 2006).In GK, paramedics perform the following routine tasks in villages such as community physiotherapy: examining pregnant women, post delivery followup, providing advice on child-care, information collection and report preparation, recording health insurance information, vaccination for disease protection, treatment of general diseases and referral, health education, and family planning, etc.The number of paramedics in the GK project offices ranges between 15-25 and usually 12 in each sub-center.
The skills and expertise of the GK paramedics have been well appreciated by an esteemed medical journal "The Lancet" published in Britain and USA.On 27 September 1975 an article titled "Tubectomy by Paraprofessional Surgeons in Rural Bangladesh" was published in the aforesaid journal (Chowdhury and Chowdhury, 1975).In another comprehensive article published in a USA newspaper, "The Express", a front page story lauded the efforts of GK's paramedics, "Le-Plate Surgeon: cannot read or write but can operate" (http://www.express.co.uk).

Methodology
The objectives of community physiotherapy is to provide patients with quick-and-easy access to health service at their door step by training an army of health workers who are efficient, dedicated, non-tiring and always smiling.The underlying idea is to have adequate skilled paramedics at any given time to cater to patient needs in rural areas.In addition, a subsidized fee system for the underprivileged promotes demand for the service provided.Service innovations by GK such as paramedic training, combination therapy, promoting community physiotherapy rather than centre based health care, an insurance policy system and behavioral training etc. help to achieve the objectives of community physiotherapy.

Paramedic training
To be eligible to train as a paramedic, the required entry qualification is at least a Secondary education certificate with at least a second division in science subjects.Almost 95% of paramedics of GK are female.Paramedics are required to attend a 6 month basic training course, which is termed as a "foundation training" program.Following this, internship training for 18 months is mandatory; during these 18 months, trainees are assigned to visit 4000-5000 persons every month covering one or two villages.However, it is somewhat impossible to cover the targeted number by the end of each month and prepare reports at the same time.In all, a paramedic completes at least 6 years of training before obtaining a certificate.The paramedics are selected from different sub-centers and brought to Savar, which acts as the main centre for the rural areas and basic training is conducted here.The certificate course in physiotherapy which runs for 6 weeks gives basic training on some of the common conditions and techniques to be applied in different specialties (Table 2).
Successful candidates are sent back to the sub-centers and during their field visits, if patients requiring physiotherapy are found, the paramedics then administer treatment.If they find it difficult to handle, the patients are referred to GK's two-referral hospitals, one is located in GK's head office premises at Savar and the other one is Gonoshasthaya Nagar Hospital at Dhaka.These two speciality hospitals have full time qualified physiotherapists who can take care of the pa-tient.It also has sufficient beds, doctors, intern-doctors, specialists, managers, supervisors, health workers/paramedics and other supporting staffs.

Combination therapy
In rural areas, without proper treatment, a patient faces a lot of stress and strain, which in turn leads to development of nodule-like structures in the muscles and they are the main reasons for pain and can handicap patients.So, until these nodules are dealt with effectively, pain management and rehabilitation is incomplete.Treatment for these patients with traditional physiotherapy techniques has not always yielded favourable results.
To tackle these secondary complications, physiotherapy (soft tissue mobilization & hot pack) has been combined with ancient Ayurveda (massage with medicated oil).Ayurveda is an ancient system of medicine practiced at the home level and gives importance to natural medicines, massage and food habits.This form of therapy helps to identify the nodules and work on them to alleviate all secondary complications thereby making treatment more effective and giving permanent relief.This combined approach helps to resolve secondary complications faced by patients (Fig. 1).
Traditional physiotherapy departments are centre-based, dependent on equipment, electricity, lot of space etc. and is usually run by qualified therapists who prefer to practice in urban areas; in contrast, paramedics are more flexible with their choice of work locations and are available for  employment in rural areas as they hail from there.Including combination therapy into the community physiotherapy has brought more success has it can be easily applied in rural areas where there is lack of adequate space or electricity.For example instead of traditional hot packs, heat is applied with the help of portable stoves instead of electricity (Fig. 2). Figure 3 and Table 3 show the difference in the number of patients between the urban (Dhaka) and rural centers (Savar, Sreepur and Vattshala) and also the common conditions for which people seek the help of a community physiotherapist.The difference in numbers is a result of the awareness and availability of physiotherapy services in urban areas compared to rural areas.
Degenerative conditions causing neck and back pain are common both in rural and urban areas.Patients visit a number of different health professionals before realizing that the correct treatment will be imparted by a physiotherapist.So by the time the patient reaches a physiotherapy department, s/he is already a victim of secondary complications.These patients respond well to a combined treatment approach.

Health insurance policy
Treatment at GK is not free.Each patient or family has to pay a monthly subscription, the amount determined by their socioeconomic status.People are charged for curative care only, not preventative health care.The aim is to change people's attitudes and encourage them to take more responsibility for preventing illness rather than relying on a cure when illness develops.The health insurance policy ensures equitable access to healthcare and the acceptance rate is also encouraging as shown in Table 4.
Based on the classification shown below in Table 5, GK's health insurance policy was designed mainly to target the poor, very poor and destitute.

Behavioral training
Behavioral training is essential which makes health workers smiling, energetic and extremely friendly with the patients.They must master the art of good communication and should be capable of transferring warmth to patients.Field Actions Sci.Rep., 2, 93-100, 2009 www.field-actions-sci-rep.net/2/93/2009/ physiotherapy has brought more success has it can be easily applied in rural areas where there is lack of adequate space or electricity.For example instead of traditional hot packs, heat is applied with the help of portable stoves instead of electricity (Figure 2).

Results
The main problem of physiotherapy as a profession in Bangladesh is the scarcity of well-qualified physiotherapists.GK has come a long way in overcoming this problem by educating and training more than 150 paramedics to fill the gap.Experienced paramedics are now able to administer treatment without direct supervision at all times, reducing the necessity of supervision.The number of patients seen by them is multiplying at a fascinating rate every year due to the growing recognition of their work.Due to inter-professional conflicts and lack of cooperation and coordination, the referral system is non-existent between physicians and physiotherapists.Generally in Asian countries, if a patient has been advised physiotherapy treatment, s/he may not pay heed to the advice especially if a physiotherapist gives it.On the other hand, if a physician recommends physiotherapy, the patient is likely to oblige.In addition, there is no government post for physiotherapists either in urban or in rural areas.Therefore, physiotherapists never have the opportunity to prove to other medical professionals and also to the general people what they are capable of.In some cases, due to lack of opportunity, some of them lost their confidence in treating patients and started to work as technicians under physicians.But in the past few years this attitude has changed due to the good will of our patients.They started to talk about their recovery and how they became more mobile especially without medicines.In the past, we use to get referrals from physicians when it involves either his/her family members or him/herself and now this has changed.Thus, the work of these paramedics has bought credibility to this profession and indirectly to the professionals.
According to the survey "Comparative advantages of public and private health care providers in Bangladesh" by World Bank, 2005  Total in % 100 100 The table pinpoints the accessibility of health care in Bangladesh in rural areas.The possible reasons for the people largely approaching the local pharmacist rather than the doctors is just to avoid the consultation fee or the absenteeism of doctors in rural areas (Chaudhury and Hammer, 2003) or the poor accessibility of health service.GK is trying hard to change this percentage by providing PHC at the doorsteps of the people by involving more trained and skilled paramedics.
Disabled and elderly people suffer, not only from medical problems but, also from lack of moral and psychological support due to loneliness.For these patients mental support is more important than the actual medical treatment.Community physiotherapists tend to spend more time with patients; using a more hands-on approach with patients instead of just handing out pills; their patience with the elderly and their reassuring words are more comforting and effective than any other treatment option.enrolled in the BSc program in physiotherapy at Gono Bishwabidyalay are also involved in paramedics training.They take basic anatomy and physiology classes which enables an establishment of good relationships between the paramedics and the future physiotherapists.GK is the sponsor of Gono Bishwabidyalay (People's University), started in 1998, the only institution which has both Health and Social faculties and which tries to promote an integrative approach through its training programs.GK will continue to work towards creating an environment where paramedics and physiotherapists can work together along with other rehabilitation workers for improving the health care for rural patients.
The purpose of this article has been to draw the attention of WHO and other international oranizations to the existing situation of physiotherapy in developing countries in general and Bangladesh in particular.Along with this, we have attempted to highlight the innovations in community physiotherapy in enhancing easy and equitable access.When the paramedics visit the homes of patients who don't have their own son or daughter or grand children around them, they endear themselves to the elderly.A touch provides a powerful comfort that is better than a thousand pain killers.

Figure 2 .
Figure 2. Community Based treatment -even without electricity.