Report of WFOT
The Indian Ocean Tsunami Disaster (2004):
A Situational Assessment to Inform WFOT’s Response and Future Planning
Authors:
Kit Sinclair, PhD
President World Federation of Occupational Therapists
[email protected]
Kerry Thomas
Occupational Therapy Consultant
Director, interPART and Associates
[email protected]
Contributors:
Marilyn Pattison
Budi Tri Santosa
Suchada Sakornsatian
Nathan Vytialingam
Acknowledgements:
Carolyn Ambrose
Bambang Kuncoro
Nimal Liyange
P.O. Yapa
Thomas Keolker
David Mattson
The WFOT recognize the initial contribution of the following organizations to the WFOT project
which will inform the ongoing work forward a global occupational therapy emergency response.
College of Occupational Therapists (United Kingdom), New Zealand Association of Occupational
Therapists, Mary Ewing and Hong Kong International School group, Kevin Sinclair (journalist
Hong Kong), Hillside Rehabilitation Hospital OT Department (Warren, OH,USA).
Production generously supported by The Hong Kong Polytechnic University
Table of Contents
Executive summary ................................................................................................. 1
Background .............................................................................................................. 2
WFOT
Response to tsunami crisis
Aim of situational assessment ................................................................................ 3
Assessment objectives ............................................................................................ 3
Methodology .............................................................................................................. 4
Approach to situational assessment
Constraints
Programme
Overall findings ........................................................................................................ 5
Context
Occupational therapy perspective
Overall recommendations for actions arising from situational assessment ........ 8
Summary
Annexes: ................................................................................................................. 10
1. Programme Schedule ............................................................................ 10
2. Country Specific Report-Indonesia ...................................................... 14
a. Proposal for national in-service training ......................................... 22
3. WHO Recommendations for Mental Health in Aceh ........................... 25
4. Country Specific Report-Sri Lanka ....................................................... 38
5. Sri Lanka Occupational Therapists Workshop (Feedback) ................ 47
6. Country Specific Report-Thailand ........................................................ 49
7. Action Learning and Action Planning Regional Workshop ................. 55
Executive Summary
The findings show:
overwhelming psycho-social needs for people affected by the tsunami
the centrality of occupation and productivity/income generation to rehabilitation and as a
vehicle for addressing psycho-social/post traumatic stress needs
the lack of occupational therapy professional involvement in the overall response, and
therefore the needs in enabling involvement of occupational therapists in ongoing
rehabilitation as well as in future emergency response
This finding substantiates the recommendation for a regional workshop, and action planning
proposals to be formed by occupational therapists in each country. There are learning/training
needs, especially for occupational therapists, in building capacity for occupational therapists
to be more actively engaged in disaster response and recovery. This may include the
development of manuals (for occupational therapists and others), and occupational therapy
education curriculum and professional development training workshops.
1
Background
World Federation of Occupational Therapists (WFOT)
WFOT is the key international representative for Occupational Therapists and Occupational
Therapy. WFOT promotes occupational therapy as an art and science internationally. The
Federation supports the development, use and practice of occupational therapy worldwide,
demonstrating its relevance and contribution to society.
Occupational therapy is a profession concerned with promoting health and well being through
occupation. The primary goal of occupational therapy is to enable people to participate successfully
in the activities of everyday life. Occupational therapists achieve this outcome by enabling people
to do things that will enhance their ability to live meaningful lives or by modifying the environment
to better support participation.
WFOT maintains liaison with the World Health Organisation (WHO) and other international
organizations such as UNICEF, UNESCO, INIA, Rehabilitation International (RI), International
Council on Disability (ICOD) and the World Confederation of Physical Therapists (WCPT) with
whom WFOT has full professional relationship.
The Federation believes that:
Occupational therapy has a valuable contribution to make to occupational performance as it
affects the health and well-being of people.
It can positively influence health, welfare, education and vocation at an international level.
The effectiveness of the Federation depends on its contribution and collaboration with other
international organizations.
Response to the Tsunami Crisis
The United Nations, large numbers of NGOs, volunteers and government agencies from the stricken
countries and their neighbours are attending to immediate needs. WFOT is focussing on developing
both short term and long term strategies to support occupational therapists to work in affected
communities and help people rebuild their lives.
WFOT feel the major task lies in much longer term strategies. In collaboration with key stakeholders,
WFOT is preparing to assist these traumatized societies to rebuild their communities and help
them to return to and re-engage in meaningful occupation. That is the basis for WFOT’s planning
and future action.
The WFOT Executive Management Team has established a task force and drafted a project plan
to support development and implementation of long term assistance programmes. These strategies
include collaboration with WHO and international NGO’s, developing resources and training
materials, and setting up communication networks for liaison and collaboration.
Many communications have been received from member associations and individual occupational
2
therapists from around the world offering help and requesting information, and a dedicated email
address has been established to answer these queries.
The types of initiatives and activities that are being considered include:
Supporting the processing of inquiries received from around the world
Producing manuals and other aids in collaboration with WHO and other agencies to help the
occupational therapists provide services for their communities. These could be guidelines for
crisis intervention, service manuals with an occupational perspective on community rebuilding
and similar aids, which could be used in other emergency situations.
Assisting therapists in the region to acquire and develop appropriate skills to provide crisis and
rehabilitation services to individuals and communities in the affected areas.
Following the direction of WHO and the national governments within the region the Federation
acknowledges that the effects of the tsunami are far reaching. Aid programmes are currently
being implemented within 5 to 10 year time frames. WFOT sees itself as an enabler and a facilitator
and the resources that come to it will be used for these purposes and not for direct primary
intervention as in disaster relief. The World Federation has made a long term commitment to
support its member associations and individual therapists to work effectively within their
communities.
Aim of situational assessment
To undertake a rapid appraisal of tsunami affected countries to inform a strategic WFOT response
to the current disaster both locally and internationally. The intent of the appraisal is to inform
ways of supporting local therapists to cope locally and provide a framework for international support
for local action. It will also lay the foundations to build ongoing worldwide occupational therapy
capacity to respond to disasters in the future.
Assessment objectives
A rapid appraisal of community, government and the occupational therapy context and needs in
tsunami affected countries with respect to the immediate, medium and longer term needs in the
region.
Identification and assessment of existing responses and plans by national occupational therapists
and governments, and others including international organisations, in responding to these needs,
which will determine the implications for the role of occupational therapy and WFOT
Introduction of WFOT and occupational therapists into the international disaster response domain,
identifying implications for WFOT and occupational therapists while also identifying opportunities
where appropriately experienced occupational therapists (international and national) could
feasibly and meaningfully contribute to the rehabilitation and recovery phases of this disaster
Identification of capacity support requirements and opportunities for meeting these within the
realities of the disaster context and the existing national occupational therapy and associated
rehabilitation service delivery framework, and available resources including, for example:
identifying partners with whom national occupational therapists can link for training and service/
program delivery and future/ongoing development, particularly in community-based rehab
access to funds and resources
opportunities for appropriately community-based/disaster experienced occupational therapists
to buddy national occupational therapists and/or provide training
3
policy and program development capacity building assistance
Information to enable WFOT to appropriately prioritise its strategic and practical decisions, now
and for the future.
Methodology
Approach to situational assessment
The situational assessment implemented a ‘rapid appraisal’ approach and techniques, with a focus
on contextual assessment, needs analysis and a capacity development response, with findings
and recommendations arising at various levels with implications for different stakeholders.
Research and analysis of current assessments, activities and resources underpinned preparation
for the rapid appraisal visit, as did networking with key stakeholders. This helped ensure that the
appraisal trip was focused and highly productive.
The appraisal team visited the countries affected where WFOT member occupational
therapists are present to:
meet with Association representatives and key/senior national occupational therapists
meet with key government officials relevant to health, social services, CBR, to the extent that
they were available and time permitted
meet with disaster response coordination bodies, national and regional/international where
possible
meet with key/pertinent INGOs, local NGOs, and others as available
with national occupational therapists, visit selected affected sites where occupational therapists
or CBR workers may be operating or may be required to work in coming months (without
unnecessarily getting in the way of response efforts)
The situational assessment was comprised of a two-person team including:
one senior WFOT person to take forward the findings
one occupational therapist with experience in disaster contexts, community based rehabilitation,
and capacity building at national and community levels within a health and social context.
Constraints
The time limitation was a major constraint. Because the assessment visit was so rapid, the
assessors were only able to see a small representation of stakeholders. There are also some
significant gaps in the data and information; for instance, the assessors were only able to speak
to social service staff in the camps in Thailand but not to national social service departments in
the other countries, and met with regional/national health coordinating groups in Thailand but not
to cross-sectoral disaster coordinating bodies in the other countries.
Programme
The rapid appraisal was completed in three countries including Indonesia, Sri Lanka and Thailand.
Three to four days was spent in each country, including visits to disaster locations in Sri Lanka
and Thailand.
Indonesia 19-21 March 2005
SriLanka
22-25 March 2005
Thailand
26-28 March 2005
Please see annex 1 for details. Other contacts who contributed country-specific information are
also noted in this annex.
4
For various reasons beyond WFOT’s control it was not possible to visit India, although input from
Indian occupational therapists has been sought through questionnaires and email correspondence
but currently remains outstanding.
Overall findings
Context
No accurate statistics were available in Indonesia or Sri Lanka making the establishment of
appropriate programmes and responses difficult to develop and/or assess. In Thailand extensive
figures are available with breakdowns yielding
insights into gender and family structure
impacts including orphans but not elderly
The Gender Impact: Four times more women than
‘orphaned’ or people with disability. The
men were killed in some tsunami-affected areas, a just
information that does exist across the region
released Oxfam-CAA study reports (Bangkok Post,
is changing rapidly and being updated and is
March 25. 2005, pg.5). In some villages it appears that
best gained through various websites as
up to 80% of those killed were women. The long term
noted elsewhere in this report.
social consequences for communities trying to rebuild
On the day the assessment was completed,
the Nais earthquake occurred. This
distressing event will further complicate
response efforts and associated statistics.
It is known that the psycho-social impact of
rapid multiple disasters on individuals and
communities is exponentially increased. With
the risk of further events apparently quite
high, the region has yet further and more
complex short and long term response
challenges to face.
will ripple through the whole society for years to come
- a profound study observation that will impact on how
occupational therapists might consider developing long
term support programs in the region. The report
suggests that men were more likely to be working inland
or on boats out at sea, and were more likely to be able
to swim and climb trees, while women were at home
looking after children. Others with whom we met noted
that had the tsunami hit on a week day the loss of
children could have been much higher in areas where
schools are located near to beaches.
The commitment and compassion of
occupational therapists was obvious
News of the Nais earthquake reached Sri Lanka where
throughout the visits. They have responded
an occupational therapist noted a media report
to the disaster individually and in groups at
attributed 3 deaths to panic from shock and congestion.
professional and personal levels. However,
the occupational therapy linkages with wider
disaster coordination mechanisms is very limited.
Post traumatic stress is by far the major issue for people affected by the tsunami.
The greatest challenges and constraints affecting communities include community empowerment
to:
enable villagers to strengthen their capacity to cope with the loss
encourage their participation in activities during stays in displaced persons camps
to encourage them to have hope for the future and not panic when there are rumors concerning
disaster.
5
Methods for responding to the stress and the greatest need identified by people themselves relate
overwhelmingly to the concerns for sustainable livelihood; that is, helping people access genuine
income generating activity is both therapeutic and essential in providing choice and the resources
to rebuild their lives.
Occupational Therapy perspective
Generally national occupational therapists are not connected into formal disaster response
mechanisms in the region. This is partially because there are so few occupational therapists
generally and even fewer occupational therapists working in regional centres and virtually none
working in more remote coastal-rural communities or the community based programs that may
service affected communities. It is also because occupational therapists have limited familiarity or
connection with the disaster response coordination systems that national governments have put
in place.
Indonesian OT group
Levels of engagement differs across the affected countries, with some
therapists responding on a professional and/or personal level.
Main Responses by national
occupational therapists: “We’re
desperate to help... but are not
sure how best we can” was a
common heart-felt sentiment almost a plea - that was heard
from OT’s across the region.
Numbers of national
occupational therapists:
Indonesia
Sri Lanka
Thailand
400
54
300
Many immediately provided
personal support to colleagues
and friends who had relatives
affected, while others contributed funds and goods
through local religious and social organisations.
Professionally, in Indonesia, the one occupational therapist based in Banda Aceh survived and
continues to work from the re-established main hospital, while there have been two occupational
therapists visit for a week each as members of a Jakarta Municipality response team. In Sri Lanka,
an occupational therapist was also part of an early assessment mission, and occupational therapists
have prepared response proposals which are yet to be submitted to appropriate authorities for
funding and approval. In Thailand, a senior occupational therapist is leading the work of the Mental
Health Tsunami Response team covering the affected provinces, including the establishment of a
Recovery Centre program.
6
From an international perspective, a number of occupational therapists are known to have been
actively involved with initial and ongoing response efforts, while there may be others similarly
engaged.
Coordination in the response has been the greatest
challenge experienced in each country with Thailand
being the most advanced in successfully addressing
this problem.
Now that the response is moving from the emergency
to the longer term rehabilitation phase, there is a
requirement for occupational therapists to be more
actively engaging with coordinating mechanisms at
policy, planning and implementation levels.
International Occupational Therapists in
the Region
In Sri Lanka, a VSO occupational therapist
based in Galle is co-facilitating development
and management of the government’s Tsunami
Psycho-Social Support Program in that
province, while a Malaysian-based Tamilspeaking occupational therapist was part of an
Asian INGO assessment and early response
team that went to the east and north-east
coastal areas of the country.
Overall there is a lack of information and data that
could help guide planning for occupational therapy
involvement in response programmes. Occupational
therapists tend not to be part of the system because they are primarily hospital based, have
limited experience in community based approaches, and their potential role is not widely recognized.
Awareness within the occupational therapy profession of key stakeholders e.g. coordinating bodies,
donors, NGO’s, is greatly limited. The implication of this is that opportunities for developing
partnership and projects to advance occupational therapy interventions and involvement are
inadequate.
Occupational therapists have noted that their ability
to engage in on-site initiatives may also be
constrained by language, culture and political/conflict
issues, particularly in Indonesia and parts of Sri
Lanka.
For the future, the priority occupational therapy
needs are for orientation, preparation and
understanding of coordination requirements and
skills in post traumatic stress management and in
particular through meaningful and productive
occupation and sustainable livelihood.
Some Indonesian occupational therapists
noted that people in Aceh were more likely to
trust foreigners than other non-Acehnese
Indonesians, while in Sri Lanka, few
occupational therapists speak Tamil which
limits opportunity to provide services to even
those Tamil communities who are in
government controlled territory. Fear of going
into these conflict areas is also a real
consideration.
Income generation in
Galle, keymaker
7
Overall recommendations for actions arising from
situational analysis
Partnerships need to be strengthened and developed by occupational therapists with key
stakeholders within each country and the region. The areas of strengthening may be primarily for
technical and funding assistance, and capacity building. Increased collaboration and liaison with
the local government ministries should be initiated and strengthened, including not only the Ministry
of Health, but also the Ministries of Education and Social Services and Labour. INGO’s and local
NGO’s should be identified and approached for collaboration. There is an immediate need to
support and provide assistance in capacity building through a regional action learning - action
planning workshop and follow-up in-country activities as established through action plans. In all
countries there are opportunities for strengthening occupational therapy policy and practice as it
relates to disaster management through the professional bodies (e.g. National Occupational
Therapy Associations) as well as through undergraduate curriculums and professional development
programs.
Regular monitoring of progress should be undertaken by WFOT with review in six to 12 months
time including assessment of the effectiveness of the situational analysis trip.
Action
Objective
Responsible person
Letters of
Support professional development initiatives
WFOT president
support
and development of services and education as
agreed and requested
Regional
Building capacity
WFOT team
workshop
Building networks and partnerships
Country delegates
(see details
Develop guidelines for emergency response
in annex 7)
Develop national action plans
Identify regional support requirements
Partnership and
Share resources and learning among OT’s and
WFOT Task force in
networking
with other stakeholders
liaison with Country
development
Identify opportunities for accessing technical
Delegate
assistance, funding and project development
8
Resource
Research and develop resource information
Task force in
development
packet for future emergency relief which
collaboration with
can be culturally adapted and translated into local
WHO and other
agencies
language
Action
Objective
Responsible person
In-service
Provide curriculum for in-service training on
WFOT Task force
training
occupational therapy role in emergency relief
and National OT
curriculum and
and community development
Associations
professional
Provide appropriate in-service training as
development
required/requested/funded
National
Strengthening communication, networking and
Associations
decision-making arrangements
Outcome
Review the outcomes of the situational assessment WFOT team
Monitoring and
Monitor and review the outcomes and impact of
review process
the follow-up actions
National Associations
to be put in place
Summary
The findings show overwhelming psycho-social needs, the centrality of occupation and productivity/
income generation to rehabilitation and as a vehicle for addressing psycho-social/post traumatic
stress needs, the lack of occupational therapy involvement and the reasons for this, and thus the
needs in enabling involvement in ongoing rehabilitation as well as future disasters. This finding
substantiates the recommendation for a regional workshop, and action planning proposals to be
formed by occupational therapists in each country. There are learning/training needs, especially
for occupational therapists, in building capacity for occupational therapists to be more actively
engaged in disaster response and recovery... and this may include the development of manuals
(for occupational therapists and others), and BSc curriculum and professional development training
workshops.
9
World Federation of Occupational Therapists:
Post-tsunami Regional Situational Appraisal
Annex 1 Programme Schedule for Dr Kit Sinclair and
Ms Kerry Thomas 18-28 March 2005
Day Date Time
Fri 18/3
Place
Persons
Indonesia
Activities/ meetings
Arrival
Jakarta
Sat 19/3
08:00-
Jakarta
Bambang Kuncoro
Briefing, introduction, & orientation
KS & KT
Preparation time
Bambang Kuncoro, IOTA President
Updates and schedule discussion
15:00
evening
Sun 20/3
08:00
Jakarta
Budi Santosa, WFOT Delegate
10:00-
70 occupational therapists
Meeting, group sharing and feedback
13:30
and 47 students
re tsunami response and options for OT,
Jakarta DHARMAIS Cancer Hospital
13:30
Rizal, OT who provided support in Aceh
Report of Aceh situation and discussion
eight days after tsunami Interested
of proposed future OTdevelopment
occupational therapists
18:00
Mon 21
08:00
Jakarta
Dr Handojo, Disability Rights
Discussion of community development,
Empowerment Centre (Solo) Indonesia
CBR, and projects for Aceh productivity
Dra. Herawani, Direktur Wat and Tek Med
Introduction and brief meeting
MoH
8:00-
Dr. Gemala Rabi’ ah Hatta, Dir of Nursing
Meetings with MoH re tsunami response,
9:30
and Allied Health, MoH
liaison with other govt ministries and
depts., and development of OT role and
profession
10:30-
Dr Stephanus Indradjava, WHO National
Briefing and discussion of WHO
11:30
Professional Officer
involvement and coordination role,
(emergency guidelines and referral
systems being developed)
14:3015:30
Dr. Muharso, Head, National Board for
Meeting and overview of MoH the
Development and Empowerment of Health activities in Aceh
Human Resources, MoH
19:00
10
Departure from Jakarta
Day Date Time
Place
Tues 22
Sri Lanka
01:00
Persons
Activities/ meetings
arrival
Colombo
08:00
Colombo
Nimal Liyange, WFOT Delegate
Thomas Keolker, Program Director,
Briefing and schedule (programme
proposed and facilitated by Motivation
Motivation, Sri Lanka
SL)
David Mattson, Regional Representative,
CBM (Christoffel-Blindenmission)
09:00
Colombo
Rohana Pierera, Head, OT & PT School
Discussion with OT staff of issues and
Occupational Therapy tutors
needs, brief introduction to OT
programme
10:00
Occupational therapy students
Welcome and introduction of
WFOT Team
10:30
Colombo
Dr Deepthi Perera, Director/ Youth, Elderly, Discussion of general problems and
Disabled, & Displaced Persons, MoH
Dr Fernando, Director / Training, MoH
issues related to post-tsunami response
and to development of occupational
Present: Nimal, P.O. Yapa, Nandana,
therapy
David Mattson
14:30
Ragama
Dr Lilani Panangala, Director and
Briefing of Centre clients and functions
Consultant Rheumatologist, Ragama
Rehabilitation Centre, Ragama
15:00
Ragama
Lalith Wickramasinghe and other members Visit to Spinal Injuries Association
of Spinal Injury Association (SIA) staff
workshops, w/c manufacturing and
special seating programme, and
orthotics-prosthetics workshop
15:30
19:00
Ragama
Colombo
P.O. Yapa and Occupational therapy
Tour of department, discussion with
Department staff, Ragama Rehab Centre
staff
Thomas Keolker, Motivation
Discussion of INGO involvement in
David Mattson, CBM
post-tsunami activities, general disability
support programs, possible collaboration
Wed 23
06:00
Travel to Galle together with Nimal and
Yapa
09:30
Galle
Jo Armstrong PT VSO, clinical coordinator
Discussion of development and projects
Shiv Sankar Sheet, Prosthetist
supported by Motivation to provide
P. Venkatakeannan, PT
prostheses, PT and training, and
SSB Manchanayake, Treasurer
disability support programmes
Southern Centre for Disabled
11.30
Galle
Lushani Vishani, L Fernando, Project
Visit to community children’s centre,
Coordinator
including medical consultation, therapies,
Azra Welandawe, Child Stimulation worker; play group, family consultation
Treasurer
and parent support group
Dr. Disna Kodikararach, Consultant
Sani Hasa Children’s Centre (NGO)
11
Day Date Time
Place
Wed 23
Galle
12:3014:30
Persons
Activities/ meetings
Chandanie Senadheera, Clinical
Discussion of the psycho-social
Psychologist, Dept of Psychiatry, Faculty
assessment and support project using
of Medicine, Karapitiya Hospital &
pre-interns to assist tsunami survivors
University
in the Galle District; and implications for
Nina Maini, OT VSO
local OT involvement
Thurs 24 06:30
09:00
Drive to Tangalle
Tangalle
Kumarini (Kumi) Wickramasuriya, Director, Discussion of Navajeevana community
Navajeevana (NGO)
based programme to serve regional
disability needs, post tsunami response
activities and tour of centre; and
implications for OT involvement
13:30
Fri 25
09:00-
Return to Colombo (8 hours drive)
Colombo
Occupational therapists and students
13:30
Meeting, group sharing and feedback re:
tsunami response
13:30
Sri Lanka OT Society Executive
Farewell lunch
Discussion of future priorities and
proposed activities for occupational
therapy development in Sri Lanka
16:00
Sat 26/3
KS & KT
01:50
Consolidation and report writing
Departure from Colombo
06:00
Thailand
Arrival in Bangkok
09:10
Bangkok
Flight to Phuket
10:30
Phuket/
Suchada Sarkornsatian, WFOT Delegate
Tour of Khao Lak affected region
Khao Lak
Anantaporn Pattanapan (Tow), Public
Khao Lak Recovery Centre site visit
Health Technican - mental health, Office
of Chief Medical Officer
Khao Lak
Namchem Camp Coordinator/Volunteer
Visit to Namchem displaced persons
camp (Buddhist temple) including play
group and income generating activities
Khao Lak
Yiriya Sanglaka, Pakweed Camp
Visit to Pakweed displaced persons
Coordinator
camp (micro-credit cooperative scheme
for fishing; batik, weaving, thai desserts future income generating)
Khao Lak
Miss Uraiwan Tunta-Ariya, Phangnga
Centre for Public Health Surveillance and
Provincial Public Health Office; Chief of
Relief After Tsunami Disaster in the Six
Public Health Development Cluster
Southern Provinces of Thailand - briefing
Mr Adisorn Wisal, Phangngn Provincial
of role, statistics, Public Health Office
networking and referral mechanisms
Sun 27
10.00
Phuket/
Patong
Suchada Sarkornsatian
Tour of Patong Beach affected area
Anantaporn Pattanapan (Tow)
Discussion with village leader - boat
Kamala Village Leader
building, school rebuilding, temple
reconstruction, etc
Kamala
Mrs Orapin Chaochiab, Kamala Public
Discussion with community health
Health Centre
coordinator of tsunami impact
(infrastructure, physical and psychosocial),
role of centre, referral systems
12
Day Date Time
Sun 27
2.30
Mon 28
9:00
Place
Persons
Activities/ meetings
Return flight to Bangkok
Bangkok
Suchada Sarkornsatian, Deputy Dir,
Briefing on MoPH infrastructure
Mental Health Technical Development
Visit to Mental Health Centre for
Bureau, Dept of Mental Health, MoPH
Thai Tsunami Disaster
Dr. Bundit Sornpaisan, Director, Child and
Discussion of ‘To Be Number One’
Adolescent Mental Health-Rajanagaindra
mental health programme
Institute
10:30
Bangkok
Dr Seri HangYok, Dept of Mental Health,
Discussion of system plan for
MoPublic Health
cooperation and coordination of post
tsunami recovery
11:30
Suchada Sarkornsatian
Discussion on role of OT in tsunami
response, and general development of
the profession for disaster response;
report development
18:00
Departure from Bangkok
MoH = Ministry of Health
MoPH = Ministry of Public Health
Kit Sinclair (KS) & Kerry Thomas (KT) both attended all meetings
13
Annex 2 Country Specific Report
— Indonesia
Approach to the Indonesia Visit
The visit to Jakarta took place from 19-21 March. Meetings took place with the President of the
Indonesian Occupational Therapy Association (IOTA), the WFOT Delegate, officials of the Ministry
of Health, the WHO National Professional Officer, 115 occupational therapists and occupational
therapy students, specific occupational therapists who have been involved in tsunami relief efforts,
and a disability rights and CBR advocate. The process of the visit was facilitated by Bambang
Kuncoro, President of the IOTA and Budi Santosa, WFOT Delegate. A visit to Aceh was not possible
in the time permitted, nor was the team able to meet with social services or INGO’s involved with
the tsunami response. Therefore some information was not directly available. A summary meeting
was held with Budi and Bambang during which jointly agreed main actions and broad
recommendations were made (see below).
During the visit, a workshop was held with 67 occupational therapists and 47 student occupational
therapists, making up eleven small groups for discussion and feedback. Guide questions related
to the tsunami were used as a foundation for feedback and discussion. Responses by occupational
therapists in Jakarta to a question concerning their personal and professional response to the
tsunami included shock, a sense of powerlessness, anger with the lack of warning and response
systems, and a sense of need to respond individually and professionally. There was a religious
interpretation of tsunami in some cases. Occupational therapists felt there was a lack of information
(personal/ relatives lost, lack of knowledge of response
systems, how to send food/relief items, need to work with
other organizations but didn’t know who or how). They
recognized that major issues focused around the
psychological impact of post traumatic stress, especially from
the professional perspective of what they as occupational
therapists could respond to, as well as the need to help
people increase their productivity and find work or return to
school.
Many practical ideas for addressing such needs were
discussed. However, the occupational therapists also
acknowledged a strong need to further develop their
therapeutic, occupational and management understanding
and skills for working in complex community contexts where
the numbers in need are so great and coordination/liaison
with NGO and government is crucial. Some indicated that
Indonesian OT workshop group
they were frightened to travel to Aceh from Jakarta due to
the conditions, the cultural differences and political context.
In summary, there is a great willingness among occupational therapists to contribute but also
constraints and tension felt in relation to providing effective assistance.
14
Presently, and unrelated to the tsunami, the Ministry of Health is concentrating on the development
of standards and manuals for allied health professions including occupational therapy. It was
agreed that there is a need for more training for emergency response. The process for planning
for providing assistance in Aceh was noted to involve putting forward a proposal which could
attract funding from WHO or INGO’s. A proposal for training of occupational therapists could involve
a number of participants (up to 20) for a period of perhaps a month, with the possibility of getting
secondment by some therapists to international NGO’s for a maximum of three months (period
allowed away from work). There was also discussion of the need for training of people in the
community to do rehabilitation. This training could be undertaken by occupational therapists.
WHO, consistent with its UN mandate of working to support national government efforts, is engaged
in a number of response initiatives with
Ministry of Health. From an occupational
therapy perspective, their approach to working
with grassroots community leaders to provide
psychological first aid, developing local
capacity, helping to establish a referring
system particularly with community mental
health teams, was of particular interest.
WHO has developed guidelines aligned with
Ministry of Health for working in Aceh under
which all foreign assistance must work, and
with which occupational therapists could
engage. WHO is collaborating regionally on
mental health needs and how to build capacity
to address these now and into the future, and
has training and seminars planned. Though
there has been discussion, to date there has
been no coordinated national level planning
or response in relation to disability and the
tsunami - this is an area of need that
occupational therapists, perhaps in
collaboration with experienced INGOs, could
usefully contribute to, particularly where
community-based rehabilitation processes are
being developed, as this would cohere with
long term national Ministry of Health goals.
Discussion with Dr Handojo Tjandrakusuma
provided insight into some of the innovative
community based rehabilitation, occupational/
livelihood and income generating initiatives
that are being developed in Indonesia and
potentially in Aceh as a contribution to the
restoration process. Occupational therapists
are already well connected with Dr Handoyo,
and opportunities to explore collaboration with
some of these other activities exist.
Meeting with Dr. Stephanus Indradjava, WHO National
Professional Officer
“There are few community health workers left and
virtually no structures or materials, so we have to build
a system with the people who remain, working with them
in Internally Displaced Persons Camps and host
communities, to provide basic psychological and
physical first aid and referral assistance. Community
Mental Health Teams provide training and follow-up
support. One of the biggest challenges is that people
don’t want to stay in camps. The population is highly
mobile, and not easy to keep track of, requiring
innovative approaches to the provision of support and
development of service systems in this unique
environment. There is lots of work to do in building
capacity of local people and Health Workers, and it
requires close coordination with all the other
stakeholders involved... UNICEF for kids, NGOs,
Government departments.. all sectors.” (WHO)
15
Meeting with Dr Muharso
A meeting with the Aceh Emergency Health Services Coordinator, Dr. Muharso, SKM, confirmed
four important things:
the primary needs relate to productivity and livelihood development;
any intervention must be done with great sensitivity and from the bottom-up - conventional
approaches will not be appreciated or tolerated;
communication and coordination is critical;
you need to access/bring your own funds and resources.
Time did not permit the holding of discussions with NGOs (international or local) who are involved
in the reconstruction and rehabilitation phase, but it appears that this is another direction within
which opportunities for occupational therapy liaison could be explored.
The Tsunami Context
According to reports, within 15 minutes after was the tsunami, 1000 villages and urban communities
were affected. 80% of the capital, Bandah Aceh was completely ruined and damaged, and all the
cities and areas on the west coast were also badly damaged. The official number of registered
deaths is 260,000, but the estimate is between 260,000 to 400,000 people dead and missing. In
the coastal area, in the fisher folk communities, the percentage of survivors was only 10% of the
original population , and the largest numbers of casualties were women and children. The WHO
notes there were in February, 394,285 IDP’s from ten districts in Aceh. They are located in 180
settlements as well as the homes of friends and relatives, but many are uncomfortable about
remaining in camps that are mostly
administered by the Indonesian military.
Health Cost Projections for Aceh:
Communities have been utterly devastated.
4,574 trillion rupiah (US$473 million):
Infrastructure is largely non-existent. Roads
are wiped out and buildings destroyed. The
Emergency phase - 721 billion rupiah
extent of the impact on community people
Rehab phase - 1,234 trillion rupiah
has been overwhelming. For example, the
Revitalisation and construction - 2,618 trillion rupiah
cost of rental of a house is noted to be 10(WHO)
25 million ruphia per month. (Nationally, the
cost of petrol recently jumped 50%, which
also impacts tsunami relief efforts.) But the
nature and number of injuries and disabilities, changes in family and community structures and
the roles that people play remains unclear as far as could be ascertained. For example, WHO are
still compiling figures in order to develop mental health and other rehabilitation plans.
•
•
•
16
An occupational therapist is working in Aceh reports 1 that there are many people suffering from
post traumatic stress disorder due to loss of relatives, belongings, work and difficulty in sustaining
their lives, lack of shelter, food, and money, but there is little confirmed data. The most common
physical trauma is brain injury, fractures and amputation. The reconstruction and rebuilding are
affected by the unique culture of Aceh augmented by the politics of the 29-year conflict between
the government and the Free Aceh Movement.
Two other occupational therapists separately went with Provincial Government of Jakarta and
Ministry of Health medical teams to Aceh on one week missions. One of occupational therapists,
Rizal, went eight days after the tsunami. The team consisted of a doctor, nurse, occupational
therapist, physiotherapist, sanitarian, nutritionist and others. The occupational therapist confirmed
the level of devastation in terms of infrastructure and systems. He noted that there were two
hospitals with military management. The numbers of cases were so enormous that they could not
be treated. Major priorities were given to basic medical intervention. Occupational therapy was
not a priority at that stage and he worked basically as a medical assistant, doing wound management
and first aid splinting using materials available there, such as cardboard, wood pieces, etc. At
that stage, people were in deep shock and were focused on immediate survival.
There was no specific preparation or orientation or debriefs related to this medical team activity.
Following the visit, reports were made and further teams were formed but to date there has been
no further known occupational therapy involvement. Most provinces are sending teams. According
to Rizal, the scale of the impact on communities is such that teams can not work alone and a
multi-systems approach was needed. The therapist was overwhelmed by the chaos, loss of
infrastructure, geographical scale of the impact and the extreme lack of coordination, which created
a huge problem of equity in the distribution of resources for people. The influx and high turnover
of personnel added further confusion to survivors as well as relief agencies - and all this amid a
diversity of largely unfamiliar community/cultural contexts.
Rizal and small group of IndonesianOTs
1
Mr. Indra Yulianto forwarded a one page summary for our visit: Overview of Post Tsunami Situation in
Nangroe Aceh, Darussalam. Received 19th March 2005.
17
Early Disaster Response: Lessons from the Field for Indonesian occupational
therapists
Major lessons learned relate to the need for coordination systems. Experiences to date suggest
that for the future, any occupational therapist who is involved in such an effort needs:
orientation and preparation
a good understanding of the multi-agency disaster coordination requirements
ability to work in a highly stressful, demanding and confusing context, with different kinds of
teams and organisations
skills in injury and post traumatic stress management in makeshift clinical and community settings.
a strong foundation in how to promote meaningful and productive occupation and sustainable
livelihood within a disaster rehabilitation context.
to consider the professional and personal challenges of working in an area of conflict in which
the culture and language are different from the rest of Indonesia
debriefing and support arrangements, on return and during longer term assignments
information about the role of IOTA and WFOT in emergencies and how they could be expected
to assist, now and in the future
This could be provided during in-service training.
As noted above, comprehensive and reliable data and statistics related to the tsunami were not
available during the visit and are constantly being revised and refined. Compilation of such data
has been further compounded by the subsequent earthquake affecting parts of the local region.
For specific, current information and statistics, including distribution of impact and response
measures, please refer to Govt of Indonesia, UN agency (including WHO) and international NGO
websites in particular (e.g. Oxfam, Surf Aid, World Vision), as well as local NGO programs (which
are mostly religious-based).
The Occupational Therapy Context in Indonesia
There are 400 occupational therapists working in Indonesia, three hundred of whom have been
trained at the Occupational Therapy School in Solo with a hundred having graduated from the
more recently opened school in Jakarta. Approximately 60 percent of these occupational therapists
are working in Government hospital and centers, while the remainder mostly work in private clinics.
Just a handful work in the NGO sector and in CBR. It is understood that there is one Filipino
occupational therapist working with Handicap International among about 30 VSO/NGO health
and rehabilitation professionals in Indonesia. A Canadian occupational therapist, who was
instrumental in the establishment of the Solo school and CBR program visits on average twice a
year.
There was and remains only one occupational therapist in Banda Aceh. Two other Jakarta-based
occupational therapists are known to have undertaken one-week visits with emergency assessment
teams.
There is currently a freeze on the creation of new civil service positions, but demand from the
private sector remains very strong, where remuneration is also significantly more competitive
than government salaries (e.g. 1-2 million Rp/month with government compared with 3-5million in
private clinics).
18
Summary Analysis of OT in terms of response to tsunami and in the long
range
Strengths
Weaknesses/needs
•
•
There is an occupational therapist in Aceh
•
•
•
Mobilizing and trying to get connected
Access to information and response
coordination mechanisms - Lack of
knowledge of who, where and how to
coordinate
•
•
Skills and experience in aspects relevant to longer term
assistance and rehabilitation (e.g. clinical rehabilitation,
children, psycho-social needs)
Lack of linkages/relationship with
implementing agencies especially
NGOs and multilateral bodies such as
WHO
•
Translation / adaptation of professional
knowledge, understanding and skills
into disaster and complex community
contexts
•
Role clarification and development and
practice models
•
Strong commitment and interest among occupational
therapists to assist in disaster response
Awareness and appreciation of the concept of community
needs and approaches to assistance
Occupational therapists have been working closely with
Ministry of Health re role, standards, etc, as a result of
which Ministry of Health is a strong advocate for
occupational therapy role and its development in Indonesia,
and in post-emergency disaster response programs
Opportunities
Constraints
Professionally:
Professionally
•
Play therapy for children, counseling, group therapy (stress
management or problem solving) pre-vocational or
vocational training, hand rehab and traumatic brain injury
rehab, as initially identified by the occupational therapist
in Aceh
•
Lack of facilities in which to establish
central rehab services
•
•
Buildings, equipment, etc.
Resources are available also as identified by the
occupational therapist in Aceh
Strategically:
•
•
Referral systems and mechanisms
•
Lack of knowledge, role clarification/
authority and possibly confidence in
approaching donors, developing
partnerships...
•
Need for strategic approach
There is a rehabilitation medicine unit at the Zainal Abidin
Hospital, temporary shelter, and collaboration with
Handicap International
Strategically:
•
To explore relationship with INGO’s and develop
partnerships... for practice, programs, training and
professional development
•
Long term community based services are consistent with
government policy and strategies.
•
To explore and develop relationship with Ministry of
Community Welfare (for disability and elderly service
development, community based rehabilitation, etc) and
other departments where appropriate (e.g. Education for
schools work, Labour for vocational training work, and also
Religious Affairs)
•
To strengthen relationships with Ministry of Health and
WHO, for expanding the role of occupational therapists in
Indonesia and in disaster response...
19
Actions and Recommendations
There is a need for occupational therapists in Indonesia (as represented by the workshop group)
to shift knowledge and use of their existing skills into a new context in the occupational therapy
perspective of community based rehabilitation and community development. This could be done
through a in-service training on role development and practice models (adapting community
approaches). This will better place occupational therapists to respond to disaster situations as
well as meet wider community needs in ways that are consistent with Ministry of Health/
government policy and priorities. There are implications for role clarification and development
and then undergraduate and professional development education as well as employment strategy
development in the government and private/NGO sectors
Occupational therapists could provide opportunities for debriefing for occupational therapists
and teams who return from working in Aceh, and in ongoing support for the occupational therapist
working in Aceh
An occupational therapy taskforce group within the IOTA could be established, composed of a
small group of occupational therapists with a balance of expertise (mental health, paediatrics)
and a balance of roles (experience with government, communities, connecting with people) to
progress professional development of disaster response capacity, strategically and practically.
Terms of reference (TOR’s) for a Task Group
TORs are established for working groups or task forces, as
this clarifies the purpose, role and function of the group for its
members and those to whom the group reports or has links
with. TORs could include:
Purpose statement
Objectives of the group
Relationship with the IOTA Mgt Group and WFOT Emergency
Response Group
Membership of the group
Structure, management and timeframe of the group, who it
reports to, when and how
Simple monitoring and evaluation criteria/process
Resources available to the group to enable it to function.
20
Action
Set up of taskforce group
Objective
Responsible persons
To follow up specific areas of development
IOTA
and resources for response to tsunami and
work in Aceh, and to position the profession
for any future emergency response
Develop plan for training for
To develop strategic action planto to
core group of occupational
gain funding for in-service training
therapists
and attachment/secondment.
WFOT Executive and IOTA
See Annex 2a for proposed national in-service
training proposal
Letter and proposal for
To enable a number of occupational therapists
occupational therapists
to participate in WHO-funded on-site training
inclusion in WHO training and
and program work in Aceh, as part of the
response program for Aceh
WHO’s Ministry of Health Staff Training
WFOT President and IOTA
Package. See Annex 2a for national in-service
training proposal.
Letter of Support of use of ICF
Use of ICF as international model which
in Ministry of Health
emphasizes participation and community
Outcome Monitor and review
To monitor the development of actions
process
and review outcomes
WFOT President
WFOT Team
Meeting with Ministry of Health, Dra. Herawani and Dr. Gemala Rabi’ ah Hatta
21
Annex 2a Proposal for national
in-service training to assist
occupational therapists to build capacity
to respond to complex emergency
situations
Background
Occupational therapy is a profession concerned with promoting health and well being through
occupation. The primary goal of occupational therapy is to enable people to participate in the
activities of everyday life. Occupational therapists recognize that major issues focused around
the psychological impact of post traumatic stress, especially from the professional perspective of
what they as occupational therapists can contribute to, as well as the need to help people increase
their productivity and find work or return to school. Occupational therapists can contribute to the
primary health care system which is capable of detecting and effectively managing the majority of
mental health problems, as well as provide rehabilitation for physical trauma and child-based
rehabilitation.
The need to rebuild the community as well as mental health system of Aceh following the recent
tsunami disaster represents an opportunity to move towards a more comprehensive mental health
system, in line with the Ministry of Health policy to shift from a hospital based to a community
based mental health system. There is a need to address the mental, physical and vocational
requirements of this population as it rebuilds its community. The needs relate to all ages.
Occupational therapists can facilitate the establishment of a referral system from primary health
care workers to community mental health teams. They can also provide supervision and consultation
to primary health care workers.
There is a need for occupational therapists in Indonesia to shift knowledge and use of their existing
skills into a new context in the occupational therapy perspective of community based rehabilitation
and community development. This could be done through in-service training on role development
and practice modes (adapting community approaches). This will better place occupational therapists
to respond to disaster situations as well as meet wider community needs in ways that are consistent
with Ministry of Health/government policy and priorities. There are implications for role clarification
and development and then undergraduate and professional development education as well as
employment strategy development in the government and private/NGO sectors.
Occupational therapists in Indonesia acknowledge a strong need to further develop their
therapeutic, occupational and management understanding and skills for working in complex
community contexts where the numbers in need are so great and coordination and liaison with
NGO and Government is crucial.
The World Federation of Occupational Therapists is proposing to hold a 5 day regional workshop
to assist occupational therapists (among other issues) to develop country specific action plans
22
(see Annex 7). Indonesian occupational therapists are keen to develop a national workshop in
collaboration with the Indonesian government, International NGO’s and WHO in order to actively
participate in the reconstruction of the damaged communities. This will enable them to progress
toward their objectives and will contribute to a regional approach.
Workshop Objectives
To ensure continued and consistent delivery of service in the long term to promote long term
community regeneration in the affected communities
* To assist the occupational therapy profession in Indonesia to further support current government
policy initiatives
* To facilitate the ongoing future participation of occupational therapists in community based health
services in the general community
* To ensure that occupational therapists are equipped with adequate skills to assist as required
with any future disaster response
Participants
The participants are occupational therapists who are highly committed to be volunteers. They are
both experienced occupational therapists and fresh graduate OTs.
Facilitators and resources people
The resources people are health professionals/experts who have engaged or involved in disaster
response and recovery in Aceh from local and international.
Proposed location
Jakarta would be a feasible place to run a workshop as most occupational therapists working in
Jakarta and the surrounding areas.
Proposed schedule
The workshop will be run in the third week of November (21-26) or the first week of December (510) considering the fasting month from October 2, 2005 through November 3, 2005. Following
the fasting month will be a long holiday (a week) to celebrate The Big Feast after Fasting.
Outcomes
Country specific action plan to strengthen capacity of occupational therapists to respond to
emergencies
Identification of national support requirements for progressing occupational therapy engagement
in disaster situations and response.
Outcomes for participants
orientation and preparation
a good understanding of the multi-agency disaster coordination requirements
ability to work in a highly stressful, demanding and confusing context, with different kinds of
teams and organisations
skills in injury and post traumatic stress management in makeshift clinical and community settings.
23
a strong foundation in how to promote meaningful and productive occupation and sustainable
livelihood within a disaster rehabilitation context.
to consider the professional and personal challenges of working in an area of conflict in which
the culture and language are different from the rest of Indonesia
debriefing and support arrangements, on return and during longer term assignments
information about the role of IOTA and WFOT in emergencies and how they could be expected
to assist, now and in the future
Monitoring and evaluation
In developing the proposal for workshop, attention will need to be given to how the following will
occur:
Monitor and evaluate workshop
Monitor and evaluate national action plans
Budget implications
Costings for airfares, accommodation, per diem allowance, internal transport, cost of facilitator
and resource persons, venue hire, information packet, materials and report publications and
distribution. Options for funding might include WHO, international donors, local funding agencies.
Budget Proposal
No.
Activities
Unit Cost
Total
1
Accommodation
Standard Room
Meals 3 times plus snack
Venue hire
Per diem allowance
50 prs x 5 days x Rp. 300.000
75.000.000
2
Airfare
Aceh - Jakarta
Solo - Jakarta
Transport (Bus/ Train)
Surabaya - Jakarta
Solo - Jakarta
Bandung- Jakarta
Suburb - Jakarta
1 person x Rp. 5.000.000
3 persons x Rp. 1.000.000
5.000.000
3.000.000
2 persons x Rp. 550.000
10 persons x Rp. 450.000
3 persons x Rp. 200.000
25 persons x Rp. 100.000
1.100.000
4.500.000
600.000
2.500.000
3
Facilitator
Resources Persons
10 persons x Rp. 500.000
3 persons x Rp. 1.500.000
5.000.000
4.500.000
4
Info packet materials
50 persons x Rp. 25.000
1.250.000
5
Letter (stamp)
40 persons x Rp. 10.000
400.000
Total
24
Rp. 102.850.000
Annex 4 Country Specific Report
— Sri Lanka
Approach to Sri Lanka Visit
The visit to Sri Lanka took place from 22-25 March. Meetings took place with the WFOT Delegate,
officials of the Ministry of Health, occupational therapists and occupational therapy students,
therapists and INGO representatives of Motivation Sri Lanka and Christoffel-Blindenmission. Visits
were made to the Physiotherapy/Occupational Therapy School, the Rehabilitation Center at
Ragama, the Southern Center for Disabled and Sani Hasa Children’s Center in Galle, the Dept of
Psychiatry, Faculty of Medicine at the Karapitiya Hospital also in Galle, and Navajeevana in
Tangalle. Tsunami-affected sites in the Galle and Tangalle areas were also visited. Much of the
process of the visit was facilitated by Thomas Koelker of Motivation and his staff. The programme
was further organized and facilitated by Nimal Liyange, WFOT Delegate, and P.O Yapa, Executive
member of the Sri Lanka Society of Occupational Therapists (SLSOT).
On the last day of the visit, a workshop was held with 15 occupational therapists and 14 student
occupational therapists at the Occupational Therapy/Physiotherapy school. Guide questions were
used to stimulate discussion and feedback. Responses by therapists to questions concerning
their personal and professional responses to the tsunami included loss of friends and relatives,
sorrowfulness and concern. Students conducted a health camp in Galle to provide assurance and
assist residents to clear areas, provide meals and medicine. Often counseling was provided to
friends and neighbours. Relief work was provided in Kalunthara, Ampara, and Bertacello. A senior
OT joined Health Assessment Missions concerns indentified included Post traumatic stress
symdrome, nightmares, suicide attempts, phobias, and depression. Proposals for furtheraction
have been prepared.
To meet the needs of the community, issues identified by OT’s include the need for counseling,
supportive psychotherapy, engaging in play therapy and recreational therapy, settling children
into routine and adults into previous or new jobs. Accessibility was considered an issue that could
addressed by OT’s in the rebuilding process. Assessment of physical problems and needs to set
up referrals for community occupational therapy were also considered important.
A lunch meeting with the Sri Lanka Society of Occupational Therapy (SLSOT) Executive provided
the opportunity to discuss future directions.
The Tsunami Context
In Sri Lanka, more than 40,000 people died in the tsunami, 6,000 were injured while almost a
million have been left homeless (Sarvodaya, Sri Lanka’s largest and most wide spread community
based organization, 17 th April). By early April, the Sri Lankan government reported that a tsunami
national reconstruction plan could finally get underway because donors had firmly committed
$1.5bn in aid. However, the government had still not agreed with the Tamil Tigers on how to
distribute aid in the worst hit rebel-dominated north and east areas of the country. A donor
coordination conference is scheduled for May. (BBC Reports, 7th April)
38
Government services and systems have struggled to respond to the impact of the tsunami, with
coordination being a major challenge. It is evident that much of the relief has been provided by
international donors and NGOs, some of whom have long term development programs operating
and thus established relationships and local partner organizations through whom aid is being
delivered. However, as the emergency phase moves into longer term relief and rehabilitation, the
responsibility for rebuilding infrastructure, services and livelihoods is increasingly falling to national
and local authorities. In particular, it would seem that cross-sectoral as well as cross-country
coordination continues to present some challenges (e.g. coordination between land titles offices,
zonal rebuilding regulations, housing design and redevelopment, and livelihood reestablishment).
This being said there are some excellent examples of innovative government responses, such as
the deployment of medical interns to a community outreach trauma counseling program being run
in Galle.
A Malaysian Tamil-speaking occupational therapist 2 who went to the Eastern State of Batticaloa
with a team from Mercy Malaysia noted that there are three religions and two languages used
there and it is in the middle of a conflict area. He reported that there were no rehabilitation
services operating in the region. He said that the hospital there has asked for a rehabilitation unit
and they are thinking of training local nurses in basic rehabilitation. There is currently no orthopaedic
surgeon. The area is 12 hours from Colombo by car and few Colombo trained people do not wish
to travel and work out there.
Independent of the enormous health, social and rehabilitation demands created by the tsunami,
the Ministry of Health has been developing policy and plans reflecting a desire to shift the balance
between hospital based services (tertiary care) toward prevention and community based primary
care and rehabilitation. Presently it appears that the government is only able to provide limited
early intervention at the community level. Major injuries caused by the tsunami were dealt with in
the hospitals, with some people being sent to Colombo for treatment, while widespread and ongoing
psycho-social trauma remains largely community-based. It would seem that the tsunami has
reinforced some Ministry of Health’s views that there needs to be a long term approach through
the development of systems and approaches to provide long term input for all people with
disabilities. For example, with issues such as building access, guidelines though legislation codes
do not yet support the efforts of the Joint Consortium of Disability Organizations.
One of the main priorities of the Ministry of Health, in collaboration with the Ministry of Community
Development and disability service providers including local and international NGOs, is the
development of a National Disability Strategy. However this is made more difficult by a significant
lack of data and records to provide the relevant statistics. Apparently lacking are early detection
or intervention assessment systems or adequate referral and discharge follow-up systems.
Community based rehabilitation and other outreach programs seem to be almost entirely developed
and managed by NGOs, and it is unclear what information is provided to government about injury
rehabilitation and disability status from these programs, although the NGO’s are collaborating
closely with government to progress development of the National Strategy. As most allied health
professionals in Sri Lanka are hospital and centre based, access to occupational therapy and
other rehabilitation services is highly limited for the majority of the community. While costs will
prohibit wide scale increases in the numbers of health professionals that can be employed in
2
Mr Nathan Vihalingam provided a telephone briefing about his involvement with Mercy Malaysia in Batticalao
and the surrounding area. February 2005.
39
government service, there is nevertheless a significant need to
improve the present rehabilitation services and provide services in
the community, with an increase required in the number of therapists
being trained. In responding to Ministry of Health policy directions
and community needs, the role and therefore the training of
therapists will also need to be expanded. This may include the need
to consider a widening range of employment options for OT’s and
policy implications to support this. There is consequently a need for
a strategic plan for training and for the development of the
occupational therapy profession.
There is one national rehabilitation center in Ragama which serves
primarily the surrounding population as many clients cannot afford
the travel, accommodation and loss of income costs associated with
attending the centre an hour northeast of Colombo. There are 18
occupational therapists working in the rehabilitation center, which
constitutes one third of the total number of occupational therapists
in the whole country. At this centre is also housed the Spinal Injuries
Association of Sri Lanka (SIASL), a national NGO that emerged
from two Motivation programs that were run in partnership with the
Ragama Rehabilitation Centre between 1997 - 2001. SIASL is now
run by local people with disabilities, and provides active wheelchairs
Ragama Rehablitation Centre and other support services to adults and children with spinal cord
injury as well as a special seating service for children with cerebral
palsy. Its outreach team extends limited services to the community through counseling, home
visits, information, and guidance on income generation.
Motivation, a UK-based NGO, is one of a small number
of international organizations who have disability
development programs in Sri Lanka. Currently their 5
year, USAID funded Disability Support Program is
working with 6 local partner organizations in Jaffna,
Kandy, Ragama, Colombo, Galle and Tangalle to
provide more comprehensive rehabilitation and
equipment services for people with mobility disabilities.
This includes staff training and organizational capacity
building, peer group training, tricycle development, wheelchair
distribution, employment workshops and job seeking skills
t r a i n i n g a n d n e t w o r k i n g , a n d a d v o c a c y. C h r i s t o ff e l Blindenmission (CBM) is another INGO providing disability
support programs in Sri Lanka, with a particular emphasis on
visual impairment. Both of these NGOs have expressed a strong
desire to be able to work with national OTs with a view to
strengthening CBR services, particularly outside the capital.
With the support of local and international donors, including
Motivation and CBM, community services are being provided
in the community by local NGO’s as evidenced in Galle and
Tangalle.
40
Spinal Injury
Association
Navajeevana is a long standing social development and
disability support organization (local NGO) based in Tangalle
in the South of Sri Lanka. Under the direction of its truly
innovative and visionary founding director, Mrs. Kumarini
(Kumi) Wickramasuriya, it is providing comprehensive, intersectoral community-based work, particularly with respect to
vulnerable community members including those with
disability and psycho-social needs. It has a large, competent
team of personnel, ranging from volunteer/visiting consultant
specialists, experienced rehabilitation staff through to a
network of community based rehab and other workers and
volunteers. It receives funding from international
organizations such as Motivation (and USAID) and
Christoffel-Blindenmission (CBM), and is well connected
nationally.
Income generation at Navajeevana
Navajeevana provides community based rehabilitation in the
form of early identification, programming, aids provision, educational development, employment
training, income generation and support for carers and families. Navajeevana also provides a
community based mental health programme for the general community with identification and
education sessions held openly in the community through group work and home visits. High risk
groups were identified as young mothers, pregnant women and children, and suicide prevention
initiatives have been established. A preschool programme, mother-child programme and physical
therapy activities are run on the Navajeevana premises, which also houses a mobility aids fitting
and production workshop and income generation initiatives. Home programmes use volunteer
mothers and community based workers,
supported and supervised by experienced and
qualified staff. The comprehensive approach
Small Donation to Make a Difference
demonstrated through the Navajeevana
A donation in the order of AUD$1,000 (USD775)
program is an exemplar by any international
would be a valuable contribution to the rebuilding
standards for community based development
and re-establishment of basic services and
and rehabilitation. The Director expressed a
programs, including early childhood and schoolstrong need for appropriate occupational
based initiatives - particularly as a means to retherapy skills input which to date have not been
establishing some level of stability and routine that
readily available, but also recognized that most
is so essential to helping young ones overcome the
health professionals in Sri Lanka are not
severe trauma they have experienced. The psychofamiliar with the participatory partnership
social needs of people generally are just enormous,
approaches that underpin the Navajeevana
and in communities/districts such as the one in
model and the notion that “communities make
which Navajeevana have responsibility, that are
people disabled”. Constraints to further
characterised by other forms of violence and
development and expansion of the
disharmony, the needs are especially great.
Navajeevana program were expressed as:
Navajeevana’s record of successfully working in
• limitation of competence in rehabilitation
difficult areas with intractable issues and complex
• lack of appropriately experienced and
dynamics is well-regarded, hence their selection to
qualified lecturers limiting the numbers and
work with this community. Supporting their efforts
competence of graduate health and social
here would indeed make a difference in an area that
service professionals
is otherwise receiving limited support.
41
• need for better professional development
programs, including access to the skills of
visiting international professionals
• lack of flexibility in the government
systems to acknowledge non-qualified
experiential competence.
Navajeevana is also directly engaged in
managing tsunami response programs (with
funding from CBM, etc). With basic needs
now provided for, community infrastructure
and social rebuilding, psycho-social trauma
management, and livelihood support and
development have been identified as the
priority needs which Navajeevana is
creatively engaged in responding to.
Navajeevana’s Learning - Factors to Success
• Creating awareness about issues... social mobilising
• Addressing both mental and physical rehab
•
•
•
•
•
•
simultanusly
A community approach (rather than the medical
model approach)
An inclusive approach
Training, support and supervision of local people in
their roles as volunteer leader mothers, social
mobilisers, CBR workers, staff and community people
Building relationships is a key attribute
Ability to be a team player with an openness to
different views and situations and a willingness to
both learn and share knowledge and skills
Building capacity of local organizations.
The Southern Centre for Disabled (SDC)
is another local organization being supported by Motivation to upgrade its mobility assessment
and intervention services with adults and children in the Galle area. A new physiotherapist will
provide support to the staff, including an orthotist and prosthetist who have received internationally
recognized training in India and Cambodia (e.g. with Cambodia Trust, another UK-based NGO
which is operational in Sri Lanka). Scholarships, access to training, exchange visits and
secondments of international staff to local programs present tremendous opportunities for the
professional development of local personnel, and yet has not been tapped into by national
professions and training programs such as Occupational Therapy.
Sani Hasa is an example of a relatively new local NGO being professionally operated by mostly
volunteers to provide assistance to children with developmental delay and disabilities and their
parents. They too would like to access occupational therapy and other therapy assistance. Previous
inputs by a VSO speech therapist were much appreciated, and they would welcome consideration
of other options to access international and/or local therapy assistance. With appropriate
supervision, places such as this provide wonderful student placement opportunities, with benefits
for all.
A Tsunami Psychosocial Support Programme has been developed and coordinated by a
psychologist, Chandanie Senadheera with support from other colleagues, including a VSO
Occupational Therapist, at the Faculty of Medicine/Psychiatry at the Karapitiya Hospital in Galle.
This programme has trained 65 pre-intern medicos to provide community based psycho-social
trauma assistance in affected villages. The teams are undertaking diagnostic assessment through
the use of the play groups with children and their families. The activities provide the opportunity
for ongoing targeted support and response or interventions including counseling, need for financial
assistance, psychological advice and treatment or follow-up for basic health needs. The team
members attend district tsunami coordinating meetings to facilitate targeting of social, financial
and other services, referral and follow-up from hospital/clinic treatment, and coordination of
approaches with distressed families and individuals etc. They also undertake awareness training
with district authorities in relation to mental health. The Faculty team is now training a second
batch of pre-intern medicos for a six week period.
42
The needs as noted by assessment teams are huge. There are practical issues around loss of
livelihood, ID cards and land title documentation, houses and boats. There is a need to link in
with support workers and primary health centre workers. There is a need to liaise through the
systems (provincial coordinating committee) that are being set up in the community at the moment
and for the longer term. Building trust - in people, in government services and disaster warning
systems - has been identified as a key factor in facilitating transition from trauma to rebuilding of
lives, and is best being advanced by establishing close, stable relationships between a limited
number of response personnel and an affected person or family.
Tsunami response program personnel noted the potential value of occupational therapy
contributions to rebuilding lives and livelihoods, reinforcing the need for initiatives to be coordinated
if not integrated with existing response programs and systems.
The Occupational Therapy Context in Sri Lanka
There are presently 48 occupational therapists working in the government service and about six
working in military hospitals. The School of Occupational Therapy and Physiotherapy administered
under the Ministry of Health, produces occupational therapy graduates every three years. There
are presently 18 students in the programme, who will graduate in 2006. All graduates bonded to
the government service for a period of eight years. They work primarily in the National Hospital,
Children’s Hospital and Ragama Rehabilitation Hospital. Therapists have in the past attempted to
carry out home visits and community based care, but there is no provision from the Ministry of
Health to support this effort and it has not been continued. The OT’s indicated their interest to be
involved in community rehabilitation and emergency response but appear to be tied to their jobs
in hospital. They have shown interest in volunteering. A project was carried out in health camps to
assess the physical and psychological needs of tsunami survivors and problems were identified
which could be addressed by occupational therapists, as reported
by normal hiyange. A plan has been proposed for the training of
Present Strategic Planning
community volunteers to provide psychological counseling and
proposals for 2010
support for adults and children, and physical rehabilitation/ referral
940 Physiotherapists
to hospital occupational therapists as identified. Therapists from
174 Occupational Therapists
the burns unit of the national hospital reported on the treatment of
two tsunami survivors who had severe burns, one from
electrocution, the other from a stove fire accident. Both were treated for post traumatic stress
diasorder, as well as the burns.
In Sri Lanka, the Task Force for Rebuilding the Nation (TAFREN) is coordinating rebuilding
of damaged houses and new homes for those previously residing in the Coastal Conservation
(Buffer) Zone. As of March 16th, the government had received pledges from 158 international
and local donors (aid, religious groups, government, businesses and individuals) for the
reconstruction of 67,857 housing units, though MOUs having only been signed for 17,075.
Nandana Welage, a Sri Lankan occupational therapist in collaboration with Nimal Liyange
and other occupational therapists, is preparing an initiative to encourage accessibility
considerations to be incorporated in design and rebuilding efforts. It is hoped that links
might also be made with international NGOs such at the International Technology
Development Group, Motivation and Christoffel-Blindenmission, who are based in Colombo
and are also advocating for accessibility requirements, thereby strengthening the proposal
while also potentially developing longer term relationships between occupational therapy
and disability programs in Sri Lanka.
43
Analysis of occupational therapy in Sri Lanka in terms of response to tsunami
and in the long range
Weaknesses
Strengths
• Commitment
•
•
•
•
•
to do something for the
tsunami
Potential for development, e.g. interest
in accessibility design, interest in
community follow-up (home visits, etc)
Strong foundation in hospital based
practice
Strong presence in national rehabilitation
centre programme
People in Ministry of Health have strong
commitment to expand occupational
therapy presence, numbers and roles
There is a relationship with Ministry of
Health, e.g. submissions of papers
requesting increased numbers (cadre) of
the therapists and tutors
•
•
limited numbers of therapists
lack of knowledge of and liaison with key stakeholders in
rehabilitation and the tsunami response
•
lack of strategic planning for the development of the
profession, including limited data and record keeping for
strategic manpower planning and development
diploma based programme which does not adequately
address occupation based perspectives, community
based practice needs, or research
lack of exposure and confidence in working with multidisciplinary, multi-agency teams, e.g. community
workers, school systems
limited community extension fieldwork experience (all
placements are hospital based)
occupational therapists are primarily Colombo-based
therapists apparently work under a prescriptive referral
system in the hospital
constitution arrangement of the Society which does not
appear to promote rotation of office bearers and does
not address development of younger therapists into
executive positions
•
•
•
•
•
•
Opportunities
Constraints
•
•
•
•
•
•
to strengthen relationship with Ministry
of Health and in particular, Department
of Youth, Elderly, Disabled and Displaced
Persons, and Department of Training
to work in liaison with national and
international NGO’s
to work through and contribute to existing
and emerging government supported
community programmes
to access professional development
expertise for staff/student training and
programme development, e.g. in-country
VSO’s
to promote a training and employment
framework that expands options to
include private practice, workshop
business, working in NGO’s
•
•
•
•
•
•
•
44
lack of coordination between departments and ministries
and other organizations
all therapists trained in Sri Lanka in the diploma
programme are bonded by government for eight years
post training; the proposed shift to a university based
education programme may alleviate problems associated
with bonding
lack of suitably qualified therapists to become lecturers
in a university based education programme
lack of awareness by other professionals of OT potential,
e.g. education (school systems) social welfare and social
services, and medical and allied health
lack of public awareness of occupational therapy
lack of registration, which leads to others claiming
occupational therapy roles, training of occupational
therapy assistant position
while there are some people within the ministry who support
the profession, resourcing and budget will constrain the
process within the current employment framework
disability services are managed under Ministry of Social
Services, children with special needs are managed
through Ministry of Education
Actions and Recommendations
It is suggested that the occupational therapy profession work with the Ministry of Health and
other stakeholders including potential employers to lobby for change in the training and
employment framework
WFOT to send letter to support increase numbers of occupational therapists, strengthen the
quality of the programme to serve a wider role consistent with prevention and primary care and
rehab objectives, as well as shift of the education programme to university
There is a need for review of occupational therapy curriculum against the revised Minimum
Standards of Education for Occupational Therapists 2002 in relation to occupation based
competencies
WFOT to send letter of support to Ministry of Health in relation to the intentions of the national
disability plan to address priority needs, such as strengthening the referral system and data
and record keeping systems, in order to inform future strategic planning, including that which
impacts on occupational therapy.
Pilot projects - occupational therapists in Sri Lanka have a lot of ideas of how they wish to
respond in the immediate and medium term, both to the tsunami and longer term general
rehabilitation and disability needs. WFOT support the development of these as pilot projects.
Consistent with government requirements and good practice guidelines, these initiatives should
be implemented in close coordination with the existing systems and approaches to post tsunami
activities. This will strengthen both the occupational therapy projects as well as wider systems,
ensuring greater impact and sustainability.
In supporting the development of projects, occupational therapist are encouraged to first spend
time building their understanding of systems and approaches to community based emergency
response and ongoing rehabilitation programmes.
Occupational therapists need to establish stronger linkages with key stakeholders engaged in
tsunami response and ongoing community rehabilitation including disaster coordinating bodies
as well as other service providers, e.g. INGO’s, national NGO’s, and national ministry bodies.
WFOT will send a letter of support for manpower planning and expansion of the role of
occupational therapy to Minister of Health, supporting initiatives to expand the numbers and the
locations distribution across the country and the expanded roles.
The WFOT supports the establishment of coordinating bodies, e.g. the National Council for
Disability and encourages stronger occupational therapy representation.
There is a need for professional development of the present occupational therapists in Sri Lanka
to meet the present and expanding roles that they could be undertaking as identified by Ministry
of Health in response to community health requirements. This could be addressed by using
sessions by local in-country expatriate occupational therapists, visits to community NGO
programmes, visits to ministries, conducting in-service workshops through volunteers, through
study tours, scholarships, action research, etc. SLSOT should liaise with WFOT to identify
appropriate international people to meet needs for capacity building, e.g. terms of reference for
individuals or teams, specify skills and experience of team member (language skills, development
experience), roles and responsibilities, activities required to be undertaken and outcomes
expected against which monitoring and evaluation will occur.
There is a need for national association organizational development to promote communication
systems, professional development, and professional culture.
45
Action List
Action
Objective
Responsible persons or
organization
Review the Curriculum in relation
To ensure that the curriculum
Sri Lankan Society of
to the new WFOT Minimum
incorporates the occupation and
Occupational Therapists
Standards of Education for
participation perspectives
(SLSOT) with WFOT Education
Occupational Therapists 2002
and Research Programme
Letter of support to encourage
The shift to university status and
Ministry of Health’s endorsement
lengthening of the course to
of a shift to bachelor degree that
Bachelor degree will support the
is university based and the
expansion of the profession into
establishment of partnerships
community
WFOT President and Executive
with other organizations to
invigorate the programme.
Develop plan for training for core
To develop strategic action plan
group of OT’s
to gain funding for post tsunami
WFOT Executive and SLSOT
emergency response in-service
training
Letter and proposal for OT
To enable a number of
inclusion in training on
occupational therapists to
emergency response and
participate in training and
community redevelopment
program work related to post
WFOT President and SLSOT
tsunami rehabilitation
Letter of Support for the National
To promote the establishment of
Council for Disability
the National Council and
WFOT President
encourage occupational therapy
representation
Letter of Support for national
To inform future strategic
disability plan to address priority
planning including that which
needs
impacts on occupational therapy
Proposal for In-service training
To follow up specific areas of
and professional development
development and resources for
WFOT President
WFOT and SLSOT
response to tsunami, and to
position the profession for any
future emergency response
Liaison with key stakeholders
To further develop and utilize
SLSOT and individual
engaged in tsunami response
links with INGO’s, national NGO’s
occupational therapy
and ongoing community
and ministry bodies for
professionals
rehabilitation initiatives
collaboration and funding
Organizational development of
To promote communication
SLSOT
system, professional
SLSOT
development and professional
culture
46
Outcome Monitor and review
To monitor the development of
process
actions and review outcomes
WFOT team and SLOSOT
Annex 5 Sri Lanka Occupational
Therapists Workshop
Feedback from guide questions at a workshop held at the OT/PT School, Colombo, on
25 March 2005 with 14 occupational therapists and 15 occupational therapy students
What has been your experience and reaction to the tsunami
1. We lost friends and relatives, we had to face a sorrowful experience, we were excited (concerned)
at once just that we heard it.....
2. The experience we had during the tsunami period is the most sorrowful disaster for us, because
most of our friends were affected. They lost family members, properties, homes, etc. It means
the tsunami affected us all directly or indirectly. There were not any direct contact (from Colombo)
with tsunami areas that were affected, so those affected people suffered mentally as well as
physically. We reacted by conducting a health camp in Galle with one assistant medical
practitioner to provide reassurance, provided meals and day to day needs and medicine, cleared
the surrounding area of the camp. Most of the survivors suffered from PTSD, many of their
family members and neighbours were missing, many houses damaged and their properties
lost. There was a concern about epidemics.
3. One of our batch-mates was affected by the tsunami, at that time we went there and take part
in her problem solution-in Kaluthara, We provided them food, cloths, medicine, and other needs.
Some of our students provided medical aid and counseling services. We help to distribute aid
in collaboration with Rupavahini (National Television). Some of the students did relief work at
Ampara and Berticello. We saw the needs as PTDS, nightmares, suicide attempts, phobia,
depression.
4. We understood most the community of Sri Lanka tried to fulfill the basic needs of the affected
people, since we know that all people need to fulfill their basic needs as well as have mentally
balanced psyche. Good health care is essential so we decided to help these people during that
time by donating some food , medicine, etc. We tried to talk with them, and tried to share their
problems, and took every possible effort to uplift their psychological state by using our skills as
occupational therapists.
In meeting the needs of community, what are the issues and how can they
be addressed:
1. It is important to build up strong mentality through counseling, supportive psychotherapy,
engaging with play therapy and recreational therapy. In terms of education, it is important to
resettle children into previous or new school, considering age groupings, textbooks and
resources; resettle adults into previous jobs or new jobs through contacts with NGO’s and
government social services, help prevent epidemic conditions.
2. Social and economic problems in the affected area included: homelessness, joblessness, lack
of services, orphans, not enough facilities and courage to go to school, inability to face altered
life, lack of land and resources.
47
3. It is necessary to identify the accessibility needs in the community and help to rebuild in an
accessible manner to overcome geographic barriers
4. It is important to identify special needs groups-elderly, children, young (adolescent) and provide
services in schools, other children’s organizations, elderly centers or social center.
5. OT’s can assess physical problems and
needs and set up referrals for community
OT intervention.
6. One suggested project for school students
would be to select some school or
displaced person camp and provide
counseling services, and assess the
students to identify the problems. Introduce
people to NGO’s which are helping with
these problems, and carry out a program
with social services department and
Ministry of Health.
Project proposal: Occupational Therapy
intervention for barrier free living environment in
the tsunami affected areas
This project was proposed by Nandana Welage who is
an occupational therapist at the Institute of Neurology
and a part-time tutor at the OT/PT School.
Project Proposal: Psycho-social Rehabilitation for
Tsunami Survivors
This project was proposed by Nimal Liyange who is
President of the SLSOT, WFOT Delegate and an
occupational therapist and part-time lecturer at the OT/
PT School.
The project proposals are available for perusal upon
request.
picture-OT workshop groups
48
Annex 6 Country Specific Report
– Thailand
Approach to Thailand visit
The visit to Thailand occurred from 26th -28th April 2005. It included 2 days of site visits and
discussions with various stakeholders in tsunami affected areas of Khao Lak and Penang districts,
followed by a day of meetings with Ministry of Public Health executives and personnel in Bangkok.
Accompanied by Mrs. Suchada Sakorsitian (Occupational Therapist) and Mr. Anantaporn
Pattanapan (a Community Mental Health team coordinator) in Khao Lak, two IDP camps were
visited, Namchem and Pakweed. Opportunities included talking with residents, village leaders
and camp personnel, observing vocational training, housing and child care facilities and other
programs, viewing where the Mental Health Recovery Centre will be established, and discussions
with staff of the District Tsunami Response Public Health Coordinating Centre. In Patang district,
affected towns were visited and opportunities included speaking with a village leader and community
members about the tsunami impact, recovery needs and efforts, observing boat building and
infrastructure rebuilding, and visiting a health clinic to discuss regular and tsunami response
programs. The foreigners’ mortuary and wall of remembrance were also visited. In Bangkok,
meetings were held with Deputy Director General - Mental Health, and visits made to the Central
Tsunami Mental Health Coordinating Centre and the
Child and Adolescent Mental Health Dept from which
The Mental Health Centre for Thailand
the national ‘To Be Number One’ drug and alcohol
Tsunami Disaster posts English language
free campaign runs. Finally, a review and planning
summary reports and statistics on the
discussion was held with Mrs Suchada Sarkorsatian
following website:
covering two main topics: occupational therapy and
the tsunami response in Thailand and across the
region, and the development of occupational therapy
in Thailand.
www.dmh.go.th/english/tsunami/
Information can also be obtained from the
www.dmh.moph.go.th/main.asp website.
Several summary observations and
recommendations for occupational therapy emerged from discussions
Primarily one occupational therapist has been practically involved in the tsunami response; she
has been providing services to children, through group activity like drawing or painting. More
occupational therapy input would be valuable. Occupational therapists in other districts were
not available for comment.
A longitudinal study of the children who are affected by the tsunami is something that occupational
therapists could contribute to. It is necessary to follow up the consequence of this disaster and
provide information for therapy and prevention of long term impact, which will inform response
needs in the event of future disasters.
Opportunities exist for occupational therapists to be more involved in livelihood rebuilding
including motivating people to participate actively in making decisions on issues related to their
living.
49
There is a need for continuous provision of psychological service to be available to survivors,
but this requires more knowledge, training and some structured manuals to serve them
appropriately. Support in developing these will be
sought from WFOT, WHO and international
It was noted that one of the main lessons learnt
organizations who have experience in this area.
from the disaster is that before you provide
While Thailand’s response was comparatively well
mental health assistance, you need to explore
managed, local authorities have identified a need
what the root cause of an individual’s problem
for a more systematic, coordinated approach to
is; mostly it relates to their living situation,
disaster responses. To facilitate this, national
especially the job or money. On this basis, a
guidelines need to be strengthened and/or
program that addresses the real causes of
developed based on lessons learnt from this time.
psycho-social distress can be made and
There is also a need to prepare national mental
implemented.
health guidelines for disaster.
In developing disaster response programs,
consideration of Taweesin Visanuyothin’s1 principles and recommendations might be promoted:
Effective practical planning to maximize the use of social capital through cooperation and mutual
support for family members, community members and volunteers in the neighbourhood areas.
Faith and religion, as well as community ways of life and local intelligence should be used.
Opportunities to participate in reconstructing the community and having some work to do will
help change victims into crisis salvagers, where they are able to defeat the feeling of loss and
sadness and recreate new aims in life.
Individual mental health rehabilitation should coordinate and integrate with community
rehabilitation. A focus should be on supporting and providing knowledge to the communities so
that they can rely on themselves and help each other. People in the community should be
encouraged to work together in managing existing resources, join together in thinking, operating,
and reconstructing the community.
Mental health rehabilitation should be in the context of families and communities, with expert
advice available if necessary, e.g. mobile teams to assist high-risk groups.
Training programs on providing basic assistance should be given to teachers, parents and other
community groups, perhaps also including youth and monks.
There should be mobilization and openess for participation from volunteers and various agencies,
both domestic and foreign country people and organizations, while identifying mechanisms to
ensure coordination with bodies such as the Mental Health Center for Thai Tsunami Disaster
within the Department of Mental Health as central coordinator.
The Tsunami Context
Six provinces in southern Thailand have been affected by the tsunami (i.e. Phuket, Pangnga,
Krabi, Trang, Satul and Ranong). 5,392 people died from the tsunami, which includes 1,838 Thais,
1,948 foreigners and 1,008 whose nationality cannot be identified. Around 13,897 persons were
injured, and 3,200 are unaccounted for. Figures for orphans and single-headed households etc
are also available, though no desegregated figures for disability have been collected to date.
Nevertheless, the availability of such precise figures is an indicator of the level of coordination
and systems that were in place and subsequently have been established in Thailand to track the
1
Reference: draft paper written by Taweesin Visanuyothin Academic Bureau, Department of Mental Health
Ministry of Public Health
50
Patong beach
impact. This being said, the impact was also generally less severe and widespread than in some
other affected countries making accounting a little easier.
The most severe damage has been to the tourism industry (e.g. hotels) resulting in loss of life and
loss of jobs for survivors. Others too have lost their means of occupation - shops, stalls, boats for
fishing and tourist activities. Community people were also affected by the loss of houses and
community facilities (e.g. schools, clinics, religious buildings, shops). Some islands disappeared
and the community people who survived have had to move to the mainland and begin a process
of rebuilding their residences and lives in a new location. The impact of such inter-community
development will need to be assessed and monitored.
During the first 24-72 hours, the search for survivors
and provision of medical assistance was given first
priority. The Ministry of Public Health has been the
key coordinating body. A Mental Health Centre for
Thai Tsunami Disaster was established at the
central Bangkok authority, with programs
implemented in the affected provinces. A senior Thai
occupational therapist, already working in the
central mental health authority, was appointed as
the Coordinator of this program; she is the only Thai
occupational therapist working at a national policyplanning level in Thailand.
Centre of Public Health Surveillance and Relief
after Tsunami Disaster
The Mental Health Crises Center (MCC), which was an existing facility, was used to coordinate all
concerned departments in the Ministry of Public Health. Through this centre, there has been
excellent control of communicable diseases, rebuilding and building temporary and permanent
house for survivors, building boats for occupational restoration, and psychological care for survivors.
Through this system data was gathered which informed and supported further deployment of
health assistance.
Mental Health Mobile Teams were set up and continue operating. Established during the first
month, they coordinate with several professional mental health agencies and provide field services
to target groups in the 6 provinces. Target groups include the injured, relatives of the deceased,
those who lost their belongings and also operational officers (i.e. personnel providing emergency
assistance). They provide mental health assistance as well as medical treatment and counseling
51
services, refer patients with serious
symptoms to the relevant hospitals,
prepared reports and arranged for
systematic monitoring by Department of
Mental Health executives. These teams
visit the camps and go from house to
house using the GHQ12 and PTSD and
suicide assessments to investigate
problems.
I DP camp
Thailand
Recovery assistance is now being
focused on the one province most
affected. To this end a Mental Health
Recovery Center is being established in
the Khao Lak area in order to provide
the psychological care to survivors and
at the same time to monitor and study
the long term effects across all ages of
survivors.
National personnel report that key
stakeholders in the tsunami response
include:
At the country level, concerned ministries, namely, Ministry of Public Health, Ministry of Labour,
Ministry of Social Development and Human Security and Ministry of Defence. There are
overarching national coordinating bodies.
At the Provincial level, the governor, and provincial offices of all concerned ministries are key
stakeholders. Coordinating offices and processes are well established.
There are also NGOs like Rotary as well as multilaterals including UNICEF and WHO involved
in response activities, together with business interests such as pharmaceutical manufacturers,
and community and religious organizations and monks.
Rotary sponsored
Boatbuilding in
Patong
The greatest challenges and constraints affecting communities include loss of power and control
over their lives and the concurrent need for community empowerment to strengthen the villagers’
capacity to cope with the loss and to participate in some productive activities during their stay in
the replacement areas, to encourage them to have hope for the future and not panic when there
are rumors concerning disaster. Communities have apparently responded to the help provided by
52
the government and various agencies and appear to
be ready to work again. The main community needs
now relate to the creation of occupation to enable
people to access work and gain money for their living,
especially in the tourist area.
Community based services and CBR already existed
before the tsunami. At present, instructors have been
sent by the Social Development and Human Security
Ministry to provide vocational training to the survivors
in the Internally Displaced Persons (IDP) camps/areas.
A national plan and training program are needed to
prepare personnel who will provide ongoing
psychological support to survivors.
IDP Camp play centre
Beyond the role of the coordinating occupational
therapist, involvement in tsunami responses by
occupational therapists has apparently been limited
to that provided by the one hospital based occupational
therapist resident in the affected area, who has
primarily been undertaking group work with children.
In Thailand there are 300 occupational therapists, mostly working in government service and
primarily based in district and urban centres. The OT School is based in Chiang Mai University
and and produces approximately 50 BSc students a year.
Analysis of occupational therapy in Thailand in terms of response to tsunami and in the long
range
Strengths
Weaknesses
•
Senior occupational therapist involved in
coordinating a national response initiative
•
Occupational therapists generally not
connected with the disaster response
•
One occupational therapist providing onground assistance with children
•
•
•
Materials and resources available
People/authorities are generally not aware of
what occupational therapy is and could offer
and thus mechanisms for occupational
therapy involvement are not in place (e.g.
secondments)
•
Identified areas where occupational
therapy could contribute now and in future
•
Links between the occupational therapists
involved and the rest of the profession are
weak
•
Succession planning /mentoring opportunities
not yet being considered
Well networked and coordinated response
via the Senior occupational therapist
Opportunities
Constraints
•
High level Ministry support for potential role
of occupational therapy
•
•
roles identified where occupational therapists
can contribute
Most of the occupational therapists are
presently located in district and urban areas
53
Actions and Recommendations
* Thailand could provide guidance and share resources and learning with others in the region
* Thailand have offered to host/provide organizational support for a regional action learning, review
and planning workshop for occupational therapists from across the region.
* Thailand occupational therapists need to review and develop their preparedness and capacity to
respond to disasters including undergraduate and professional development training as well as
mechanisms to enable occupational therapists to participate in on-ground response programs
* Occupational Therapy Association of Thailand and OT professionals to review professional
development and succession planning mechanisms to encourage more occupational therapists
to move into senior health positions.
Action
Objective
Responsible persons
Develop plan for reviewing and
To enable a number of occupational
Occupational Therapy
developing capacity of occupational
therapists to be prepared for
Association of Thailand (OTAT)
therapists to respond to disasters
future emergency response
Review undergraduate curriculum
To ensure that occupational
for inclusion of community
therapists have understanding and
development and emergency
preparation for future emergency
response
response
Provide guidance and share
To contribute to the regional
resources on tsunami response
response capacity development of
within region
occupational therapists
Review professional development
To encourage mor occupational
and succession planning
theropist
mechanisms
Thailand- IDP camp income
generation -batik painting
54
OTAT
OTAT, Senior OT’s
OTA, Senior OT’s
Annex 7 WFOT Action Learning
and Action Planning Regional
Workshop Draft Proposal
Purpose
Building capacity of occupational therapists to respond to emergency situations
Specific objectives
to share learning and experience arising from responses to the tsunami and identify implications
for occupational therapy
to draft guidelines for occupational therapy response to emergency situations
to develop country specific action plans to strengthen capacity of occupational therapists to
respond to emergencies
to identify regional and national support requirements for progressing occupational therapy
engagement in disaster situations and response.
Participants
five occupational therapists from each of the affected countries:
• one senior OT in policy planning
• one from OT school
• two to three therapists with experience working in the affected areas representing a spread of
specialty areas-eg children, general rehab, mental health
• one of team members should represent the national OT association
Facilitators and resources people
five people:
• three resource people who have expertise in emergency response and rehabilitation with
relevance to occupational therapy, preferably from non-tsunami countries, eg Japan, Philippines
• one World Federation representative
• one facilitator
Proposed location
Colombo, Sri lanka is suggested as the proposed location as it provides accessible and suitable
facilities for workshop of this nature. The Galle region can be easily visited (several hours away
55
by bus), providing excellent examples of ongoing activities relevant to occupational therapy in
emergency response. Local and International NGO’s which were involved in the WFOT rapid
appraisal visit in Sri Lanka could possibly assist with the logistical arrangements.
Proposed schedule
A five day workshop is proposed with one day of site visits and four days of workshop activities
based on an action learning and action planning process.
Day one-site visit provides the context for the workshop discussions*
Day two-presentations by country teams, by resource people
Day three-drawing out lessons from presentations and drafting guidelines
Day four- consolidating guidelines and commencing country level action planning
Day five-complete country level action planning and agree regional level support requirements
*Presentations - one hour per country
Summary of OT experience and response
Key lessons learned particularly with examples of technical competence, coordination with other
stake holders, data management, context related issues
Follow-up actions and long term planning implications for occupational therapy
Outcomes
Draft guidelines for occupational therapy response to emergency situations
Country specific action plans to strengthen capacity of occupational therapists to respond to
emergencies
Identification of regional and national support requirements for progressing occupational therapy
engagement in disaster situations and response.
Monitoring and evaluation
In developing the proposal for workshop, attention will need to be given to how the following will
occur:
Monitor and evaluate workshop
Monitor and evaluate national action plans
Monitor and evaluate regional support plans
Budget implications
Costings for airfares, accommodation, per diem allowance, internal transport, cost of facilitator
and resource persons, venue hire, information packet, materials and report publications and
distribution.
Options for funding might include WHO, international donors, local funding agencies.
56