Building the Foundation for Sustainable Prosthetic and Orthotic Services in Cambodia

by Michael Scott [ The Cambodia Trust ]

The Cambodia Trust was formed in 1989 to meet the rehabilitative needs of Cambodia’s many landmine survivors. Five years after its inception, the Trust helped establish the Cambodian School of Prosthetics and Orthotics, which has since provided invaluable services to Cambodia’s landmine survivors. This article explores the various ways rehabilitation services are being strengthened in Cambodia through this school and its partnership with other organizations.

Four prosthetists/orthotists with a prosthetic limb.
Four prosthetists/orthotists with a prosthetic limb.
Photo courtesy of Steve Cord

Cambodia’s population includes an estimated 43,926 landmine survivors.1 After suffering from nearly three decades of conflict, Cambodia is one of the countries most severely affected by landmines and explosive remnants of war. During the Khmer Rouge regime, the health-care system was destroyed and the majority of Cambodia’s educated citizens were murdered, were killed through forced labor, or fled the country. As a result, when the Cambodia Trust opened its first rehabilitation center in 1990, there were no qualified Cambodian prosthetists/orthotists. This shortage severely hindered the development of sustainable, low-cost rehabilitation services for the large numbers of amputees and other persons with disabilities.

Cambodian School of Prosthetics and Orthotics

The Cambodian School of Prosthetics and Orthotics is the only prosthetics and orthotics school in the world with ISO 9001:2000 certification. This quality-management standard helps to build technical and managerial sustainability by establishing processes that focus on continuous improvement and the satisfaction of its students and PWDs who seek its aid.

Courses at CSPO are instructed in English and foreign students undertake local language classes in order to be able to communicate with Cambodian PWDs during their practical work. The CSPO course is a three-year, full-time program that accepts a maximum of 14 students for each intake year. Students spend approximately one-third of their time learning theory and two-thirds of their time learning clinical and technical procedures. A functioning rehabilitation center is attached to the CSPO, providing a structured and real-life learning environment for students. Third-year students complete their clinical placement in the rehabilitation center. Student fees are provided by international and philanthropic organizations and individual donors with an interest in prosthetics and orthotics.

CSPO has received support from several international donors, most notably The Nippon Foundation of Japan, which has also supported the establishment of the schools of prosthetics and orthotics in Sri Lanka and Indonesia in partnership with the Ministry of Health and the Cambodia Trust. In addition, CSPO receives financial support from the United Kingdom Department of International Development.

Another major barrier in Cambodia to landmine survivors’ reintegration into their communities is the discrimination they continue to face at every level of society. The presence of extreme poverty, prejudice and cultural taboos means that PWDs are often viewed as nothing more than a burden on their families and society. Frequently excluded from education and job opportunities, PWDs who lack support have little chance of employment and remain trapped in the cycle of poverty.

Evolution of Rehabilitation Services

The Cambodia Trust was founded in 1989 in response to a request by Prime Minister Samdech Hun Sen for help to address the plight of the country’s amputees. In the early 1990s, several organizations provided survivor assistance in Cambodia, including the American Friends Service Committee, the American Red Cross, Handicap International Belgium, Handicap International France, the International Committee of the Red Cross, and Veterans International. At that time, several countries still considered prosthetics and orthotics to be a craft instead of a profession, and there were no prosthetics/orthotics standards required by law. Consequently, some of the survivor-assistance organizations used local materials such as leather and bamboo to create the assistive devices, while others used thermo-plastics and total contact sockets, along with proper alignment and training.

Two key initiatives encouraged cooperation between the organizations:

  1. The ICRC established a factory in Phnom Penh to provide prosthetic and orthotic components (using polypropylene technology) free of charge to all physical-rehabilitation centers in Cambodia. This initiative greatly encouraged the adoption of common standards of technology across the country.
  2. The Cambodia Trust, in conjunction with AFSC, established the Cambodian School of Prosthetics and
  3. Orthotics in Phnom Penh in 1994. The school aims to provide internationally recognized prosthetic and orthotic training for Cambodians, thereby helping to build the foundation as a sustainable, locally-run physical-rehabilitation service for landmine survivors and disabled persons.

These steps allowed the various organizations to agree on common standards of conduct and educational training in prosthetics/orthotics. The first tentative steps have been taken toward closer institutional involvement with the Cambodian government. Various organizations encourage the Cambodian government to take responsibility for the rights and rehabilitation of the country’s disabled citizens. While progress has been made, this process still has a long way to go.

CSPO’s Impact in Cambodia

A landmine survivor’s feet next to a landmine.
A landmine survivor’s feet next to a landmine.
Photo courtesy of Wendell Phillips/CIDA

Five partner organizations currently support the 11 physical-rehabilitation centers in Cambodia; three of the centers are managed by the Cambodia Trust and the other eight are managed by the partners. Today, all prosthetic/orthotic services in Cambodia are delivered by graduates from CSPO. Developing this capacity has reduced reliance on expatriate expertise and helped to develop technically sustainable physical-rehabilitation services in the country.

As of 2009, 94 Cambodians have graduated from CSPO, many of whom are employed in physical-rehabilitation centers across the country. Nineteen of CSPO’s graduates have now earned bachelor’s degrees outside of Cambodia as part of an initiative to develop regional professionals as leaders and educators. This trend marks the next step in CSPO’s sustainability, with bachelor’s degree holders taking over from expatriate lecturers and managers, enabling the school to localize its staff and reduce costs.

Cambodia Mine Victims Information System

The Cambodia Mine Victims Information System is one of the leading casualty collection systems in the world. CMVIS was established in 1994 by the Cambodian Red Cross and Handicap International to provide continuous and systematic collection, analysis, interpretation and dissemination of information about casualties due to landmines, unexploded ordnance, improvised explosive devices and abandoned explosive ordnance. The data is obtained through a chain of operations that begins with an expansive volunteer network at the community level and ends with the dissemination of the data to the end-users.

A positive development in Cambodia during the last decade has been the significant drop in the number of victims of landmines and UXO reported and recorded by CMVIS.3

Total Number of Victims

Beyond Cambodia: A Regional Role

Since CSPO was accredited as a Category II2 training center by the International Society for Prosthetics and Orthotics in 1999, CSPO has offered training to students from other low-income countries in the region. Currently, CSPO trains students from 11 nations: Cambodia, Democratic People’s Republic of Korea, East Timor, Indonesia, Iraq, Lao People’s Democratic Republic, Nepal, Pakistan, Papua New Guinea, the Philippines and Sri Lanka. Of CSPO’s students, 41 percent are women and 11 percent are persons with disabilities.

The Cambodia Trust is now exporting the CSPO model to other conflict and poverty-affected countries in the region, with schools in Indonesia and Sri Lanka established and funded by The Nippon Foundation of Japan. Further expansion to the Philippines is under consideration. The Cambodian prosthetists/orthotists trained at CSPO are now playing an active role in this expansion through staff exchanges.

Conclusion

With 15 years of prosthetic/orthotic education experience, CSPO is helping to meet the need for prosthetic/orthotic education in low-income countries where this training is not available. This education enables thousands of people with disabilities in these countries to receive prosthetic and orthotic services each year. In total, 143 graduates have completed their training at CSPO and are now working in the profession in their home countries—countries such as Afghanistan, Burma/Myanmar and Iraq. With the spread and development of CSPO training methods, the number of professionals will continue to grow, as will the number of landmine survivors and persons with disabilities who receive their invaluable aid. J


Biography

Michael ScottMichael Scott is the Country Director of the Cambodia Trust’s projects in Cambodia. A graduate of the Scottish Prosthetics Orthotics School, he also holds a Master of Business Administration from Strathclyde Graduate Business School, Glasgow. Scott has spent 25 years working in developing countries, most recently in Sri Lanka with the Trust, where he helped to found the Sri Lanka School of Prosthetics and Orthotics.


Endnotes

  1. “Cambodia.” Landmine Monitor Report 2009. http://www.the-monitor.org/index.php/publications/
    display?act=submit&pqs_year=2009&pqs_type=lm&pqs_report=cambodia&pqs_section=
    . Accessed 20 January 2010.
  2. Category II accreditation is the common qualification among the Association of P&O Schools, ensuring that graduates are equipped to deliver appropriate prosthetic-orthotic interventions no matter the technology.
  3. Long, Sok, and Chhiv, Lim. E-MINE: Electronic Mine Information Network. Cambodia Mine/Explosive Remnants of War Victim Information System, Annual Report 2008. http://www.mineaction.org/project.asp?pr=1188. Accessed 20 January 2010.

Contact Information

Michael Scott
Country Director
The Cambodia Trust
P.O. Box 122
Phnom Penh / Cambodia
Tel: +855 23 864 047
E-mail: michael@cambodiatrust.org.kh
Web site: http://cambodiatrust.org.uk