Replicating the Cambodia Trust Model

by Carson Harte [ Cambodia Trust ]

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Cambodian School of Prosthetics and Orthotics includes a rehabilitation center where students gain practical experience working with patients. The patient shown here is a landmine survivor.
Cambodian School of Prosthetics and Orthotics includes a rehabilitation center where students gain practical experience working with patients. The patient shown here is a landmine survivor.
Photo courtesy of Cambodia Trust.

Cambodia Trust was established in 1989 to assist those affected by disaster, conflict and poverty. It provides prosthetic-orthotic training, physical rehabilitation for persons with disabilities, assistance programs that enable children and adults with disabilities to secure general or higher education, vocational training and employment. Cambodia Trust originally focused on aiding amputees affected by war-related trauma, but management quickly shifted focus after recognizing the need for more trained prosthetists, orthotists and prosthetic technicians in conflict-affected countries.

History

Initially, Cambodia Trust concentrated on amputee rehabilitation and established a physical-rehabilitation center in 1991 at Calmette Hospital in Phenom Penh, Cambodia, a second clinic in the port of Kompong Som, a province in southern Cambodia, and a third in the Kompong Channang province in central Cambodia. These rehabilitation centers became part of a 16-center network of service providers spread across Cambodia.

In addition, Cambodia Trust has worked closely with other key players in the prosthetic field, including the International Committee for the Red Cross, Handicap International, Vietnam Veterans of America Foundation, the American Red Cross and the American Friends Service Committee. The Trust’s partnership with the Royal Government of Cambodia also contributed to its success.

At its inception in the early 1990s, Cambodia Trust imported second-hand prosthetics which were salvaged from abandoned and donated prostheses in the United Kingdom. Simultaneously, the ICRC invested in a sustainable prosthetic technology, which used thermoplastic polypropylene that developing countries could locally manufacture. This material was a more practical option than the second-hand wood or metal that was used for prostheses at the time. In 1993, Cambodia Trust was working closely with the Cambodian Ministry of Social Affairs, Veterans and Youth Rehabilitation (MOSVY) when it reached a consensus that all Cambodian clinics would adopt the more sustainable polypropylene technology.

Employing foreign prosthetists was too expensive and impractical for Cambodia Trust. In 1990, the World Health Organization and the International Society for Prosthetics and Orthotics established guidelines for the training of prosthetists and orthotists in developing countries. This document and its later revision in 2004 are the bedrock of prosthetic and orthotic training and victim assistance, not only in Cambodia, but also throughout the world. At first, these goals seemed unachievable in Cambodia; however, in 1994, Cambodia Trust established the Cambodian School of Prosthetics and Orthotics with support from its donors, it implemented the guidelines of WHO and ISPO. Located in Phnom Penh, the school trains students who take over national rehabilitation services.

Development of CSPO

WHO/ISPO guidelines list three categories of professionals and outlines training requirements. The Cambodian School of Prosthetics and Orthotics originally aimed to provide training for Category II clinicians, as listed in the WHO/ISPO document. Category II clinicians do not necessarily graduate with a university degree like Category I clinicians but receive up to three years in training, prosthetic and orthotic fitting, and clinical care.1 The CSPO successfully met this goal and received Category II accreditation from ISPO in 1997.

By 2000, CSPO was well on track to delivering sustainable national professionals to the centers run by nongovernmental organizations and the Cambodian Government, now numbering 14 centers. With 10 to 12 Cambodian students graduating each year, the CSPO had nearly reached its original target of training 60–80 practitioners.

From 2004 to 2008, the CSPO closely worked with Latrobe University in Melbourne, Australia to develop a Category I program. This allowed the best Category II graduates with three years of clinical experience to receive Category I certification in a challenging, distance-learning program.

In 1998, the first international student attended the CSPO. In recent years, the majority of its students have been international. Students from 18 countries, including mine-affected countries such as Afghanistan, Myanmar (Burma), Iraq, Laos, North Korea and Sri Lanka have been trained. The CSPO accepts 12–15 students per year and of these only three or four are Cambodians. However, fees from foreign students provide additional help in sustaining the school.

As the CSPO graduates participate in train-the-trainer programs, many are helping to develop rehabilitation programs in their own countries. Since 1994, the CSPO has trained 143 students. In 2011, the first Latrobe graduates became teachers and trainers in the school’s program. In fact, the school and related programs are now managed by a Category I graduate, Sisary Kheng, who also received a master’s degree at the University Strathclyde in Glasgow, Scotland.

Because of these developments, the CSPO now has a sustainable program managed by Cambodians, and it was recently integrated into the National Institute of Social Affairs. The school is the central hub of all physical rehabilitation centers across the country and is in the center of an effort to create education opportunities across the region.

Today, all of Cambodia Trust's operations in Cambodia are ISO 9000-2008 accredited. This management standard reflects an international quality imported from the business sector. Through the International Organization for Standardization and ISPO/WHO accreditation, the Cambodian School of Prosthetics and Orthotics has a framework that documents all processes, including management and service delivery. As a part of the accreditation process, external audits and peer review help to insure that all programs run as planned and allow for effective improvement and evaluation. This oversight provides quality-assurance and helps replicate the programs in Cambodia and abroad.

International Training

Jessica Buchanon
Chen Vandet, who was born with one leg, practices walking at Cambodia Trust's Kompong Chhnang rehabilitation center. Vandet attends the clinic approximately every six months to replace his prostheic limb.
Photo courtesy of Martin Flitman

In 1999, the Nippon Foundation, a Japanese nonprofit philanthropic organization, suggested that Cambodia Trust could replicate its CSPO program in other countries in the region. With the Nippon Foundation’s support, Cambodia Trust carried out an 18-month feasibility study, identifying nearby countries most in need of rehabilitation services. Following this study, a variety of programs were initiated to meet needs in the region that utilized the support of the Nippon Foundation and the experience of CSPO. These programs included:

Sri Lanka. Cambodia Trust established the Sri Lanka School of Prosthetics and Orthotics in 2004 to provide rehabilitation services for the disabled, which includes those affected by recent conflicts and the 2004 tsunami. Students at the Sri Lanka School of Prosthetics and Orthotics learn how to make and fit prostheses and braces, and the course involves two years of academic and practical training followed by a one-year clinical placement. The school is located in the Ragama Rehabilitation Hospital, just north of Colombo. With the Ministry of Health and the Nippon Foundation, Cambodia Trust is re-establishing two centers in North and East Sri Lanka where conflict recently ended.

Timor Leste. In partnership with local NGOs, Cambodia Trust established ASSERT (Asosiasaun Hi’it Ema Ra’es Timor), an NGO that created the Timor Loro Sa’e Centre for Physical Rehabilitation in 2005. The Centre is based on the CSPO model, in which persons with disabilities receive prosthetic limbs, braces, mobility aids and physical therapy. In addition to training local staff in prosthetics, orthotics and physical therapy, ASSERT established a local organization to coordinate services for persons with disabilities, which includes training and education.

Indonesia. According to WHO guidelines, Indonesia needs approximately seven prosthetic and orthotic schools to accommodate its population of about 249 million (which would indicate a physical disability workload of 1.5–2 million clients). The first of these schools was established three years ago in Jakarta as a department of one of the Health Service Poltekkes colleges. The school uses a regionally modified version of the CSPO curriculum, and its first class will soon graduate. In order to shorten the supply chain of Indonesian teachers, five Indonesians were sent to Tanzania for prosthetic and orthotic training. Accreditation takes place next summer, and work is also underway to support an existing school in the city of Solo in central Java.

Thailand. In Thailand, Nippon Foundation working with Mahidol University established a new school—Sirindorn School of Prosthetics and Orthotics to train Category I prosthetists and orthotists. This school is intended to serve as a regional hub and will enable students to upgrade from Category II to Category I certification.

Philippines. The Cambodia Trust’s most recent venture is the establishment of the Philippine School of Prosthetics and Orthotics at the University of the East Ramon Magsaysay Memorial Medical College, one of the country’s most prestigious universities. The university built a new building to meet the program’s needs. In addition to the Bachelor of Science degree program available through the Philippine School of Prosthetics and Orthotics, the school will offer a general education (high-school equivalent), pre-training course for students before they enter clinical courses.

These international programs were designed to train local prosthetists and orthotists in the rehabilitation of persons affected by landmines and explosive remnants of war, conflict and disasters, and those suffering from polio, cerebral palsy and leprosy. Cambodia Trust also trains physiotherapists, administrators, managers and technicians so that local staff can maintain the rehabilitation services.2 The curriculum, timetables and teaching materials developed by Cambodia Trust for the CSPO are adaptable tools for these international programs.

Cambodia Trust also played an important role in facilitating the programs of the Alliance of Prosthetic and Orthotic Schools, a collaboration between the newer and more established prosthetic and orthotic schools in the region. With support from the International Society for Prosthetics and Orthotics and the Nippon Foundation, Cambodia Trust continues developing capacity in this important area of Asia.

Current Realities

Since 1993, the rehabilitation centers in Cambodia have treated more people with cerebral palsy, congenital disorders and polio than landmine victims. As a result, Cambodian Trust began providing more orthotic care, as future services would integrate general assistance to people with mobility impairment. As diabetes-linked impairments increase, a demand also grows for services involving general population assistance.

A qualified prosthetist or orthotist can fit between 250 and 270 braces and limbs each year. Cambodia Trust calculates that its CSPO graduates now fit between 27,000 and 30,000 devices a year2—a great improvement over Cambodia and the region’s original situation in the early 1990s.

While the International Campaign to Ban Landmines recognizes that victim assistance is complex and needs integration into broader disability services, Cambodia Trust is also inspired by the Convention on the Rights of Persons with Disabilities, which demands that persons with disabilities have the right to appropriate and affordable rehabilitation and should be treated by qualified personnel.

The challenge of treating and providing rehabilitation to PWDs and ERW and landmine victims specifically remains largely unanswered. Many throughout the world still wait for prosthetic, orthotic and other assistive devices. To help address these issues, Cambodia Trust and the CSPO have a workable and proven model of training, service delivery, and restoration of mobility and dignity. However, Cambodia Trust, the CSPOs and related organizations face challenges of under-funding, under-utilization and misunderstanding.

Prostheses do not last for life; they wear out, break or no longer fit clients who change in height or weight as they age. As a result, services providing assistive devices must be self-sustainable in order to meet clients’ changing prostheses needs. Cambodia Trust, through strong partnerships and careful planning, has successfully defined and applied sustainable practices regarding prosthetic and orthotic services within the victim-assistance field. As proven by its international work, the Cambodia Trust model is replicable. J

~ Rachael Weber, CISR staff, assisted with this article.

Biography

Carson HarteCarson Harte is a prosthetist, orthotist and Chief Executive Officer of the Cambodia Trust with 36 years of experience in the field and almost 20 of those in International Development. He graduated from the National Centre for Education and Training in Prosthetics and Orthotics, University Strathclyde, Scotland in 1980. He also established prostheses and orthotics training in Cambodia, Indonesia, Sri Lanka and the Philippines. Additionally, he is a member of the ISPO Education Committee, working specifically on guidelines and protocols. Harte works closely with the disability and rehabilitation section of WHO Geneva, where he is a Task Officer for ISPO.


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Contact Information

Carson Harte
Chief Executive Officer
The Cambodia Trust
The Saunderton Estate
Wycombe Road
Saunderton
Buckinghamshire HP14 4BF / UK
Tel: +44 (0)1494 568930
Email: carson@cambodiatrust.org.uk
Website: http://cambodiatrust.org.uk
Skype: carsonharte
Facebook: http://on.fb.me/CambodiaTrust

Center for International Stabilization and Recovery
James Madison University
MSC4902
Harrisonburg, VA 22807 / USA
Email: cisr@jmu.edu
http://cisr.jmu.edu

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Endnotes

  1. “Guidelines for training personnel in developing countries for prosthetics and orthotics services.” WHO/IPSO. http://whqlibdoc.who.int/publications/2005/9241592672.pdf. Accessed 19 January 2012.
  2. “Impact.” The Cambodia Trust. http://www.cambodiatrust.org.uk/CT/en/what-we-%E2%80%9Cdo/training/. Accessed 19 January 2012.