d i s a b i l i t y a n d r e h a b i l i t a t i o n , 1999; v o l . 21, n o s . 10± 11, 474± 478

Vietnam and activities of community-basedrehabilitation

TRAN TRONG HAI ‹ and TRAN VAN CHUONG Œ

‹ Rehabilitation Department, Institute for Protection of Child Health, Hanoi, Vietnam

ΠRehabilitation Department, Bach Mai Hospital, Hanoi, Vietnam

Summary

This paper describes the development of, and currentsituation regarding, community-based rehabilitation (CBR) inVietnam. Vietnam is one of the few countries to universallyadoptCBR as a meansof deliveringeŒective rehabilitationto itscitizens. Some information regarding the demography of thecountry is presented. The administrative structure associatedwith rehabilitation delivery and the prevalence of disability inthe country are also discussed. Finally, the strengths, weak-nesses and constraints of CBR are discussed.

Background

Vietnam is a country occupying 331700 square

kilometres at the centre of South East Asia. It is

bordered by Laos and Cambodia on the west, the

People’ s Republic of China to the north, and bounded by

the Paci® c and Indian Oceans to the east and south. The

country is divided into ® ve geographical regions : coastal

region, alluvial plains, a middle region, low mountain

region and a high mountain region. The two wide fertile

alluvial deltas have a great potential for agriculture.

The population of Vietnam comprises 64.3 million

persons, of whom approximately 50% are 20 years of

age and under. This population is growing at a rate of

2.1% per annum, and the life expectancy at birth is 64

years for men and 66 years for women. The under-5 years

of age mortality rate per 1000 livebirths is 65. The major

contributory causes of this death rate are acute res-

piratory infection, diarrhoeal diseases, preventable trans-

missible diseases, and malnutrition. The majority of the

population (81%) live in rural areas.

The administrative structure in Vietnam consists of

three levels: 40 provinces which include three major cities

(Hanoi, Haiphong, and Ho Chi Minh), a special zone,

and 444 districts which include quarters in rural areas

and 9611 communes which incorporate residential blocks

in urban areas. Each local unit has provincial councils

and people’ s committees.

Administrative structure for disability-related matters

Primary health care and the improvement in the

quality of health care are the two main tasks of Vietnam’s

health services. The concept of preventative medicine,

the rationalization and maximization of local resources,

and the assistance of international agencies are among

the aims and objectives of the health-care system.

Disability-related issues are dealt with by the Ministry

of Labour, Invalids and Social AŒairs (LISA), the

Ministry of Health, and the Ministry of Education. LISA

has eight rehabilitation centres and orthopaedic work-

shops responsible for social welfare and job placement.

The Ministry of Health is responsible for disease

prevention, primary health care, and rehabilitation.

Rehabilitation and medical care for disabled persons

provided by provincial, district hospitals, or communal

medical workers are the principal tasks of the Ministry of

Public Health. This Ministry is responsible for the

establishment of the community-based rehabilitation

(CBR) strategy and ensures that it is integrated into the

primary health-care system. The Ministry of Public

Health also ensures that the curriculum in all medical

schools is adapted to accommodate the concepts and

strategies of CBR.

The special education section in the Ministry of

Education’ s general education department is responsible

for the administration of educational programmes

delivered to disabled children in special schools. The

National Institute of Education and Science carries out

research on optimizing educational opportunities for

disabled children.

Facts on disability

A survey of the prevalence of disability was conducted

in 1983 by the Ministry of Labour, Invalids and Social

AŒairs in cooperation with the Ministry of Health and

Disability and Rehabilitation ISSN 0963± 8288 print} ISSN 1464± 5165 online # 1999 Taylor & Francis Ltdhttp:} } www.tandf.co.uk} JNLS } ids.htm

http:} } www.taylorandfrancis.com} JNLS } ids.htm

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Vietnam and activities of CBR

Table 1 Principal disabilities identi® ed in 1983 survey

Disability Percentage

Motor disability, including amputees, and polio-

aŒected people

55

Sensory disability, including visually impaired and

hearing-impaired persons

34

Mental retardation 8

Other 3

the Department of General Statistics. According to that

survey 1485000 persons (2.7% of the population) were

identi® ed as disabled. The principal disabilities identi® ed

in this survey are presented in table 1.

Among the 1485000 disabled persons, 950000 were

working, 370000 were capable of bene® ting from further

rehabilitation, 340000 were dependent on assistance in

their daily lives and, 210000 were totally dependent.

Disability prevention and rehabilitation programmes

Basic or primary-health workers are principally re-

sponsible for disability prevention and ensuring correct

nutrition. These people work under the supervision of

the management of a communal health station. Each

commune, consisting of 5000± 6000 persons, has a

communal health station. Primary health-care services

provided at these stations include immunization, pre-

natal examination, dental care, delivery of babies, minor

surgery and CBR. A station is generally staŒed by an

assistant physician, a nurse and a midwife. There are also

some inter-communal polyclinics which are able to

provide more extensive services.

At the district level there are general hospitals which

provide somewhat more specialized treatment than is

available at the communal stations. These hospitals have

hygienic and epidemiological brigades which serve to

control malaria and to provide vaccinations. At the

provincial level there are both general and specialist

hospitals. The latter hospitals encompass social disease

dispensaries (which deal with trachoma, goitre, venereal

skin disease, and mental illness), sanitaria, maternal

protection and family-planning stations, and rehabili-

tation departments.

At the top of the primary health-care pyramid is the

Ministry of Health. There are some specialized institutes

attached to this Ministry. These institutes are the

Institute for the Protection of Children’ s Health; the

National Institute of Nutrition; the Institute of Hygiene

and Epidemiology; the Institute of Dermatology and

Venereology; the Centre for Health Education and

Propaganda ; the Human Resource Centre for Health;

the Institute for the Protection of Mother and Infant; the

Institute of Tuberculosis and Respiratory Diseases ; the

Institute of Malariology, Parasitology and Entomology;

and the Institute of Traditional Medicine.

Vietnam has eight orthopaedic and rehabilitation

centres associated with orthopaedic workshops in the

major cities of Hanoi, Ho Chi Minh, and Haiphong.

There are three rehabilitation centres for children and

one orthopaedic factory which trains orthopaedic tech-

nicians and produces part-completed articles such as

arti® cial limbs. The part-completed products are tailored

to ® t individuals in the orthopaedic workshops. In

addition to rehabilitation sections in district and prov-

incial hospitals there are homes for disabled persons,

handicraft cooperatives, and a rubber factory run by the

Association of the Blind.

The Special Education section, the Department of

Education in the Ministry of Education, is responsible

for the education of disabled children. The centre of

special education for the impaired children, the National

Institute of Educational Sciences, provides expertise in

teaching children with blindness, deafness, mental re-

tardation, and speech problems. This Institute

administers two schools for the blind in Hanoi and Ho

Chi Minh cities, one school for the deaf in Haiphong,

one school for the mentally retarded in Hanoi, and one

school for those with speech di� culties in Hanoi. Other

special education schools and educational programmes

for physically disabled children are conducted under the

Ministry of Labour, Invalids and Social AŒairs. This

Ministry also conducts 15 schools for deaf children ;

however, the teachers are trained by the Ministry of

Health.

Braille classes are also conducted by the Association of

the Blind. These classes are for both children and adults

who have limited or no access to educational oppor-

tunities as a consequence of their disability. The Nguyen

Dinh Chieu school for the blind in Hanoi has commenced

a pilot programme of integrating blind and sighted

children into the one school.

Steps to develop the CBR programme in Vietnam

CBR commenced in Vietnam in 1986 in a number of

pilot centres. Today 115 communes in 15 districts of the

seven provinces have CBR programmes. However, only

1300000 persons (including 53000 disabled) are covered

by these CBR programmes.

The steps taken to implement CBR in Vietnam are as

follows. Initially there was adoption of the World Health

Organization publication Training Disabled People in the

Community and its subsequent translation into

Vietnamese. The pilot schemes proved to be of such

475

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T. T. Hai and T. V. Chuong

Table 2 Results of the house-to-house survey of Cai Lay District

Communes No. of hamlets Households Population Disabled Prevalence (%)

Ngu hiep 7 1785 10868 180 1.67

Long trung 14 2334 11429 250 2.1Nhi qui 5 1880 9825 133 1.39

Phu nhuan 6 1057 8092 155 1.71

Nhi my 5 1121 5338 121 2.25

Trung an 9 2013 10048 211 2.09

Total 46 10190 55600 1050 1.88

Table 3 Manpower model for training in CBR

Form of training Duration Who trains whom Managed by

National and international

specialists

National Steering Committee

Seminars 7 days National regional leaders of

diŒerent sections

Training course 4 weeks Doctors, assistant doctors,

therapists, teachers

Provincial steering committee

Seminars 2 days Provincial district leaders of

diŒerent sections

Training course 14 days Brigade nurses, Red Cross

members, teachers

CBR steering committee at community level

Practical demonstration on disabled at home,

discussion meetings

Family members Family, community

The disabled person

bene® t to the country that, within 2 years of im-

plementation of the pilot schemes, processes for national

implementation had been developed.

When communes in districts or provinces wished to

initiate a CBR programme they were required to follow

the following steps developed by the National Steering

Committee :

(1) Conduct and attend introductory seminars at

diŒerent levels for the various kinds of leaders.

(2) Ensure that there is an established steering

committee at the community, district and prov-

incial levels.

(3) Implement a training course for intermediate-level

workers (doctors, assistant doctors, teachers,

therapists).

(4) The trained intermediate-level workers would then

conduct training courses for primary health

workers (brigade nurses, Red Cross members,

family members).

(5) The trained primary health-care workers (or CBR

workers) conduct house-to-house surveys to

identify the disabled and to assess who will bene® t

from rehabilitation. The survey in each commune

to be completed within 1 week with the assistance

of doctors and the assistant doctors from the

established referring institutions (commune health

station, district hospital, etc.). The results of these

surveys to be compiled and forwarded to the

Ministry of Health in the prescribed format (see

table 1).

(6) Identify the family or community member who

will be the `family ’ trainer of the disabled person.

(7) Commence the home-based training and include

the disabled person in the decision-making pro-

cess.

To provide some indication of the prevalence of disability

in Vietnam the results of the screening programme

conducted in Cai Lay District are given in table 2."

Manpower for CBR in Vietnam

The model for training personnel at the various levels

in the CBR programme has been developed at the

national level. Manpower training of CBR has been

integrated into the primary health-care training pro-

gramme. The established model is illustrated in table 3.#

Impact of CBR

One of the major impacts following the introduction

of CBR has been changes to and modi® cation of a

variety of training curricula. Speci® cally new curricula

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have been adopted for physiotherapists (who are now

designated rehabilitation therapists), a CBR orientation

is now included in medical student training, and CBR

training is incorporated into all mid-level medical schools

(assistant doctors, midwives, nurses).

In 1990 the National Assembly passed laws for the

protection of people’ s health. In these laws there is an

article which states that `the approach of solving

problems of disabilities in Vietnam must be through

Community Based Rehabilitation’ .

Strength of the CBR programme

The strength of the CBR programme is evidenced by

the enactment of laws at the national level. This has been

as a direct consequence of the interest shown by Party

leadership and people’ s committees from provincial to

commune levels. CBR has involved the local com-

munities both in mass organizations and as individuals.

One of the major strengths which has grown out of the

CBR programme has been the availability of, and access

to, medical referral institutions. Special health pro-

grammes such as prevention of leprosy, mental illness,

and trachoma have received support from provincial and

district health bureaus. These latter bureaus have

undertaken the management of the special health

programmes within the primary health-care network and

have ensured delivery and access to all communes and

hamlets.

The apparent success of the CBR programme has

resulted in a high degree of motivation of directors of

commune schools and school teachers. More and more

disabled children are being accepted into and trained in

the mainstream educational system.

Individuals, families and their community

The greatest success of CBR lies in its impact on the

lives of the people that it has served ; those with

handicaps, their families, and their community members.

This impact appears to be immeasurable. Changes that it

has brought about in the relatively short time the

programme has been operational are often dramatic.

These changes have served to stimulate an awareness and

interest in the rehabilitation needs of handicapped

community members. It has also become apparent that

rehabilitation needs can be met by community eŒort, and

there is consequently a high degree of community

satisfaction with their involvement.

More than 50% of the disabled in Vietnam are

children and most of these have bene® ted from the CBR

approach. Since the family is the basic structure of the

community in Vietnam it has become the basis of the

approach to disability prevention. Once the family (the

extended family) is trained by the local supervisor

(usually a brigade nurse) in prevention, early detection,

and intervention the CBR scheme appears to become

self-su� cient and creates an eŒective network in the

reduction of childhood disability. In the ® ve provinces

which currently have adopted CBR, 80% of the disabled

children attend school with their non-disabled peers.

The CBR programme has also adopted a community-

based approach to the delivery of disability prevention

and intervention through the use of existing community

resources. Community involvement is one of the guiding

principles of the programme. This approach enables

access to rehabilitation for a great number of persons at

a cost that can be maintained by the community and the

family.

In most instances trainers are family members such as

mother, father, grandparents, or sibling. In those cases

where family members are unavailable (such as elderly

persons living alone) the primary health-care workers

have undertaken the role of trainer. However, it should

be noted that the primary health-care worker is fre-

quently either a family member or a close neighbour. In

future the primary health-care worker will recruit other

members of the community to undertaken the role of

family trainer for the isolated disabled person.

Constraints and conclusions

The major problem confronting the CBR programme

is the lack of middle-level rehabilitation support. Despite

this it is concluded that CBR has been successfully

integrated into the country’ s primary health-care service

at all levels under the direction of the Party leadership

and the People’ s Committees with management

delegated to the health sector.

People with handicaps and their families can suc-

cessfully carry out rehabilitation intervention, which has

resulted in the social integration of the disabled. The

success of this integration is determined by the support

of the Party organization and the People’ s Committees in

their commune, and the support of the health, ® nance

and education sectors. Support from social aŒairs,

collective organizations, women and youth movements,

the Red Cross and other societies is essential for the CBR

programme to achieve optimum outcomes.

Primary health workers, people with handicaps and

their families can eŒectively use the Vietnamese manual

Training Disabled People in the Community. The value of

the manual has also been proved in the provision of basic

rehabilitation technology. Primary health workers, fol-

lowing the appropriate training, can successfully carry

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T. T. Hai and T. V. Chuong

out rehabilitation tasks with the support of assistant

doctors and therapists.

Following appropriate training the assistant doctors

assume the management, organization, and adminis-

tration of CBR as part of their duties in the health

station. These assistant doctors can provide a certain

amount of technical support to the primary health

workers, but this assistance is complemented by physio-

therapists who have a more specialized knowledge of,

and skill in, rehabilitation.

The commune, district and provincial health services

can and do meet the existing referral needs of the CBR

programme. It can be seen that the CBR project has

made a signi® cant social impact on the lives of people

with handicaps, their families and the community. This

impact has resulted in other communes initiating CBR

programmes.

The achievements of the CBR programme to date

clearly con® rm that:

(1) CBR is an excellent tool for improving the

participation of disabled persons in decision-

making, and their integration into society.

(2) The programme has made a signi® cant impact on

the lives of disabled persons (particularly children),

their families, and community, and has been a

major stimulus to the development of primary

health care in the communes.

(3) CBR has promoted the mobilization of community

resources, human resources, the disabled, and the

coordination and integration of services at com-

munity and intermediate levels. Functions and

responsibilities at the national level have been

further evolved to consider a national programme

and appropriate curriculum for training rehabili-

tation workers.

(4) The CBR programme has increased public aware-

ness of disability and the need to equalize

opportunities for the disabled.

References

1 Hai TT. Vietnam and activities of community-based rehabilitationprogrammes. Intercountry Workshop on Planning and Manage-ment of Community-based Rehabilitation Programmes.Guangzhou, Guangdong Province, People’s Republic of China,10± 14 June 1991.

2 Hai TT, Chuong TV. Activities of CBR programmes in Vietnam.Intercountry Workshop on Planning and Management ofCommunity-based Rehabilitation Programmes. Guangzhou,Guangdong Province, People’s Republic of China, 10± 14 June1991.

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