by Claire Smyth

In July 2018, I travelled to a rural hospital in south-west Uganda for one month in my role as a Physiotherapist with a team of allied healthcare students. Our team flew into Rwanda, from where we completed a 2-hour bus journey to the Rwandan/Ugandan border. Here we got out of the bus and walked across the border unaccompanied, our driver had to stay with the bus. This was the first experience a lot of the team had of a long drop toilet! We then continued our bus journey for a further 2 hours, the last hour of which was mainly narrow gravel track. On arrival, we received the warmest welcome and the most delicious local food. The immediate comradery of the local hospital staff was like being welcomed home.

The main project that I was working on, which was identified by the local physiotherapist, was a residential therapy camp for 18 children with Cerebral Palsy and their care givers. This project had been developed over several years and was growing from strength to strength. The feedback from the hospital staff and locals was very positive and shaped yearly changes in the camps structure and content.

The local physiotherapist and community health care worker recruited the children for the camp in the previous months. Many had to a travel a long distance and many of the care givers, mainly the mothers, had to leave other children at home while they stayed on the grounds of the hospital for the camp. The cost of the journey was reimbursed as they would not have been able to attend the camp otherwise. This is one of the barriers to accessing healthcare in rural areas. As a result, many of the children and their care givers had previously had minimal interaction with health care professionals.

Our team assisted the local rehabilitation department in providing assessments, treatments, education and locally made equipment. Each child had daily physiotherapy sessions and play therapy with the team. The care givers also had daily education sessions in the afternoon. The topics of the education sessions were directed by the local rehabilitation team and feedback from previous camps. The sessions covered related specifically to Cerebral Palsy to help improve understanding of the children conditions. In particular we discussed ‘What is Cerebral Palsy?’ including why/how Cerebral Palsy can occur. In a group of 18, only one mother had been given the explanation as to why her child had Cerebral Palsy. We also broke down the different symptoms associated with Cerebral Palsy, why these are happening and how best to help manage them at home.

Over the duration of the camp, a positive relationship was developed between the child, the care giver and the rehab team. This relationship helped facilitate the learning experience of all involved and helped provide the team with a clearer understanding of individuals home environments and how they could be best facilitated at the end of the camp. On discharge the family were provided with print outs of personalised exercise programs, copies of the education sessions in their local language and locally made equipment as appropriate.

These pictures illustrate the 4 different types of equipment (passive stander, standing frame, corner chair and stool) that were made locally for children attending the camp. The local physiotherapist measured the children for the equipment and a local carpenter made them to measure. We discussed and provided an education session on other methods, sourced locally, that care givers might use for providing the same therapeutic activities as these pieces of equipment.

The aim of any Physiotherapy session, in Ireland or in Uganda, is to be able to provide accurate information in an appropriate way for the person in front of you. It was the aim of this rehabilitation camp to help the local rehab team to reach more people, a greater distance away from the hospital and provide them with the education and tools to manage their child’s long-term condition in their own homes.

Sustainable Development Goal #3 demands ‘Good Health and Well-being for all’. There are 13 targets within this goal, some of which include reducing maternal mortality rates, children and neonate mortality rates, mortality rates related to cardiovascular disease, cancer, diabetes or chronic respiratory conditions to name a few. One of the targets within this goal is to achieve universal health coverage, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

In my profession, I continually observe inequalities and barriers to reaching this goal. While on project in Uganda, some of the major barriers to accessing health that I understood were the following:

– The physical distance to travel and physical ability to cover this distance to access a health care provider; – The time this would take, this could take people hours one way, this is also time away from working or looking after their family; and

– The cost, people may not be able to afford the transport required, the treatment needed or the medication prescribed, let alone the lost earnings of not providing for their family that day.

Outreach clinics are helping to bridge these issues but again cost of transport, fuel and maintenance of vehicles becomes a new barrier for the service to overcome.

In Ireland, people can much more easily travel from country areas into more populated areas for GP, community and acute hospital care. In Ireland, children under 6 years old have access to free GP care, immunisation programme as a baby, vaccine programme as a child in school and health screening. A child with Cerebral Palsy in Ireland, would have regular health visits from a range of health care professions, equipment that would be regularly replaced as the child grows along with free/affordable medication to manage their symptoms including spasticity and seizures.

These are stark differences in the ability to access and afford healthcare. And this inequality is based purely on where you happen to be born.

Looking locally again, The European Union Statistics on Income and Living Conditions 2018 showed Ireland to be the worst country in western Europe to live with a disability with a 24 % chance of living in consistent poverty if you have a disability.

There are also differences in access to healthcare depending on which county you live in! Services can be better staffed and equipped in one county compared with another. Some services have been completely cut where other areas have centres of excellence. Regional charity organisations offer valuable support and services to people with long term conditions that are not available countrywide.

The Sustainable Development Goal #3 is important, because equal access to quality essential health-care services should not be a privilege. It is a right.

I observed the empowerment and confidence the education sessions and child orientated therapy sessions gave to the carers of the children with Cerebral Palsy at the camp. The time spent with both the carer and the child helped to build therapeutic relations. It encouraged discussions about future potential barriers when the camp was over and how best they can help the development of their child within their own community.

In Ireland, I observe the same thing on a daily basis with my patients. Spending time with people, getting to know them, understand them and building a therapeutic relationship helps you to provide them with the information that they want, in order to facilitate them to manage their own conditions for the long term. In this way, the provision of physiotherapy is no different in Uganda compared to

Ireland. It is about the person, listening to their needs and facilitating them to the best of abilities. What is different is the access to these services.

Going forward, in line with SDG3, we need to continue to identify inequalities, improve access to healthcare for all, and strengthen our communities both locally and internationally with the knowledge and power to manage our own conditions.