Physiotherapy changing lives… setting up a physiotherapy service in southern Rwanda

Categories: Care, Featured, Leadership, and People & Places.

by Kate Hunt, MSc MCSP

Overwhelmingly, the drive for physiotherapists is to help others through our skills and knowledge. In some cases this is extended beyond the clinic and treatment of individual patients to volunteering to help promote physiotherapy for the benefit of wider communities. Here, Kate Hunt shares her experience of being part of a team of who travelled to southern Rwanda to help to set up a physiotherapy service for the community there.


Introduction
From the moment we started working in our first clinics eight years ago, to standing in the foundations of our unfinished building at the beginning of 2020, to now looking at pictures of our up and running purpose-built physiotherapy centre, it has so far been an incredible journey. We now have a 30-bedded building with inpatient and outpatient services up and running. The team and the patients moved in during August 2020.

Our journey
For me, it started with an email from my friend, and now colleague and fellow Trustee, Alison Hawksley asking if I was interested in going to Rwanda with her to do a series of pop-up clinics in the southern province, to explore the possibility of setting up a physiotherapy service for children with disabilities.

Alison is a wonderfully inspiring philanthropic person who I instantly wanted to say yes to and follow anywhere, but I had never been to Africa and like many people I suspect my only experience of Rwanda had been watching the news in my 20s and seeing the suffering the country and its people had endured during the genocide. I had a busy physiotherapy clinic to run, a husband and two children, a dog to walk and a house to look after. The sensible answer seemed to be thank you but no.

In a matter of weeks I was sitting on a plane with Alison, her daughter Brooke and a physiotherapist colleague Jette Jakobsen, heading to Kigali. With advice taken from the Foreign Office, a yellow fever certificate in my hand and a feeling that, at 48, I would never get the chance to take the passion I have for physiotherapy out to a place like Rwanda, I had said yes.

Between us, we had crammed as much clinical equipment as we could into our check-on luggage limit, meaning that I had to pack all that I would need for a two week trip to Africa into my hand luggage. I remember being horrified at that thought for my first trip but, over the years, we have become very adept at packing light for us and heavy for the centre. The equipment in our hold luggage was all donated; from patients, hospitals, schools and friends in the UK, and the continued generosity of people to help others so far away in another country has never ceased to amaze us.

FIGURE 1: Jette Jakobsen with the Rwanda physio centre care team (with permission)

“There have been times when we have cried when seeing patients whose conditions have gone untreated.”

Our first major achievement was to get all the equipment through customs and on to the truck that was to take us on our five-hour journey south. To start the day at Heathrow and end in a place so remote we couldn’t find it on Google maps was mind-blowing! Although we broke our first rule of “do not travel in the dark” on our first day, leaving the tarmac roads and bumping along tracks that felt like dried river beds, staring out into the darkness lit only by our headlights, was the most amazing experience. Added to this, I had met my new physio colleague Jette only once before we left and, as we drifted off to sleep under our mosquito nets on that first night, we felt like gap year students all over again.

Our patients
The first three pop-up physiotherapy clinics we held were a humbling experience. News had spread of our arrival and in each place that we held our clinics there were queues of people so long they stretched around the buildings we were in. Many of the patients had travelled for hours to see us, and I don’t think I have ever loved my job more than I did on that first day. With the help of expert translation from a Rwandan medical student, we found that our physiotherapy skills were immediately transferable.

We have so many memories of the patients we have seen over the years. We all remember the incredible, positive spirit of a severely disabled 18-year- old boy who had spent his life lying in a basket on the floor in his father’s tailoring shop. His sister had pushed him many miles in his wheelchair to see us. As he asked if we could help him get better so he could go to school and get an education we all had tears in our eyes.

Another patient with spinal and multi- joint TB did so well with physiotherapy that, after a couple of years of treatment, she has gone on to become a lead member of our care team.

While there were many occasions that we were able to laugh, there have been times when we have cried meeting patients whose conditions have gone untreated. We acknowledge over and over again how lucky we are to have the healthcare system we do in the UK. A particularly poignant moment was meeting a family with four sons with Duchenne muscular dystrophy.

   

   

FIGUREs 2-6: Above, a selection of photos of our patients attending clinic (with permission)

There was always a varied start to the clinic day. My youngest patient was a two-week-old baby with talipes, and my oldest a lady of 75 who had a fractured hip and was carried in to clinic on a stretcher by her sons. One young girl attended with a bilateral lower limb oedema and, as we assessed her, my colleague Jette and I realised that we were seeing elephantiasis for the first time outside of a text book.

“Our team has undergone a steep learning curve in the attributes of flexibility and resilience.”

Our treatment service

Since we started our clinics in Rwanda, we have seen patients with many different conditions ranging from autism, cerebral malaria, Down’s syndrome, hydrocephalus, osteomyelitis, TB, congenital talipes and genu valgum / varum deformities, among others. Our data collection process consistently showed that the most common patient diagnosis was cerebral palsy and developmental delay.

We responded to this by limiting our adult outpatient service in the short term so that we could focus on paediatric inpatient and outpatient services. We started with a small but solid outpatient service nestled into a multipurpose hall owned by our local Rwandan partners, but we quickly realised that, because so many of our patients travelled a long way to see us, outpatient treatment was difficult for some and impossible for most.

This drove us to set up an inpatient service and within two years we had 10 inpatient beds. We very quickly became pushed for space, however, and realised that the sustainable future of our physiotherapy service relied upon accreditation from the Rwandan Government. That was when we really understood the project we had taken on was bigger than we had first thought, as we would need a dedicated building in order to be accredited.

Play therapy

As part of our treatment service, Jette worked tirelessly to introduce therapy through play, and to promote the idea that for our patients their whole day is their therapy. Moving away from the old medical model that treatment is only happening when the child is with the physiotherapist has allowed us to engage our care team and our patients’ parents in a totally different way. Our care team understands that getting dressed, eating, washing and playing are all part of the treatment programme, and that they are therapists when they facilitate those activities with the patient. Parents have taken a bit of time to accept this concept but, through this new understanding, we have been able to better support and empower them to know that they are key to the outcome of their child’s treatment plan and goals.

By introducing play therapy, we could then move on from a situation where parents wanted to leave their children with us for unlimited months. Patients now stay with us for three-month admissions with varying periods of time at home in between, for which they have home treatment programmes and goals set. Parents and staff have noticed the very positive results of this approach and through this we have built more engaged relationships with the parents of our patients.

FIGURE 7: Fine motor skill group led by the care team therapy assistants (with permission)

Teamwork

We are a small team and we all have our separate roles and responsibilities that ideally link with our individual skill bases, but sometimes the roles we perform are just based on urgent need. We have undergone a steep learning curve in flexibility and resilience, attributes that have been at the top of the list of what has been required of us.

There have also been many practical things to consider in designing our new building such as natural ventilation to provide heating and cooling to accommodate the changeable temperatures of a two rainy seasons climate, provision of toilets and plumbing for many more people, and power supply.

Sitting watching the skies during one of the many spectacular electric storms, we quickly learned the importance of lightening rods in protecting the buildings that sit high on the hilly landscapes of Rwanda.

From an organisational point of view, my main role in the team is operational, and that included the responsibility for setting up the physiotherapy service.

Getting started

Setting up, and managing, a physiotherapy centre and service from scratch has certainly been a challenge. Looking back at what we took on from the distance of time, starting one in southern Rwanda is not something that I would have ever thought I would agree to do. However, despite it being an enormous undertaking, we have found that by taking small steps you can achieve great things. One thing has truly led to another and it has felt to be a very organic process.

The starting point was in treating our first patients on the very first trip. Everything about the way we work as physiotherapists made so much sense to me in those early days. Working in such a different place enabled me to view what I do with fresh eyes and to revisit what I had often found very dry and procedural. Our assessment format felt like an old friend, safe and reassuring in a bewildering new world.

Patient notes

A WhatsApp conversation with a new physio in Rwanda who was asking me to direct them to where notes for a patient might be while I was cooking supper for my family in London made me resolve to change the system. On our next trip to Rwanda, after a week of evenings of working long into the night, we stood back to admire our new filing cabinet, purchased in Kigali, and our new system of perfectly filed patient notes.

While change is never easy, our colleagues quickly noticed the increase in efficiency that this change brought about and, with the clinic having only one physio and one physio assistant in a catchment area of 300,000 people, we badly needed to maximise efficiency.

It required gentle persuasion over time to change the accepted way of recording daily patient attendance in huge handwritten ledgers, repeating lengthy details over and over. Once we had our new documentation and notes storage systems in place, we were able to move on and introduce much more streamlined monthly statistics sheets, making information about our service more easily accessible. This was a crucial step in enabling us to develop informed policies and procedures.

We are trained to work with good systems at the heart of our practice and over the past eight years I have often felt, and relied upon, the safety net of having this ingrained set of high standards and processes in place. They are essential in protecting our patients and ourselves, and in the provision of a best practice physiotherapy service.

We were also lucky at the time when we were setting up our clinic, that we had a wonderful gift, in the form of UK physio Jessica Edwards who was living in Rwanda and worked for us on the ground alongside our Rwandan team. She helped us to use the information we had collected to keep much more accurate waiting lists and develop admissions criteria, so we could direct care to those in most urgent need.

This gave us a framework into which we could introduce the gross motor function classification system (GMFCS) and the goal attainment scale (GAS) and these have been hugely important in helping us to prioritise patients and to provide safe staff / patient ratios for our level 4/5 complex patients. With these important cornerstones in place, we were on a roll, and as we moved onwards and upwards we needed to put in place many different policies and procedures such as first aid and resuscitation training, continuing professional development for our staff, appraisals and safeguarding and clinical governance reviews.


FIGURE 8: Construction of the physio centre (with permission)

Safeguarding

Being in a different country, with different acceptable social and cultural practices, meant that safeguarding had an element of extra challenge. With Jessica’s on the ground help we set up focus groups to explore what our own staff thought, and what safeguarding actually meant to them. We shared experiences of our childhoods and lives, comparing and contrasting the UK and Rwanda. It was a truly bonding experience for both the Rwandan and UK teams to work on this together and develop a robust understanding of what safeguarding actually means on a daily basis for our staff and our patients.

Having always had a dislike of only paying lip service to paperwork and processes, I found it exhilarating in Rwanda to be in a situation where processes I had previously found difficult to see the purpose of suddenly showed meaning, and their true value in directing change.

Continuing professional development (CPD)

Our monthly patient data collection is used to inform the in-service training for our care team staff. This involves weekly staff meetings and training sessions that include a safeguarding review of our current patients.

Some lovely and unexpected adventures and successes have occurred as our policies developed. As in the UK, CPD credits are required in Rwanda to retain professional membership. In a remote village, some five hours travelling distance from the capital with fluctuating internet connection, this was difficult and costly.

However, as our UK team was already providing training when we visited, I wondered if we could somehow get our teaching accredited. The Rwanda Allied Health Professions Council (RAHPC) was very encouraging and, following a couple of meetings with them, we set about becoming an accredited provider of CPD in Rwanda, something we achieved in 2018. We were excited to be told we are the only non-Rwandan accredited provider of CPD in Rwanda. We have run accredited courses on-site for our physio team each time we have visited, and have also run two courses in the capital, Kigali, for physios countrywide. This has had the bonus of linking us to the wider physio network in Rwanda and that has helped to build the reputation of the centre. We had seven courses planned and accredited at the start of 2020 that sadly had to be cancelled due to Covid restrictions, but we hope to get these up and running again as soon as we can.

“Good recording systems are the heart of physio practice as they are essential in the provision of a best practice physiotherapy service”

More recently, we were contacted by a Rwandan occupational therapist (OT) who had found us via our website asking for work. We have always known that we needed OT input but up until now we have not been in a position to add another staff member. Through a donation, we were able to give him a six-month internship which has been an immediate success. It has been hugely rewarding to see how specific OT skills can enhance what we do as physiotherapists, and we have quickly witnessed how this has benefitted our patients.

Our future plans

In March 2021, a container full of donated equipment that we had collected over the last few months in partnership with PhysioNet set sail for Rwanda, and the container ship that blocked the Suez Canal quickly became another of the many hurdles we have faced over the past year!

When the container reaches Rwanda, having the equipment safely installed in our clinic will be the last piece of the puzzle that will enable us to invite Rwandan government officials to visit and assess the centre. Accreditation will give us the sustainability we need for the future, and complete this leg of our journey.

Our goal has always been for the centre to stand alone in its ability to self-fund and, with the confidence and skills of the Rwandan team, to be a centre of excellence in Rwanda. At that point, our UK team will be able to step back from day-to-day financial and operational support, but we will stay on as clinical advisors. We will always be there in spirit though and, as we get closer to obtaining our accreditation, I dream of so many possibilities, including setting up a back pain programme, becoming a talipes / club foot specialist centre and having an orthotist in situ. There are always new challenges to be taken on.

Our project joined forces, in 2017, with UK charity Make A Difference for Africa (MAD4Africa ) and I am proud to be working with a very dedicated team of trustees who guide our work in health and education. Our projects are completely funded by donations and all UK staff members are unpaid volunteers. We are always grateful for donations of money and equipment and, once the centre is accredited, we will be in a position to offer work for volunteers who are ready for adventure and challenge in a different environment and would like to share their clinical expertise with our colleagues in Rwanda.

FIGURE 10: The completed new building

 

About the author

Kate has worked as a musculoskeletal physiotherapist for 35 years, following her graduation from King’s College, London. Before setting up her own practice she worked at The Royal London Hospital, St George’s Hospital and in India.

While Kate continues to support the running of the physio centre in Rwanda, she balances that with her current role in London, working within two health and wellbeing departments of large news companies in London, with a particular interest in posture and muscular strain related to working with technology. She loves that physiotherapy allows for knowledge, skills and experience to be used in such different settings.

Acknowledgments

I would like to thank our hardworking team on the ground in Rwanda, PhysioNet for everything they did in collecting and getting our container of equipment to Rwanda, and to the Rwanda Allied Health Professions Council (RAHPC) for their help and support. Thank you to Alison and Jette who made an idea become real, and to all my colleagues at MAD4Africa and to Jessica Edwards for sharing her experience with us and for making a huge difference to our organisational processes. Finally, I thank my family, Patrick, Joseph and Rachel for supporting me in my adventure.

Contact details
kate@huntphysio.co.uk

https://www.mad4africa.com

Lead Photo: The care team receiving CPD certificates with, from right to left: Jessica Edwards, Jacqueline Ntakirutimana, Francine Nyirandikubwimana, Vestine Uwimana, Leatitia Uwingabiye, Diogene Murwanashyaka and, far left, Kate Hunt.  (with permission)

This article first appeared on www.physiofirst.org.uk.

ehospice is grateful to Kate Hunt for permission to republish this article.

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For information about how Palliative Care Physiotherapy can play a key role in improving quality of life go to:

https://www.csp.org.uk/frontline/article/managing-symptoms-palliative-care

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