USAID's War Victims' Fund
L. FEINBERG *
USAID's (United States Agency for International Development) War Victims' Fund was established in 1989. Since that time AID has provided a modest amount of funds each year to respond to the needs of people injured by war and civil strife in developing countries around the world. Recently, this has amounted to approximately five million dollars per year. As the needs in any single country can far exceed the resources of the programme the Fund attempts to address the humanitarian needs of those injured, but also to complement and leverage other donor funding to establish sustainable systems which might be able to meet these needs on a long term basis.
The programme has emphasised the importance of "unassisted mobility" and especially the provision of artificial limbs to civilian victims of civil strife, because amputations, especially of the lower limb, are one of the most common and critically disabling aspect of civil conflict in the developing world.
In addition to prosthetic assistance, where feasible, a comprehensive programme of medical, surgical, orthotic, physical and vocational rehabilitation services is provided.
For the purposes of funding "war victims" have been defined to take local circumstances into account. For example, children who contract paralytic polio as a result of interrupted immunisation programmes during periods of strife, are considered to be victims as much as those who step on land-mines, during or after the period of conflict. The scope of the programme has been focused on the direct and swift response to the needs of physically disabled war victims.
The dilemma of the War Victims Fund (WVF) is how to strike an appropriate balance between support for direct and swift provision of prosthetic devices to as many victims as possible, and addressing the medium to long-term needs of prosthetic supply and rehabilitation. The supply of an initial prosthesis to an amputee, while critical, is not sufficient, as the victim has a life-long problem and thus a need for long-term services.
Rather than get involved with many small and geographically scattered projects, an effort has been made to focus assistance on a few countries where significant results can be expected. Wherever possible, support has been directed to the expansion, improvement and sustainability of existing programmes, since amputees and other disabled individuals require continuing, life-long access to rehabilitation services. The probability of ensuring continuation of services is increased by improving existing programmes that have a financial base, rather than by initiating new activities which are dependent on continued USAID support.
USAID has used the following guidelines in setting priorities for use of the Fund:
- Develop programmes that are country specific and provide direct services to civilians injured in civil strife. Projects of a worldwide nature are not a priority unless there are special circumstances.
- Design interventions with the purpose of providing the greatest number of war victims with the most appropriate assistance possible, with an emphasis on safety and efficacy.
- Provide priority funding to programmes that can be continued after USAID funds are no longer available and which promise a comprehensive rehabilitation system.
- Favour larger and more comprehensive programmes which would eventually develop into national rehabilitation systems having lasting results. Smaller, less ambitious projects will be considered, with the understanding that the objectives and funding levels will be lower so that management and evaluation will not be undue burdens.
- When possible, fund programmes in countries with USAID Missions that are able to commit support and can assist with project development, management and evaluation.
- Continue support, as needed, to projects that have already been started under the Fund, but ensure that project integrity is not compromised by undue dependency on future funding.
- Implement projects, wherever possible and appropriate, through US PVOs and/or local NGOs.
- Most important, provide support to projects that have the best potential to improve the quality of life of people injured in civil strife in countries where the need is greatest.
What AID and the War Victims Fund hope to gain from this conference is a consensus on as many of the following issues as possible.
1. Guidance on assessment and programme planning for developing countries related to:
- techniques and technologies;
- local manufacture versus importation;
- human resource development, training, supervision and management.
2. Requirements for emergency response, and long term development.
3. Means of achieving collaboration, co-ordination and standardisation within countries, which will allow for responsible innovation but which also ensures maximal utilisation of scarce human, material and financial resources.
4. Means of encouraging joint, and/or collaborative planning of various donors, and the development of complementary interventions by host government, NGOs and, where appropriate, private providers.
5. Methods of supporting and facilitating the development of community based initiatives for the long term care of the disabled and to protect their rights. "Community" in this context, refers to both a geographically defined community and to the "disabled community" at local, district and national levels.
War Victims Funds have ben committed to programme activities in fourteen countries, from 1989 through 1994. Slightly more than $30 million was committed in these years, with about 4% used for planning and evaluation. The number of countries funded in one year has ranged from four to seven. Total funding for a country ranges from $5.5 million for Mozambique to $120,000 for Mali. The Agency has assigned one person to administer the programme from the Office of Health in Washington, referred to in this report as the WVF Manager. The legislation includes a "notwithstanding" clause which exempts the Fund from other restrictions in the Foreign Assistance Act.
The programme is far flung and it is difficult to get good and comparable statistics. Even so it is possible to make some estimates of what is being accomplished. Probably the best indicator is the number of prostheses fitted to individuals over a year. Using the data that is available, at least 20,000 limbs are made and fitted over an average twelve month period. In addition thousands of medical professionals and technicians that have received training that has, and will continue to, improve the help they provide to disabled people.
War Victims Funds in fiscal year 1995 will be used in Angola, Laos, Mozambique, Sri Lanka, Uganda and Vietnam.
What follows is a summary of activities in each country where the WVF has provided assistance. This includes the name of the organisation that the funds where granted to, the amount of the grant, the duration of the grant, the objective of the project and some indications of accomplishments. The countries where the War Victims Fund has provided technical assistance and considered significant projects, but where a decision not to proceed was made, also need to be mentioned. These are: Eritrea, the former Yugoslavia, Honduras, Nicaragua, Peru, Rwanda and Somalia.
USAID's War Victims Fund: description of activities: June 1995
American National Red Cross (ANRC), 1993-1994, $200,000.
The ANRC contributed funds from their agreement with USAID/Washington to ICRC for renovations in Jalalabad Hospital. This hospital is the primary source of orthopaedic surgery and care for land-mine victims in eastern Afghanistan.
Handicap International (HI), 1990-1992, $420,000.
HI established four prosthetic rehabilitation centres attached to NGO hospitals inside Afghanistan. The grant provided funds for construction, equipment and supplies for the centres and training of the staff of each centre. Each centre makes canes, crutches, trans-femoral and trans-tibial prostheses. During their first year of operation these workshops produced 58 limbs and 350 pairs of crutches.
American National Red Cross (ANRC), 1991-1992, $58,000.
The ANRC sent an American prosthetist/orthotist to work with ICRC at one of its orthopaedic centres for 12 months. He made orthopaedic devices and trained Angolan technicians.
International Committee of the Red Cross (ICRC), 1991, $596,000.
Funds were used for equipment and supplies needed for the ICRC's prosthetic programme in Angola. In 1991 ICRC's workshops in Angola made 1,406 limbs, 6 braces, 1,024 pairs of crutches and 16 wheelchairs.
World Rehabilitation Fund (WRF), 1993-1995, $1,078,000.
The WRF opened a prosthetic workshop in the capital of Armenia in 1990 in response to the devastating earthquake. Beginning in 1993 funding for this workshop was provided from the WVF. The reason was that the disabled people coming to the workshop were no longer earthquake victims, but were victims of Armenia's civil war. An American prosthetist is working at the workshop, training local people to take over his role. To make sure that the workshop remains open alter the end of USAID support the WRF has successfully reduced the cost of making a trans-tibial prosthesis by 65% and is developing mechanisms to generate cash through the sale of prostheses. During April-June 1994 the workshop produced 122 prostheses and orthoses. Some 52% of these patients were war victims, mostly from anti-personal mines. Since the project's start in 1990 through December 1994 the workshop has fitted 1,445 prosthetic/orthotic devices and had over 11,000 patient contacts (physical therapy, gait training, exercises, stump care).
United Methodist Committee on Relief, 1994-1995, $70,000. Funds are to bring approximately 60 women who were raped and mutilated during the civil war within Soviet Georgia to the plastic surgery unit in Yerevan, Armenia for recontructive surgery.
American National Red Cross (ANRC), 1992- 1993, $118,000.
Funds provided to ICRC were used for the construction of two buildings at the ICRC's centre in Battambang. This centre produces the component parts that are used by most groups making prostheses in Cambodia.
Vietnam Veterans of America Foundation (WAF), 1992-ongoing, $1,637,000.
The VVAF independently began a project in Phnom Pehn that provides medical services to displaced families, helped people (and their families) with multiple disabilities find housing and work and made artificial limbs for amputees using the Jaipur prosthetic technology from India. In 1992 the WVF began supporting this project. This support allowed VVAF to train more prosthetic technicians, greatly expand prosthetic production and begin the only workshop in Cambodia that makes wheelchairs. In an average month in 1993 VVAF's workshop is making 140 limbs, several braces and 30 wheelchairs. Output has increased dramatically, from 150 limbs in 1992 to 1,221 in 1994. Wheelchair production went from 169 in 1993 to 336 in 1994.
World Rehabilitation Fund (WRF), 1994-ongoing, $1,000,000.
The USAID Mission in El Salvador has been involved with providing prosthetics and recontructive surgery for victims of the civil war for a number of years. Over $5 million of Mission funds have been used for these purposes. Together with the WVF, the Mission planned a new project involving a large grant to one organisation (WRF won the competition). This group will in turn give smaller grants to local groups providing rehabilitation services that include surgery, prosthetic and orthotic and vocational rehabilitation. The WVF contributed $1 million to this $3.8 million project.
Handicap International (HI), 1993, $115,400.
Support or rehabilitation and orthotic services for disabled persons (primarily refugees from Somalia) in Hartesheeik Refugee Camp and surrounding areas.
International Committee of the Red Cross (ICRC), 1991-1994, $1,650,000.
WVF support has been used for supplies and equipment that allowed the four prosthetics/orthotics workshops that ICRC supports to make more legs than they would have otherwise. USAID support also allowed the opening of a fifth prosthetics/orthotics workshop. A month's production at the four workshops was approximately 100 prostheses.
International Labour Organisation (ILO), 1993, $472,500.
This $1 million project was to re-integrate disabled war victims into broader society through vocational training and job creation. It was jointly funded by USAID and the Government of the Netherlands. ILO ran into problems starting the project and after several unsuccessful attempts to resolve the problems ILO returned the funds to USAID.
Medecins du Monde, 1992-1994, $651,750.
With USAID support Medecins du Monde:
- brought specialists in maxillo-facial, orthopaedic and plastic surgery to Ethopia to work with disabled people whose injuries could not be resolved by local surgeons;
- renovated orthopaedic wards and surgical facilities in hospitals;
- improved teaching in the Department of Orthopaedic Surgery at Ethopia's Medical School;
- ran outreach clinics from the Department of Orthopaedic Surgery;
- provided orthopaedic training to paramedical personnel in regional hospitals.
USAID Project Management, 1992-1994, $75,350.
USAID hired a full-time physician who managed the WVF grants.
World Vision Relief and Development (WVRD), 1990-ongoing, $1,360,000.
Given the extreme difficulty of delivering prostheses in rural Laos, where the need was, WVRD's project took a different tack. A first phase focused on upgrading orthopaedic surgery. Next WVRD helped the National Rehabilitation Centre (NRC) improve prosthetic production with training, supplies and equipment. The NRC also began working on outreach and started making wheelchairs. Since the beginning, the greatest effort has gone into small income generating projects in rural communities where there were large numbers of amputees. The rationale was that the disabled could best be helped by providing employment. Efforts have ranged from the introduction of improved strains of cattle through a "cattle bank" (864 cattle distributed to almost 300 families in 6 communities - cattle have increased in number by almost 100 in first year) to raising produce for sale in urban areas (2.5 tons of garlic was harvested in 1994). A final component of this project has been mine awareness campaigns.
As a result of a 1994 evaluation, it was decided that WVRD would now focus entirely on prosthetics, especially outreach. Technicians from the Prosthetic Foundation of Thailand set up shop in rural areas of Laos and make legs on the spot. In the first round, 40 technicians fit 112 limbs in one week. Production at the NRC still has along way to go, but it is increasing. During April-June 1994, 38 legs were made, from October-December 1994, 71 were made.
World Rehabilitation Fund (WRF), 1991-ongoing, $2,173,500.
The WVF is supporting a long term effort by the WRF to improve the practice of prosthetics and orthotics in Lebanon with the expectation that it will again become the best in the region. The first phase of the project was training a new cadre of 26 professional prosthetists/orthotists at the American University of Beirut. They will be the backbone of the system for the next 20-30 years.
The second part of the project is focused on insuring the NGO workshops that these technicians return to function well, that civilian war victims have access to them, and that a system to monitor the quality of practice be one function of a professional prosthetist/orthotist association that will be started with WRF's help.
UNICEF, 1991-ongoing, $1,115,000.
Liberia has been devastated by its civil war with thousands of civilians killed and disabled. There are few groups capable of providing rehabilitation services in Liberia and there is only a small USAID mission with limited management capability. Through this grant
UNICEF will help two groups that are providing rehabilitation (primarily prosthetics and orthotics). These are the Benedict Menni Rehabilitation Centre for Children in Monrovia and the Ganta Methodist Hospital in rural eastern Liberia. Both efforts involve training, equipment and supplies that together will improve quality and increase production of prosthetics and orthotics.
World Vision Relief and Development (WVRD), 1990-1994, $120,000.
The government of Mali asked the US Embassy to help with the treatment of people disabled in rioting in 1992. Rather than send just one person to the US for treatment, the WVF provided a grant to WVRD. This grant provided immediate help to many and improved the practice of physical therapy in Mali. WVRD provided the services of two physical therapists (PTs) for two years. The PTs worked with patients in the major hospital, trained practising PTs and helped revise the curriculum and train new PTs.
American National Red Cross (ANRC), 1992, $15,000.
Through a grant from USAID/Washington the ANRC sent ICRC equipment and supplies so they could include upper limb prostheses in their training of prosthetics technicians.
Health Volunteers Overseas (HVO), 1989-1993, $883,200.
HVO took on the job of improving the standard of orthopaedic surgery in Mozambique. A resident American surgeon trained local surgeons. Training was also conducted for surgical technicians, nurses and physical therapists.
Handicap International (HI), 1989-ongoing, $1,385,000.
HI is contributing to the rehabilitation manpower pool by training 30 physical therapy assistants and 20 orthopaedic technicians. HI also runs orthopaedic workshops, hostels and vocational training centres at five sites. HI's production figures for an average year are: prostheses (109), braces (75), crutches (2,000) and wheelchairs (16).
International Committee of the Red Cross (ICRC), 1989-ongoing, $1,525,000.
The WVF helped ICRC expand production in the four workshops they operate. Total production of limbs at these sites were: 1990 (784), 1991 (898), 1992 (1,027), 1993 (696, January-August). The WVF funded the training of a new group of 23 technicians that graduated in April 1993 and were certified by the International Society for Prosthetics and Orthotics.
Save the Children Federation (SCF), 1990-ongoing, $1,241,000.
At several of the prosthetic workshops in Mozambique productivity is only limited by the scarcity of adequate living accommodation for amputees who have come in for treatment. SCF took on the job of building hostels in Maputo, Beira and Nampula.
USAID Project Management, 1989-ongoing, $495,000.
Funds have been used for evaluations, technical assistance, surveys, audits and for hiring, on a long term basis, local professionals to manage the project.
Friend in Need Society (FINS), 1991-1994, $420,000.
The grant to the FINS has allowed them to expand production in its four orthopaedic workshops. Technical assistance provided by US AID/Washington has introduced new technologies that have improved the quality and reduced the cost of the limbs and braces the FINS makes. Over the first two years of this grant the FINS made: 2,381 legs, 113 arms, 162 wheelchairs, 89 tricycles and over 617 braces.
British Red Cross Society (BRCS), 1989-1994, $610,000.
The BRCS was working with the orthopaedic workshop in Kampala, the only source for prosthetics, orthotics, wheelchairs and other orthopaedic devices in Uganda. The production of these items was far below what was needed. For example in 1989 they made 6 prostheses and 12 orthoses per month (1993 figures show the workshop produced on a monthly basis 15 limbs, 80 braces and 40 wheelchairs). With the added support the BRCS renovated a building that is used as a hostel for patients coming to town for help (run by the Uganda Red Cross). The BRCS also took on training a new group of prosthetics/orthotics technicians as most of the current technicians making limbs and braces are close to retirement age. The first group graduates in September 1995.Some of these graduates will staff three prosthetics/orthotics workshops which will be opened in up-country hospitals with the WVF's assistance.
Health Volunteers Overseas (HVO), 1989-ongoing, $1,000,000.
Late in 1989 a sub-group of HVO, Orthopaedics Overseas took on the task of improving orthopaedic surgery in Uganda. Initially this involved training 40 Ugandan surgeons in orthopaedic surgery. To ensure a continued supply of qualified surgeons. HVO established a postgraduate masters degree programme in orthopaedic surgery. HVO has also trained medical students, nurses and orthopaedic assistants who handle orthopaedic problems including surgery in up-country hospitals. Besides all the training, HVO has had an orthopaedic surgeon on site since the project began. The operating room that HVO renovated has been the site for over 3,500 operations performed by the HVO surgeon, HVO volunteers and Ugandan students.
Without USAID assistance, another of HVO's sub-groups, Anaesthesia Overseas has started a training programme in this discipline at the Medical School. Internal Medicine Overseas and Paediatrics Overseas plan to begin programmes in Uganda within the next year.
Health Volunteers Overseas (HVO), 1992-ongoing, $750,000.
Teams of volunteer US experts hold week long training seminars on various aspect of clinical rehabilitation. The seminars are held consecutively in the south and in the north. Some of the topics have been: trauma surgery, prosthetics, spinal cord injury, rehabilitation nursing and head injury.
Prosthetic Research Foundation (PRF), 1991-ongoing, $775,000+.
The PRF set up the first computerised prosthetic workshop in developing country in Hanoi. The limiting factor in production with this system is funds for component parts. The WVF has provided funds for these components thus allowing the PRF to at least double its anticipated production of limbs. PRF's workshop is producing over 1,000 limbs of very high quality per year. They are also running outreach programmes so people far outside of Hanoi have access to their limbs.
Vietnam Assistance for the Handicapped (VNAH), 1992-ongoing, $1,250,000.
VNAH is working with the orthopaedic centre in Can Tho and opened a new centre in a suburb of Ho Chi Minh City. They are providing training and have a unique system of contracting for the production of limbs at these orthopaedic centres. VNAH also sponsors outreach programs from the two centres. From the start or their project, through March 1995, VNAH has delivered 13,000 limbs and 682 wheelchairs.
Vietnam Veterans of American Foundation (WAF), 1994-ongoing, $730,000.
VVAF is introducing the use of modem techniques of brace making at teaching hospital in Hanoi. This technology is of higher quality and less cost than the old metal braces. If successful it will be replicated in other orthopaedic centres in Vietnam.
World Vision Relief and Development (WVRD), 1991-ongoing, $2,075,000.
Prior to receiving support from the WVF, WVRD was working with the orthopaedic centre in Da Nang. WVF support allowed WVRD to work with three additional centres, establish outreach programmes and begin a programme of training and general improvements that has increased production at each centre by 10% each year and improved the quality of the legs being made. During the first three months in 1994 the four orthopaedic workshops the WVRD works in produce 1,124 legs, 269 arms, 206 braces and 761 pairs of orthopaedic shoes. Total production of prostheses and orthoses during 1994 in the four centres was 7,713.