QATAR MEDICAL JOURNAL VOL. 15 / NO.
1 / JUNE 2006
ORIGINAL
Evolution of Community Based Rehabilitation
Concept in Qatar
Bobinac-Georgievski A., Al Sulaiti E., Zafa Z., Farran C., Travia A.
Physical Medicine and Rehabilitation Department, Hamad Medical Corporation
Doha, Qatar
Abstract:
A community based rehabilitation (CBR) project was
initiated in Qatar on September 2001 and the CBR service
was introduced at the beginning of2003. Until December
2004,189 patients with primary physical disabilities were
included 49% Qatari and 51% non-Qatari nationals; 81%
male, 19% female; 6% children; 94% adults, aged 37±18
years. The main interventions were training for involve-
ment in life situations, job site training and providing fam-
ily counseling and support. Rehabilitation conferences were
held for 132 individuals of whom 25% were with traumatic
brain injuries (TBI), 23% with spinal cord injuries (SCI),
20% with stroke, 9% with cerebral palsy (CP), 4% with neu-
romuscular dystrophy (NMD), and 19% with other physi-
cal disabilities (amputee, trauma etc.).
The project demonstrated that CBR could successfully
evolve using available resources and that patients present-
ing with favorable predictors for reintegration could ben-
efit from CBR programs. It was found that health and com-
munity participants involved in CBR activities were able to
collaborate on common goals but there is room for im-
provement in the services available for people with disabili-
ties (PwD). Implementation of CBR is sustainable only if
people from the community take a leading and active role
and work together with the experts and with the disabled
people themselves.
Introduction:
In 2003 Qatar had a total population of 724,125; an increase
of 22% since 2001, with 2-5% over the age of 60 and 26.6%
younger than 15 years (l) . Life expectancy at birth was 74.4 years
for men and 74.7 years for women (1) . The estimated prevalence
Address for correspondence:
Ana Bobinac-Georgievski
Chairperson, Physical Medicine and Rehabilitation Department
Hamad Medical Corporation, P. O. Box 3050, Doha, Qatar
Tel.: (+974) 4397009; E-mail: ageorgievski@hmc.org.qa
52
STUDY
of physical disability, based on use of various services, was 3-
4%(2). Leading causes of death were diseases of the circulatory
system with a mortality rate of 20.3%, followed by injuries with
the rate of 17.8%(1); injuries due to road traffic accidents (RTA)
being the most common cause of death in males aged 15-44
years(3). In the period of 2000-2003,114 patients were admitted
for inpatient rehabilitation following severe TBI (65%) or SCI
(35%). TBI rehabilitation admissions increased from 19 in 2001
to 29 cases in 2003 (52%), RTAs being the major cause of neuro-
trauma injuries in 81% of TBI group and 45% of SCI group,
followed by falls related to work accidents in 13% of TBI group
and 38% of SCI group(4).
Medical rehabilitation in Qatar was introduced in Rumailah
Hospital (RH) in 1982(5) which had been opened in 1956 and
was later renovated in 1997 to house more than 300 beds of
which 210 are for both Geriatric Department (GD) and Physi-
cal Medicine and Rehabilitation Department (PM&R), with an
average of 20% of the beds for patients with acute physical dis-
ability. Since then the rehabilitation service has been growing
but the needs have also increased. The problem has been in dis-
charging patients from the hospital when their families and the
community were not able to cope with their disabilities. Gradu-
ally it has been realized that rehabilitation should continue in
the community to improve integration to regular life, as reported
from various parts of the world, advocated by the World Health
Organization (WHO) (611) and in the United Nations document
"Standard Rules on the Equalization of Opportunities for Per-
sons with Disabilities" (12) . The CBR project in Qatar aims to
use community resources and to match them to the rehabili-
tation needs of the individual throughout the continuum of
care(13"i5).
Material and Methods:
The project was introduced to develop and implement the
CBR concept across Hamad Medical Corporation (HMC) and
the community of Qatar, encompassing the WHO principles of
CBR (8) .
The available structures within PM&R and GD were used
as a platform to develop a new service of CBR.
Evolution of Community Based Rehabilitation Concept in Qatar
Hamad Medical Corporation
Hamad Medical Corporation (HMC) consists of Hamad
General Hospital (HGH), Al Amal Hospital, The Women's Hos-
pital, Rumailah Hospital, Al Khor Hospital and the Primary
Health Care and Family Medicine Department(16) and it employs
qualified health professionals and administrative staff from all
over the world. At the end of 2003 there were 1253 medical
doctors, (of whom 16% were consultants, 23% were specialists
and 61% were resident doctors) and 3613 nurses. In 1983 HMC
became a teaching facility for the Arab Board and in 2004 for
the Weill Cornell Medical College in Qatar. HMC provides care
for the entire population of the State of Qatar, with a vision "to
be an internationally recognized world class center for health
care"(17). From the year 2000 to 2003 there was an annual in-
crease of more than 40 000 patients and a 12% increase of in-
jured patients receiving treatment(3). Besides the usual medical
specialties, there are PM&R and a GD incorporating a home
care service.
The Physical Medicine and Rehabilitation
Department
This department employs 12 medical doctors, including one
consultant, five specialists, eight resident doctors and 209 em-
ployees in the paramedical disciplines, 129 in physiotherapy
(PT), 47 in occupational therapy (OT), eight in speech therapy
(ST), twenty in prosthetics and orthotics (P&O), and fourteen
in special education (SE) (18) providing early rehabilitation in-
tervention, post-acute primary medical rehabilitation and sup-
portive rehabilitation for long-term patients. For the year 2003
there were 155 inpatient admissions, 75% being non-Qatari; 88%
male and 12% female patients, with diagnosis of stroke 41%,
TBI 28%, SCI 17%, and other diagnoses 14%. There were 2073
visits to the outpatient rehabilitation clinic, including subspe-
cialty clinics for Amputees and Acupuncture. The PM&R is lo-
cated primarily in RH, but outreaches to several other locations
within HMC in Doha, and to other towns such as Al Khor and
AlWakra.
The Geriatric Department
The department is composed of inpatient services (four male
geriatric units, four female geriatric units and two long terms
care units), a home care service and an outpatient clinic(19). Ser-
vices of the GD include medical care, skilled nursing care, nurs-
ing aide care, physical and occupational therapies, social, speech
and dietician services, weekly case conferences and a home care
service. The GD currently operates with ten medical doctors
(two consultants and eight resident doctors), 140 nurses and 61
nursing aids. The Home care team is composed of two doctors,
five nurses, a secretary and a driver.
Patients are mostly elderly but with up to 20% of adults with
mental retardation. The most common diagnoses for care and
QATAR MEDICAL JOURNAL VOL. 15 / NO. 1 / JUNE 2006
Bobinac-Georgievski A., et. al.
services include diabetes mellitus, heart failure, stroke, demen-
tia, wound care, and post-operative care. There are up to 6-7%
of young adult male patients in institutional long-term care due
to severe disabilities such as TBI or SCI following RTAs. The
mission of the GD is to provide comprehensive health care for
elderly patients with the aim of maintaining their health status
at an optimal level and by educating their families and provid-
ing them with all the necessary services and equipment to inte-
grate them with the community as soon as possible. Home care
is provided as a follow-up service. For the year 2003 there
were 39 inpatient admissions, nine discharges, 20 transfers to
other units and 25 deaths among male patients, and 74 admis-
sions, 30 discharges, five transfers and 11 deaths amongst fe-
male geriatric patients. Outpatient services were provided to
2400 patients, and 700 patients were included in the home care
program.
Home care patients are visited once a month, with a ratio of
one nurse to 15 patients seen in a week. Since 2003 the Home
Care service has been located in the same building as the CBIJ
facility thus providing better opportunities for collaboration of
community services.
CBR Project
The CBR project developed in several stages with the first
step being initiated in September 2001, when the rehabilitation
team of PM&R (with the first author as a team leader) explored
opportunities for re-integration for patient I.K. The need was
to increase his participation in everyday life and supporting the
plan for returning to school. I.K., 13 years of age, was an ex-
cellent student at primary school when he sustained a severe
TBI following a RTA, 14 months earlier. He reached the stage
of moderate disability with the potential for further recovery.
At that time his primary goal was to play with his Play Station
and hang out at the nearby shopping mall with his brother. The
Rehabilitation team acknowledged this goal, but did not have
the necessary structures in place to proceed.
The decision was made to establish an innovative retraining
program for patients who had sustained a TBI, SCI or a stroke.
The program focused on identifying training opportunities out-
side of the hospital setting to meet the challenges of everyday
living. The "Group" approach was chosen as a working model.
A letter from the Chairperson of PM&R, with a request for sup-
port was sent to Doha City authorities and to other organiza-
tions of interest, in collaboration with the social worker. The
program was carried out under the title "The community re-
integration group program". The group met twice a week, for
two hours per session with two to three staff members and up
to nine clients, aged from 13-42 years (five with TBI, one with
stroke, and three with SCI). Activities were categorized as "In-
door" and "Outdoor". Indoor activities took place in the hospi-
tal garden and activity rooms in different departments and uti-
53
Evolution of Community Based Rehabilitation Concept in Qatar Bobinac-Georgievski A., et. al.

lized games, music, meal preparation, arts and crafts. Outdoor CBR Practice and Outcomes
activities took place at various locations such as the City Center
Clients were referred by their attending physicians or their
Shopping Mall, Bowling Center, Falcon Club, a picnic at the
attending therapist or were self referred. Many were referred
Corniche, the Zoo, the Museum, Cinema, Al Jazeera Space
for continuity of care to prepare for discharge from hospital.
Channel. The program was active from February to July 2002.
Activities were carried out both at the CBR building and
The budget was of primary concern, but the program sur-
within the community e.g. client's home, work place, school,
vived due to the generosity of all involved at HMC and the lo-
and community venues (Table 1). Individual as well as a group
cal community. Transport and the entrance fee to various ven-
approaches were applied to optimize the client's level of inde-
ues were provided free of charge. Staff participated during regu-
pendence, raising his or her confidence level and finding re-
lar working hours. Satisfaction of clients and their families was
integration opportunities in the community. Home assessments
reported for both components of the program, but more were in
and further training in life skills were the main areas of inter-
favor of the "outdoor" activities. In August 2002 consultants
vention within the client's home, as well as providing client and
from the PM&R and GD sent a letter to the medical director
family consultation and education. With clients who wanted to
advocating a Community Re-integration Center.
return to work or school, accessibility to the immediate envi-
The second step followed with the allocation of space in a ronment was assessed, followed by finding an appropriate job,
renovated building outside the main hospital for the home care implementing a work hardening program and providing educa-
unit and the CBR service. The OT service devoted the first full tion to managers and co-workers.
time clinician to organize and coordinate the development and
practice of CBR(20). From January 2003 exhaustive work was
Table 1: Services and activities provided by Community
done to set up the centre and develop the blueprint for the ser-
Rehabilitation Team in 2003-2004.
vice. There was still no formal budget allocation for staffing
but core professionals were reassigned from their original posts
CBR Practice CBR Development CBR Promotion
to the CBR team. The Geriatric Chairman (second author), be-
1. Training of life skills 1. Renovation of the 1. Submitting a poster
ing a staunch advocate, offered his support by sharing some of in real-life situations. CBR building to pro- on "Equal Opportu-
vide a model of an nities" in coordina-
the resources available to home care such as a vehicle for home 2. Training in instrumen- "accessible environ- tion with the Qatar
tal activities of daily ment". Tourism Authority
visits. living within a wheel- for the Disabled
chair accessible envi- 2. Modified Personal. People International
The third step was initiated with the official recognition of ronment, both indoors Computer using acces- World Summit of
and outdoors. sibility options (e.g. People with Disabili-
CBR by the higher management of HMC. In his letter dated modified mouse) ties held in Winnipeg,
3. Facilitate the return to
March 8th 2003, the Medical Director appraised the earlier pro- previous duties or to 3. Raising the awareness
Canada, from 8 to 10
September 2004.
posal for a "Community Re-Integration Center" as being a worth- begin a productive life on CBR and acting as
(school or work). a link between hospital 2. Newspaper interviews
while and essential component of the rehabilitation process. CBR and community with Al Sharq and the
4. Arranging opportuni- services. Gulf Times.
began in daily practice and was also incorporated into the vi- ties for socialization
within the community. 4. Development of 3. Observing of the 3rd
sion of both PM&R and GD. More than one year later, in Octo- specific projects of December Interna-
5. Holding Support concerning the needs
ber 2004, the Ministry of Finance approved additional funding groups and counseling of people with SCI,
tional Day of People
with Disabilities.
for HMC, and thereafter, the Budget Committee decided to re- for CP, TBI, SCI. TBI, stroke, CP and
other disabilities. 4. Sensitizing the
lease monies for the 2004/05 New Programs and Development. 6. Facilitation of com- community to the
munication skills and 5. Encouraging people needs of PwD and
This created the opportunity to obtain the initial budget for capital use of assistive tech- with disabilities advocate for equal
nology. themselves to form opportunities for all
equipment and manpower for the CBR program. associations and to
7. Indoor and outdoor people.
take a more proactive
leisure activities.
The CBR Team role in the re-integra-
tion process.
8. Facilitation of creati-
The CBR members were recruited from available disciplines, vity and productivity.

PM &R and GD Physicians, PTs, OTs, STs, P&Os, SEs, Nurses
and Social Workers. The position of Peer Counselor has been
created and approved. The team always included the person with
disability, a significant family member and community mem-
bers in the process of assessing, discussing and deciding on the
rehabilitation problems, goals and solutions. Essentially, the
composition of the team varied according to the client's indi-
vidual needs. The team was primarily involved in two main types
of activities - clinical practice and the promotion of CBR. The
team conferences were held once a week.
9. Participation in dis-
charge planning from
inpatient setting.
10.Peer counselor inter-
ventions.
From January 2003 to December 2004, CBR service was
provided to 189 individuals. One or more rehabilitation case
conferences focusing on community integration were held for
132 individuals of whom 25% were with TBI, 23% with SCI,
20% with stroke, 9% with CP, 4% with NMD, and 19% with

54 QATAR MEDICAL JOURNAL VOL. 15 / NO. 1 / JUNE 2006 54

Evolution of Community Based Rehabilitation Concept in Qatar
other physical disabilities (amputee, trauma etc.). Family sup-
port was offered and home evaluation was performed for 30%
of the clients. Mean age was 37 (SD 18), 81% were male, and
19% were female, 6% children and 94% adults.
Two young adults were reintegrated back to their jobs, 6
and 23 months after severe TBI and two school age boys were
assisted in reintegration to their schools.
Discussion:
CBR practice was the missing component in the process of
care at HMC. WHO principles of CBR, such as the use of avail-
able resources in the community, knowledge transfer, commu-
nity participation, facilitation of multi-sectorial collaboration,
and communication from the tertiary hospital level to the com-
munity level were applied in our project(8). The process of de-
veloping a community oriented rehabilitation service was
primarily guided by the needs of PwD after severe neurotrauma.
We experienced positive changes and supportive feedback from
hospital management, professionals and society at large. The
core CBR team leader was an occupational therapist, but all
other available clinicians at RH and community representatives
were recruited to the working team as required. The candidates
were evaluated not only for their academic abilities but also for
their caring attitude, motivation, knowledge on the subject of
disability and community integration, and a holistic approach.
The team profile evolved according to the needs of each client
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Bobinac-Georgievski A., et. al.
and his/her family, with the ultimate goal of reaching and in-
volving important others from the community such as the em-
ployer or school representatives.
Further effort is needed to make a closer link to the primary
health care system. The recruitment of staff for the CBR team is
a permanent open process.
There is also a need to introduce the CBR concept to the
educational program of the medical, nursing and paramedical
graduates in Qatar and to the curriculum of specialty training
for community physicians and primary health care workers.
Through this project, we realized that the active role of PwD,
their families and the community could be mobilized by a skilled
CBR team. Rehabilitation clinicians should transfer their knowl-
edge to the families and the PwD themselves as well as to the
community. They also should upgrade their professional skills
as educators and trainers. Professionals in health and the educa-
tional, social, and employment sectors, should be more sensi-
tized to the human rights of PwD(21).
Acknowledgments:
The dedicated work of project team members in various
stages of development is gratefully acknowledged. Appre-
ciation is also due to colleagues from management and de-
cision makers within rehabilitation services and adminis-
tration of HMC for their dedicated assistance.
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55