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Introduction

We have been operational at our premises in Hayatabad for two years, we moved in February 2017.

This paper will give an introduction on the scope of work being supported by our primary donors.

I. In the past two years we have continued with a very energetic development of the services
we can offer children with disabilities, and their families. Mostly these developments have
required capacity building to provide the skills and knowledge our staff need to be effective,
efficient and able to comply with the International guidelines on best practises in treatments.
II. Some developments have necessitated the installation of equipment for a ‘Partial
Weightbearing’ gait training area. It has been engineered by Jim Frizzell and manufactured
locally. This is part of our policy of being sustainable by relying as much as possible on locally
sourced skills and materials.
III. We have lost experienced Physiotherapy (PT) staff who have taken up very good positions in
the UK and in Pakistani private hospitals and teaching facilities. We have a reputation of
enabling staff who join us to be more professional and more skilled. No matter how short their
time is with us they get employment quickly elsewhere. We understand the need for service
expansion through other agencies taking up this work. However, we are greatly concerned
that the necessary skills and experience cannot be gained with the limited training exposure
AKi can provide in a very busy clinic. We initiated a three-month paid Intern program in Dec
2017 to begin to address the need for more trained professionals in Paediatric Rehabilitation.
The concept of AKi becoming a more active agent for training for Physiotherapy for Children
with disabilities (CwD) is being discussed with the Government. We are taking care to ensure
we do this in a considered way with diligent investigations on the implications for the effect it
might have on AKi and how we can comply with all regulations and safe guards for future
sustainability.
IV. We engaged a tailor in November 2018. He is making individual custom cushion covers and
belts for our chairs. We have replaced glue and Rexene with heavy-duty material covers for
these cushions. This has made our children more comfortable and postural devices covers last
longer. It also complies more with good health and safety practises for our technicians; we
had concerns about the effect of inhalation exposure to the glues. Now soft hand splints for
therapy needs are available and the harnesses for our partial weight bearing system. Our tailor
is an amputee and very hard working, he has quickly become one of the team.
V. We have an extended program for final year undergraduates in Physiotherapy. 5 MoUs have
been signed for 2019. In 2018 we had 75 students. Each came for 8 morning sessions and we
accommodate 15 students at any one time. We take a donation from universities of 2,000 PKR
per student in 2018 but our current MoUs state that the donation will be 3,000PKR per student
in 2019. We have a prepared a syllabus that we expect them to follow with some teaching
time and some clinical experience.
VI. We have had a Memorandum of Understanding (MoU) with the International Committee of
the Red Cross (ICRC) for five years that has three more years to run.
a. They have been consistently good partners to Akbar Kare and we have had valuable
support from them in a few different projects and opportunities. These include
approval to provide the funding for the training of three of AKi PTs and one local ICRC
PT in S. Africa in August on the Early Recognition (ER) of babies (as requested in the
latter part of 2017).
b. The ICRC minibus we were waiting for as reported in our 2017 report was delivered in
spring 2018. With this we can have two outreach programs with three PTs for three
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days a week. We alternate weekly between one in Lala Kala, Peshawar and one in
Jalozai camp, Nowshera. This service is funded through CHIP. (CHIP is a not-for-profit
company created in October 2004 under Section 42 of the Companies Ordinance (PAK)
and registered with Security and Exchange Commission of Pakistan). We have an MoU
with CHIP who then get the funding for our program through their work with Handicap
International (HI). This MoU was revised to be paid by a grant directly by HI.
c. An old shipping container was delivered by ICRC in mid-2018 but was not equipped
for the Orthotics as agreed in our MoU. ICRC did not consider this container suitable
for this. So, now we are waiting for imminent delivery of 40 foot fully converted and
equipped container. We have been allowed to keep the smaller 25 foot one for
storage. This should come into service by early summer 2019. At the moment we are
supported by ICRC for orthotics that are made at the Paraplegic Centre Hayatabad,
(PCH). The new 40foot container has been delivered and fully equipped by ICRC for
manufacture of orthotics. We have a PnO recently employed by AKi to work with ICRC
to make this all operational. It will begin making orthotics from the 15th August.
d. ICRC have assured us that they will supply the materials for orthotics for the next three
years and will help with specialist training of an Orthotist that we will employ for our
work with children with complex problems. They will also supply shoes for children
who are enabled to walk with these orthotics and who cannot afford them.
e. ICRC have facilitated Mrs. Shawana Zeeshan to understand how budgets are
organised and presented for grant or funding proposals. She attended a one-day
course with their financial personnel. She has been working on a proposal for
assistance for our children from Bait ul Maal. This is an ongoing process and no
agreement will be made without a full report to the Board. This was delayed until we
had all our operational procedures more regularised to reflect management
standards for our growing organisation. Donation mapping will now be undertaken by
AKi staff. Mrs Shawana has resigned from Aki.
f. ICRC are offering the same degree help to Mrs Huma Habibullah for learning how to
prepare and present infographics for her upcoming presentation in Genevá of our
research on our understanding of the Early Intervention practises in Khyber
Pakhtunkhwa. The Presentation was a great success and Mrs Huma Habibullah has
subsequently presented this research at a symposium at AFIRM on the 5th July 2019.
YF was the keynote speaker on Early recognition of neurological anomalies and
appropriate Early Intervention for neurological developmental issues.
VII. Mrs Saadia Ahmad is now our lead PT with speciality in the Early Years Therapy. She was on
of the staff trained in S Africa. This training was conducted by Dr Christa Einspieler of the
(Prechtl) General Movement Trust hosted by the Eastern Cape Cerebral Palsy Organisation in
Port Elizabeth. We continue to see referrals from Medicine Sans Frontier and have a dedicated
mothers and baby room for new born babies who need assessment. It is a private quiet room
where guidance can be given to mothers for feeding issues and to help her baby have the best
possible chance for development. Early Intervention is the international gold standard of
practise for babies at risk of neurological deficits.
VIII. We have a structured service with Mr Mohammed Raza as the Head of the PT staff, we have
then a group of Supervisory PTs, Senior PTs, Junior PTs and Interns. This encourages the
commitment to become a team who have support and monitoring at every level. This career
is quite daunting when the PTs are recently qualified. Our work is complex and often these
young staff are faced with very distressing stories and problems families face with, often, very
disabled children. Mrs Saadia Ahmad has subsequently joined M Raza as co-Head of Pt
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services as she has gained additional qualifications that allows her to supervises all Early
Intervention services.
IX. We held only 5 full study days in 2018. Our work load has increased and I have taken every
opportunity to encourage learning opportunities through any quieter periods, (rainy days).
However, I realise the need to ensure all staff are up-to-date with all interventions and the
reporting that is needed to maintain an effective and proper service. This year we will have 1
full week in March and 1 full week in the Autumn when we close the department for in-service
training. We conducted our internal Workshop program in march and invited a representative
from ICRC to participate and learn with us. This was highly appreciated and we intend to offer
ICRC partners more opportunities to join us for our workshops. ICRC recognise us as the most
well informed and skilled in paediatric rehabilitation in KP.
X. Following a one-week training opportunity for myself (YF) offered by ICRC to train in the
implementation of a Physiotherapy Minimum Standard Tools manual in the Indus hospital in
Lahore, we are adopting the practises these tools facilitate. This will help to validate our work
as being committed to best profession of PT standards. It will also be a more complete record
of what is happening in the department over the next year. This will form the basis for next
year’s report. Those attending were ICRC International trainers and some of their therapy staff
working in other countries. The Pakistani contingent was a small group of 8 people who are
working in Rehab centres from Lahore, Karachi and Peshawar and in Khyber Medical
University (KMU).
XI. Two staff attended two days training in Rehab readiness in times of disasters and
environmental issues. Conducted in Peshawar hosted by HI.
XII. For a second year we also held a First Aid course (refresher) for all staff, again hosted by HI.
XIII. We now have the ability to conduct 2D video gait analysis. We have two apps that help with
determining the limitations a child has in walking by using these videos. We have also started
to use the Edinburgh Visual Gait method for this. YF attended an International CP Conference
and Gait workshop in Dublin in March 2018 hosted by the Central Remedial Centre, Akbar
Khan’s former service provider in Ireland. This introduction to 2D video assessment followed
this workshop training.
XIV. We continue to hold regular birthday parties for celebration of every child’s birthday. These
are very popular days that children and families look forward to. We also continue with the
women’s groups for grandmothers and mothers. Isolation and depression and guilt is often
present when a child with disability is in the family. These groups provide an opportunity for
women care-givers to share experiences and problems.
XV. We have had our own annual Open Day celebration that is held each year on World CP Day.
The staff take great care to make these days memorable for our children. We also attended
World Disability Day in the grounds of Islamia College grounds, Peshawar. We had our own
stand to illustrate our work.
XVI. Our Facebook page is active and regularly highlights the work happening in the department.
Please all subscribe to this page and share our work with all your friends, you will enjoy the
page! Facebook address: AKi Paediatric Rehabilitation Centre.
XVII. We have had our problems in 2018, in November we were hacked and prevented from
accessing our data by Ransomware. With a great deal of effort, we have our software restored
and have regained our access.
XVIII. AKi staff attended the International Conference in Fauji Foundation University in February
2018
XIX. National Action Plan: YF presented a proposal for a method for ‘A Prevalence Survey for
Children with Disabilities in selected districts of K.P.’ This was a National meeting with just 7
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invited presenters from all of Pakistan. It was held in the Fauji Foundation University at the
time of their International Conference.

Discussion:

Our extensive data is a very valuable. In February 2018 we had a group of five Australians from The
Melbourne Rehabilitation Hospital visit the centre. This was following AKi staff attendance at the
International Rehabilitation Conference held in the Fauji Foundation University in Rawalpindi. Visiting
specialists Professor Fary Khan (doctor), Professor Mary Galea (Neuroscientist and Physiotherapist)
both expressed the opinion that our data could be the basis of very valuable research work for further
studies. They encouraged us to make sure we did not just allow others to use it. They also encouraged
Mrs Huma Habibullah to consider applying for a PhD in epidemiology from Australia to use the
information we have in our data and in our work. She is currently applying for a scholarship to study
for a Master at Monash University in Melbourne in Epidemiology, with hopefully a PhD to follow. This
could really bring benefit to AKi as it will strengthen our ability to advocate and highlight issues in
Pakistan and other LAMIC. The WHO and UN agencies involved in disability issues all request that
better research and better data be collected to enable more effective and efficient use of
development funding in this sector. We know of nowhere else in K.P. that has the ability to have such
a comprehensive data base.

Discussion:

Our social fund, from donations other than our primary donor, has been used for assistance to families
for a wide variety of resources. Regular donors have consented to our using some donations for some
of our additional non-therapy activities, such as our open days for families and extra staff educational
training expenses. It is also used to augment our increased need for assistive devices as our number
of registered children increases yearly. Other donors request that the funds they provide are used for
extra wheelchairs or for families in extreme poverty to be supported. We are conscious of the
responsibility to be careful and diligent in the use of these funds in accordance to our donors wishes.

Here are some of the expenses outside of the rehabilitation costs in 2018:

 357,806 PKR on:

- Diapers, for incontinence children due to paralysis caused by Spina Bifida.

- Epival, anti-seizure medication.
- Blankets, socks, shoes, sweaters, caps. We give these to poor families with children with
disabilities during the coldest months.
- Biscuits, often the children and their siblings come without breakfast and are hungry.
- Medicine, where prescribed and essential but unaffordable.

 Patients given food 3,536, an average of over 13 each day.

- 19% of the families that travel to AKi come from more than 4 hours away.
- 54% of the families have food insecurity due to unemployment, irregular work as day-
labourers, or the child is fatherless through death or family breakup.

Our move to Hayatabad has had one major cost implication. We are in a sector considered commercial
and have therefore increased utility costs. For comparison with University Town costs in 2016:
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 Utilities 2016 (average per month) 2018 (average per month)

Electricity 14,182 34,976

Gas 5,404 11,207
Telephone 4,352 9,611
Water Own tube well 17,879

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Total (per month) 23,938 73,673

 2018 shows an increase of 208% on 2016

Discussion:

We have strived to cap our cost of wages for the past two years. We have increased wages only
for those that have been given promotion and more responsibility due to merit and experience.

We have made adjustments within the department employing more people who are less
expensive as they have lower qualifications and experience, when we have lost senior staff. This
allows us to maintain a service that is increasingly in demand from families all over K.P.

In the present economic climate, we are aware that we must protect the ability of the primary
donors to continue to support us in a manner that is sustainable. However, with all government,
private hospitals, and local NGOs offering more attractive terms it is a fine balance to maintain
morale when the inflation has had an impact on the ability of even professional people to maintain
a family. Fortunately, our therapy staff are also aware that they have good working conditions,
have security of employment and have the benefit of continuing access to good training
opportunities within the service.

Additional Activities and Opportunities 2019:

We are actively looking for opportunities for fund raising.

On 28th February members of the OGDC team of corporate responsibility representatives visited Akbar
Kare. This was on invitation through a Pakistani contact YF has in London who has been involved with
maintaining the platform for our website and has personal interest in Cerebral Palsy.

They were given a full account of our work and our aims. We asked for the funding for installation of
photovoltaic to reduce our dependency on expensive commercial zone mains supply. They stated they
could not see any problems with this as we see children and their families from districts that they
intend to be able to offer something back to for the benefit they take from these districts.
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They also asked what else we might request from them and an Inclusive Playground and a dedicated
facility and resources for using Prechtl GMA to offer early identification of children with brain damage
was discussed.

This has the possibility of being an ongoing relationship with OGDC for support in new developments.
Insha’Allah. This opportunity became stagnant when OGDC had some internal issues. They did not
follow-up with this offer.

On 28th February / 1st March:

A two-day course was conducted for all front-line workers with our children and their families by
Handicap International (HI). This was on a resource called ‘The Blue Box’. The purpose is to provide
care givers, through our work, with an understanding of the importance of building into a child’s early
development the best possible environment and stimulation. This will help build relationships that are
the building blocks for a child to have the resilience and the skills necessary to develop to their
potential. This is true for typically developing children and even more important for our children with
disabilities.

This was an interactive and very interesting workshop and HI have given us the manual for future
training opportunities.

We take every opportunity to avail of workshops and courses when they are deemed to be in directly
relevant to our work and are conducted by reliable organisations.

YF with senior PTs from AKi conducted a workshop for Community Health Workers on the 3rd July. This
successfully developed a communication channel for future collaboration when we resume our
outreach program in the Autumn. We provided them with and understanding of the role of
rehabilitation in Family Centred Services and how they can identify and communicate with families
who have children with disabilities to facilitate them in working towards functional goals.

On the 2nd July we held a Down’s group workshop for families. This was conducted by YF who
illustrated the concept of ‘Serve and Return’ as developed by the Children developmental Center from
Harvard University - promoting relationships and communication with children with developmental
disabilities such as Children with Down’s syndrome. This was received with enthusiasm and the group
had many questions and lively discussions.

During the years since AKi opened we have conducted several workshops by request in Karachi,
Lahore, Islamabad and Manserha. YF has presented AKi’s work in Edinburgh Scotland at an
International Conference hosted by Rehab International. It’s Patron Princess Anne attended this
conference. In the London School of Hygiene and Tropical Medicine (LSHTM UK) YF presented an
academic Poster of Aki’s work at the Symposium on the UN Sustainable Development Goals and
attended a special meeting on Cerebral Palsy where we were given access to all the training materials
for the Getting to Know Cerebral Palsy (GTKCP) manual.

YF has presented at the Royal Melbourne Children’s Hospital and at a clinical meeting in the
Melbourne Rehabilitation Hospital the work we do at AKi. This has led to very useful contacts both in
Melbourne and also now in Sydney with the Australian CP Alliance. This has led to the training material
for the Hammersmith Infant Neurological Examination (HINE) being made available to AKi.

AKi work is used on an on-line course which when originally hosted as a MOOC had more than 14,000
participants. YF was the facilitator for week two of the six-week course. Videos of work being done at
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AKi is still being used on the site www.physio-pedia.com which is the largest on-line professional
training platform for Physiotherapists globally. YF still acts as a consultant for the forum.All staff who
were present at the time of the original course gained certificates from this course and all staff
members have access to Physiopedia which is now free to them as partners of ICRC.