Many health systems have three levels of health care: primary, secondary and tertiary. These are usually linked by a referral system. While there is often overlap between each level, it is important for CBR personnel to understand the basic differences between them to facilitate access for people with disabilities and their family members.

• Primary level of care refers to basic health care at the community level. It is usually provided through health centres or clinics and is the first contact people have with the health system. Medical care provided at primary level includes short, simple treatments for acute conditions, such as infections and routine management of chronic conditions like leprosy, epilepsy, tuberculosis and diabetes. CBR works at the community level closely with primary health care services.
• Secondary level of care refers to more specialized medical services that are provided by large clinics or hospitals that are usually present at the district level. Primary health care provides an important link to secondary care through referral mechanisms.
• Tertiary level of care is highly specialized medical care. It is provided by specialized medical professionals in association with nurses and paramedical staff and involves the use of specialized technology. These services are provided by large hospitals, often located in major cities at the national or regional level. Medical care provided at the tertiary level may include brain surgery, cancer care or orthopaedic surgery.

Surgery is part of medical care and is usually provided at the secondary or tertiary levels of the health-care system. Some types of surgery can improve function and limit deformities and complications that may be associated with impairments. Examples of surgery include:

• removal of cataracts that are causing visual impairment
• orthopaedic surgery to address fractures or spinal deformities
• reconstructive surgery for cleft lip and palate, burns, or leprosy.

There are many things to consider before surgery is undertaken:

• families must be informed properly about the consequences;
• surgical care is often very expensive and, without social security or health insurance, it will be difficult for poor people to access;
• successful outcomes from surgery are dependent on comprehensive follow-up for further medical care, therapy or assistive devices, so close links are required between medical and rehabilitation professionals. 

It is important to remember that surgery alone cannot address all problems that may be related to impairments.

Self-management or self-care management does not mean managing your health without medical intervention. Instead, it means that people take control of their own health, are responsible for making informed choices and decisions about medical care and play an active role in carrying out care plans to improve and maintain their health.

Self-management requires a good relationship between individuals and their health-care personnel to ensure that good health outcomes are achieved. People who self-manage their care must be able to:

• communicate regularly and effectively with health personnel
• participate in decision-making and care planning
• request, obtain and understand health information
• follow a treatment regimen that has been drawn up with health personnel
• perform appropriate self-care activities, as agreed with health personnel.

Self-management is important for people who experience a lifelong disability, such as paraplegia, or a chronic condition such as diabetes. 

Self-help groups can provide a good opportunity for people with disabilities to learn about self-management through the sharing of knowledge and skills with others.

Learn the results of a research study that attempted to determine whether people could learn self-management skills by participating in a group made up of others with the same condition.

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The Italian association Amici di Raoul Follereau (AIFO/Italy) together with the Disability and Rehabilitation team at the World Health Organization and Disabled People International, carried out research across several countries to determine whether people could learn self-management skills and play a more active role in improving their own medical care if they got together as a group of people with disabilities with similar medical care needs. 

Pilot projects were asked to:

• Identify and create groups of people with disabilities with similar medical care needs
• Identify the main medical care needs
• Provide knowledge and skills for self-care for addressing the identified needs (in collaboration with health professionals)
• Assess if the quality of self-care and medical care by people with disabilities and family members had improved, and 
• Determine if the knowledge and skills of people with disabilities were recognized and given some role within the medical care system

A pilot project in El Salvador focused on spinal cord injury. AIFO/Italy, in partnership with Don Bosco University and Instituto Salvadoreno Para La Riabilitacion de Invalidos, worked with 30 people with spinal cord injuries and their families from the areas of San Salvador and the village of Tonacatepeque. Four self-help groups were formed and regular meetings were held. Members of these groups identified their major medical care needs which included: 

• Urine, bladder and kidney issues
• Pressure sores
• Joint stiffness, and
• Sexuality and parenthood-related issues

Health professionals involved in the project provided self-management skills training to address the issues that had been identified. Over time, members of the self-help groups and health professionals involved in the project began to change their thinking. They realized that with proper support and training, people with spinal cord injury could manage their health and achieve a better quality of life. They also realized that health professionals needed to look beyond their traditional medical roles and facilitate and promote self-management care – a concept of shared responsibility. Members of the self-help groups went on to form their own association called ALMES (Asociacion de Personas con Lesion Medular de El Salvador).