| Understanding
Community-Based Rehabilitation
Table of Contents
Introduction
This publication focuses on understanding community-based
rehabilitation (CBR). It does not try to define CBR, as
it has become apparent in recent years that CBR defies definition.
This is because its simplicity and complexity have led to
confusion about what CBR means. The simplicity of CBR has
to do with its history of starting with the delivery of
primary rehabilitation therapy to people with disabilities
in their communities[1]. The complexity of CBR is the result
of the current concept that CBR programmes should be multi-sectoral
(or multi-disciplinary) so that they can provide assistance
in all of the areas which are central to improvement of
the quality of life of people with disabilities. This complexity
recognizes the need for close coordination, collaboration
and cooperation between governmental and non-governmental
organizations of all types and at all levels.
The basic concept inherent in the multi-sectoral approach
to CBR is the decentralization of responsibility and resources,
both human and financial, to community-level organizations.
In this approach, governmental and non-governmental institutional
and outreach rehabilitation services must support community
initiatives and organizations.
For the multi-sectoral approach to CBR to be successfully
translated into action, both governmental and non-governmental
service capacities need to be improved in most countries
of the Asian and Pacific region. Of special importance is
improvement of the capacity and skills for facilitating
community involvement. Such improvement and related activities
must be closely coordinated to ensure the optimum use of
scarce resources. In accordance with the multi-sectoral
concept, systems are developed, at the community level and
among governmental and non-governmental organizations, that
interact and reach out to each other.
Another factor for the success of the multi-sectoral approach
is the empowerment of the community to assume responsibility
for ensuring that all its members, including those with
disabilities, achieve equal access to all of the resources
that are available to that community, and that they are
enabled to participate fully in the social, economic and
political life of the community. This approach ensures that
what is done in the name of CBR actually fits into the reality
of the community and is owned by the community.
The Multi-sectoral Approach
The starting point for understanding CBR is the following
approach agreed to in 1994 by ILO, UNESCO and WHO[2]:
Community-based rehabilitation (CBR) is a strategy within
community development for the rehabilitation, equalization
of opportunities and social integration of all people with
disabilities. CBR is implemented through the combined efforts
of disabled people themselves, their families and communities,
and the appropriate health, education, vocational and social
services.
This approach to CBR is multi-sectoral and includes all
governmental and non-governmental services that provide
assistance to communities. Many of the services which can
provide opportunities for and assistance to people with
disabilities are not traditionally considered relevant to
CBR programmes and people with disabilities. Examples include
community development organizations, agricultural extension
services, and water and sanitation programmes.
In the ILO-UNESCO-WHO approach to CBR, the phrase "within
community development" is understood to be the following
strategy recommended by the United Nations[3]:
... the utilization, (in an integrated programme)[4], of
approaches and techniques which rely on local communities
as units of action and which attempt to combine outside
assistance with organized local self-determination and effort,
and which correspondingly seek to stimulate local initiative
and leadership as the primary instrument of change.
In the CBR context, community means: (a) a group of people
with common interests who interact with each other on a
regular basis; and/or (b) a geographical, social or government
administrative unit.
Programme Criteria
The development and implementation of CBR programmes should
be based on the following criteria:
People with disabilities must be included in CBR programmes
at all stages and levels, including initial programme design
and implementation. In order to give significance to their
involvement, they must have distinct decision-making roles.
The primary objective of CBR programme activities is the
improvement of the quality of life of people with disabilities.
One focus of CBR programme activities is working with the
community to create positive attitudes towards people with
disabilities and to motivate community members to support
and participate in CBR activities.
The other focus of CBR programmes is providing assistance
for people with all types of disabilities (physical, sensory,
psychological and mental); for people of all ages, including
older people; for people affected by leprosy; for people
affected by epilepsy; and for other people who may be identified
by the community as needing special assistance.
All activities in CBR programmes must be sensitive to
the situation of girls and women. This is because in many
communities throughout the Asian and Pacific region women
are not treated equally. When they are disabled, the problems
that they face in life are doubled. Furthermore, women are
usually the primary family care-givers for all people with
disabilities.
CBR programmes must be flexible so that they can operate
at the local level and within the context of local conditions.
There should not be only one model of CBR because different
social and economic contexts and different needs of individual
communities will require different solutions. Flexible,
local programmes will ensure community involvement and result
in a variety of programme models which are appropriate for
different places.
CBR programmes must coordinate service delivery at the
local level. Community members seldom understand the different
roles and specializations that are part of providing assistance
to people with disabilities. They tend only to see the problem
of disability and only to want access to "one window"
for help. They may focus only on where to go and who to
see about a specific "problem", rather than understanding
the totality of what constitutes a fulfilling life for a
community member who has a disability.
The Components of Community-based
Rehabilitation Programmes
The components of a CBR programme should include:
1. Creating a positive attitude towards people with disabilities:
this component of CBR programmes is essential to ensure
equalization of opportunities for people with disabilities
within their own community. Positive attitudes among community
members can be created by involving them in the process
of programme design and implementation, and by transferring
knowledge about disability issues to community members.
2. Provision of functional rehabilitation services: often
people with disabilities require assistance to overcome
or minimize the effects of their functional limitations
(disabilities). In communities where professional services
are not accessible or available, CBR workers should be trained
to provide primary rehabilitation therapy in the following
areas of rehabilitation:
- Medical
- Eye care service
- Hearing services
- Physiotherapy
- Occupational therapy
- Orientation and mobility training
- Speech therapy
- Psychological counselling
- Orthotics and prosthetics
- Other devices
3. Provision of education and training opportunities: people
with disabilities must have equal access to educational
opportunities and to training that will enable them to make
the best use of the opportunities that occur in their lives.
In communities where professional services are not accessible
or available, CBR workers should be trained to provide basic
levels of service in the following areas:
Early childhood intervention and referral, especially to
medical rehabilitation services
Education in regular schools
Non-formal education where regular schooling is not available
Special education in regular or special schools
Sign language training
Braille training
Training in daily living skills
4. Creation of micro and macro income-generation opportunities:
people with disabilities need access to micro and macro
income-generation activities, including obtaining financial
credit through existing systems, wherever possible. In slums
and rural areas, income-generation activities should focus
on locally appropriate vocational skills. Training in these
skills is best conducted by community members who, with
minimal assistance, can easily transfer their skills and
knowledge to people with disabilities.
5. Provision of care facilities: often, people with extensive
disabilities are in need of assistance. When they have no
families or their families are incapable of caring for them,
in order for them to survive, long-term care facilities
must be provided in the community where they can get the
assistance that they need. Moreover, day-care facilities
may be needed to provide respite for families who either
work or need time off for other activities.
6. Prevention of the causes of disabilities: many types
of disability can be prevented by relatively simple measures.
Proper nutrition is one of the more significant ways of
preventing disabilities. Another important area of disability
prevention is the detection of disability in young children
and intervention early in their development, to minimize
the effect of impairment. There are many other areas of
disability prevention that are also important. These include
activities to decrease the number of accidents in the home,
on the road and at work, as well as other initiatives to
encourage people to pursue healthy lifestyles over the course
of their lives.
7. Management, monitoring and evaluation: the effectiveness
and efficiency of all CBR programme components, both in
the community and in the area of service delivery outside
the community, depend on effective management practices.
The impact of programme activities must be measured on a
regular basis. People must be trained in effective management
practices. Data must be collected, reviewed and evaluated
to ensure that programme objectives are met. In this way,
the success or failure of a CBR programme can be honestly
measured.
Sectors and Roles for the
Development and Implementation of Community-based Rehabilitation
The initiative to start CBR programmes and to facilitate
their development may come from any one of the following
groups. However, the effectiveness of CBR and the long-term
development and sustainability of any CBR initiative will
require the coordination, involvement and collaboration
of all seven groups. The seven groups and their suggested
roles are as follows:
1. People with disabilities
People with disabilities can and should contribute to all
levels of CBR programmes in every position within a programme.
They know what the effects of local conditions are on themselves.
They are likely to have a good understanding of those effects
on their peers with disabilities. They also know what impairment
really means in the context of their family, community and
nation. This knowledge enables them to be very effective
members of a CBR team. They can be more effective than non-disabled
people as role models for and counsellors of other people
with disabilities. People with disabilities have an important
role in community education. As community educators, they
serve as living examples of people with disabilities who
make a significant contribution, provided that they are
given the opportunity and the right type of assistance.
CBR programmes should also facilitate the development of
self-help organizations of people with disabilities at the
community level.
2. Families of people with disabilities
Families have the primary responsibility for caring for
all of their members. They are the first line of support
and assistance for people with disabilities at the local
level. As such, families must be included in CBR programme
activities. Where the individual with a disability is not
able, for whatever reason, to speak for himself or herself,
a family member should represent him or her and should be
considered a legitimate member of disabled people’s
organizations. Members of families with experience in caring
for people with disabilities are the people who most often
initiate CBR programmes and are, or prove to be, the most
effective contributors at all levels.
3. Communities
Community members should be involved in CBR programmes
at all levels because they already know the local environmental
conditions, the local economy, the local political situation
and how to work with them. They also know about the accessibility,
availability and effectiveness of locally available rehabilitation
services; who in the community cares enough about other
people to become a programme leader or worker; and, which
community members have the knowledge and skills for training
others in micro-economic activities. They are the people
most likely to want to live, work and stay in the community.
Community involvement usually requires the agreement and
approval, both formal and informal, of the community leaders.
4. Governments (local, regional, national)
Governments have the most important role in the development
and sustainability of CBR programmes. Their cooperation,
support and involvement are essential if CBR is to cover
the total population and be sustainable. They should implement
and coordinate the development of the entire programme structure,
including the development of the referral system, as well
as the activities within the community. They also should
provide resources for non-governmental organizations (NGOs)
and community activities. Finally, they should ensure that
discriminatory legislation is changed and that the rights
of people with disabilities are guaranteed and protected.
5. Non-governmental organizations, local, regional, national
and international organizations
NGOs, including organizations of people with disabilities,
are often able to provide resources and skills to facilitate
the development of new programmes, especially in areas where
none exist. They can develop new approaches to CBR and provide
training programmes for government employees, CBR workers,
people with disabilities, families, and community members.
NGOs are effective in facilitating the development of community
members as CBR programme leaders. They are often best able
to provide long-term care facilities for those people with
extensive disabilities whose families cannot or will not
look after them.
6. Medical professionals, allied health science professionals,
educators, social scientists and other professionals
Professionals are often in a position where they can, as
trainers and educators, facilitate the development of new
programmes by making their knowledge and skills accessible
to community members and CBR programme workers. They can
also ensure that they support community efforts by making
themselves available and accessible on a referral basis.
When they are in government service, they can advocate and
promote the development of CBR programmes as an effective
way to provide local-level services quickly.
7. The private sector (business and industry)
The private sector has a social obligation to return some
of the benefits of its operations to the communities that
support it. In the past, this support has largely taken
the form of charity. Charity occurs when donors "give"
whatever they feel is needed or appropriate to people with
disabilities. This approach to assisting people with disabilities
is no longer appropriate and needs to be changed. Supporting
CBR programme activities eliminates the need for charity.
CBR support is a much more appropriate way of directing
resources to communities and people with disabilities. By
supporting CBR programmes, the private sector receives credit
for its social involvement while being guaranteed that its
support is put to effective and efficient use. Who but trained,
knowledgeable community members would know what is most
needed by the people of their own community?
Summary
In recent years a multi-sectoral (or multi-disciplinary)
concept of CBR has evolved. That concept emphasizes working
with and through the community to create positive attitudes
towards people with disabilities, to provide assistance
to people with disabilities and to make the necessary changes
to the environment and service delivery systems.
In response to this conceptual change, CBR is now defined
as a community development programme that has seven different
components:
Creation of a positive attitude towards people with disabilities;
Provision of rehabilitation services;
Provision of education and training opportunities;
Creation of micro and macro income-generation opportunities;
Provision of care facilities;
Prevention of the causes of disabilities;
Monitoring and evaluation.
The resources, skills and initiatives to start and sustain
CBR programmes require the cooperation and collaboration
of seven relevant sectors:
People with disabilities;
Families of people with disabilities;
Communities;
Governments (local, regional, national, international);
NGOs, local, regional, national and international organizations,
and organizations of people with disabilities;
Medical professionals, allied health science professionals,
educators, social scientists and other professionals;
The private sector (business and industry).
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Footnotes:
* Prepared by the Working Group on CBR of the Regional Inter-agency
Committee for Asia and the Pacific (RICAP) Subcommittee
on Disability-related Concerns. ESCAP serves as the secretariat
of the Subcommittee. All members of the Subcommittee contributed
to the preparation of the document. The subcommittee, at
its fourteenth session in May 1997, finalized and adopted
the document to mark the mid-point (1997) of the Asian and
Pacific Decade of Disabled Persons, 1993 - 2002.
1. The Alma Ata Declaration of Health for All and its emphasis
on primary health care included services for people with
disabilities. It is this concept that led to the development
of the first models of CBR which emphasized delivery of
primary rehabilitation therapy in the community.
2. Community-Based Rehabilitation for and with People with
Disabilities, 1994 Joint Position Paper, International Labour
Organization (ILO), United Nations Educational, Scientific
and Cultural Organization (UNESCO) and World Health Organization
(WHO).
3. See document E/CN 5/291.
4. The original definition has been changed from "under
one programme" to "in an integrated programme".
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