CLASSIFICATION OF DISABILITIES - ICIDH

The International Classification of Impairments, Disabilities and Handicaps (ICIDH), was first published in 1980 by WHO. The ICD (International Classification of Diseases) deals with diseases and the ICIDH deals with the consequences of diseases. The revision of ICIDH will be adopted by WHO in 1999. This revision is to be titled as International Classification of Impairments, Activities and Participation.

The ICIDH (1980) relies on a model where there is a progression from disease, impairment, disability to handicap in a linear fashion. Impairment is defined as abnormality of structure or function of the body or an organ. Disability is defined as a restriction of activities as a result of impairment. Handicap is defined as a social disadvantage resulting from either impairment or disability.

The revision of ICIDH will avoid the term `disability' because it indicates a negative connotation, and replace it with `activity'. `Handicap' will be replaced with `participation' to indicate the person's nature and extent of involvement in life situations in relation to impairment, activity and contextual factors. `Contextual factors' are extrinsic factors that play an important role in determining the participation. This classification is not linear any more and suggests interaction of the health condition and the contextual factors simultaneously on impairment, activity and participation.

The latest revision still has deficiencies such as poor differentiation of boundaries between impairment, activity and participation, as well as between ICD and impairment classification. The level of details to define different segments is poor. The ease of its applicability in all different situations is also suspect.

DEFINITIONS OF CBR

CBR, as promoted by the World Health Organisation, was designed to be integrated into the Primary Health Care system. The WHO model of CBR has had an `impairment' bias, focusing largely on the transference of basic rehabilitation techniques to community level workers and to disabled people and their families. Over time definitions of CBR have shifted away from an impairment focus towards `community development'. In 1994 WHO, ILO and UNESCO issued their Joint Position Paper with the following definition of CBR. `Community based rehabilitation is a strategy within community development for the rehabilitation, equalisation 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 is accepted by many people as a working definition. It moves away from the idea that CBR is somehow a form of `community therapy'. It is perfectly possible for services to move their geographical location `to the community', but to retain identical practice to that which is used in a clinical setting. It is suggested that such activity is community based therapy, where there is little, if any, empowerment of disabled people and their families. The professional, though now `in the community' retains control. In contrast, one can differentiate those services which move `to the community' but also revise their practice by, for example, listening to disabled people and their families, assessing perceived needs rather than the observed needs of the professional, and working in partnership with disabled people. This method, the authors suggest, is the community disability service that is desired. Unfortunately CBR is a generic label used for community based therapy as well as for empowering community disability services. CBR should also include thinking about issues of disabled people's lives at all times, and not exclusively about rehabilitation. Disabled people should also have access to all services which are available to other people in the community, such as community health services, child health programmes, social welfare and education.

CURRENT COMMON USAGE OF THE TERM `CBR'

1. Home based services provided by the families to their disabled members in the homes.
2. Self help projects run by disabled persons.
3. Out-reach projects run by rehabilitation institutions.
4. NGO projects run by paid CBR workers.
5. An ideology which promotes inclusion of disabled persons in developmental projects.
6. Institutional programmes located in the villages.
7. A current fad to describe anything related to rehabilitation of the disabled persons.

CLASSIFICATION OF DISABILITY RELATED ORGANISATIONS

1. Service providers.
2. Foreign funding organisations.
3. National funding organisations.
4. National organisations for disabled people.
5. National associations of disabled people.
6. Groups related to disabled persons, such as `parents' group'.
   

The western countries are in the process of partial devolution of rehabilitation services. If one takes the example of Canada, one can view this emerging pattern in devolution of services as a result of the human rights movement. Unlike the developed countries, this pattern of devolution has not been initiated in the developing countries, due to the need for higher coverage of services. Even in Canada, however, the community based services expect the communities to act as a source for their resources. Along with the devolution process there is a growing debate about its level of accountability and its relevance in terms of the impact it can generate.

The international community has been spending great efforts to make CBR a human rights movement, while the developing countries have been actively resisting this stance by increasing controls over the delivery of rehabilitation services. The broader view of rehabilitation services in the community development perspective, reduces the component of medical rehabilitation into a less significant peripheral activity. After a decade of CBR using the western approaches, there is now a diminishing interest in community participation in developing countries. The attempt now in many places, is to develop the existing `top-down' service delivery model into a more humanitarian one, rather than to develop a new service system as in the west to protect the human rights aspects. The original WHO model of rehabilitation, which is often criticised as highly prescriptive without any encouragement to participate in the process, `low-tech' and `top-down' is still the most commonly practised community based rehabilitation in most of the developing countries.

Quite paradoxically, in spite of the great international pressure against it, there is a growing feeling in many former colonies such as India, that CBR projects implemented via a top down administrative approach would have failed with a less authoritarian structure. This fact is attributed to the situation that had prevailed in the former colonies where the people had not been encouraged to take social development activities on their own. Secondly, it has been attributed to the relatively low priority given to CBR initiatives in the minds of people due to its lack of immediate impact when compared with other curative services.

Dr. Maya Thomas & Dr. M J Thomas
J-124, Ushas Apts, 16th Main, 4th Block, Jayanagar, Bangalore - 560 011, India
Tel and fax : 91-80-6633762
Email : thomasmaya@hotmail.com

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