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TRANSITION OF CBR OVER THE LAST DECADE INTO A PLANNED SYSTEM OF SERVICE DELIVERY

DISCUSSION LED BY :
Maya Thomas, J-124 Ushas Apts, 16th Main, 4th Block, Jayanagar, Bangalore - 560 011

Over the last two decades, there has been a major growth in the number of community based rehabilitation (CBR) projects around the world, providing the minimum services required for disabled people in countries that had scanty resources and poorly developed services. Alongside, there have been many changes in the understanding and implementation of community based rehabilitation interventions. The focus has now begun to shift from the issue of a minimum level of service delivery, to other management issues that influence effectiveness of services, such as planning and management, monitoring and evaluation, research, information generation and dissemination, and so on. This paper outlines some crucial programme management issues that have been observed by the author to have an impact on the outcome of community based rehabilitation. The author begins with a critical analysis of the norms followed in CBR planning over the last decade, and concludes with the current trends in three areas of planning of CBR, namely programme planning, community participation, and sustainability.

1. PROGRAMME PLANNING

A close look at many CBR programmes in India and other South Asian countries shows that they originated as a set of activities without clear goals. Some programmes were started because of the availability of funds for that particular activity. With shifts in donor priorities, the activities of some of these organisations also changed accordingly. These programmes often did not have monitoring and evaluation systems, nor did they define their outcomes or attempt to measure them. Instead, they repeated a set of activities year after year, with some illustrations and anecdotes from their clients, to justify why they had to continue their activities. Such activities tended to be donor dependent, cost-intensive, seldom successful, and rarely sustained once the donor withdrew support. Consumer satisfaction was also limited, as client needs were rarely taken into account for these activities.

The major lacuna in these programmes had been the absence of a sustained, long term and systematic planning process, which is a crucial factor influencing outcome of development activity.

Often, programme planning is mistaken to mean merely a project proposal to donors for funding purposes, or it is seen as a rigid process, usually according to donor formats, that curtails individual programme creativity. However, programme planning is a process to be carried out within the implementing organisation for itself, out of which various proposals may arise for funders. Similarly, while the principles of planning may be common, there is tremendous scope for creativity in the way the principles are operationalised, from programme to programme. Planning thus actually enhances creativity within a programme instead of curtailing it.

Pre-policy stage :
Many programmes are started merely because of availability of funds for that activity, without doing a feasibility exercise, checking if there is a need at all for that activity, whether other services are available, what the major needs are in that community, and so on. A very good plan of action, which does not address these issues, can fail because there really was no demand for the programme, or because it is different from what the community perceives as its major need, or because there are too many agencies providing the same service in that area.

In the context of a CBR programme, the pre-policy stage needs to determine if disability is perceived as a 'problem' that needs intervention on a priority basis in the target community. This is followed by a situation analysis, which helps to confirm whether there is a need for intervention, what priority the consumers assign to the proposed problem in relation to other problems, whether the consumers view the proposed intervention as beneficial to them in addressing their problem, and so on. Since CBR interventions influence the lives of disabled persons, their families and their non-disabled peers in the project area, the needs of the different groups have to be identified before undertaking strategic planning for the programme. The different groups in the same community can have differing needs that conflict with each other. For example, the needs of disabled persons may not necessarily be related to the priorities identified by other groups. They may also differ widely from the priorities of other groups in the same community, which usually are short term poverty alleviation and curative health interventions. In situations where the needs of the different constituent groups differ from the priorities of the CBR programme, the first strategy should be to reduce this attitudinal gap by changing the attitudes of people favourably towards the rehabilitation interventions. For this purpose the existing beliefs and attitudes of the different constituent groups need to be studied, and strategic plans designed to introduce changes in the attitudes of the groups. The community's attitudes may also be influenced by its experiences of services that existed in the past in the project area. Needs analysis helps to assess the opinions of different groups within the local community, as well as of interested groups outside the community, such as the government, donor organisations, catalyst NGOs and so on. In the pre-policy stage there is also a need to identify the different material, financial and personnel resources available locally for later use, their accessibility, and the modifications required for utilising them. The resource analysis gives an idea in advance about what new resources will have to be generated for the programme

Policy development :
Successful completion of the pre-policy stage usually progresses to policy development, which includes defining the vision, mission and objectives of a programme. Very few organisations actually have policy statements containing these elements. In some instances where such documents exist, they have been put together by a few people, without the participation of all stakeholders. In some organisations one finds that while the organisational members are able to articulate the organisation's vision and mission well, they have difficulties in clearly stating their objectives and activities. They often describe numerous objectives that are over-inclusive, without considering whether it is feasible for the organisation to fulfil them at all, in the available time. Sometimes activities are confused with objectives and vice versa, which results in poor strategic plans.

The 'vision' is the ultimate goal of the programme as long as the programme lasts, while the 'mission' is the sum of all activities to achieve the vision. The vision and mission are timeless and concise statements of what the programme stands for. Objectives are the medium term directions to achieve the vision, that may be changed sometimes if deemed necessary after an evaluation. These components of the policy are best evolved in a participatory and democratic manner involving all stakeholders of a programme, rather than by any particular group. A participatory process of policy development will help to avoid future conflicts and enhance collective action. Once a policy is formulated, it requires to be widely disseminated amongst all stakeholders and other associates of the project.

Activity planning :
Selection of activities and formulation of a strategic plan are usually the responsibility of the executives of the programme, and are executed with the approval of the governance. Many organisations repeat the same set of activities year after year, without targets or defined outcomes. As a result, their annual reports also contain repetitious descriptions of activities, without any indication of how effective these activities were. Some other organisations usually enumerate their activities with quantitative measures of coverage, in the belief that they can represent outcomes and impact. Most organisations continue to face difficulties in defining outcomes and indicators of impact. However, without these measures, it is impossible to know if a programme has been genuinely successful.

Individual activities of a strategic plan are short term components of a programme, usually planned for a calendar year or a financial year. In order to monitor a programme easily, the activities need to be defined precisely, with well defined, quantitative targets for achievement for each activity in a unit time. The expected outcomes, the indicators to measure the outcomes and the resultant impact are also required to be defined clearly. Although some effort is required to develop a detailed strategic plan with well defined activities, targets, expected outcomes and their indicators, such a process can be of great benefit to the programme in many ways. It helps the organisation to monitor and control the progress of their efforts easily, to clearly define the individual responsibilities to the programme personnel, and to make the programmes transparent and accountable to the stakeholders.

Budgeting:
Most organisations tend to repeat their budget heads and figures every year, with a correction sometimes for escalation of costs. Often the budget and the programme plan are unrelated, and the budget may only relate to how much money is available in the coming year from the donor. Very few organisations carry out the exercise of activity costing, from which a realistic budget can be made. Similarly, cost effectiveness and cost benefit studies are rarely carried out by organisations involved in CBR. Because of this, large amounts of money tend to be wasted by both implementing and donor organisations on repetitious activities.

In a good plan, each activity that is to be carried out needs to be costed. The sum total of all the activity costs makes up the budget. An exercise of resource matching for the different activities will also need to be carried out to see what kinds of resources are available. In case of a shortfall in resources, the planners may decide to defer or drop some activities. A realistic activity costing and budgeting will also help the programme personnel to carry out cost effectiveness and cost benefit analyses, and thus reduce wastage of resources.

Monitoring and evaluation: Monitoring and evaluation are important because they help the implementers to know if the programme works, if it is of benefit to the clients, and to plan for the future. Some organisations carry out some form of monitoring of their activities, particularly quantitative monitoring. However, most of them do not systematically analyse, interpret or draw inferences from the data generated, or they tend to interpret the data randomly. Many organisations are also resistant to the concept of evaluation for various reasons. It is important for programme implementers to understand that monitoring and evaluation primarily address their own need for better and more cost effective service delivery methods. Even with simple methodologies, a great deal of valuable information can be elicited, which needs to be systematically analysed and interpreted, and which can be of value in planning and improving the programme.


2. ENHANCING COMMUNITY PARTICIPATION

Community participation was considered as an essential part of CBR ever since it was promoted as a suitable approach for rehabilitation in developing countries. In practice, however, most programmes have found it difficult to achieve community participation for several reasons. Many developing countries had a period of colonial rule before they became independent, followed by socialist governance in which the state is viewed as solely responsible for all welfare and development work. Concepts of decentralisation and bottom up approaches are relatively new in many of these countries even today. Besides, the majority groups in the community are not altruistic enough to address the needs of the minorities such as disabled persons, until their own needs are met. Another issue is that small, but powerful groups in the community often corner the benefits from development programmes, ignoring the needs of marginalised groups.

Community participation of the highest degree, where the community members take on the responsibility for planning, implementing, sharing the risks of and monitoring a CBR programme which benefits disabled people, is desirable, but difficult to achieve. Depending on the cultural context, the ideal level of community participation is viewed in different ways by different people. On the one extreme, a community may be viewed as passively participating by being a recipient of services, while on the other extreme, participation may be viewed as complete ownership of the programme. Developing countries are still unfamiliar with Western notions of consumer ownership of programmes. Hence to begin a programme with the concept of full ownership by the consumers sometimes results in failures. In these countries, it is often necessary to enhance community participation from the inception of the project, in a planned manner, keeping in mind the difficulties that can be encountered as the concept of full community responsibility is introduced. In the context of CBR programmes, ways have to be found to motivate the marginalised groups of disabled persons, their families, and communities to achieve a participatory mode of development, in which the community will assume some of the responsibilities to begin with, and move on at a later stage to take on most of the responsibilities of the rehabilitation programme. As in any other strategic plan, enhancing community participation requires clear understanding of the attitudes of people in the community, their current level of participation in the programme and the expected level of participation to be achieved in the future.

Though it is difficult to speedily enhance community participation in programmes from developing countries, having a strategic plan to enhance participation and monitoring its success periodically can result in better sustainability in the long run. It will also influence more realistic goal setting practices during the planning stage.

3. PLANNING FOR SUSTAINABILITY

Concerns about sustainability of CBR programmes surfaced with the threat of diminishing funds for welfare work, and the increasing emphasis on accountability and cost effectiveness. However, the term 'sustainability' tends to be commonly associated even now with 'finding funds' for a CBR programme. Such an interpretation of the term ignores the other important aspects that contribute to the meaning of sustainability.

Financial sustainability also often refers mistakenly, to the ability of the organisation to access enough funds to maintain its structure and personnel. When funds become scarce, the organisation may change the goals of the programme, sacrificing the programme in the interest of maintaining itself. This is counterproductive and detrimental to the interests of the programme and its clients. Sustainability of the programme, in more accurate terms, refers to sustaining the vision and mission of the programme, and to keep the programme going till the vision is realised.

In planning for sustainability, it is important for planners to first identify the different factors that influence sustainability of a programme in its given social and cultural milieu, and then to develop strategies to improve sustainability in relation to the different factors identified through this exercise.

CONCLUSION
CBR planners have not concentrated sufficiently on developing viable programme management systems until now. The field is unlikely to achieve progress and expand, unless good systems are established for efficient management of these programmes. The last decade has seen many changes and adjustments in CBR, and it is hoped that the coming years will witness more efficient management of these programmes, to ultimately benefit the people with disabilities whom they serve.



Friday Meeting Transactions
Associate Publication of Asia Pacific Disability Rehabilitation Journal
Vol.2 @ No.1 @ 1999

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

Printed at:
National Printing Press
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