音声ブラウザご使用の方向け: SKIP NAVI GOTO NAVI

TOWARDS THE 21ST CENTURY : CHALLENGES FOR COMMUNITY BASED REHABILITATION IN ASIA AND THE PACIFIC REGION

Abstract


This paper deals with the concept of CBR as seen by a section of practitioners in the Asia Pacific region. In their view, CBR is a form of a community development programme onto which different components of rehabilitation are grafted, rather than a specialised programme meant exclusively for people with disabilities. In such a programme, the change in the community's behaviour towards people with disabilities is more vital to promote integration into the mainstream, than changes in the disabled people themselves. This article quotes the example of CBRDTC to illustrate how the changes in the community are brought about. CBRDTC uses professionals, volunteers and existing institutions in the community to take up a form of community development programme to integrate people with disabilities into the mainstream. PRA techniques are widely used in this programme. The programme personnel are managers, technologists and scientists who are trained by CBRDTC. According to the author, this form of CBR is cost effective and can be a possible alternative method for countries in the Asia Pacific region. The major constraints to the wider application of this method are absence of a well documented strategy, lack of personnel, funds and donor organisations that are willing to support less visible community development programmes, and inadequate sources to access information on CBR in the Asia Pacific region.

Introduction

In April 1992, thirty three countries in the Economic and Social Commission for Asia and the Pacific (ESCAP) region proclaimed 1993 to 2002 as the Asia Pacific Decade of Disabled Persons, in order to pay more attention to people with disabilities (1). As a result, more developing countries in this region began to implement programmes to improve the quality of life of people with disabilities in their population. Community based rehabilitation (CBR) was chosen by these countries as the suitable method to achieve the goals of full participation and equality for people with disabilities.

Understanding community based rehabilitation

CBR is now acknowledged as an effective approach to solve the problems associated with disability. However, it is still a relatively new concept, which has not always been successful in its many forms, nor is it accepted by everyone as the best or the only approach to promote equal opportunities and full participation of people with disabilities. Continuous efforts are therefore required to develop a better understanding of what CBR means, and to develop better techniques for the implementation of CBR programmes.

In 1994, the World Health Organisation, the International Labour Organisation and the United Nations Educational, Scientific and Cultural Organisation agreed on a common definition of CBR. According to these organisations, "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" (2).

The Community Based Rehabilitation Development and Training Centre (CBRDTC) approach to CBR is based on the understanding that the problems faced by people with disabilities in their daily lives are the result not only of their individual impairment, also of the attitudes and beliefs of the communities where they live. The problems that result from negative attitudes such as lack of social acceptance, lack of opportunities for income generation and for education, must be resolved if persons with disabilities are to have equal opportunities and achieve full participation. For these reasons, the Centre's programmes are directed towards the whole community as well as the individual members who are disabled. Based on this understanding, CBRDTC describes CBR as a set of "efforts to change community behaviours (attitude, knowledge and skills) to enable community members to improve their understanding about disability issues (socio-economic, socio-cultural, medical, psychological etc.), to be involved in the disability prevention activities and to provide a positive environment (physical, psychological, socio-cultural, economic, etc.) to improve the quality of life of persons with disabilities."

Although CBR has no specific definition, there is a general agreement that the purpose of a CBR programme is to solve problems related to disability, with the involvement of the community. CBRDTC understands CBR as a system consisting of several components which can be illustrated as a house with three pillars (Figure 1).

The first pillar represents the members of the local community with an understanding of disability issues and with positive attitudes towards disabled persons. The second pillar represents a selected group of local volunteers and others who have specific knowledge and skills in CBR and also have positive attitudes. The third pillar represents individuals and organisations outside the local community who have knowledge and skills in CBR, resources for CBR, along with positive attitudes. The base represents the community development philosophy which believes in the capability of the community. The roof represents the achievement of CBR when the community takes the responsibility of implementing its own programme. It must be emphasised that when a CBR framework is proposed, it must consider the different contributions from all these participants, and facilitate easy understanding of the concepts so that all those who are involved in the programme can work together efficiently.


Figure 1
Figure 1



CBR in Asia and the Pacific Region

ESCAP, a United Nations organisation, has fifty three member countries. Of these, about ninety four percent are developing countries which have two thirds of the population of the world. Although one is not sure exactly how many countries have already initiated CBR programmes in the Asia Pacific region, each country that has implemented a CBR programme has done so using its own strategy, rather than follow a common programme.

In Indonesia, CBRDTC carries out a CBR programme, successfully using the community development approach to promote community involvement in the CBR activities. In Bangladesh, income generation activities of the CBR programme have led to improvement in the lives of persons with disabilities. In India, an innovative activity is the development of appropriate technology for assistive devices. In Philippines, CBR programmes have established self help groups that successfully integrate people with disabilities into the community through their initiatives. There are many more examples of CBR programmes in different countries in Asia and the Pacific, but not much is known about them because they are not well publicised.

Countries in Asia and the Pacific region and their development

A study by ESCAP in 1995 of the economic development in Asia and the Pacific region states that there is impressive development in this region. The world economic growth in 1990 was 1.5 percent, while in 1995 it was 3 percent. In developing countries however, the economic growth in 1990 was 3 percent, which grew to 5.5 percent in 1995 (3). The developing countries in the ESCAP region continued their robust performance in 1994 as well. Their combined gross domestic product (GDP) growth rate was estimated at 7.7 percent, compared with the 7.2 percent recorded in 1993. These countries were expected to do well in 1995 and 1996, with projected growth rates of 7.5 and 7 percent respectively (4).

When a country raises its GDP, it is usually assumed that there is improvement in the health status too. A survey has found that some countries have improved in the field of education during their economic development. However, others hold the view that it is improved education that leads to better economic development. Asia and the Pacific region is developing fast in the field of science and technology, with more countries becoming industrialised in the past ten years. The ESCAP Ministerial Conference in 1995 stated that a substantial and growing proportion of the people in the region today enjoyed longer life expectancy, improved health, better education, access to safe water and sanitation, higher incomes and in general greater opportunities to pursue their economic and social aspirations, than was the case a generation ago or even a decade ago (5). These improvements in the welfare status are expected to increase the demands from people with disabilities for corresponding improvement in their quality of life as well.

The challenges for CBR in Asia and the Pacific region

There are at least four major challenges for the development and implementation of CBR programmes in Asia and the Pacific region, with the fast changing environment and the huge demand for services. They are an improved strategy or methods to implement CBR programmes, human resource development for CBR, funding for CBR activities, and dissemination of information about CBR services (6).

Strategy for CBR

In the developing countries of Asia and the Pacific region, there are limited resources for welfare and development in general. Another disadvantage is that disability is not seen as a high priority issue. To establish a new system of working exclusively for CBR may be complicated and very expensive. To deal with this situation, CBRDTC has been using a "patchwork strategy", wherein a CBR activity is added to an existing programme. In Indonesia, there is a programme called "Posyandu", the rural integrated health service clinic in the village, which is managed by the community. It is a monthly activity in which children under five years of age are weighed, immunised and given supplementary nutrition. There may be four to five Posyandus in a village, depending on the population and geography. Since early detection of disability is an important aspect of a CBR programme, this activity is added to the Posyandu programme. Likewise, early intervention activities are integrated into the Health Centre programme, while disability prevention and awareness are added to the Women Development Organisation programme. This way, there is no need to build a new system to carry out the CBR activities.

CBR programmes have not been very successful in developing supportive socio-cultural environments for people with disabilities, or in mobilising community resources. Also, CBR programmes have not done much in the area of responding to the needs of both people with disabilities as well as the community. The challenge for CBR is to implement a programme that can cover and respond to the needs of people with disabilities as well as the community. CBRDTC has been implementing a technique of community development called participatory rural appraisal (PRA) to motivate the community to be involved in CBR activities (7). From its experience, CBRDTC concludes that PRA techniques such as mapping, Venn diagrams and matrix ranking can be used as entry points to establish a CBR programme in the community, to identify needs and priorities with regard to disability issues, to elicit the perspectives of people with disabilities as well as the communities, and to monitor and expand the existing programmes. However, each country will have to evolve its own strategies, depending on the kind of problems that it faces and the resources that it has.

Human resource development

There are two problems with regard to human resources in CBR that need to be solved. One has to do with the need for personnel who have the understanding and skills in various aspects of CBR, while the other is the lack of adequate numbers of trained personnel in this field. CBR programmes need personnel who understand and know how to deal with rehabilitation and community behaviour. But CBRDTC's experience in conducting international workshops has shown that most CBR personnel such as physical therapists, occupational therapists, doctors or vocational trainers, have primarily rehabilitation skills. Very few have studied sociology. Since the educational background of most CBR personnel has to do with rehabilitation, the programme tends to concentrate on rehabilitation interventions alone. There is thus a need to improve the quality of human resources in CBR by providing training in community development as well as in rehabilitation methods and skills. With two thirds of the world's population living in the Asia Pacific region, the needs for services are huge. Since the number of personnel to work in CBR is very limited, there should be greater emphasis on human resource development in this region.

To deal with the problem, CBRDTC is now developing a concept of a human resource development system, illustrated in Figure 2.

Figure 2
Figure 2



This system defines three main types of personnel that are required for effective CBR programmes. The managers are persons who have the skills of project development and management, identification and development of resources, proposal writing, negotiating with donors, organising workshops and so on. The technologists are the specialists with technical skills in areas such as medical rehabilitation, community development, income generation, access and so on. The scientists are those with skills in conducting research to improve both the strategy and the techniques in CBR implementation. At the centre of the triangle is the institution that has the resources in terms of funding and policy to support the activities of the three types of personnel.

Funding for CBR

Most donors for rehabilitation prefer a charitable approach which is more visible and easy to evaluate. Donors are satisfied with pictures and numbers of persons with disabilities who have received rehabilitation services. But it is not so easy to evaluate a CBR project that is involved in community development. However, community oriented programmes are more effective because they work not only for people with disabilities, but also develop the communities where they live and their families. CBR involves change in the community's behaviour, motivation, knowledge and skills in relation to disability issues. This change, which is crucial for CBR, is difficult to see or evaluate. For a funding agency that is not used to supporting development programmes, this is difficult to understand. In order to change the attitudes of donors, there should be regular communication between the donors and the implementers about CBR concepts and strategies, in order to convince the donors that CBR is a development programme and not a charity effort.

Information dissemination in CBR

CBR programmes have been implemented in different countries in the Asia Pacific region using various strategies and methods. Each programme has its own strengths and weaknesses. But they do not disseminate information about their strategies and methods to others. For example, though CBRDTC has been developing manuals in English for CBR training programmes, many organisations are not aware of the resources available with CBRDTC because of inadequate communication channels, There is an urgent need for information dissemination so that all countries in the region can access information about developments in the CBR field. Every country will be required to make some effort to share its information. On the other hand, there is the wide availability of sophisticated information technology tools such as the Internet. The challenge for CBR practitioners is to make full use of the technology in the fields of information and communication for the further development of CBR in the region.

Conclusion

Asia and the Pacific region with its huge population has been developing rapidly in all fields. With these changes, the field of CBR also needs to adapt its strategies and methods accordingly so that the goal of tackling disability issues within the community can be reached. It is equally important to emphasise human resource development for CBR in the region, to increase the numbers and to improve the expertise. Since CBR implementation will need financial support, there should be closer communication between donor agencies and CBR programme implementers. Asia and the Pacific is a vast region and the available sophisticated information and communication technology will need to be effectively utilised to bridge the distances. Considering the huge and diverse needs, CBR personnel, programme implementers, government agencies, donor agencies and others involved in CBR should co-ordinate, communicate and organise activities jointly, in order to deal with the challenges facing CBR as it moves towards the 21st century.

Handojo Tjandrakusuma
Director, PPRBM Prof. Dr. Soeharso - YPAC Pusat, CBR Development and Training Centre, Jl. L.U. Adi Sucipto Km 7, Colomadu, Solo - 57176, Indonesia


Acknowledgement: The author would like to acknowledge the assistance of Heny Soelistyowati, Chief of Training Division, CBRDTC, in preparing the final draft of this paper for publication in the Asia Pacific Disability Rehabilitation Journal.

References

1. ESCAP. Asian and Pacific Decade of Disabled Persons, 1993-2002: Mandates for Action. United Nations, 1994.

2. ILO, UNESCO, WHO. Community Base Rehabilitation for and with People with Disabilities : Joint Position Paper. United Nations, 1994.

3. United Nations. Economic and Social Survey of Asia and the Pacific, 1995. United Nations, 1995.

4. ESCAP. Compendium of Social Development Indicators in the ESCAP region : Quality of Life in the ESCAP region. United Nations, 1993.

5. ESCAP. The Quality of Life in the ESCAP region : an Overview. Asian and Pacific Ministerial Conference in Preparation for the World Summit for Social Development. United Nations, 1995.

6. Report of the Rehabilitation International Asia Pacific Region Pre-Conference Workshop. The Future of CBR - Crucial Issues, Solo, Indonesia, 1995.

7. Tjandrakusuma H. Participatory Rural Appraisal (PRA) in Community Based Rehabilitation : An Experiment in Central Java, Indonesia. Actionaid Disability News, 1995, 6 (1): 6-10.


ASIA PACIFIC DISABILITY REHABILITATION JOURNAL (VOL.9, NO.1, 1998)

Produced by:
Shree Ramana Maharishi Academy for the Blind
3rd Cross, 3rd Phase, J.P. Nagar
Bangalore - 560 078, India
Tel : 91-80-6631076, Fax : 91-80-6638045
Printed at:
National Printing Press
580, K.R. Garden
Koramangala
Bangalore - 560 095, India
Tel : 91-80-5710658