Community based rehabilitation has been in existence for quite some time, promoted to address the needs of developing countries to enhance the coverage of rehabilitation services within reasonable costs. However many of the concepts related to CBR are controversial even today. This paper discusses some of these concepts and the controversies surrounding them, which have implications for planning.


Introduction

In developing countries, the governments have limited resources, and their needs in the field of rehabilitation of people with disabilities are for establishing wider coverage of interventions rather than for providing high quality of services. The community based rehabilitation (CBR) approach is viewed as a possible method to increase coverage in these countries, to address the needs of governments with limited resources, and not as a consumer movement evolved out of the needs of disabled people. Thus, the CBR concepts that grew out of these requirements had to accommodate the agenda of the donors as well as the consumers. Because of this evolutionary background, the development of CBR concepts in these countries has been embroiled in various controversies. This paper presents some of these issues and controversies, and discusses their significance in the planning and practice of CBR programmes.

CBR concepts and their controversies

Well before the WHO popularised the CBR approach, it had been in existence in a small way in many developing countries (1). The concept gained more prominence in the decades of eighties with the statements of the world bodies that it was the most suitable and appropriate method of rehabilitation for developing countries.

Coverage

One of the important issues behind the CBR approach is `coverage', the attempt to shift from `everything for a few' to `something for everyone'. This issue was perceived as important from the very beginning because it was estimated that in most developing countries, hardly 2-3% of those in need of rehabilitation services ever received them (2). The challenge that most developing countries face is to see how best to arrive at an optimum quality of services, given the limitations of providing a large coverage with limited resources. Following the Alma Ata Declaration which targets `Universal Coverage' by 2000 AD, many developing countries are trying to achieve this target in their states through CBR programmes. However, these countries have only limited resources. At the same time, they require to invest very heavily in setting up new services because the existing services cover only 2-3% of their disabled population at present. In such a situation, the resources may be spread so thinly in trying to achieve coverage, that the quality of services may become very poor.
The votaries of universal coverage opine that since less than 3% receive rehabilitation services at present, some services, even if it is of poor quality, is better than nothing. Others argue that such poor quality services would destroy the traditional forms of rehabilitation that now exists in the community, and therefore become counter-productive.

Costs of CBR

CBR is seen as an approach that is affordable to the governments in developing countries. Affordability is to be achieved by shifting some of the responsibilities of family based interventions to the disabled persons' families, and thereby reducing the unit costs of rehabilitation. The question is, for whom is it inexpensive ? Is this a cheaper programme for the government who funds it, or is it inexpensive to the consumers ? CBR programmes appear to be cheaper because of the shift of the costs of home based interventions to the consumers. If the costs to the consumers, of their efforts in terms of time and money are actually added to the outlay of the programme, it may turn out to be much more expensive than what it is generally believed to be.

The controversy here is whether the consumers are ready to take on the additional burden in terms of costs of CBR interventions. Another aspect is, even if they are willing to take on these costs, can families from developing countries afford to do so ? In the developed countries, disabled persons' groups advocate the transfer of the right to govern rehabilitation programmes to themselves. This has to be viewed in the context of well established professionally manned rehabilitation services available to most of those who require them in the developed world. Many developing countries have a long history of a colonial past, which was followed by a period of socialist governance which do not encourage consumer ownership of welfare activities. As a result, most consumers in these countries believe that the responsibility of carrying out welfare activities rests solely with the government rather than with themselves.

Community participation

Another important issue is community participation, which means the active involvement of disabled people, their families and communities in planning, implementation and governance, as well as in sharing the risks of the programme. This is expected to make the programme more sustainable. However, the concept of community participation in CBR has generated much debate. It involves the readiness of the community to take up the ownership and the risks of the programme. The issue here is whether the community is actually ready to do so. In an ideal state, the community is willing to shoulder the responsibilities of providing necessary services to the vast majority of its members. However, disabled people are neither a majority group in the community, nor are their needs seen as a priority by the community. In most communities, the more vocal members corner the provision of services, and most disabled people are excluded from this group because of their disability. It is not convincingly clear yet whether community ownership of rehabilitation programmes will sustain them better, or marginalise them and be detrimental to them.

The confusion about whether rehabilitation can sustain itself amongst the plethora of activities of the community has continued over the last fifty years. In the decades of the sixties, seventies and eighties, most planners believed that rehabilitation programmes would not sustain unless special privileges were given to disabled people to develop and run their programmes separately from the other community development activities. In the nineties, they believe that in order to sustain rehabilitation programmes, they have to be integrated into community development programmes, which implies that the community is ready to address the needs of its disabled members, just as those of its majority groups.

Community based rehabilitation `versus' institution based rehabilitation

Most CBR programmes try to address the needs of all identified disabled persons in the community, through a comprehensive set of interventions, such as medical rehabilitation, education, vocational rehabilitation, social rehabilitation, awareness building and prevention. Such a shift from institutions is complicated because it is important to consider the 'levels' and the 'limits' of care in providing rehabilitation services in a community setting before they are undertaken. This is particularly true in cases of people with multiple or severe disabilities.

The challenge is to shift the interventions from a structured, organised, systematic and professional environment of institutions to an unstructured, unfamiliar setting in the community without the back up of infrastructure, systems or professionals to help in the process. Faced with new and unstructured settings, what is required most of a CBR worker is the ability to be creative, innovative and solve problems continuously on the job, without much guidance (3). Innovative use of local resources, whether it is in the form of personnel, materials or technology, is central to the concept of CBR. By innovative use of local resources, interventions can be made more appropriate, more effective and more acceptable, besides having the advantage of building on what may already exist in the community by way of traditional forms of rehabilitation.

In reality, there are limits to the extent to which a CBR programme achieves the shift from institutions to the homes of disabled people. Most CBR programmes achieve the shift up to a certain level only, beyond which they need to have institutions to depend on. In this context, the controversy of institutions versus CBR becomes irrelevant.

Do all disabled people need rehabilitation ?
Definitions of impairment and disability may be common across most cultures, in any part of the world, while the definition of handicap is culture dependent. Handicap is the social disadvantage faced by disabled people, and is therefore quite dependent on cultural norms. Most traditional cultures have their own spontaneous ways of reducing the impact of disability. This is usually achieved in two ways; by the acceptance of the disabled person by the community, and by the assignment of a role or responsibility to him in his community setting. In such communities which already have their traditional forms of rehabilitation, it may be counter-productive to introduce an externally planned CBR programme which does not take into account the local needs and existing local practices.

Rights of disabled persons
Another issue is that of social integration of the disabled people. In a move away from the segregation of disabled persons that was practiced in the earlier years, social integration was sought to be promoted through provision of equal opportunities for disabled people, and protection of their rights in the society. However, integration of marginalised groups is a distant dream in most developing countries. In a country like India, a majority of people belong to some form of marginalised groups. They compete amongst themselves to avail of the provisions granted to everyone. The advantage given to one group is often viewed by the other as its loss. At the same time, the legal system in these countries is unable to enforce the law granting equality to the disabled persons because of the very nature of the law. The law is punitive towards those who break it, but provides no incentives for those who do not, hence it actually seems to favour those who are able to circumvent it in some way. Many CBR practitioners in developing countries debate if it is worth spending their efforts to gain rights for the disabled persons at this point of time, rather than providing rehabilitation services which are non-existent.

Conclusion
CBR is a concept, which in practice, varies from place to place, depending on the setting. Unlike institution based approaches, there is no universal model of CBR which is applicable everywhere and each CBR programme has to evolve its own strategies and methods as appropriate to its context. It is unlikely that rigid standardisation of CBR can ever become possible, as long as there are different cultures. Any attempt at standardisation is as good as trying to standardise different cultures and races.

References
1.Miles M. Disability Care and Education in 19th Century India : Some Dates, Places and Documentation. ACTIONAID Disability News, 1994, Vol. 5, No. 2, Supplement, 1-22.

2. World Health Organisation. Disability Prevention and Rehabilitation. Technical Report Series 668, 1981, Geneva.

3. Thomas M and Thomas M.J. A Brief Report on the Innovative Use of Local Resources in Community Based Rehabilitation. Paper presented at the REHASWISS Annual Seminar, 1997, Thiruvananthapuram.

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

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