PERSPECTIVES FOR THE 21ST CENTURY RI IN THE YEAR 2000

REHABILITATION INTERNATIONAL TOWARDS THE YEAR 2000

SUSAN R.HAMMERMAN
Secretary General,Rehabilitation International

The 16th World Congress of Rehabilitation International today draws to a close. Thousands of participants, representative of all continents and all peoples, have joined together in Tokyo for the first World Congress of Rehabilitation International ever held in an Asian nation. The event has offered an unprecedented opportunity for international exchange of experiences and sharing of knowledge. Rehabilitation International is deeply indebted to the Organizing Committee for the 16th World Congress in Japan, to the Government of Japan, and to our host organization, the Japanese Society for Rehabilitation of the Disabled, for the extraordinary organizational effort,support, and gracious hospitality which has characterized this World Congress event.

Like Rehabilitation International, the World Congress has been representative of the unique partnership which exists within our membership among all groups concerned with issues of disability and society - disabled people, parents,professional service providers, officials of government, representatives of the United Nations and its specialized agencies, representatives of international non-governmental organizations. Thank you all for the contribution which you have made to the success of this world event.

Above all, the 16th World Congress has emphasized that disability policies and programs must be understood as an ordinary aspect of societal development,an aspect fundamental to the maturation of all nations committed to the democratic values of progress, social justice, equality of opportunity and respect for the lives and contributions of others.

As we move towards the year 2000, the beginning of the 21st century of human civilization, we the people of the world, grow increasingly inter-dependant upon each other. Our individual worlds have become global. We are learning to communicate from one corner of the earth to the other in lightening speed. We are transcending traditional barriers of geography and culture. People and areas formerly considered remote are now very much a part of the dynamic of world change.

The world of the future is forecast to be a world of enormous technological capacity whose nations are increasingly inter-dependent and where computerization is catapulting the transmission of ideas globally. A veritable revolution is underway in our understanding of the bases of life.

New technologies are creating unprecedented opportunities for people with disabilities in daily life and productive work. Literacy no longer only means the ability to read and write, but now includes the capacity to interface with advanced technical equipment.

Four decades of development activity worldwide have increased life expectancy for us all and the number of babies who die during their first year of life has declined significantly.

As a result of trends of these kinds, and the emerging movement towards peaceful cooperation among all nations, the world is entering what has been called a "period of historic optimism."

And yet, as the world approaches its fifth and final development decade before the beginning of the twenty-first century, more people than ever are trapped in absolute poverty. The number of poor people in the world by the year 1995 will exceed nine hundred million, with Africa contributing a major portion of the increase.

The poorest countries present a major challenge to the world community with wides pread malnutrition, hunger, ignorance and the deaths of nearly forty thousand small children daily. The number of illiterate women in the third world has never been greater and population growth is outstripping resources of food and energy in alarming numbers of countries. Africa, one of the regions most deeply affected by the AIDS pandemic, includes the majority of the world's forty least developed countries and will be the focus for United Nations development action in the period ahead.

Goals for the Fifth United Nations Development Decade, 1991 through the year 2000, emphasize actions to sustain achievements already made and call for utilization of approaches which are lower cost and more effective. The key to development in the next decade is better utilization of under-utilized resources.

Clearly Rehabilitation International and the disability community have a great deal to offer within the overall picture of development forecast until the turn of the century.

Comprehensive rehabilitation must be based on realistic approaches rooted in the community, low in cost and appropriate. As we have heard over and over again during this 16th World Congress week, community-based rehabilitation is the core of all action for strengthening societal development through activation of the capacities of people with disabilities and their families. Who can deny that people with disabilities and their families represent one of the most underutilized resources available to serve the development of our communities and our nations worldwide?

We may take hope in the fresh perspective imbuing the disability movement throughout the world by the self help movement of organizations of disabled people stimulating us to recognize that equalization of opportunities is an aspect of social development very much within the capability of all nations to achieve.

As United Nations Secretary General Perez de Cuellar said in his message to the 16th World Congress, the guiding principle for the remainder of the Decade of Disabled People must be equalization of opportunities with recognition of people with disabilities as citizens first and then as beneficiaries of services.

Many achievements have characterized the Decade of Disabled People now in its second half. Disability prevention is accelerating as the global campaign for Universal Child Immunization takes effect. Nevertheless malnutrition, infection, accidents and wars mean that tens of millions of people are being unnecessarily disabled each year. Trained rehabilitation personnel are needed more than ever to sustain and invigorate the process of community based rehabilitation. And the overall priority within development planning of action on behalf of people with disabilities and their families must still be raised to a higher level.

We can anticipate therefore that in the world of the future, people with disabilities will continue to be represented disproportionately among those groups in society at greatest risk: the very poor, the war injured, refugees, street children, persons deprived of their civil and human rights.

These are the realities facing Rehabilitation International as we refine our vision and develop a shared strategy with our partner organizations for the balance of the United Nations Decade of Disabled Persons and beyond.

Rehabilitation International as a world organization is poised for action. It has benefited in recent years from an increase in its member organization network, a stabilization of its financial base, and a renewed vitality in its leadership including strong representation by leaders of the disability rights movement.

Rehabilitation International has a special capacity, as a result of its globalism and humanitarian base, to help the world become aware of the unacceptable conditions which characterize the life of the majority of the world's disabled people.

It remains as true today as it did at the beginning of the United Nations Decade of Disabled People, that hundreds of millions of people with disabilities exist without access to rehabilitation services or even the most basic education, health care, nutrition and shelter required by people everywhere. It remains true that hundreds of millions of disabled people, children and adults, live deprived of their fundamental human rights and opportunities.

In a world which no longer tolerates that millions perish in silent holocausts of famine, disease, and war, it is a responsibility of Rehabilitation International to make known that hundreds of millions of people with disabilities continue to exist in need of attention to their basic needs.

We have honored our responsibility here at the 16th World Congress in Japan. We must continue to honor it in the decades ahead. It is on this basis that the Rehabilitation International strategy towards the year 2000 will be built.

<REPORT>

COMPREHENSIVE REHABILITATION

MASAO NAGAI
National Rehabilitation Center for the Disabled, Saitama, Japan

I am highly honoured to present to you my General Rapporteur's Report concerning the "Comprehensive Rehabilitation" part of our theme, Realistic Approaches--Looking Ahead Towards Comprehensive Rehabilitation, which may appear antinomic from a certain angle.

It is my pleasure to report before you that this theme was enthusiastically challenged this week by all of us, reaching fruitful results, and actualising the Integration amongst ourselves.

Once upon a time in America, a president was invited to speak at the meeting of a group, of which membership was limited to descendants of persons who rendered material aid to the cause of independence. His speech to these U.S. founders' families was started with "Dear Immigrants". This type of episode tells us that we would, more often than not, see only one side and overlook the fact that there is the other side of the mountain.

Especially in the future of rehabilitation, in which the bi-polar nature will be in more evidence, it is imperative not to lean towards one end but to tackle both ends at once.

When the stress is laid upon our similarities, all human beings are exactly the same, whereas when the emphasis is on our differences, not even a single person is the same as any other individual. These two conclusions are apparently contradictory, but both are true. It is merely the matter of looking at things from a macroscopic or microscopic viewpoint. Likewise, in the field of rehabilitation, the difference should be accepted, and, at the same time, equal opportunities should be given. In other words, human rights must be equally appreciated by all people, whether disabled or not. Simultaneously, it should be understood that each person's individualistic needs must be specifically met.

Along the same line of thinking, Comprehensive Rehabilitation means both integrity and specialisation, and Realistic Approaches and Looking Ahead can bear the meaning of both present practicality and future idealism. Thus, rehabilitation is not a one-sided but a two-way street.

Through the Congress discussions, it became apparent that we need solve the seemingly controversial apsects searching for a balanced parthership as soon as possible. It must also be borne in mind that the best approach or treatment in one realm is not necessarily so from the other. Looking Ahead, the two-way street will not be only between the disabled and non-disabled, but also between rural and urban districts, between ordinary people and professionals. And so, needless to say, between the so-called developing and advanced countries.

As stated by President Otto Geiecker, rehabilitation can no longer remain as isolated process in the medical, vocational or social field, but has to become a coordinated process encompassing all these areas. The aim will be the best possible integration of the person into society whilst preserving his or her own personality.

In Comprehensive Rehabilitation, the success ought not to be attributed only to the performers, individuals or disabled, but also the spectators, society or environment. Hence, the total or balanced approach towards the disabled, together with their background is required. That is to say, Comprehensive Rehabilitation has become the matter of social interaction or interculturally helping each other for mainstreaming. The society itself will be the one to be rehabilitated.

In a practical sense, rehabilitation aims primarily to minimize the handicap on the part of the disabled, and then leave the rest up to society. Nullifying the gap between the disabled and society is, therefore, essential in achieving rehabilitation partnership. In order to rehabilitate society, it was pointed out by some of the Congress speakers that accessibility of the social system must become attainable to all. This includes housing and transportation, social and health services, education and work opportunities, and cultural and social life.

Welfare measures and financial benefits may also contribute to the quality of life. However, the economic rewards are not of prime importance, but a sense of participation and self-respect are the ones to be gained.

If the physical obstacles are merely the ones to be removed, full participation is not foreseeable.The speakers emphasized that the attitudinal barriers must be lifted as well as the mechanical one.Some insist to focus rehabilitation on goals relating to handicap,towards which correcting functional limitations or reducing disabilities are subsidiary goals.It was also mentioned that the welfare of the families and communities must be taken into consideration sometimes even prior to that of the disabled from the standpoint of prophylaxis.

After all,the disabled are members of society.Any of the ablebodied members can have a sick part,and any of the disabled can hols a healthy part.Comprehensive Rehabilitation,thus,is for everybody helping each other.If we consider our similarities rather than our differences,practically all of us here have some disability.I might have been allowed to address you as "Dear Handicapped"

Society and disabled persons are not independent of each other, but must interact with each other.Realistically speaking,the immediate environment around the disabled intervenes between society and disabled persons.The success of rehabilitation is in large part contingent upon the function of this small society. Comprehensive Rehabilitation can then be interpreted as minimizing the gaps amongst these three.

In order for the disabled to achieve a full life in the context of his or her community,this small society must tackle both the big society and the disabled.To be more exact,both society's standards and the disabled's individual requirements must be satisfied.The medical or paramedical staff,for instance,are not only reguired to function in a longitudinal balance by providing a bridge between the disabled and society,but also a latitudinal one amongst themselves.This attitude must be applied even in the case of allowing bed-ridden persons to pursue their own meaningful lives.

Furthermore,the staff,family members or fellow workers who remain in one situation must keep their own mental health or rehabilitate themselves,lest they should be caught by the closed society and should become involved in the "Third Party Handicapped". This endeavor,in turn,becomes very beneficial to the welfare of the disabled.

Today,I am indeed privileged to report to you the agreement we made that Comprehensive Rehabilitation is a reflexion of society on one hand,but its actions on society in the future will become more important on the other.It is my firm belief that the spirits of the Rehabilitation International are functioning well within this Congress and will also be extended to without.

<REPORT>

LOOKING AHEAD:THE CHALLENGE OF THE FUTURE

NORMAN ACTON
Chairman,International council on Disability,U.S.A.

My task is to summarize for you how the discussions of this Congress have helped us think about the challenges of the future.Let me start with my conclusions.

The future is made up of problems and opportunities.In the Congress papers and discussions,in the sessions and outside them,we have received much valuable information about the problems and about the opportunities before us.

In order to plan for the future, we must analyse in a systematic manner the implications of these problems and opportunities, study how they relate to more general trends in the development of human society, identify the probable alternatives for disabled people and for the disability movement, and plot our course of action. The techniques exist for such analysis and study but, to my knowledge, they have not been employed in any significant way in our field. For the most part, we continue to plan for today which, by tomorrow, will be yesterday.

As we think about the future, about the problems and opportunities it will bring, it is important that we remind ourseives of two significant realities. The first is the certainty that, for the foreseeable future, the world will have every year more disabled people than it had the year before. There is no time to discuss the reasons, but I think you know them: population increase, longer lives, inadequate preventive measures, insufficient understanding about causes and effects, faulty priorities, pollution of the environment, growing accident rates on the highways, in the workplaces and elsewhere, and the stupidities that continue to give us famine, pestilence, violence and war. Unless we change some of these conditions, we may anticipate that there will be at least 700 million disabled people by the year 2000.

The second, and more positive, reality is that thanks to our collective efforts there is a movement at work in the world that is changing the human perception of disability. This movement is not based in any one organization, in any one country, in any one profession; nor is it derived from any single formula for solving the problems we face. It is a composite of the ideals and the work of many people and many organizations in many countries and at the world level. Its banners carry the great and creative messages of our epoch: messages about integration, about full participation and equality, about prevention, about rehabilitation, about normalizaiton, about access, about independent living, and, as the greatest challenge, about human rights.

This movement has improved and increased the flow of information about disability. By persuasion and by regulation, it has enlarged the arena of experience for people who are called disabled and for those who are not. It has, I believe, launched a process of change in human thinking and behavior that cannot be reversed, but must be nourished and expedited.

The issues of disablement will certainly be altered in the future by these as well as by other global trends affecting all of humanity. Population changes will place more people on the earth, give us a larger proportion of elderly people, concentrate more and more people in huge urban areas, and remove growing numbers from the economic and social environments of their families and cultures. The rapid development and proliferation of new technology is producing radical modifications in education, employment and in the availability of work. The dominant role in our lives of new methods of information processing brings both problems and opportunities. Traditional systems of economic security are failing for many in the midst of all these rapidly moving transformations in the human condition. There are, or we may anticipate, important changes in many social systems, especially in the role of the family.

Individually and collectively, these trends, affecting as they will many millions of people, will lead to modifications in the political, social and economic climates in which we seek to accomplish our goals. Each of these trends will have a profound impact in the future on the maning of full participation and equality, and on the resources that will be required to achieve and maintain that ideal condition.

The Congress discussions have given us an excellent overview of the situation as it is today. They have emphasized one pervasive issue: the gap between what needs to be done and what we are doing. When we project our thinking into the future, we must take today's deficit and expand it by the impact of trends such as those I have listed. I have not heard any reason to believe that the deficit will not grow. I have not heard any proposal to plan better than we have. I have not heard any intention to apply systematic and creative research to a definition of the situation we are likely to rate in the year 2000 and beyond or to an examination of the alternatives that may be open in the future for disabled people and for the disability movement.

To illustrate what I am saying let me take two examples of subject areas that have had significant attention in this Congress.

The evolving concepts cf community-based rehabilitation give a basis for hope that we can eventually meet the problems of the developing countries. The discussions here about CBR have identified the enormous gap between current capabilities and what is required to assist the hundreds of millions of people not yet reached. Using today's data, this is a very large challenge. Think how much larger it will be when we add the collective impacts of population increase, urbanization, breakdown of families and communities, and other trends that must be taken into account when we make projections for the future of disabled people in developing countries.

Can there be any question about giving a higher priority to the further development of CBR and about the dedication of more resources to the accomplishment of our objectives in the developing countries?

We have heard much about technology and its tremendous present and potential benefits for independent living,for mobility,for communications, for employment, and for other things. We have also heard that we do not have the social, organizational and financial capabilities to make the connection between the potential of technology and the needs of all the people who could benefit. If we cannot make that connection today, what will we do in the future when the problem is certain to be larger and more complex?

What about the impact of general technological development on enployment? It has reduced the physical requirements for some tasks, but it has vastly increased the needs for communications and intellectual skills, for dexterity. Should we not be examining the implications of these kinds of developments for the job markets of the future, for the content of our education and training programs?

These and other areas of challenge and of opportunity demonstrate the importance of realistic planning for the future. We have head about two similar master plans at the world level, the RI Charter for the 80s and, derived from it, the United Nations World Programme of Action Concerning Disabled Persons. These documents have much to recommend them, but those of us who had a hand in their drafting did not give enough attention to changes to be expected in the future. As usually happens, we were preoccupied with the deficits of what was then the present, and we wrote plans for that present -- which is already the past.

We have heard about some national plans, but not about any that includes provision for the changing circumstance of the future.

We have heard about the promise and disappointment of the United Nations Decade of Disabled Persons. That was and is another chance to think about the future -- and to plan for it. Mr. Sokaiski, the representative of the United Nations, has informed the meeting about an initiative by some nongovernmental organizations and the UN Secretary General to invigorate the Decade with a global envent dedicated to it and its goals. If this happens, as we hope it will, there will be another opportunity to plan with the future in mind.

To repeat my conclusions, the Congress has given us much useful information and many valuable insights about the problems and opportunities of the future. It has not -- and this confirms an area of vacuum in o r thinking, planning and research -- it has not brought us any systematic analysis of the future, of the trends that will shape the future, or of the alternatives for disabled people and for society that may exist in the future. The nost important challenge for the future is to understand the future, to plan for the future, and to act to make the future what we want it to be.

<REPORT>

REALISTIC APPROACHES

SMT.SUSHILA ROHATGI
Home Minister, Government of Uttar Pradesh and President of Rehabilitation Coordination India, India

At the outset I must thank the office bearers of the Rehabilitation International for giving me the opportunity to attend this Congress and address the delegates assembled here from all over the world.

The attention of the world was drawn to the problems of the disabled during 1981 which was celebrated as International Year of the Disabled Persons. The UN General Assembly has also proclaimed the period 1983 - 1992 as the Decade of Disabled Persons as "one means of implementing the World Program of Action". The UN agencies like UNICEF, ILO and WHO have made significant contribution to the prevention, early treatment and community-based rehabilitation of the handicapped. There is, however, a need to introduce more dynamic concepts and to give better media coverage to the problems of the disabled during the remaining five years of the Decade.

In India the constitution guarantees that disabled persons should have the same rights as other members of the society. Article 41 of the Constitution of India enjoins on the State to "make effective provision for securing the right to work, to education and to public assistance in cases of unemployment, old age, sickness and disablement and other cases of undeserved want."

The Government of India has introduced a number of schemes for the welfare of the handicapped such as grants to voluntary agencies working in the field of the welfare for the handicapped, supply of aids and appliances such as artificial limbs, hearing aids, aids for mobility for the disabled persons, especially to persons in the lower income group. About 30,000 handicapped persons benefit annually under the scheme, at per capita cost of about Rs. 500/-. The Central Government has also established an Artificial Limbs Manufacturing Corporation at Kanpur City in Uttar Pradesh - the largest state in the country and also my home state.

In developing countries poverty and disability often go together. A majority of these disabilities are preventable and are primarily related to malnutrition, Iow sanitary standards, Iack of medical care and high prevalence of infectious diseases. A Iarge number of handicaps could be prevented if the malnourished and starving people are given adequate and balanced diet.

In rural areas the problem of disability is more acute because of lack of services as well as lack of awareness. People are unaware of the fact that the handicapped persons by education and training can become useful members of society. In the rural areas, therefore, rehabilitation should be closely related to the immediate environment of the disabled individual, and should be functional as well as cosmetic. In addition to functionality, the disabled person should achieve economic independence and also assimilation in society.

Another factor which comes in the way of rehabilitation of the handicapped, especially in developing countries, is the lack of special facilities for the handicapped in public transport, access to buildings, places of work, shopping centres, pedestrian crossings, etc. These changes can be effected by the cooperation of the Government, public bodies, voluntary organisations and the community and by educating public opinion by well-planned publicity and information campaigns with the help of the media.

For the education of the handicapped children special schools have been established, but simultaneously more concerted attempts need to be made to integrate the education of the handicapped with other normal children in the community. This aspect of integrated education of the handicapped should be developed in a short span of time. A large number of handicapped children do not suffer from learning disability and can receive education in normal schools.

Another hurdle in the proper education of the handicapped children is dearth of qualified teachers specially trained in educating the handicapped. It is necessary to have a steady flow of trained teachers for expanding this programme. Since disability is usually coupled with poverty, the Government of India is implementing a scheme for providing scholarships to handicapped students to enable them to pursue their education.

Securing employment for the handicapped and helping them to utilise their innate talents to their satisfaction, but we have miles to go in this direction, is the ultimate objective of their rehabilitation programme. The attitude of the employers, co-workers and the general public has also aggravated the problem. In order to assist the handicapped in securing jobs, measures like reservation of jobs in Government and public sector, establishment of special employment exchanges for the hansicapped, etc. have been adopted.

Much larger allocation of funds for various schemes of welfare of the handicapped mentioned above is necessary, coupled with the awareness of society about the problems as well as potential capacities of the handicapped, will go a long way in helping their ultimate rehabilitation in society. The Government and the voluntary sector should come together for helping the disabled in facing life with courage and confidence.

SECTORAL SESSIONS

THE DEVELOPMENT OF COMPREHENSIVE NATIONAL DISABILITY POLICIES: THE DYNAMICS OF POLICY DEVELOPMENT

DEVELOPMENT OF COMPREHENSIVE NATIONAL DISABILITY POLICIES

L. CARTER-JONES
The Royal Association for Disability and Rehabilitation, London, U.K.

Today's speakers are all distinguished in their own field and I am sure they will all make valuable contributions to our discussions. Far be it from me to attempt to forecast what they will say, but I am sure that some introductory remarks are necessary, if only because for the last 20 years I have been closely involved in the production of one country's national disability policy and, indeed, after those 20 years, doubt if we have produced anything which is coherent and cohesive, though we have a system which provides more services and financial benefits in an unco-ordinated system.
Thinking has changed over these years and there can be no doubt that were one to start now with a clean sheet, it would be easier to produce a national policy than it was 20 years ago. Much of what is done has been on a piecemeal basis; there has been agitation from groups of disabled people and something has been done about the needs of that group with a specific disability. We have produced a patchwork quilt of services and facilities provided to meet the needs of an insistent group or because political expediency demanded it. Despite expressed concern for a national policy, little has been done to implement it.
There can be no doubt that in the last five years there has been an increase in the awareness of the needs of disabled people and a greater acceptance that disabled people themselves need to be considered in meeting those needs. We do, however, still come up against one major problem; disabled people are still to a certain extent regarded as a group - The Disabled - yet nothing can be further from the truth. Disabled people in their needs and their problems are as diverse as the rest of the community. There are disabled young people and disabled old people; disabled millionaires and disabled paupers; there are disabled men and disabled women; disabled people are to be found in the ethnic minorities; and the principle for any national disability policy must be what do we do to ensure that disabled people are part of the community in which they live, able to exercise their rights in that community and to undertake their responsibilities.
The basis must be education, housing, training, employment, mobility - all these need to be taken into account. We must ensure that the same or even better education is available to disabled children as to the rest of the children in the community. Only in this way can we ensure that they are not doubly handicapped. We must ensure that they are trained for employment always accepting that employment for some may be not what is considered the employment norm. There must be adequate and suitable housing which allows them to take part in activities around them if they so wish and, above all, there must be choice of housing and accommodation. Employment must be available and open to all on their merits and the environment must be friendly, accessible to them, and they must have mobility within it. The changes that we have seen in the last few years have shown us what can be done to give disabled people freedom of movement in every sense of the word. I can only emphasise this and repeat that access and freedom of movement is not merely a question of removing physical barriers and providing assistance and support. We need acceptance of people with disabilities, bearing in mind that society usually defines disability and handicap and can equally eliminate them. We can only hope that the present trend continues. We seek to ensure that in the years to come each government will see that disabled people can play their full role in the community. They are able to capitalise on their abilities and minimise their disabilities. Let us remember that in most disabled people there is a great deal of ability restrained and contained by a small percentage of disability.
Every government must accept that it has responsibility to its disabled people; after all, they are 10% of the population. We have made this comment regularly over the last 20 years but it cannot be stated often enough. If government policies can ensure that those steps which I suggest actually are taken, not only will they be producing independence rather than dependence, they will be improving the state of disabled people, improving their lifestyle, creating for them a satisfaction which at the moment is not available and, in many cases, turning tax users into taxpayers.

FINNISH NATIONAL DISABILITY POLICIES

E. VILKKONEN
The National Association of the Disabled, Helsinki, Finland

The Finnish national disability policies were founded during the years of the Second World War, the outcome of which was a large groud of disabled war veterans in Finland. Due to the serious war disabilities, surgery and other medical care reached a high level. Also medical rehabilitation in the proper sense of the word was initiated. The same applies to occupational rehabilitation. Most of the disabled men were farmers, agricultural workers or forest workers, since Finland was an agrarian society until the early 1950s. It was necessary to retrain the men for new jobs, which, however, were not easily available. Exept for occupations requiring academic degrees, the available jobs were mostly concerned with handicraft.
As a whole, Finnish disability policies have aimed at integrating the disabled persons with the rest of the population to as large an extent as possible. At the ideological level the aim is to get rid of the metaphysical aspect earlier connected with disability, in other words, to change the concepts related to disability. At the practical level, integration means, for example, that disabled children and young people are placed in public schools, not in special educational institutions. Efforts are now being made to change the physical environment so as to make it more friendly toward disabled persons and to make it possible for seriously disabled persons to participate in social life. The United Nations' Year of the Disabled meant a distinct improvement in the status of disabled persons in Finland.
Naturally the national disability policies have always had a legistlative basis. The Disabled Persons Welfare Act came into force in 1946, and some of its provisions are still valid. There has been special legistlation applying to disabled war veterans. A drastic change in Finnish disability policies and relevant legistlation has taken place in the 1980s, evidently as a result of the United Nations Year of the Disabled. It is interesting to note that the first reform involved economics and administration, and, in brief, the responsibility for the welfare of disabled persons was transferred to the municipalities. The state participates by granting financial assistance. The amount of state subsidy depends on the officially confirmed financial categort of the municipality conserned. It may turn out to be a drawback that the Finnish municipalities are so different as to their size. There is a danger that a certain kind of local law may develop: the statutory rights of disabled persons may be different in the various parts of the country, although the law is formally the same for all. This administrative reform was followed by a material reform in 1988, including provisions on services and assistance for the disabled, such as adaptation training, transport, interpretation services and the right to have a personal assistant. Also disabled persons are entitled to get the aids they need, for example a wheelchair. At the level of law in books, the status of disabled persons in Finland is one of the best in the world. It remains to be seen how this status will be implemented by law in action.
Maybe the right to work of the disabled has been arranged most unsuccessfully. There is a great deal of unemployment in Finland, and consequently disabled persons are in a weak position in working life as compared to the rest of the population. A high education will quarantee employment for a disabled person, but it is not possible for all disabled persons to acquire such an education.
A special feature in Finnish disability policies is the significant role of the organizations of the disabled in policy-making. As a rule the non-governmental organizations in Finland hold an important position in many fields of life. The Services And Assistance for the Disabled Act, which came into force in 1987, includes provisions concerning special councils for the disabled both at the municipal, provincial and national level. Since the Act provides the possibility to set up councils for the disabled, and since the representatives of the organizations of the disabled hold an important position beside the government officials, this means that the Finnish organizations of the disabled have been legalized to a certain extent. These organizations have become an esteemed part of Finnish disability policies.
The most important issue in Finland is now to follow up the practical implementation of the new disability legistlation. Significant rights have been granted to disabled persons in the name of equality. Now we must hold on to these rights.

CPMPREHENSIVE MEASURES FOR DISABLED PEOPLE IN JAPAN

TERUMI MURAOKA
The Headquarters for Promotion of Welfare of Disabled Persons, The prime Minister's Office, Japan

A. 1) Policies relative to disabled people in Japan have progressed dramatically since World War II. The forerunner of such policies was was the enactment of the "Child Welfare Act" in 1947, which legislated basic policies involving child welfare, including mentally and physically disabled children.

This was followed by the "Physically Disabled Persons Welfare Law" in 1949. For those people with mental disabilities, in 1950 the "Mental Hygiene Act" was enacted as independent legislation. In 1960 both the "Mentally Retarded Persons Welfare Act" - designed to aid planning of projects to protect and assist mentally retarded people - and the "Physically disabled persons Employment Promotion Act", which aimed at promotion and stability of employment for physically disabled people, were enacted.

1968 saw the establishing of the "Child Welfare Act", which covered children with severe and multiple impairments, and legal measures were also taken regarding the rights to institutional care of both adults and children. In 1970 there was a move among the entire nation for further welfare measures for physically disabled and mentally retarded people, which led to the enactment in that year of the "Fundamental Law for Counter-measures for Mentally and Physically Disabled Persons." With this, Japan established basic concepts relating to development of assistance and measures to protect their disabled population.

Further, in 1979, steps were advanced in the field of education. Following a three year preparation period, compulsory education for all disabled people became a reality. This promoted a trend for disabled people to live and receive care in their own homes, instead of being institutionalized. Emphasis shifted to more treatment and rehabilitation becoming home-based, instead of institution-based.

2. Thus, legislation was established which provided the basic framework for comprehensive measures for disabled people. However, it must be said that the biggest boost to overall improvement of measures was seen in the International Year of Disabled People (IYDP).

In this year, various projects were undertaken to increase society's awareness of disabled people and their needs. Taking the United Nations action-plan as a guideline, the National Council for Disabled People - including disabled members - met. (This had been set up as part of the previously-mentioned 1970 Fundamental Law for Counter-measures for Mentally and Physically Disabled Persons). They discussed a Long-Term Plan for Measures for Disabled Persons. In March 1982 this plan was officially formulated by the government, which also established the department of Promoting the Welfare of Disabled Persons in the Prime Minister's Office. This had followed a Cabinet Council meeting which requested this department to seek comprehensive and effective measures for disabled people.

3. In viewing the above span, one can see the expansion of care (including action taken following the IYDP, to be mentioned shortly) from disabled children through to disabled adults, and from a previous emphasis upon physical disability to include other types of handicaps. From light through to severe disabilities (requiring education, welfare and employment measures) and from institutionalization onto living at home, with vocational self-support to participation and involvement in society.

Measures to assist disabled people are also being expanded with regard to classification and degree of disability, action in health and medical care, education, welfare and living environment. Patterns of care are continuing to shift from institutionalization to community care with a consequent development of legislation, planning and implementation.

B. 1) The Fundamental Law for Counter-measures for Mentally and Physically Disabled Persons is the one that provides foundational measures for disabled people in Japan. This law is to be regarded as epoch-making in that it seeks to undertake not only welfare measures but also a comprehensive promotion of all matters affecting disabled people. It considers each disabled citizen is entitled to their individual dignity and a decent life.

The law provides for legislative and fiscal measures in the areas of welfare, education, living environment, culture, societal awareness, and public relations. It also seeks to have local and central governments extend necessaty measures and consideration of their responsibilities. Thus, the scope of this legislation is unparalled in its detailing of measures for disabled people. Unfortunately, however, it is regrettable that this law - in spite of its high ideals - has not received the attention and overall support that it so richly deserves.

2. Another achievement by the government in measures for disabled people is the Long-Term Plan for Measures for Disabled People. Formally established in 1982 following the International Year of Disabled People, as mentioned earlier, it followed U.N. guidelines. The National Council for Disabled Persons was involved in developing these measures. Since then - and following up the positive results of the above Plan - the "Latter-Term Priority Measures for the Long-Term Plan" was formulated in the middle year of the U.N. Decade for Disabled Persons.

Measures for disabled people are not limited to national level, but also to all prefectures, government-designated cities and local municipalities. Plans have been revised and updated at this, the mid-point of the U.N, Decade for Disabled persons. Private organizations have established the Welfare Promotion Headquarters for Disabled Persons and also local Disabled Persons' Councils, exerting efforts to fulfill their roles in implementation of assistance relative to disabled people.

3. Since the U.N. Decade, budgets have been increased substantially, and steady progress has been made in aid and assistance available. In 1984 the Physically Disabled Persons Welfare Law was amended to incorporate the concepts of the IYDP. 1986 saw revision of the pension system to include basic disability benefits ensuring disabled people had some steady income.

Also at the mid-stage of the U.N. Decade, the Physically Disabled Persons Employment Promotion Act was revised, and became the "Law concerning Disabled Peoples Employment Promotion". The Mental Hygiene Act was amended and renamed the "Mental Health Act, which aimed to increase the human rights and increasing activity of mentally-ill people in social events and activities.

4. The Latter-Term Priority Measures for the Long-Term Plan were drawn up in the middle of the U.N. Decade for Disabled Persons. These Measures took into consideration the results achieved so far, and were designed to be carried out during the latter half of the Decade. These measures were submitted by the National Council for Disabled Persons and finalized by the Headquarters for Promoting the Welfare of Disabled Persons. (This Headquarters consists of the Prime Minister as Director General, the Chief Cabinet Secretary and Minister of Health & Welfare as Deputy Director Generals, and nineteen Administrative Vice Ministers of all Ministries and Agencies). The results of the Latter-Term Plan have meant a delineation of basic policies and priority measures of each field, and can be regarded as epoch-making in this respect.

Measures relating to disabled people have been supported in terms of legal bases furnished for each field and each type of disablement. However, legislation tends to be taciturn when it comes to outlining of policies, and the basic laws make no provision for concrete measures to be taken. In Japan. various Councils are responsible for discussing and submitting recommendations regarding the direction of these matters. In such matters as formulation of social welfare policy, Council members would normally consist of authorities in the field, pioneer researchers, those with specific knowledge and experience of the problems involved, and disabled people themselves. However, the Councils' recommendations are not necessarily fully agreed by the government.

The latter-term priority measures for the Long Term Plan for Measures for Disabled Persons have been finalized. They were based upon the ideas submitted by the National Council for Disabled Persons. The government's comprehensive plans for disabled people have also been discussed by the National Council; these recommendations have been forwarded in turn, for finalization, to the Headquarters for Promoting the Welfare of Disabled Persons, which consists of related ministries and agencies. This procedure has occurred twice since the IYDP, and now seems to be the standard path taken.

5. Latter-term priority measures have explicitly defined "basic overall concepts" as opposed to "concepts for each particular field." Concrete measures for each individidual field have also been defined. Though this has not received the attention it deserved, this is an epoch-making accomplishment.

In the area of basic concepts, the Long-Term Plan for Disabled Persons has emphasized the need for "rehabilitation" and "normalization" to be of foundational importance. "Total participation and equality" together with personal support services that enable each disabled individual to achieve self-support and independence are also required. At the same time, improving living environments, dealing with the needs of the increasing number of elderly people, technological assistive innovations, furthering research and promotion of international cooperation have also been cited as areas for future concern. Concrete measures have been defined for the latter term of the U.N. Decade for Disabled Persons as regards societal awareness, public relations, health and medical care, education, training, employment, job opportunities, welfare, living conditions, sports and recreation, culture and international cooperation to promote priority measures.

C. In formulating social policies related to the needs of disabled people, it is vital that these needs are accurately grasped and understood. A nation-wide consensus regarding these measures is required.

As stated in the latter-term measures of the Long Term Plan, future efforts will be concentrated upon areas involving:

There is also a need to ensure steps are taken to encourage "integration" and acceptance. That through the combined efforts of disabled and nondisabled people, all prejudices and discriminatory thinking will be removed.

THE DEVELOPMENT OF COMPREHENSIVE NATIONAL DISABILITY POLICIES: THE DYNAMICS OF POLICY DEVELOPMENT

M.P.DE TAVERA
Department of Social Welfare and Development National Council for the Welfare of Disabled Persons, Quezon City, Philippines

The reduction of the socio-economic cost of disability and the consequent integration of disabled persons as contributing members of the Philippine community are major national concerns. Toward this end the Philippine government has declared a comprehensive national disability policy establishing and developing a broad and coordinated approach to the problem of disability and had adopted a National Plan of Action for the Decade of Disabled Persons incorporating the programs of both the government and private sectors.
Consequently, the government's premiere social welfare arm which is the Department of Social Welfare and Development has as one of its major objectives: the care, protection, an rehabilitation of socially disabled constituents and the physically and mentally handicapped for effective social functioning.
It is within this framework that the major programs along promotion of disability prevention and rehabilitation of the physically and mentally disabled persons is implemented nationwide utilizing various community and center-based approaches and strategies.
A key factor in the achievement of goals set for the sector of persons with disability is the National Council for the Welfare of Disabled Persons, an agency attached to the Department of Social Welfare and Development that serves as the central policy making, coordinating and monitoring body for disability prevention, rehabilitation and equalization of opportunities for disabled persons being undertaken by both government and non-government organizations (NGOs).

The Philippine National Plan is directed towards three major goals: disability prevention, rehabilitation and equalization of opportunities. It sets into motion policy directions for implementation as follows:

1. The reduction of the incidence of disabilities and impairments through the inclusion of measures for disability prevention within all national programs for health, education and environmental control.
Disabilities which limit the capabilities of people are, for most part, preventable. Among the major causes of disability are infectious diseases like polio, measles, and rubella; nutritional deficiencies of pregnant mothers and children including vitamin A deficiencies resulting to blindness; abnormal pre-natal or peri-natal events and accidents including those that are work related.
With these realities, preventive measures should include the intensification of the immunization program against bacterial and viral infections, genetic testing and counseling, family education to reduce consanguineous and intermarriages patterns; improved pre-natal and peri-natal care and condition; elimination of prolonged exposure to high noise level and accident prevention at home, at work and recreation places and on the road.

2. The institutionalization and expansion of inexpensive but effective community based strategies and approaches in the delivery and integration of rehabilitation services with the end in view of strengthening support and referral systems and hastening community integration of disabled persons.
In the Philippines, only one or two percent of the disabled persons living in rural areas have access to rehabilitation services, be it medical, social, vocational or educational, since such services are mostly in urban centers. But studies tend to show that approximately 70% of disabled people do not require specialized tertiary level services and that their rehabilitation needs can be met in their own communities. Current trends and development on disabled persons and rehabilitation have shown the viability and growing acceptance of community based approach as an innovation in delivering rehabilitation services to disabled persons more efficiebtly, effectively and economically. Its concept involves measures taken at the community level, using and building on resources of the community, the disabled themselves, their families and their community as a whole. Community based is distinguished from the traditional center-based approach of service delivery in terms of the following:
a. it develops the capability of the people and community to identify and assess their needs and resources and mobilize what they have to meet their needs;
b. it trains and provides certain skills to indigeneous community volunteers including disabled persons on prevention and on certain phases of rehabilitation activities like assessing the disabled person's working capacities and matching with work opportunities and needs of the community, or tapping local resources;
c. it makes use of evey resource available in the community such as old machines, expertise, service, opportunity for employment;
d. it enables the disabled person to stay in the community and receive rehabilitation services provided by family and neighbors;
The community based approach of service delivery is presently being used in the Philippines in medical and vocational rehabilitation-oriented projects in ten selected regions throughout the country. The replication of such approach shall be instituted to cover not only the rural but the urban areas as well.

3. The provision and maintenance of necessary steps to ensure the rights an benefits of disabled persons at all levels to achieve fuller participation and equalization of opportunities.
The focus of social policy in the Philippines is the equalization of opportunities and the mainstreaming of the disadvantaged sector of the populaltion, including the disabled, in national development efforts. Equalization means that disabled people have rights equal to the non-disabled, including the right to participate in and contribute to all aspects of economic, social and political life. Each social structure should therefore be planned and organized such that disabled persons are provided with opportunities for their full participation. Such structures include physical environments, housing and transportation, social and health services, educational and work opportunities, cultural and social life including sports, recreational and religious services. Supportive to all these should be measures to develop rehabilitation engineering programs that will enhance the production of technical aids and rehabilitation equipment, using indigeneous materials and at a cost affordable to all.
Disabled persons also often encounter not only physical but social barriers which make it difficult for them to develop close relationship with others. Formation of positive attitudes towards them should therefore be encouraged.
Maby countries have taken important steps to reduce barriers in order to facilitate full participation of disabled persons in community affairs. In the Philippines, Batas Pambansa Bilang 344 or the Accessibility Law, was passed requiring the installation of access facilities and other devices in establishments. This is considered a giant step in the major effort towards providing greater mobility to disabled persons. It also provides, among others, for parking areas and special bus stops for disabled persons. While the law has not yet been fully implemented, there are beginning signs of compliance. Recently, the Department of Public Works and Highways has caused the slicing of side walk gutters in the Metro Manila area. Access symbols are likewise posted in buildings with access features. A massive information campaign on the provisions of the Law through symposia/fora and the mass media has been launched to create greater awareness on the needs of disabled persons.

A significant step also was the appointment by president Corazon C. Aquino of a sectoral representative for the disabled sector to the Congress of the Philippines. This sector has submitted a more comprehensive Accessibility Bill to ensure greater opportunity for disabled persons.
Government and private sectors must take equal responsibility in the implementation of all these. The disabled themselves should also take an active part in planning, implementing and evaluating programs and services and projects geared towards the maximization of their benefits.
The above underscores the extent to which comprehensive national disability policies have been translated into programs and services for the welfare of disabled persons.
Much remains to be done, it is true but we have certainly begun. It is a beginning that augurs well not only from persons with disabilities but also for society as a whole.

THE DEVELOPMENT OF COMPREHENSIVE NATIONAL DISABILITY POLICIES

-A SINGAPORE PERSPECTIVE-

LIM PUAY TIAK
Disabled People Section, Ministry of Community Development, Singapore

1 TWO WAYS TO ASSIST THE DISABLED

1.1 There are 2 possible ways of providing welfare services for the disabled in our Society. One is through state welfare spending. The other is through voluntary assistance through community participation.

2 STATE WELFARISM

2.1 Singapore is not a welfare state. This does not mean that our Government pay less attention to the needs of disabled people. As a young nation, we could benefit from the painful experience of other countries that state welfarism is fraught with intractable problems.

2.2 Professor Else Oyen of the University of Bergen, Norway lamented: "The grand vision of the welfare state as a lodestar have faded and have been replaced by small and unrelated decisions, the sum of which is staking out a path we might not have followed had we known where it was leading us."

2.3 State welfarism has 3 basic flaws. These are:

2.4 This will gradually erode the incentive for productive investment and motivation for hard work.

3 COMMUNITY PARTICIPATION

3.1 In Singapore, we take the view that Government should not shoulder the sole responsibility of looking after the needy and less fortunate in our society. We advocate that care for the disabled is a tripartite responsibility involving the family, the community and the Government.

3.2 The best care that a disabled person can receive is from his family.

3.3 Government's objective with regards to disabled people is to provide, with the support of concerned Ministries, the environment and opportunities for them to develop their physical, mental and social capabilities to the fullest extent circumscribed only by their disabilities.

3.4 It seeks to encourage and sustain the growth of volunteer effort in meeting the needs of disabled people. The community is encouraged to take on an enlarged role for the eradication and alleviation of social difficulties faced by the disabled and the less fortunate.

3.5 There are 3 distinct advantages in having the community at large assisting its less fortunate members through financial assistance and voluntary social work. They are:

4 WELFARE SERVICES

4.1 Welfare services in Singapore was first introduced in 1946 to alleviate the ravages caused by the Second World War.

4.2 Over the past 42 years, it has evolved from the emergency and remedial approach of post war Singapore to a more rehabilitative, preventive and developmental model of today.

4.3 Recently, the Singapore Government adopted an Agenda for Action as a basis for nation building and future Government policy. The Deputy Prime Minister announced that the goals enshrined in the Agenda for Action will be implemented by a "sectoral approach" through 6 specific advisory councils, each headed by a Cabinet Minister.

4.4 The Advisory Council on the Disabled, under the Chairmanship of the Minister for Education, was appointed to:

4.5 Members of the Advisory Council include disabled and non disabled people from outside Government so that policies and programmes formulated by the Government can be assessed by others outside Government. This will ensure that future programmes for disabled people will be more national in character providing for different points of views and most importantly, practicable.

4.6 This is a watershed in improving the plight of disabled people in Singapore.

NOTE : The above views are personal and does not reflect that of the Government of Singapore.

REFERENCES

1 Forsberg, Mats, the Evolution of Social Welfare Policy in Sweden. The Swedish Institute, 1986.
2 Ministry of Communications and Information. Singapore - Facts and Pictures 1988. Singapore National Printers, 1988.
3 Oyen, Else Ed. Comparing Welfare States and Their Futures. The University Press, Cambridge, 1986.
4 Report of the Regional Expert Seminar to Review Recommendations at the Mid-point of the United Nations Decade of Disabled Persons, ESCAP, 1987.
5 Society for Aid to the Paralysed, Issues Concerning Disabled People - A report submitted to the Advisory Council on the Disabled. Society for Aid to the Paralysed, 1988.

THE DEVELOPMENT OF COMPREHENSIVE NATIONAL DISABILITY POLICIES: THE DYNAMICS OF POLICY DEVELOPMENTS

M. TINAZ TITIZ
Kultur ve Turizm Bakanligi, Turkey

Mr.Chairmen Ladies and Gentlemen;
Development of any policy relies on the needs of such a development and this rational applies to the development of any National policy on any given subject. Since the subject is "Disability" here, the very first question will be "WHY" do we need to develope a policy for Disability? The answer is actually within the question itself, because: there is an existing situation as "disability". The second question will be then "WHAT" kind of policy? Here; in most instances the answer usually begins with therapetic and REHABILITATIVE meassures which answer only to the second half of the question and the problem.

I believe that, dynamics of any policy must contain the answers and reasons to the basic question. The basic question of this case must be "WHY DISABILITY OCCURS?" Unless we have answers to this, we will not be able to move a head and ask the second question "HOW TO PREVENT IT?" Without this WHY and HOW questions and their answers, we will not be able to design any successful policy. While asking these questions I am very well aware of the fact that the answers to both, varies in different parts of the world, as developed and developing countries certainly have their own patterns and causes of disability. Nevertheless,the great majority of causes of disability are common and these could be eradicated, a voided or at least minimized with common approch. Then of course country-specific disabilities will countinue to exist and those could be dealt with specific national policies and actions.

As it emerges from this introduction "PREVENTION" must be the KEY WORD or rather most important component of any National Disability policy and this is our main concern in my country. It is interesting to see that how few certain components in community like social on economic and educational inadequecies could be the cause or reason of several multipl problems. For instance poverty and malnutrition could be the reason for disability as the lack of proper education could be the reason for accidents which also causes disability.

So, with one "Education" component one could alter or at least aims to alter several problems and their consequences, and this brings us to the necessity of knowledge which will be drowned from the questions WHY and HOW disabilities accur? This data-base will enable policy makers to design an effective preventive policy.
Up to the moment, the problem of non-availability of proper disability statistics caused a lot of myth and misunderstanding about the causes of disability. Once scientfically we show WHY and HOW they occur then we can drow a policy WHAT could be done in order to prevent or to treat and to rehabilitate. International attention as well as most national efforts have been centered mostiy on the "end-result" more than the "causes". Naturally this was due to the conditions which disabled people were forced to live in. Now we must begin to put at least equal emphasis on PREVENTION if not more. However- while making this statement I am very well aware of the fact that PREVENTION polices require a giant inter and intra-sectorial co-operation which may be more complicated than the co-operation needed for Rehabilitation. But I am sure none of us is after easy ways out anyway, and this could be achieved in spite of the potential complications.

Models for Prevention of Disability should be developed and these models should include all causes and should be aimed at all age groups not only for elderly. All national programmes of D isability and Rehabilitation should be run by a National Board where all disiplins are represented. It should not be left with one sector of the Government. National policy makers must not forget that, disabled people could contribute a lot to any level of these programmes.

In conclution, Disability polices should be based on PREVENTION, where ALL AGES and ALL CAUSES receive equal attention. The causes of disability must be studied and docummented more thoroughly and this could be done by more international co-operation and research. This data should be made available along with the other existing data on disability and rehabilitation for international use by means of computerized information exchange and the terminology should be basic in order not to cause miscoding implementation could be varied according to each country but TOOLS for EVALUATIONS should be internationally acceptable and these could be developed through international cooperation also.

Turkey is willing and ready to start such a comprehensive policy; which will cover all aspects of Disability concept, from CAUSES-PREVENTION to medical vocational REHABILITATION, along with legislation etc etc, and she is already implemented certain part of this plan as "better opportunities for the bodily disabled by working on Employement and Environmental factors, though BEGV "Foundation for the Strenghtening the Bodily Disabled" which has just joined the Rehabilitation International as a member. Turkey will be looking forward to exchange information and ideas with all of you, through RI in order to develope a very affective national policy which will help to reduce all kinds of disabilities, if not to be able to prevent as much as possible, and try to treat and rehabilitate the ones that could not be prevented. It is our aim that disabled persons should have the same quality of life as so called able population has.

I like to finish with sincere wish for a happier and healthier world which embraces all disabled or abled equall.

COMMUNITY BASED REHABILITATION

COMMUNITY BASED REHABILITATION

CHALOTTE A.FLORO
College of Allied Medical Professions, University of the Philippines, Manila, Philippines

Treditionally, rehabilitation services are planned, organized and carried out in institutional settings such as hospitals and clinics, rehabilitation facilities, day care centers and special schools. Within this context, clients are either confined or obliged to go to these institutions in order to receive the needed rehabilitation services. The main characteristics of these facilities are of course familiar to us: elaborate infrastructure manned by various levels of specialized trained personnel, modern technology, high cost of services affordable by a few, concentrated chiefly in urban areas, intended primarily for industrialized societies.
While these institution-based services were being developed, they were being modelled and introduced in developing countries where the world's vast majority of disabled people live and where at least 70% of these disabled people exist in remote rural communities which generally are deprived and poverty-stricken, have little access to basic services and with minimal economic growth and development. Here, the lives of people are, for the most part, hinged on strong extended family ties, superstitious cultural beliefs, fatalistic attitudes, misinformation and ignorance.
We have all come to realize that rehabilitation services evolved in the West are not appropriate for developing countries of adopted en toto. We are doing a great injustice by imposing rehabilitation measures on emerging countries which are meant for a New York City clientele. A pervasive sense of urgency was felt by rehabilitation workers to produce an alternative strategy that would be more relevant and meaningful to reach out to assist disabled persons in third world communities. In 1979, the World Health Organization responded to this and gave impetus to a rehabilitation revolution when it launched the field testing of its unique concept and method of community-based rehabilitation. It captured world-wide interest and attention and the experimentation of the method become a dynamic and widespread movement proving, as it did, that CBR is relevant, valid, applicable and replicable in community settings especially in rural areas.
The focus of community-based rehabilitation revolves around the key concept that the resources of the community are the core participants in the rehabilitation process. Human resources are tapped, mobilized, motivated and trained to be responsible for the care and training of disabled so that they can function optimally in the mainstream of community living. All are involved: disabled persons themselves, members of their families, neighbors, the farmers, local political officials, village craftsmen as well as the basic social units of the community such as the church, the school and political parties. Through a volunteer trainors team of local people, family members are instructed in simple, practical procedures such as how to identify and prevent disability or how to assist in doing basic rehabilitation techniques. The CBR approach is low-cost, makes use of indigenous materials and maximizes the linkages among existing community services and groups.
Let me summarize by pointing out that the so-called "professional" rehabilitation workers need preparation themselves and must develop new sets of behavior to effectively function in this new arena of rehabilitation.
First, CBR involves transfer of technology wherein the so-called technical knowledge and skills of the professionals are broken down into units understandable and acceptable by the village people. Once basic principles underlying different rehabilitation principles and measures are explained and demonstrated on why and how things are done, the people themselves begin to see relationships which prepare them to be responsive to devising their own practical adaptations to suit their needs within the resources and capability of the community. They learn to appreciate the versatility of their own indigenous materials and to make full use of these local materials in the fabrication of devices and aids. For the teaching-learning process to be effective, there is need for health workers like us to be first trained to recognize, respect the values, the time-honored traditions and views of the community they are working with and to understand the type of relationships occuring within their primary institutions. We also must learn how to communicate, develop and identify with village people. What occurs is an exchange and sharing of knowledge - the folk health beliefs, technology and practices on the one hand, and the scientific on the other.
In this reconciliation, we also accept their ideas and respect their values while we clarify concepts and principles, while we verify and confirm through concrete events and examples. We therefore, must continually be open to new learning because village people have long been in the business of living and have a vast store of experience and practical insights verified through time and tradition.
Second, as agents of change, we act in the role of facilitator. This enables the people to articulate their solutions to problems and at the same time enables us to be fully cognizant of the fact that village people have an amazing inherent quality - a "built-in" capacity and ability to seek, discover, invent ways to try out solutions to their own problems. The CBR approach gives us an opportunity to be in the setting most natural to disabled persons - his home, among loved ones, familiar community surroundings. It gives us an actual face-to-face encounter with the stark realities of village living and to meet village people on their terms.
Third, the CBR approach brings together the different elements of the community building a network of linkages and what emerges is a collaborative mechanism created by and for the community and to be managed and sustained through their own collaborative efforts.
Fourth, the CBR approach encourages us to perform the important task of documenting results and findings of our work at the village level to form the basis of a data bank needed for information dessimination and sharing as well as for research and field studies. This would give us basis to replicate the CBR strategy in other communities and form the basis of evaluation/monitoring.
With this as an introduction, ladies and gentlemen, I have the honor to present our distinguished panel of speakers - all with first-hand and very credible experience in CBR activity.

COMMUNITY BASED REHABILITATION FRAMEWORK AND SOME STRATEGIC ISSUES ON THE PROGRAMME IMPLEMENTATION

H. TJANDRAKUSUMA
C.B.R.Development and Training Centre, Y.P.A.C.Pusat, Surakarta, Indonesia

INTRODUCTION:

The Community Based Rehabilitation (C.B.R.) programme answers the increased demand for, and better distribution of, rehabilitation services, particularly for those in developing countries.
The rationale for this includes the population growth, increased volume of traffic leading to more road accidents and expansion in industry leading to more industrial accidents. Improved health services help to combat terminal illne ses, but disabling factors are increasing.
The general public now has a heightening awareness of health concerns and of disability. Subsequently, there is an increasing demand for appropriate services.
The existing services in most developing countries are inadequate. These inadequacies are due to essential sectors, eg. food-production, primary health care and family-planning having high priority, whereas, relatively low priority is given to rehabilitation work. Besides this, there is a shortage of skilled personnel in rehabilitation work.
Convential rehabilitation services are provided by "rehabilitation professionals" in rehabilitation institutions, In this system, the community in general and related non-rehabilitation service-providers,eg. primary healthcare programmes, primary schools and nutrition programmes, are excluded from contributing their large potential.
Hence, we see the necessity for a C.B.R. programme with the following intrinsic values. The programme must be easy to be implemented extensively. Exiting resources within the community and resouroes from the rehabilitation institutions, together with related non-rehabilitation institutions should work together for the effective implementation of C.B.R. programme.

STRUCTURE OF C.B.R. PROGRAMME:

Firstly, to define "structure" - it must be easy to understand and applicable to the resources at hand. In C.B.R. terms it can be seen as a directiongiver, rather than inflexible device. Rehabilitation involves a variety of services, such as medical, educational, vocational and psycho-social services to name just some. These are needed in differing quantities and gradings which may range from simple, through intermediate to advanced. The different levels and types of services can be grouped according to the most appropriate service-providers, based on C.B.R. concept, i.e. the general community, specially trained community members and professionals/institutions.
The "community" in C.B.R. terms refers to those of the population living in a limited geographical area, who have similar cultural values, and between whom there is regular frequent contact. Forming the base of the C.B.R. structure we have the community acting as the main agent, whose responsibility includes decision-making with regard to programme-planning, implementation and evaluation. The objective of the programme itself should be based on community needs and availability of community resources.
Upon the base of the structure we have rehabilitation activities grouped as namely A, B and C. These are the groupings, or Pillars, of the structure. Pillar A represents the rehabilitation activities done by the general community menbers. These, among other activities, include early detection and home care. Also included are information dissemination, organisational skills, such as fund-raising and awareness promotion, etc..
Pillar B activities are those carried out by specially selected and trained community members. Within this grouping, simple rehabilitation intervention, implementation of referral systems, monitoring and accountability take place.
Pillar C rehabilitation activities are those done by professionals who are living within the area, and who are working at higher feferral centres, outside the community. The service includes a higher professional service, such as the organising of training programmes, plus research and developmental activities. The services of institutions would be a valuable asset in this capacity of providing higher professional services to C.B.R. programme.
The capping achievement is the ability of the community to be involved in developmental activities in C.B.R. programme, to be self-innovating, and to use its experience in helping C.B.R. to be implemented in other areas.

EFFECTIVE ENTRY OF C.B.R. PROGRAMME IMPLEMENTATION:

Introducing C.B.R. programme through the most effective entry-point will ensure not only the initial success of the programme, but also its long-term effect. It is important that the awareness initially stimulated by the programme entry into the community, has sufficient impact to sustain community involvement for future activities.
Considering this aim, the following criteria are essential to the entry of C.B.R. programme:

1 It must be psychologically attractive by readily displaying that it is non-complex, easy to understand and to develop. Another psychological attraction is the universal appeal of children, and contributing to their well-being.

2 The programme must be able to be implemented in the community. It must give scope for the application of the natural knowledge inherent in the community - particularly in mothers - as to what is normal and abnormal in children's development and behaviour. Confirmation of the validity of that knowledge through C.B.R. detection methods, will add to the confidence of community members in their natural judgement.

3 There must be visible evidence of C.B.R. programme's success. This is achieved through choice of the under- 5's (5 years of age)as the target group. Intervention at the under-5's level usually involves only medical rehabilitation. Hare-lip repair and club-foot operations are good examples of this. Added to this, children who need exercise soon respond to this therapy. These results are readily noticeable and become rewarding to the community.

4 The programme should be easily attached to an existing service. In this way we avoid the cost of a new facility. In many instances, health programmes for under-5's already are functioning in the community.
Considering the above-mentioned/discussed criteria, we may conclude that Early Detection of disability for under-5's is the most appropriate entry programme for C.B.R..

MAINTENANCE STRATEGIES OF C.B.R. PROGRAMME:

Since C.B.R. programme was introduced into village areas, community knowledge, awareness and skills concerning disability and rehabilitation have led to implementation of C.B.R. services. This consequently has raised the level of achievement of C.B.R. programme. This level must be maintained for community benefit. A danger that may eventuate if not pre-empted, is that once a disabled person has overcome his/her disability through C.B.R. programme, he/she may take his/her rightful place back in the community, and, with the seemingly decreasing need for rehabilitation services, the programme may decline in attention and activities.
Strategies to counteract this, are, among otheres, continued focus through C.B.R.'s services attachment to the existing services programmes, such as the under-5's weighing programme and other routine services in the community, eg. the primary health care programme and the nutrition programme.
The problem of disability can also retain focus through people with disabilities being encouraged to join community programmes, such as Nightwatch. Their participation in village sports events, arts and crafts displays, and parades, can also draw attention to the need for sustained attention to disability. Village monographs, too, should include statistics concerning disability in the villages. In inter-village competitions, attention is drawn to the villages' achievements in health programmes, environmental issues and agricultural projects, but disability and rehabilitation achievement statistics should also have exposure in these competitions.
A good C.B.R. programme should have an in-built strategy of maintenance.

CONCLUSION:
There are many other issues that must be considered. Among these are rehabilitation research, training programmes and programme management at the local level. The participatory roles of existing rehabilitation services and related non-rehabilitation services must be given attention. Added to these and especially important, are those issues arising from field experience.
It is from both theory and field experience that we have to develop effective strategies of C.B.R. programme implementation.

VARIOUS MODELS FOR COMMUNITY BASED REHABILITATION

P.MENDIS
World Health Organization, Sri Lanka

The topic "Various Models for Community-Based Rehabilitation (CBR)" that I have been invited to speak on by the organizers of this special session gives me the opportunity to share with you the hopes and fears of some of us in the developing world who have been interested in the progress of CBR over the past 10 years or so. In early conferences of this sort I recall my particular role to have been to voice our views on the issue "Why CBR?" The fact that it has now changed to "How CBR?" presupposes the acceptance of the concept at the International level but does not make the task any the easier. In the last few years interest and activity in rehabilitation in our countries appears to have increased significantly, most of it in the name of CBR. What concerns us in the developing countries isthat too often this interest and activity is manifested with no apparent understanding of the concept of CBR. All too often we see the pattern of the rehabilitation therapies that is traditional in the Northern hemisphere being extended to our communities with and without adaptation and being called CBR. I propose to utilize this opportunity to elaborate on the concept which I hope will help to clarify the issue of CBR models.

In CBR we work within a defined concept and any approach calling itself CBR must be in line with what that concept envisages. In other words, approaches must keep within a certain pattern, otherwise it cannot be CBR. It is in this context that we can talk about "models" for CBR, the term "models" being used to denote possible variations or approaches manifesting the basic features that are envisaged in the concept.

Some such models which I believe come within the concept of CBR (that I have either seen or had described to me by those directly involved) are, to name a few in our region, Tiang Giang province in Vietnam; Baktapur in Nepal; Kerala in India; Sarvodaya in Sri Lanka; Bacolod in the Philippines; Kuala Terranganu in Malaysia and Burma. No two of these models are identical. Each has its own particular characteristics. Yet in this diversity there is an underlying basic pattern all these various models are striving to achieve and have achieved to a lesser or greater degree; a pattern that is specific to CBR, with features that are distinctive to CBR.

To make clearer these distinctive features one needs to look at the raison d'etre for the evolution of the concept. Our familiarity with that suffices a summing up at this time as, first, the desperate social and economic situation of disabled people coupled with the second, the failure of the traditional rehabilitation system to have an effect of positive significance on their quality of life. The latter is borne out by Senator Edward Kennedy's address to the Democratic Convention in July this year when he stated -

"America needs to bring the disabled into the mainstream, not relegate whole groups of our people to the backwaters of our economy".

In the context of this paper and in the brief time available, I believe that the CBR concept can most relevantly be described in terms of 3 distinctive features. The first distinctive feature is its emphasis that social change must pave the way for therapies to be effective, rather than the traditional emphasis on therapies with inadequate, if any, attention to social change. Social change is vital to enable the effect of the therapies to be maximised and to achieve rehabilitation's goals.

Lessons from the past and most recently with primary health care have taught us that deep and lasting social change can only be brought about when families and communities themselves take on the responsibility for that change - that attitudinal change must come from within.

The second feature of CBR is a corollary to this; community responsibility for rehabilitation of its disabled members, which gives the concept its name. In the concept community responsibility for rehabilitation or community-based rehabilitation does not mean merely that rehabilitation services function at community level, or merely that the community participates in service delivery. There is a recent proliferation of such services - Outreach, Portage type early stimulation programmes,etc. etc. in the name of CBR. In CBR, rehabilitation services function at community level and the community participates in delivering the service, but these arise from a deeper basis in that the community recognises and accepts that services for people with disabilities are part of its total community development effort. Rehabilitation is not an isolated programme or activity but is part of the overall systemic change by which the community seeks to improve itself. Only when this happens does social integration, full participation and equalization of opportunity have any meaning and become realistic goals.

Experience with traditional rehabilitation approaches with its primary emphasis on therapy to improve the individuals abilities is that it does not bring these goals within reach. However much an individual, whether disabled or not, may strive to achieve self-fulfilment he is unable to do so unless his social environment accepts that the achievement of self-fulfilment is his right. A change in the discriminatory nature of our social environments as regards disabled people is fundamental to rehabilitation; this is what CBR seeks to do by pervading all social development processes from planning and beyond it; in education; in economic activity; in health activity; in culture; in politics; etc.

To take an example,in education the global trend in Special Education is towards "one school system for all" where Special Education will no longer remain only an isolated speciality but invades all forms of general education. A recent Reuter release from New Delhi describing the reaction of Indian Women's Groups to a plan to improve their lot reported the Head of the Centre for Women's Development and Studies to have said, "How can a plan which looks at women as a separate issue hope to bring them into the mainstream?"

The third basic feature of the pattern is the dissemination of information within communities and the acquisition of skills by communities to enable the realization of the first two features. The development of the WHO manual 'Training Disabled People in the Community' reflects the relationship between these three features. Knowledge and skills must be made freely accessible, not just doled out; and not only to people with disability, their families and rehabilitation workers, but also to neighbours and friends, formal and informal community leaders, school teachers, health workers and other community development workers and groups.

The conventional focus on therapy alone even if carried out by community workers in the homes of people with disability and with their active participation does not constitute CBR. Therapeutic skills must be integrated in the context of social change and community development. I believe that it is the failure to understand and accept this that has led to some confusion about what CBR is.

A large part of this confusion is due to inadequate dissemination of relevant information. An equally large part is due to irresponsible dissemination of disinformation. Criticism which follows an understanding of the concept whether the concept is accepted or not, can be positive and can help us on our path towards equalization of opportunity. Criticism arising out of failure to understand the concept, and yet professing to accept it, hinders us.

It is interesting to note that criticism of the latter variety comes particularly from isolated but vociferous northern expatriates working in developing countries. Their specific criticism is aimed at what has come to be called the 'WHO Model'. This is the one described in the WHO Manual and designed to be adapted to the socio-cultural ethos of each country. They state that the model is too rigid and inflexible and call for a rejection of the model and of the Manual. The variations of this model that are evident globally in many member states of the WHO and the value placed on the Manual by field workers provide evidence of the invalidity of the criticism. Such criticism then is an insult to the intelligence of the developing countries and reflects the arrogance, prejudice and inflexibility of those that hold this view.

This kind of failure to understand the concept of CBR and of propagating various models that are not CBR in the name of CBR, arises from approaching the concept from the reference of industrialised societies. The concept can be understood and appreciated only when looked at from the viewpoint of the developing world.

Whether developed or developing, both worlds share common goals for rehabilitation . Most developing countries are still many decades behind the developed. But we have had the benefit of learning from the experience of the developed world. With industrialization the intervention of the institutional system for rehabilitation was expected to mark a significant improvement over the existing situation. Retrospectively however it has turned out to be one that delays attitudinal change in Society. This experience has enabled us to evolve a concept which maximises the resources available to us at our stage of development to bring closer to us the common global goals of social integration, full participation and equalization of opportunities for our disabled people.

References

World Programme of Action Concerning Disabled Persons. UNSCDHA Vienna, 1983
Helander E, Mendis P, Nelson G, Training Disabled People in the Community,
WHO Geneva RHB 83.1, 1983
Miles M, Where there is no Rehab Plan. A critique of the WHO Rehabilitation
Scheme, Mental Health Centre, Peshawar, (Undated)
Myrdal Gunnar, An Approach to the Asian Drama, Vintage Books, New York, 1970
Corea Gamini, Third World Cooperation and the Development Crisis, Inaugural
Senaka Bibile Oration, Sri Lanka, 1987
Meadows Donella H, Whole Earth Models and Systems, (from the CoEvolution
Quarterly, Summer 1982 Vol 34

IMPROVING THE QUALITY OF LIFE WITHIN THE COMMUNITY

ROBERT SABOURIN
Canadian Rehabilitation Council for Disabled, Quebec, Canada

INTRODUCTION
In February(1) 1981, the <WHO Expert Committee on Disability Prevention and Rehabilitation> presented its report which concluded as follows:

<About 10% of the world's population is affected by various kinds of disability and handicap. These cause serious social, economic, physical, and psychological problems not only for the disabled or handicapped persons and their families, but also for their communities. In view of the seriousness and widespread occurrence of disabilities and handicaps, the Committee made the following recommendations for governments:>

and I now quote the 5th recommendation:

<Governements should initiate development programs related to community-based rehabilitation(2) and disability prevention as an urgent matter.>

I will comment later on the other recommendations.

This introduction puts into perspective the central idea of my presentation:

IMPROVING THE QUALITY OF LIFE WITHIN THE COMMUNITY

(1) WHO - World Health Organization, Geneva, 1981 Disability Prevention and Rehabilitation for the handicapped, Technical Report Series 668
(2) Opus Citatus, p 38, the underlining is by the presentator

When that WHO brochure appeared during the International Year of the Handicapped, a few months before the announcement that the 1982-1992 Decade for the Handicapped was accepted by many countries, I had adopted this booklet as my bedside book and my vade mecum in the habilitation and rehabilitation field.
That WHO booklet has not only inspired my actions in regard to the planning of the objectives, of the programs and services offered by the rehabilitation centre of which I am director, but it also has been instrumental in my accepting to actively participate since 1982 in the Associate Committee on Research and Development for Rehabilitation of Disabled Persons set up by the National Research Council of Canada.
This Associate Committee on research in habilitation and rehabilitation has, after extended consultation throughout Canada, identified TEN PRIORITIES in the field of research concerning people living with impairments, disabilities and handicaps.
One of these priorities specifically concerns the improvement of the quality of life of these same people within their natural environment.
But the Associate Committee has realized that the Canadian Federal Government as well as the ten Provincial Governments, have done very little for the development of research in these fields. Less than 1% of the allocated budget for research was given for rehabilitation. This situation exists even if the WHO Expert Committee had, as early as 1981, denounced the urgency of developing programs stressing the need of support to the community.
How could this recommendation be fulfilled? This presentation aims to answer this question. My presentation will be divided into two sections:

I - DEFINITION
<Improving the quality of life of persons with functional limitations...
These are persons who would be independent in as far as all involved care personnel consider them full-fledged persons and not as "beneficiaries" or as "assisteds";
These are persons who will have access to the same services of housing, education, transportation, accessibility to the work force, be it paid or volunteer work, as all other citizens;
These are persons who will be able to keep whatever acquisitions they already have by physical, intellectual, social, cultural activities for as long as possible within their natural environment;
so that they will feel happy and useful in all respect and dignity.
...within the community
This related to the city of village, the neighbourhood, the family, friends and relatives wherever natural community groups are formed from common and well identified needs.
These do not require long studies nor long debate; what are needed, however, are innovative as well as close to life means.
This brings me to enumerate certain postulates that you can compare with your own experience before putting into action.
Postulate no 1 - Persons with disabilities can organize themselves independently, not only to defend their rights, but also to find original and non-expensive ways to improve their life.
Postulate no 2 - Within the family (friends and relatives), there is a will to cooperate in order to keep the disabled person within his or her natural community, but that willingness is accompanied with needs for support, information and respite.
Postulate no 3 - Within the community, there are decision makers or rulers, agents of change, volunteers, who are willing to give of their time and energy if they have adequate support.
Postulate no 4 - There are many retired persons who would ask no better than being useful if we allowed them to discover and develop their extraordinary potential.
Postulate no 5 - If the rulers decide to invest millions in research in habilitation and rehabilitation, in alternative therapies, in the evaluative research of community experiences, the government would save fabulous amounts by maintaining persons with disabilities longer in their normal environment.
Postulate no 6 - If we were to use the cities and villages as focus points for society projects wherein the decision makers from the municipal, school and social levels could unite in a common goal to improve the quality of life of people with disabilities, the results that could be obtained would assuredly be more important than the total of the individual non-concerted results.
II - PRINCIPAL MEANS OF ACTION
The important thing to remember in life is not where we are, but rather what direction we are taking.
As I am talking to you, 10% of the population is touched by some disability, linitation or handicap situation. This means that at least 80% of all human beings will, at some time or another of their life, be affected by either one or the other of these situations.
This means that most of us present here will have to live with these restrictions.
This means that habilitation-rehabilitation is a subject with national as well as international implications and that it demands concerted effort from all those who want to improve the quality of life of persons living with impairments, disabilities and handicaps in our society.
The WHO Expert Committee recommendations I quoted at the beginning of my presentation are stated in this spirit.
Among the multitude of suggestions and real life experiences related at the last Canadian Congress of Rehabilitation held in June 1987 in Quebec City, whose theme was IMPROVING THE QUALITY OF LIFE WITHIN THE COMMUNITY,(1) I retain three kinds of actions that I think allow us a sure and enlightened direction for the future of habilitation and rehabilitation.

1. SELF-HELP GROUPS(2)
Self-help groups are small groups formed by peers voluntarily offering mutual aid to persons with common needs and similar life situations. One essential characteristic (REISMAN, F. 1977) of a self-group is that it is made up of persons who have lived through the experience.
All those who have influence in our society must support this'kind of organization. Because the benefits are enormous in many ways:

(1) 3rd Canadian Congress of Rehabilitation Report Improving the Quality of Life within the Community Les Editions Papyrus 1987, 745, avenue Eymard
Quebec, Que. CANADA GIS 3Z9
(2) Ideas taken in a presentation during the 3rd Canadian Congress on Rehabilitation of June 1987 - SELF-HELP GROUP - GILBY, Valerie
Faculty of Nursing, University of New Brunswick, Fredericton,N.B. CANADA

Health and welfare workers should be involved in the development of self-help groups. They need to link persons to non professional supporters in their neighborhood. The National Association for Psychiatry in the United States now recognizes self-help groups as an acceptable helping method. The British futurist James Robertson stated that the future task of the health care worker is to enable and empower people to take greater responsibility for their own health. (ROBERTSON, J. 1985) The self-help process itself can be empowering.
2. COMMUNITY PROJECTS
Improving the quality of life within the community should be a community project. The natural pivot point of the project should be the city. Because it has the responsibility for transport, lodging, leisure activities of all kinds and that of the ecological environment, it can become the focal point of the needs of its citizens living with impairments, in concert with the organisms responsible for education, health and employment.
The compartmentalization of the organisms offering services to people living with limitations often affects them (in a negative way).
If 80% of the citizens of all municipalities have to live at one moment or the other of their life, with a situation of limitation, impairment or handicap, why not plan the environmental and organizational aspects of our cities so that the majority of our co-citizens will benefit from a better quality of life even during these periods of limitations.
The antique city had a tradition. Among its elected rulers, there were wise people, usually elderly people who could, not only share their life experience with the younger people, but also helped to maintain the important human values such as respect and dignity of all human beings.
With all our scientific progress, citizens can enjoy a longer life. But of what use is this if it is to "stagnate" in some institution? The direction that all decision makers of our world should take is that of community projects centered on the city.
Everything should be done to ensure that people with disabilities and limitations can actively participate in the development of the city of tomorrow.
3. GOVERNMENT POLICIES
The rate of spending of the industrialized countries concerning health and rehabilitation seems to indicate that they will not be able to afford such expenses in twenty years or even less. A new direction must be taken. As the WHO Expert Committee stated, it is the governments who are best situated to give the impulse of a more realistic direction in that area.(1)
Four sectors should be favoured in the elaboration of government policies:

1. RESEARCH AND DEVELOPMENT
Very little money is allocated in most countries for research in prevention and in the habilitation and rehabilitation fields.
As habilitation and rehabilitation is a science that is presently defining itself and that it needs well established reference points, I believe that every national government would benefit by creating a research coordinating mechanism that would promote glossaries on habilitation-rehabilitation, significant statistical data and characteristics that should be included in research in habilitation and rehabilitation. (See Appendix 1)

2. RESTRUCTURING TRAINING PROGRAMS
The 6th recommendation of the WHO Expert Committee reads as follows:

<Governements should pay particular attention to the need for promoting manpower development so that the community-based rehabilitation program(2) can provide sufficient supervision and referral.>

If we add the new approach of that same committee on rehabilitation to this recommendation,(3) it is easy to understand that a restructuring of the college and university levels of training are necessary.

(1) Opus citatus: Recommendations for governments - pp 37 and 38
(2) Opus citatus p 38
(3) Rehabilitation not only aims at preparing persons with impairments and handicaps to adapt in their environment, but also to intervene in their immediate environment and in society as a whole to facilitate their social insertion.
Persons living with an impairment or handicap, their family and the community they live in should involve themselves in the planning and in the realization of rehabilitation services.

3. HOME CARE SERVICES
The decision makers have understood that maintaining people at home, even those whose impairments are quite severe, is not only psychologically helpful in improving the quality of life but also financially advantageous for the state.
This will be possible in as much as the policies favor the material, psychological and financial support for parents, friends and volunteer workers who can become first class resources in the maintaining at home of people with limitations.
4. POTENTIAL RESOURCES OF THE ELDERLY
A few years ago, a movement was created to encourage elderly people to return to studies in a background appropriate to their situation. The Third Age University was born in Toulouse, France, with Professor Pierre Vellas.
Experience has shown that these people were not only capable of producing cerebral activity as intense as when they were 40 years old, but also that these exercises had a huge influence on their neurological tonus and that they could then continue to be very active in society.

Governments as well as universities do not concern themselves with educational policies for the elderly. (VELLAS, P. 1986)

<They are concerned with social actions, old age pensions, health services organization, but not yet with educational actions. Nonetheless, this will come to pass, because we cannot provide the old person with a satisfiing life condition and with a place in our society if we do not act on all his components, and the(1) education component is the most important.)

(1) Presentation by P. Vellas in Les Cahiers de l'Agence
L'universite et le troisieme age: education et recherche
Actes du Colloque international 1986 p 106
Les Editions Agence d'Arc Inc.
6872 Jarry Street East
Montreal, Quebec
Canada H1P 3C1

Seen from another angle, the work or job dimension is very important in maintaining the residual capacities of the older person. The countries which have encouraged retirement at 55 or 60 will possibly have a too heavy financial burden if they have not accompanied that policy with an encouragement to an active life either as volunteer or as paid workers. In Japan, elderly people work fewer hours and with less heavy salary costs. This is evidently more easily in a country where the unemployment rate is no higher than 3%.
Governments should take advantage of this potential by developing policies that would allow elderly people to remain active, by volunteer or paid jobs, by maintaining cerebral activities (training, proficiency courses), by participating in committees on research, on social and community actions.
This extraordinary potential, too often hidden or forgotten, is a major asset that all decision makers could use.
In my opinion, this is the area in which are found answers to our questionings, not only in order to control the enormous health costs, but also for
IMPROVING THE QUALITY OF LIFE WITHIN COMMUNITY.

APPENDIX 1

1. Begin by clearly defining habilitation and rehabilitation science, which should involve a systematic study of the biophysiological, mental and social aspects of IMPAIRMENTS, DISABILITIES and HANDICAPS, according to the international classification terminology adopted by the WHO.
2. RESEARCH includes the collection, analysis and interpretation of data on the frequency, extent and nature of impairments, disabilities and handicaps.
3. RESEARCH should determine causes and risk factors related to people's environment, genetic and cultural background, lifestyle, work place, recreation and sports interests, and so on.
4. RESEARCH should study social consequences, costs, and measures to prevent or reduce impairments, disabilities and handicaps.
5. RESEARCH should promote the development of the person's residual capacities.
6. In keeping with the holistic approach, RESEARCH should address the person as a whole. Throughout the process, it will require the person's(1) active participation and an increasing involvement of family and friends
7. RESEARCH should find effective ways of acting upon the social environment, in terms of behaviour and the enormous potential of this environment.
8. RESEARCH should include organizational and operational aspects, in addition to its basic, evaluative, technological and psychological aspects.
9. RESEARCH should promote co-operation among service, educational, consumer and industrial organizations.
10. RESEARCH should lead to a systematic dissemination of results and their use.

This direction in habilitation and rehabilitation research will have a multifacetted impact:
Impact 1: It will significantly reduce service costs within the next ten years.
Impact 2: It will step up the educational, professional and social integration of persons with psysical, sensory or mental limitations.
Impact 3: It will promote greater consistency among training programs for those working with the disabled, client service objectives, government program objectives, and the concerns and claims of consumer associations.
Impact 4: It will rise to the emergence of habilitation and rehabilitation researchers in educational, industrial and clinical settings.

(1) Habilitation or rehabilitation is not a process of conforming or becoming as normal as possible; rather, it involves FULFILLING ONE SELF by willingly developing one's capacities and creating new links between them. Very little research has been done on ways of maximizing residual capacities... The whole sector of biomedical, electrical, mechanical and computer engi-
neering must become involved in a clinical setting.
FRSQ p 13

URBAN COMMUNITY BASED REHABILITATION

- THE HONG KONG EXPERIENCE -

S. F. LAM
Maclehose Medical Rehabilitation Centre,Hong Kong

Community Based Rehabilitation (CBR) is a system of providing "rehabilitation care" at a level commensurate with the capability of the local resources available. It is based on the age old principle that the ideal nurse and "therapist" to care for a child is the mother with family members and friends in the community communicating with a person (patient) best.
At present there are three ways in the delivery of CBR, these being as:-

In 1978, the World Health Organisation produced a manual on Community-Based Rehabilitation for Developing Countries entitled "Training Disabled People in the Community". Field testing over four years revealed the following:-

It is significant that CBR in its present form - using Local Supervisors and Family or Community Trainers have only been field tested in rural regions of the undeveloped and developing countries.

In 1986 with the designation of its MacLehose Medical Rehabilitation Centre as a WHO Collaborating Centre; one of the first projects undertaken by the Society running the Centre, the Hong Kong Society for Rehabilitation; was to initiate a Community Based Rehabilitation Programme in an urban setting - UCBR. How can we in Hong Kong adapt CBR to our advantage ? To answer these questions we need to:-

(1) What has Hong Kong got ?

Rehabilitation facilities for the physically disabled is provided both by the Government and by Voluntary Agencies with the private (pay for service) sector playing a slowly increasing part. Much of the facilities are institutionalised in Hospitals, Clinics or Centres where the patients visit (as out-patients or day-patients) or live (as in-patients).

There is a generous provision of these facilities of a standard comparable with some of the best in the developed World. All persons in Hong Kong needing or requiring rehabilitation services can have access to them provided they are willing or able to make the journey from their homes to these facilities.

While there is a Community Nurse Service provided by both Government and Voluntary Agencies; there is not the domiciliary physiotherapy and occupational therapy services that are found in the more affluent countries with a comprehensive national health service.

(2) Our Shortcomings

Though our rehabilitation services are institutionalised, it does not mean that our staff limit their work to these places only. Very often home visits are made by our staff - physiotherapist, occupational therapists, medical social worker etc; prior to patient being discharged to see if their homes are suitable and adapted to the patient's needs. Similarly family members are alerted to and instructed in the care of the patients on returning home.

All patients would be given instructions and appointments to return to certain Hospitals, Clinics or Centres for follow-up at specific times. Herein lies the weakness of our system - for the decision whether to keep or not to keep the appointment or return for follow-up is left entirely at the discretion of the patient. For a multiplicity of reasons - inconvenience in travelling, unavailability of transport, inability of family members to get off work to accompany them and so forth may prevent patients keeping up this liaision on discharge. In other words, there is a breakdown in continued patient care bridgeing their discharge and further care if needed.

(3) UCBR and our Continued Community Care Programme (CCCP)

In our attempts to overcome this shortcoming, we looked at the "Extended Patient Care Programme" introduced by Sir George Bedbrook for his patients in Shenton Park in Perth, Western Australia. Paraplegics discharged from his rehabilitation hospital are followed-up, cared for and given further treatment (if needed) at home by the Extended Patient Care Nurse.

It is our aim to apply the UCBR concept to provide the extended care which our patients need when they go home from our institutions. This programmme I call the Continued Community Care Programme i.e. UCBR - CCCP.

Our plans are to tie this in with our Nursing Service. The Community Nurse would be the Intermediate Level Supervisor - the link between the Local Supervisor of the CBR system and the Professionals of our Institutional Based Rehabilitation System (IBR).

With this link completed, we have a two-way set up whereby our Community Trainers and Local Supervisors have a readily available back up system to channel their difficult or complicated cases for a second opinion, a definite diagnosis or more sophisticated therapy when the need arises - the 20% professional involvement and the 10% specialist referrals in Susan Hammerman's 1982 report.

REFERENCES

(1) Dr. Jerzy Krol, Community Based Rehabilitation - The Basic Principles and Their Implementation. Proceedings of the 15th World Congress of Rehabilitation International, Lisbow 1984.
(2) Ms. Susan Hammerman - report of the field testing of the WHO Manual presented at the 1982 Asia-Pacific Regional Conference of Rehabilitation International in Papus New Guinea.
(3) Dr. Sankaran, WHO Consultant reporting on the field trials of CBR presented to the Medical Commission of Rehabilitation International in Geneva, November 1985.

THE FUTURE OF REHABILITATION

EINAR HELANDER
World Health Organization, Geneva, Switzerland

WHO estimates that between 100-120 million people with disabilities need and could benefit from rehabilitation. This estimate is based on surveys, studies and observations of a large number of community-based programmes.

Only some 2-3 million people receive a programme at present. This implies that about 100 million people are without access to services. The gap is enormous and is widening.

There is one single big challenge for all of us who are partners in rehabilitation: to plan for the best way in which we can close this gap.

Rehabilitation services in developing coutries are partly operated by governments, partly by donors, mainly nongovernmental organizations. There is annually transfer of large resources from the industrialized countries to the developed ones, of at least US $200 million. There are more than 4000 projects for people with disabilities paid for by various donors.

These programmes use several different approaches, and should like to mention the main ones:

a) service projects: personnel, equipment etc. are sent to a developing country for a limited time period. All services are provided by expatriates, and they return home without having trained the nationals.

b) development projects: these aim at the transfer of knowledge and skills to a developing country. Nationals are trained by expatriates.

Development programmes may operate on several different levels. There are three main types:

a) institution-based: professional services for people with disabilities are given in a center (boarding or day-care). Such centers are most often only set up to the capital or big cities.

b) outreach service programme: the professional staff delivers services at home to the extent possible.

c) community-based programmes: build on the idea of mobilizing community resources. The person with a disability is trained at home and in the community. A family member acts as the trainer, and a community worker as the local supervisor. Community workers are trained in rehabilitation tasks by an intermediate level supervisor, who in most cases is a professional. This programme needs the support of referral services.

The institution-based and the outreach service programmes require a lot of personnel and are costly to operate. It is unrealistic to assume that these approaches will contribute much to the reduction of the rehabilitation gap.

The community-based approach aims at a massive transfer of knowledge and skills to the person with disabilities, his or her family and the community. Such a transfer of skills and knowledge is a very clear characteristic also of modern rehabilitation programmes in the industrialized countries, where parents and other relatives are trained to become active partners in rehabilitation.

WHO has developed a model for community-based rehabilitation. This model is described in a manual "Training in the Community for People with Disabilities". There may be other models, and we recommend that each country seeks to develop approaches that fit into their society. At present there are community-based programmes in about 60 countries.

The future of rehabilitation lies in understanding that the rehabilitation gap can be closed, if one recognizes the following:

1. Only governments can provide the services which will eventually close the gap. Services set up by non-governmental organizations can only serve to stimmulate governments by providing good examples of how to operate a programme. In order to cover all needs, the governments need to have a complete service delivery structure operating at the community level.

2. The most realistic approach to rehabilitation is the community based one, and its success relies on the willingness of the communities to provide the necessary local resources.

3. The main constraint for "rehabilitation for all" is the lack of adequately trained personnel: community workers and intermediate level professionals. Personnel for planning and management is also a problem.

4. Donor organizations should work much closer with each other and with the governments. There is almost a total lack of coordination of rehabilitation in the developing countries. We are left with the impression that many organizations enter and do what they like without much concern about the realities. There is also a noticeable lack of competence among expatriates, who may be experts in their own home countries, but do not know how to apply their expertize in a foreign country.

5. The rehabilitation gap cannot be closed in any quick or easy way. It is in a number of countries necessary to point out that the realistic time perspective will be about 25 years.

AN URBAN MODEL OF COMMUNITY BASED REHABILITATION IN CHINA

D. ZHUO
Sun Yat-Sen University of Medical Sciences, Guangzhou, P.R. China

INTRODUCTION

According to WHO (World Health Organization), community-based rehabilitation involves measures taken at the community level to use and build on the resources of the community, including the impaired, disabled, and handicapped persons themselves, their families, and their community as a whole.(1981).h1iFor the past 12 years community-based rehabilitation (CBR) has been carried out in more than 25 countries in quite a diversity of format adapted to suit the particular setting and needs of each country, as CBR is very much dependant on the social, economic and cultural status of each country or region. Since 1986 China has embarked on CBR projects in a number of pilot sites, starting from Jin Hua Street, an urban community in Guangzhou City. Preliminary evaluation of the CBR work in Jin Hua Street reveals that a promising model of urban CBR is shaping.

ORGANIZATION NETWORK AND MANPOWER

Jin Hua Street is situated in the west of Guangzhou City with a population of roughly 30,000. The inhabitants live in an area of 0.44 square kilometer with 146 narrow and short lanes spread irregularly like a maze. In spite of the disadvantage of the physical environment the street community has been working hard to improve the sanitary condition of the street and to enhance the quality of life of the residents.
In March 1986, under the sponsorship of the Department of Rehabilitation Medicine, Sun Yat-sen University of Medical Sciences and with the support from this resource center, the administrative authority of Jin Hua Street initiated a pilot project on CBR. A Supervisory Committee organized headed by a street community leader and assisted by a school physician in the local area. Other members of the Committee include representatives of local health workers, civil welfare workers, Red Cross Society activitists and handicapped persons. Three rehabilitation professionals from the University serve either as a consultant or temporary member of the Supervisory Sommittee. This Committee is a decision-and-policy-making group on CBR at the community level. Therefore, the CBR project in Jin Hua Street is run and supervised by the Street administration with active participation by the community people and technical support from the University.
Under the Supervisory Committee, an intermediate level supervisor was selected who was a young physician of a middle school in the Street area. He is familiar with the knowledge and skills for CBR which he has learnt from a National Workshop on CBR held in Guangzhou, 1986. He is a key person in the CBR network, playing the role of manager, organizer and instru ctor for CBR, though he is only a part time worker in this field. Under the intermediate level supervisor there are 33 local supervisors selected from every residential area of the Street by the Supervisory Committee. post of the local supervisors are middle-aged women active in community work. They work with the disabled persons for home-based rehabilitation training. The workload for each local supervisor is on the average,taking care of the disabled persons in her/his residential area, usually one local supervisor for 5-6 disabled who need rehabilitation treatment, 6-8 hours a week for this purpose. In every family which has disabled person a family trainer is picked out to train the family member with disability on a daily basis under the guidance of the local supervisor. Persons with complex disabilities are referred to Distric or municipal or University hospital. The local supervisors work on a volunteer basis without being paid for the CBR service they render to the street community.

HOME-BASED TRAINING AND STREET REHAB MINISTATION

Screening and locating the disabled persons in the street community and conducting home-based traing program for those who need it are two of the main tasks of CBR. The local supervisors were trained in a special course for this purpose by physiatrists and therapists from the University and also by the intermediate level supervisor. A simplified manual was developed as teaching materials and workbook for the local supervisors.
In the initial phase of the CBR project, a house-to -house survey for screening and locating the disabled persons was carried out by the local supervisors, which was then followed by a recheck by health workers and physicians. It was found that out of the 29964 persons in the street There are 344 disabled persons (1.15% of the total population). The figure shows that the prevalence of disability in Jin Hua Street is lower than that of China as a whole,(4.9% of the sampled population ensamble).h2i Four major categories of disability were on the top of the list of disabilities, i.e. neuromuscular disabilities :86 persons (25%), psychiatric disabilities: 75 persons (21.8%), cardiopulmonary disabilities:44 persons (12.8%), hearing-speech disabilities:43 persons (12.5%). Other disabilities which should be mentioned are : blind and low vision 26 persons (7.6%), arthritis:28 persons (8%), mental retardation:19 persons (5.5%). The remaining less significant disabilities constitute 6.8% of the total disabilities.
In the Phase 2 of the CBR project, home-based functional training was carried out for persons with physical disabilities, such as hemiplegia due to stroke, neuromuscular problems due to poliomyelitis, paraplegia due to spinal cord injury, cerebral palsy arthritis and others. The local supervisor usually visits the disabled person's home twice a week to teach motivate and supervise the family trainer to train the disabled persons. Training packages in the shape of leaflets are used in dealing with some common disabilities like hemiplegia, post-polio sequale, arthritis. Monitoring records are made by the local supervisors. The rate of improvement in functioning is 90%. In recent months, home-based training service has extended to persons with mental and psychiatric disabilities. At the same time, education sessions was scheduled for those mentally retardate working in the sheltered workshop. Up to present, the home-based training programs have been implemented for 105 disabled persons.
As a supplement to the home-based training, a community-run rehab ministation was set up in March 1987. The ministation occupies an area of 50 square meters with a modest amount of basic equipments such as exercise bicycle, wall pulleys, hand function training apparatus and materials and tools used for acupuncture, moxibustion and therapeutic massage. The idea behind setting up such a ministation is that in a concentratedly and densely populated community like Jin Hua Street (so is the case in other urban communities in China), it is feasible and beneficial to set up a rehab ministation to facilitate somewhat complex training with apparatus and under more skillful guidance than in home-based training. Disabled persons who areambulatory or use wheelchair to travel around the street or disabled children taken by the parents can visit the ministation and do their training activities there in order to obtain better therapeutic effects. In the last year, 125 disabled persons visited the ministation for rehabilitative treatments and training. The rate of improvement is 93%, according to the statistics made by the local health workers.It must be pointed out that in CBR service the rehab ministation is only an adjunct to the home-based training. In any circumstances, the focus of CBR should be on home-based training.
One of the characteristics of CBR in Jin Hua Street is the extensive use of traditional Chinese methods in the care of the disabled persons. Acupuncture, traditional massage and manipulation, Chinese herbal drugs work in a number of conditions such as paralysis, pain and numbness, rheumatology problems.

COMPREHENSIVE REHABILITATION

Community-based rehabilitation in Jin Hua Street takes a comprehensive approach. In addition to physical, mental and psychological rehabilitation, much attention was paid to vocational and social rehabilitation.One hundred and fifty-two physically disabled persons were given job places in community-run factories integrating with non-disabled workers. Twenty-two mentally handicapped people were accomodated in a sheltered workshop run by the street community doing gainful jobs with satisfaction. To promote social rehabilitation, the street community sponsored and organized sport and recreational activities regularly to enable the disabled get together with the non-disabled. Sport games were organized specially for the handicapped by the community with success. The Jin Hua Street Association for thh handicapped established in 1987 as the self-consciousness of the disabled population is growing along with the progress of CBR.

EVALUATION

A recent evaluation On CBR in Jin Hua Street by means of questionnaire and interview has shown that CBR is making progress and the community has benefited from CBR in many aspects. (1) attitudinal changes: the public and the families now have more concern and sympathy with the disabled population, ready to give assistance; (2) The disabled persons now have a better outlook to the future, more motivated and more confident; (3) motor function and ability of activities of daily living of the disabled have made improvement, the quality of their lives is incceased; (4) CBR makes rehabilitative treatent more accessible, convenient and cost-effective, thus lessening the burden (economical and psychological) of the family.

References
(1) World Health Organization: Disability Prevention and Rehabilitation. 1981, 9, Geneva
(2) State Stastistical Bureau of the People's Republic of China: Press Communique about Principal Data of the National Sampling Survey of Handicapped in China. 1987

Title:
16th World Congress of Rehabilitation International No.4 P.136-P.181

Publisher:
The Organizing Committee of 16th World Congress of Rehabilitation International

Month,Year of Publication:
Jun,1989

To access/retrieve this document:
Japanese Society for Rehabilitation of Persons with Disabilities
1-22-1, Toyama, Shinjuku-ku, Tokyo 162-0052, Japan
Phone:03-5273-0601 Fax:03-5273-1523