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The logo of Asian and Pacific Decade of Disabled Persons.

ECONOMIC AND SOCIAL COMMISSION
FOR ASIA AND THE PACIFIC

UNDERSTANDING COMMUNITY-BASED REHABILITATION(*)

The United Nations logo.

UNITED NATIONS
New York, 1998

ST/ESCAP/1761

Appreciation is expressed to Council of Disabled People of Thailand and DPI Asia Pacific Regional Council printing this publication


Table of Contents

I. Introduction

II. The Multi-sectoral Approach

III. Programme Criteria

IV. The Components of Community-based Rehabilitation Programmes

V. Sectors and Roles for the Development and Implementation of Community-based Rehabilitation

VI. Summary


INTRODUCTION



This publication focuses on understanding community-based rehabilitation (CBR). It does not try to define CBR, as it has become apparent in recent years that CBR defies definition. This is because its simplicity and complexity have led to confusion about what CBR means. The simplicity of CBR has to do with its history of starting with the delivery of primary rehabilitation therapy to people with disabilities in their communities(1). The complexity of CBR is the result of the current concept that CBR programmes should be multi-sectoral (or multi-disciplinary) so that they can provide assistance in all of the areas which are central to improvement of the quality of life of people with disabilities. This complexity recognizes the need for close coordination, collaboration and cooperation between governmental and non-governmental organizations of all types and at all levels.

The basic concept inherent in the multi-sectoral approach to CBR is the decentralization of responsibility and resources, both human and financial, to community-level organizations. In this approach, governmental and non-governmental institutional and outreach rehabilitation services must support community initiatives and organizations.

For the multi-sectoral approach to CBR to be successfully translated into action, both governmental and non-governmental service capacities need to be improved in most countries of the Asian and Pacific region. Of special importance is improvement of the capacity and skills for facilitating community involvement. Such improvement and related activities must be closely coordinated to ensure the optimum use of scarce resources. In accordance with the multi-sectoral concept, systems are developed, at the community level and among governmental and non-governmental organizations, that interact and reach out to each other.

Another factor for the success of the multi-sectoral approach is the empowerment of the community to assume responsibility for ensuring that all its members, including those with disabilities, achieve equal access to all of the resources that are available to that community, and that they are enabled to participate fully in the social, economic and political life of the community. This approach ensures that what is done in the name of CBR actually fits into the reality of the community and is owned by the community.


THE MULTI-SECTORAL APPROACH



The starting point for understanding CBR is the following approach agreed to in 1994 by ILO, UNESCO and WHO(2):

Community-based rehabilitation (CBR) is a strategy within community development for the rehabilitation, equalization of opportunities and social integration of all people with disabilities. CBR is implemented through the combined efforts of disabled people themselves, their families and communities, and the appropriate health, education, vocational and social services.

This approach to CBR is multi-sectoral and includes all governmental and non-governmental services that provide assistance to communities. Many of the services which can provide opportunities for and assistance to people with disabilities are not traditionally considered relevant to CBR programmes and people with disabilities. Examples include community development organizations, agricultural extension services, and water and sanitation programmes.

In the ILO-UNESCO-WHO approach to CBR, the phrase "within community development" is understood to be the following strategy recommended by the United Nations(3):

... the utilization, [in an integrated programme](4), of approaches and techniques which rely on local communities as units of action and which attempt to combine outside assistance with organized local self-determination and effort, and which correspondingly seek to stimulate local initiative and leadership as the primary instrument of change.

In the CBR context, community means: (a) a group of people with common interests who interact with each other on a regular basis; and/or (b) a geographical, social or government administrative unit.


PROGRAMME CRITERIA

The development and implementation of CBR programmes should be based on the following criteria:

  1. People with disabilities must be included in CBR programmes at all stages and levels, including initial programme design and implementation. In order to give significance to their involvement, they must have distinct decision-making roles.

  2. The primary objective of CBR programme activities is the improvement of the quality of life of people with disabilities.

  3. One focus of CBR programme activities is working with the community to create positive attitudes towards people with disabilities and to motivate community members to support and participate in CBR activities.

  4. The other focus of CBR programmes is providing assistance for people with all types of disabilities (physical, sensory, psychological and mental); for people of all ages, including older people; for people affected by leprosy; for people affected by epilepsy; and for other people who may be identified by the community as needing special assistance.

  5. All activities in CBR programmes must be sensitive to the situation of girls and women. This is because in many communities throughout the Asian and Pacific region women are not treated equally. When they are disabled, the problems that they face in life are doubled. Furthermore, women are usually the primary family care-givers for all people with disabilities.

  6. CBR programmes must be flexible so that they can operate at the local level and within the context of local conditions. There should not be only one model of CBR because different social and economic contexts and different needs of individual communities will require different solutions. Flexible, local programmes will ensure community involvement and result in a variety of programme models which are appropriate for different places.

  7. CBR programmes must coordinate service delivery at the local level. Community members seldom understand the different roles and specializations that are part of providing assistance to people with disabilities. They tend only to see the problem of disability and only to want access to "one window" for help. They may focus only on where to go and who to see about a specific "problem", rather than understanding the totality of what constitutes a fulfilling life for a community member who has a disability.


THE COMPONENTS OF COMMUNITY-BASED REHABILITATION PROGRAMMES


The components of a CBR programme should include:

  1. Creating a positive attitude towards people with disabilities: this component of CBR programmes is essential to ensure equalization of opportunities for people with disabilities within their own community. Positive attitudes among community members can be created by involving them in the process of programme design and implementation, and by transferring knowledge about disability issues to community members.

  2. Provision of functional rehabilitation services: often people with disabilities require assistance to overcome or minimize the effects of their functional limitations (disabilities). In communities where professional services are not accessible or available, CBR workers should be trained to provide primary rehabilitation therapy in the following areas of rehabilitation:
    • Medical
    • Eye care service
    • Hearing services
    • Physiotherapy
    • Occupational therapy
    • Orientation and mobility training
    • Speech therapy
    • Psychological counselling
    • Orthotics and prosthetics
    • Other devices

  3. Provision of education and training opportunities: people with disabilities must have equal access to educational opportunities and to training that will enable them to make the best use of the opportunities that occur in their lives. In communities where professional services are not accessible or available, CBR workers should be trained to provide basic levels of service in the following areas:
    • Early childhood intervention and referral, especially to medical rehabilitation services
    • Education in regular schools
    • Non-formal education where regular schooling is not available
    • Special education in regular or special schools
    • Sign language training
    • Braille training
    • Training in daily living skills

  4. Creation of micro and macro income-generation opportunities: people with disabilities need access to micro and macro income-generation activities, including obtaining financial credit through existing systems, wherever possible. In slums and rural areas, income-generation activities should focus on locally appropriate vocational skills. Training in these skills is best conducted by community members who, with minimal assistance, can easily transfer their skills and knowledge to people with disabilities.

  5. Provision of care facilities: often, people with extensive disabilities are in need of assistance. When they have no families or their families are incapable of caring for them, in order for them to survive, long-term care facilities must be provided in the community where they can get the assistance that they need. Moreover, day-care facilities may be needed to provide respite for families who either work or need time off for other activities.

  6. Prevention of the causes of disabilities: many types of disability can be prevented by relatively simple measures. Proper nutrition is one of the more significant ways of preventing disabilities. Another important area of disability prevention is the detection of disability in young children and intervention early in their development, to minimize the effect of impairment. There are many other areas of disability prevention that are also important. These include activities to decrease the number of accidents in the home, on the road and at work, as well as other initiatives to encourage people to pursue healthy lifestyles over the course of their lives.

  7. Management, monitoring and evaluation: the effectiveness and efficiency of all CBR programme components, both in the community and in the area of service delivery outside the community, depend on effective management practices. The impact of programme activities must be measured on a regular basis. People must be trained in effective management practices. Data must be collected, reviewed and evaluated to ensure that programme objectives are met. In this way, the success or failure of a CBR programme can be honestly measured.

SECTORS AND ROLES FOR THE DEVELOPMENT AND IMPLEMENTATION OF COMMUNITY-BASED REHABILITATION

The initiative to start CBR programmes and to facilitate their development may come from any one of the following groups. However, the effectiveness of CBR and the long-term development and sustainability of any CBR initiative will require the coordination, involvement and collaboration of all seven groups. The seven groups and their suggested roles are as follows:

  1. People with disabilities: People with disabilities can and should contribute to all levels of CBR programmes in every position within a programme. They know what the effects of local conditions are on themselves. They are likely to have a good understanding of those effects on their peers with disabilities. They also know what impairment really means in the context of their family, community and nation. This knowledge enables them to be very effective members of a CBR team. They can be more effective than non-disabled people as role models for and counsellors of other people with disabilities. People with disabilities have an important role in community education. As community educators, they serve as living examples of people with disabilities who make a significant contribution, provided that they are given the opportunity and the right type of assistance. CBR programmes should also facilitate the development of self-help organizations of people with disabilities at the community level.

  2. Families of people with disabilities: families have the primary responsibility for caring for all of their members. They are the first line of support and assistance for people with disabilities at the local level. As such, families must be included in CBR programme activities. Where the individual with a disability is not able, for whatever reason, to speak for himself or herself, a family member should represent him or her and should be considered a legitimate member of disabled people's organizations. Members of families with experience in caring for people with disabilities are the people who most often initiate CBR programmes and are, or prove to be, the most effective contributors at all levels.

  3. Communities: community members should be involved in CBR programmes at all levels because they already know the local environmental conditions, the local economy, the local political situation and how to work with them. They also know about the accessibility, availability and effectiveness of locally available rehabilitation services; who in the community cares enough about other people to become a programme leader or worker; and, which community members have the knowledge and skills for training others in micro-economic activities. They are the people most likely to want to live, work and stay in the community. Community involvement usually requires the agreement and approval, both formal and informal, of the community leaders.

  4. Governments (local, regional, national): governments have the most important role in the development and sustainability of CBR programmes. Their cooperation, support and involvement are essential if CBR is to cover the total population and be sustainable. They should implement and coordinate the development of the entire programme structure, including the development of the referral system, as well as the activities within the community. They also should provide resources for non-governmental organizations (NGOs) and community activities. Finally, they should ensure that discriminatory legislation is changed and that the rights of people with disabilities are guaranteed and protected.

  5. Non-governmental organizations, local, regional, national and international organizations: NGOs, including organizations of people with disabilities, are often able to provide resources and skills to facilitate the development of new programmes, especially in areas where none exist. They can develop new approaches to CBR and provide training programmes for government employees, CBR workers, people with disabilities, families, and community members. NGOs are effective in facilitating the development of community members as CBR programme leaders. They are often best able to provide long-term care facilities for those people with extensive disabilities whose families cannot or will not look after them.

  6. Medical professionals, allied health science professionals, educators, social scientists and other professionals: professionals are often in a position where they can, as trainers and educators, facilitate the development of new programmes by making their knowledge and skills accessible to community members and CBR programme workers. They can also ensure that they support community efforts by making themselves available and accessible on a referral basis. When they are in government service, they can advocate and promote the development of CBR programmes as an effective way to provide local-level services quickly.

  7. The private sector (business and industry): the private sector has a social obligation to return some of the benefits of its operations to the communities that support it. In the past, this support has largely taken the form of charity. Charity occurs when donors "give" whatever they feel is needed or appropriate to people with disabilities. This approach to assisting people with disabilities is no longer appropriate and needs to be changed. Supporting CBR programme activities eliminates the need for charity. CBR support is a much more appropriate way of directing resources to communities and people with disabilities. By supporting CBR programmes, the private sector receives credit for its social involvement while being guaranteed that its support is put to effective and efficient use. Who but trained, knowledgeable community members would know what is most needed by the people of their own community?

SUMMARY



In recent years a multi-sectoral (or multi-disciplinary) concept of CBR has evolved. That concept emphasizes working with and through the community to create positive attitudes towards people with disabilities, to provide assistance to people with disabilities and to make the necessary changes to the environment and service delivery systems.

In response to this conceptual change, CBR is now defined as a community development programme that has seven different components:

(i) Creation of a positive attitude towards people with disabilities;
(ii) Provision of rehabilitation services;
(iii) Provision of education and training opportunities;
(iv) Creation of micro and macro income-generation opportunities;
(v) Provision of care facilities;
(vi) Prevention of the causes of disabilities;
(vii) Monitoring and evaluation.

The resources, skills and initiatives to start and sustain CBR programmes require the cooperation and collaboration of seven relevant sectors:

(i) People with disabilities
(ii) Families of people with disabilities;
(iii) Communities;
(iv) Governments (local, regional, national, international);
(v) NGOs, local, regional, national and international organizations, and organizations of people with disabilities;
(vi) Medical professionals, allied health science professionals, educators, social scientists and other professionals;
(vii) The private sector (business and industry).

foot notes

* Prepared by the Working Group on CBR of the Regional Inter-agency Committee for Asia and the Pacific (RICAP) Subcommittee on Disability-related Concerns. ESCAP serves as the secretariat of the Subcommittee. All members of the Subcommittee contributed to the preparation of the document. The Subcommittee, at its fourteenth session in May 1997, finalized and adopted the document to mark the mid-point (1997) of the Asian and Pacific Decade of Disabled Persons, 1993-2002.

1. The Alma Ata Declaration of Health for All and its emphasis on primary health care included services for people with disabilities. It is this concept that led to the development of the first models of CBR which emphasized delivery of primary rehabilitation therapy in the community.

2.Community-Based Rehabilitation for and with People with Disabilities, 1994 Joint Position Paper, International Labour Organization (ILO), United Nations Educational, Scientific and Cultural Organization (UNESCO) and World Health Organization (WHO).

3. See document E/CN 5/291.

4. The original definition has been changed from "under one programme" to "in an integrated programme".


Economics and Social Commission for Asia and the Pacific
Understanding community-based rehabilitation

UNITED NATIONS
New York, 1998

ST/ESCAP/1761