During the past year, representatives of the competent services of ILO, UNESCO andWHO met to discuss the concept of community-based rehabilitation (CBR), to exchange information based on experiences in CBR, to agree on a common approach for the promotion of CBR programmes, and to facilitate multisectoral coordination and cooperation in the implementation of CBR programmes.
The Purpose of this position paper is to clarify for policy-makers and programme managers the objective of CBR and the methods for implementing it. The issue of sustainability is also addressed. It is hoped that this position paper will encourage governments and nongovernmental organizations to review what has been accomplished under the heading of CBR or similar concepts, to adopt CBR in disability policies and programmes and to integrate CBR in community development programmes. In particular, the agencies wish to promote increased collaboration among personnel in the health, education, social services and labour sectors; and between rehabilitation personnel and organizations of or for people with disabilities.
OBJECTIVE OF CBR
The major objective of CBR is to ensure that people with disabilities are able to maximise their physical and mental abilities, have access to regular services and opportunities and achieve full social integration within their communities and their societies. This objective uses the broader concept of rehabilitation, that is, one which includes equalization of opportunities and community integration. As a broad concept, CBR is recognized as a comprehensive approach which encompasses disability prevention and rehabilitation in primary health care activities, integration of disabled children in ordinary schools, and provision of opportunities for gainful economic activities for disabled adults.
As a component of social policy, CBR promotes the right of people with disabilities to live within their communities; to enjoy health and well- being; and to fully participate in educational, social, cultural, religious, economic and political activities. CBR requires upon governments to transfer responsibility and necessary resources to communities so that they can provide the base for rehabilitation.
CBR is appropriate for both industrialized and developing countries. The broad methods used to implement it are applicable in either setting. However, the detailed methods of implementing CBR, and the resources available for it, will certainly vary among countries.
The definition below presents the essential elements of community-based rehabilitation.
Community-based rehabilitation 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.
METHODS FOR IMPLEMENTING CBR
CBR should be seen first and foremost as a programme which belongs to the community, as represented by the local government or authority. It should be considered an element of the social, educational and health policy at all levels, but particularly at the most decentralized level of the public sector. In national policy, CBR is part of a country’s action in favour of people of all ages who have any type of disability. In provincial and district level policy, it is supported with referral services and by transfer of knowledge to communities. At community level, the policy of integration is implemented under the control of the community, which ”owns” the CBR programme and which gives a major role to people with disabilities and their families.
Hence, the broad methods for developing CBR include the formulation and implementation of policies to support CBR; the encouragement and support of communities to assume responsibility for the rehabilitation of their members who have disabilities; the strengthening of rehabilitation referral services for health, education and labour at district, provincial and national levels; and the establishment of a system for programme management and evaluation. The participation of disabled people in all of these activities is essential.
The formulation of a national policy to support CBR may come from an external stimulus, such as the recommendations of the World Programme of Action Concerning Disabled Persons, prepared during the United Nations Decade of Disabled Persons. It may also come from pressures within the country, which can be initiated by organizations of people with disabilities, by representatives of the sectors concerned with rehabilitation, or by a combination of the two. When a CBR policy is established at national level, it should be reflected in policy and programme priorities within all sectors and at all other levels.
Community action for CBR is often initiated by a stimulus from outside the community, most likely from the ministry, committee or organization responsible for the programme. Following initial discussions with the representatives from outside the community, it is the community that decides whether CBR will become part of its ongoing community development activities.Various partners in the community, such as the community development committee, organizations of disabled people, and other nongovernmental organizations should be empowered to take responsibility for the programme. Once the
community chooses to initiate a CBR programme, the CBR programme management should provide the necessary support and referral services, sufficient awareness, preparation and mobilisation. It is important to underline the necessity of thorough preparation at all levels.
CBR may provide the means for all disabled people in a community to be socially integrated, or it may be more limited in its achievements. This depends on the commitment of the community, its resources, and the support services that it receives from both government and nongovernmental organizations. A municipal government in an industrialized nation has different resources than the local government of a rural town has in a developing country, although both may be committed to assisting their members with disabilities. Both will also be dependent – albeit to a varying degree – on some support from other levels. This consists of support to community members to enable them to actively participate in the CBR programme, as well as support directly to disabled people for treatment, education or equipment which they cannot obtain at the community level.
Support to community members
CBR programmes require initial support from the CBR management for the transfer of knowledge and skills which community members need in order to carry out rehabilitation activities, and ongoing support in the form of training and accessible referral services. The teacher who has a blind child in the class; the primary health care worker who is expected to help a child with paralysed legs to walk; the mechanic who wonders whether the young man who cannot hear can be trained in mechanics;the traditional healer who cannot treat the strange behaviour of a child; the mayor who wants to plan an accessible community hall – all of these members of the community require knowledge about disabilities and guidance on how to assist disabled people.
To meet the CBR objective, communities must strengthen their abilities to assist people with disabilities and their families. It is the primary responsibility of the CBR programme management and rehabilitation personnel to ensure that the community and the families receive the necessary information concerning the various aspects of disabilities. This transfer of information must include the knowledge and skills necessary to assist disabled people to develop their abilities. The information must be simple and practical, yet comprehensive.
It should include relevant facts about issues concerning living with a disability, such as child development, activities of daily living, schooling, vocational training and work, as well as guidance on how to identify and use resources within and outside the community. Such information should be factual; should stimulate positive reactions; should create awareness and motivation to change habits, prejudices and attitudes; and should appeal to positive cultural and ethical values.
Preparation and dissemination of information materials requires a multi-disciplinary effort from the relevant government departments, agencies and organizations, particularly organizations of disabled people. Joint production of the materials enhances their credibility and effectiveness.
Referral services for people with disabilities
The community is able to handle a large part of the rehabilitation process, but there are situations where the community cannot be expected to have the expertise to perform certain tasks. For example, a CBR worker cannot correct a deformed leg, nor decide when a child who has had surgery to correct a deformity can begin walking. A referral service is needed for the surgery, and is also needed for follow-up advice to the child and the family, and to the CBR worker. Some children and adults with disabilities may have special needs in education or skills training that cannot be addressed at the community level. These individuals may require skilled assessments and interventions from specialists outside the community It is important for the credibility of a CBR programme that the disabled people within the community have accessto specialized services and facilities. The linkage to referral centres, and the referral back and forth between the community and those centres, may be as important to CBR as the community-based activities.
The referral services provided by the social, health, education and labour sectors should work in close collaboration to support the community and to make appropriate choices among the specialized services. It is not sufficient for each one to have a good system of communication with the community; the various sectors must also establish close collaboration among themselves.
SUSTAINABLE CBR PROGRAMMES
A CBR programme will be sustained when three factors come together: the articulation of a need, a response from within the community indicating readiness to meet this need, and the availability of support from outside the community. If one of these factors is missing, CBR will fail. One cannot expect community involvement without a perceived need, and there should be no support to the community unless it is willing to meet that need.
Articulation of a need
A good management will always seek out what is needed by people with disabilities, their families and communities. The CBR programme management will allow each community to determine its priorities with regard to the rehabilitation and social integration of people with disabilities. Disabled people and their families must participate in the process of identifying the priorities for a CBR programme. If the programme does not address needs identified by those most concerned with disabilities, it cannot be effective. However, those from outside the community may also point out measures which can be taken concerning the rights of people with disabilities, which may not have been identified within the community, but which can be addressed realistically.
In order to ensure that the community responds to the needs it perceives, CBR activities must be discussed with community leaders, who will eventually decide on the activities which they will undertake. This should be done in consultation with disabled people, their families and their organizations. Arguments based on purely technical considerations are not likely to impress a community. The approach which is most likely to succeed is a joint search for the best answer within existing constraints, recognising that the final say is with the community and its leadership. A community- based rehabilitation programme which is not viewed by the community as its own scheme is a contradiction in terms.
Availability of support
If there is a government policy which promotes community efforts in favour of people with disabilities, this may contribute to the community’s willingness to participate in CBR. The community will easily know whether community action is being promoted at higher levels because sincere government promotion will be reflected in various types of support to communities.
The absence of one of the three factors will undoubtedly result in a programme that is not sustained. However, even given those three factors, there may be other issues which can weaken a CBR programme, or prevent its implementation.
An isolated CBR project, which is not related to some government policy or programme, has little chance of being sustained. Sometimes an organization, in its zeal to promote CBR, provides a great deal of external support to a CBR project which is not linked to government policies or priorities. There may be a perceived need, and the community may be enthused because of the initial external support. Gradually, as that support decreases the CBR project will wither and die.
Another weakness of a CBR programme may stem from the lack of a community worker. One aspect of support to communities is the training of selected community members who will work with individuals with disabilities and their families. The CBR worker may be a community member participating in another programme, who takes on the additional responsibility for rehabilitation activities. Sometimes, it is a community volunteer who works only for CBR. In such a situation, the community must make the selection and provide that person with some incentive, which will vary according to the custom of the country and the community Maintaining the commitment and motivation of the CBR worker is one of the major challenges for community leaders and CBR programme managers.
This position paper is intended to clarify the CBR concept, its objective and methods. It is hoped that this will lead to more awareness of what can be accomplished through CBR programmes, and will thus stimulate governments and nongovernmental organizations to adopt this approach for rehabilitation, equalization of opportunities and social integration of all people with disabilities.
International governmental and nongovernmental organizations interested in supporting CBR programmes are urged to join forces and help to create a more conductive environment for formulating national policies. They should seek to coordinate their activities and inputs in the interest of making CBR an effective and sustainable programme at national and community levels, for the benefit of people with disabilites, their families and their communities.
Governments are invited to adopt the CBR strategy as policy, to provide support for a nationwide CBR programme, and to create the conditions for interministerial and interdisciplinary cooperation and coordination in advancing community development and CBR.
People with disabilities and their organizations should play an active part in setting priorities for CBR and in obtaining the national and community commitment to address them. Disabled people should also participate in planning monitoring and evaluating all CBR programmes.
INTERAGENCY COLLABORATION FOR CBR
During the past few years the three U.N. specialized agencies with programmes for people with disabilities, i.e., the International Labour Organization (ILO), the United Nations Educational, Scientific and Cultural Organization (UNESCO) and the World Health Organization (WHO) have intensified their efforts to share experiences and to collaborate in the development of CBR programmes.
This collaboration has included other U.N. agencies, particularly the United Nations Development Programme’s Interregional Programme for Disabled People, as well as international nongovernmental organizations.
The active participation of the agencies at country level varies from country to country. Some countries request the assistance of only one agency, while others may seek the assistance of two or more agencies depending on the national situation and the need to strengthen health, education or vocational components of a rehabilitation programme. While all of the specialized agencies will promote an intersectoral approach at the community level each will provide technical advice for the referral services which is relevant to its mandate and expertise.
ILO, UNESCO & WHO