cbr sangli seminar

Community Community Based Based

Rehabilitation:Rehabilitation:New New

perspectivesperspectives

Outline Outline

Origin & developmentOrigin & development What is CBR What is CBR Models of CBRModels of CBR New WHO CBR Guide linesNew WHO CBR Guide lines

CommunityCommunity ““A community consists of people living A community consists of people living

together in some form of social together in some form of social organization and cohesion. Its members organization and cohesion. Its members share in varying degrees, political, share in varying degrees, political, economic, social and cultural economic, social and cultural characteristics, as well as interests and characteristics, as well as interests and aspirations, including health. Communities aspirations, including health. Communities vary widely in size and socio-economic vary widely in size and socio-economic profile, ranging from clusters of isolated profile, ranging from clusters of isolated homesteads to more organized villages, homesteads to more organized villages, towns and city districts”.towns and city districts”. (Helander (1993 (Helander (1993))

CommunityCommunity

Currently, the term “community” has Currently, the term “community” has two general meanings.two general meanings.

The first refers to ‘actual groupings The first refers to ‘actual groupings of people’ or ‘of people’ or ‘geographical groupsgeographical groups’. ’.

The second refers to ‘social ideals ofThe second refers to ‘social ideals of

solidarity, sharing and consensus’ or solidarity, sharing and consensus’ or ‘‘affinity groups’affinity groups’..

RehabilitationRehabilitation Rehabilitation is a dynamic Rehabilitation is a dynamic

multidisciplinary process, that, in multidisciplinary process, that, in partnership with a client, often combines partnership with a client, often combines interventions of medical, social, interventions of medical, social, educational and vocational disciplines to educational and vocational disciplines to maintain, or obtain and secure, for a maintain, or obtain and secure, for a person who is experiencing certain person who is experiencing certain problems related to a health condition or problems related to a health condition or disorder, a respected and satisfying disorder, a respected and satisfying place in society. place in society. (JW Brandsma, 2004)(JW Brandsma, 2004)

Historical DevelopmentHistorical DevelopmentRehabilitation servicesRehabilitation services

Traditional

Institutions

Community-based reh.

Resource centers

Information-based

1950 1980 1990 2000

Charity approach- Charity approach- Institutions to take care of the Institutions to take care of the

disabled disabled Medical Model onlyMedical Model only Urban centeredUrban centered Expensive Expensive Not empowering Not empowering SegregationSegregation Reaching out to very fewReaching out to very few

Why Community Based Why Community Based Rehabilitation?Rehabilitation?

Institutions are Institutions are expensive expensive (Helander, WHO, 1976)(Helander, WHO, 1976)

Institutions require high tech Institutions require high tech personnel personnel (Helander, WHO, 1976)(Helander, WHO, 1976)

Institutions are reaching only Institutions are reaching only 2% of disabled population in 2% of disabled population in developing countries developing countries (Helander, WHO, 1976)(Helander, WHO, 1976)

Institutions segregate/isolate instead of integrateInstitutions segregate/isolate instead of integrate

IBR versus CBR debate:IBR versus CBR debate:• Rehabilitation can be done in most cases Rehabilitation can be done in most cases

without specific expensive equipmentwithout specific expensive equipment

• IBR does use a medical model IBR does use a medical model

• While costs of IBR are high, specialised While costs of IBR are high, specialised services may be more effective and efficientservices may be more effective and efficient

• Community services can also be specialisedCommunity services can also be specialised

• Complementary models and servicesComplementary models and services

• Risks: CBR as second rate, under-funded Risks: CBR as second rate, under-funded servicesservices

Following the Alma Ata Declaration1 (1978) Following the Alma Ata Declaration1 (1978) "Health for all" and considering the "Health for all" and considering the limitation of specialized medical limitation of specialized medical rehabilitation services, the World Health rehabilitation services, the World Health Organization introduced the concept Organization introduced the concept Community Based Rehabilitation (CBR). Community Based Rehabilitation (CBR). CBR was designed to enhance the quality CBR was designed to enhance the quality of life for people with disabilities through of life for people with disabilities through community initiatives. It was also community initiatives. It was also introduced to ensure that rehabilitation introduced to ensure that rehabilitation services reached those in developing services reached those in developing countries where the majority of disabled countries where the majority of disabled people live. The focus was on training a people live. The focus was on training a person with disability to carry out daily person with disability to carry out daily activities such as going to school, playing activities such as going to school, playing with others, joining in family and with others, joining in family and community activities and making a living, community activities and making a living, mainly by using local resources. mainly by using local resources.

Community Based RehabilitationCommunity Based Rehabilitation

Delivering rehabilitation withDelivering rehabilitation with limited limited and and local available resourceslocal available resources to as to as many peoplemany people as possible is at the as possible is at the core of CBRcore of CBR

The original concept of CBR was an The original concept of CBR was an extension of PHC system, which expanded extension of PHC system, which expanded services to reach underprivileged people services to reach underprivileged people who had no access to services till then. who had no access to services till then. This was to be done through the use of This was to be done through the use of manual based training of community manual based training of community volunteers and family members The key volunteers and family members The key element was the transfer of minimum and element was the transfer of minimum and essential rehabilitation intervention skills essential rehabilitation intervention skills to families and other volunteers in the to families and other volunteers in the community. In the early eighties, CBR was community. In the early eighties, CBR was conceptualized and evolved primarily as a conceptualized and evolved primarily as a service delivery method with a medical service delivery method with a medical focus, following the WHO recommendation focus, following the WHO recommendation that CBR be integrated into the PHC that CBR be integrated into the PHC system, which was already well system, which was already well established in many developing countries established in many developing countries

The International Classification of Impairments, Disabilities and Handicaps (ICIDH) published in 1980 by WHO also contributed to a medical approach.

ICIDH defines a model that progresses from disease, impairment and disability to handicap in a linear fashion.

disease impairment disability handicap

ImpairmentImpairment is defined as abnormality of is defined as abnormality of structure or function of the body or an structure or function of the body or an organ.organ.

Disability Disability is defined as a restriction or is defined as a restriction or lack of ability as a result of impairment.lack of ability as a result of impairment.

HandicapHandicap is defined as a social is defined as a social disadvantage faced by an individual disadvantage faced by an individual resulting from either impairment or resulting from either impairment or disability. disability.

With these influences, early CBR programmes tended to have an ‘impairment’ bias, focusing on prevention of impairments and restoring functional ability in disabled individuals in order to ‘fit’ them into their community.

The Medical Model of DisabilityThe Medical Model of Disability

Disability is individualised. It is regarded as a Disability is individualised. It is regarded as a disease state that is located disease state that is located within an within an individual.individual. Thus, the problem and Thus, the problem and solutionsolution may may both be found both be found within that individualwithin that individual

Disability Disability is a disease state, a deviation from is a disease state, a deviation from the norm, which inherently necessitates some the norm, which inherently necessitates some form of form of treatment or curetreatment or cure

Being Being disableddisabled, a person is regarded inherently , a person is regarded inherently as biologically or psychologically as biologically or psychologically inferior inferior to an to an able bodied personable bodied person

Disability is viewed as a personal Disability is viewed as a personal tragedytragedy. It . It assumes the presence of a assumes the presence of a victimvictim

Community Based RehabilitationCommunity Based Rehabilitation Developments in eighties in the WestDevelopments in eighties in the West

• MainstreamingMainstreaming

• Attention for the social modelAttention for the social model

• Decade for Disabled People Decade for Disabled People (1980-1990) with International (1980-1990) with International

Year of the Disabled in 1981Year of the Disabled in 1981

• Rise of Disabled Peoples Rise of Disabled Peoples Organisations and focus on Organisations and focus on rights issuesrights issues

1981 launch of DPI in Winnipeg1981 launch of DPI in Winnipeg National and regional DPOsNational and regional DPOs

Social Model of DisabilitySocial Model of Disability Human rights principlesHuman rights principles are at the core of are at the core of

the social modelthe social model A person’s impairment is not the cause of A person’s impairment is not the cause of

restriction of activityrestriction of activity The cause of restriction is the organisation The cause of restriction is the organisation

of societyof society Society discriminates against disabled Society discriminates against disabled

peoplepeople Attitudinal, sensory, architectural, and Attitudinal, sensory, architectural, and

economic barriers are equally, if not more, economic barriers are equally, if not more, important than health barriersimportant than health barriers

Less emphasis is placed on the involvement Less emphasis is placed on the involvement of health professionals in the life of a person of health professionals in the life of a person with disabilitywith disability

The social model focuses on the The social model focuses on the strengths of the person (and not on her strengths of the person (and not on her limitations as in the medical model) limitations as in the medical model) and and valuesvalues her her potentialpotential. This model . This model frames disability as part of human frames disability as part of human diversity. Fear, ignorance and prejudice diversity. Fear, ignorance and prejudice create barriers and cause create barriers and cause discrimination which increases discrimination which increases disability.disability. The issue becomes an The issue becomes an attitudinal one requiring individuals to attitudinal one requiring individuals to changechange their their perceptionsperceptions in order to in order to ensure full participation of people with ensure full participation of people with disabilities in society.disabilities in society.

The ICF(The ICF( the the International Classification of International Classification of

Functioning, Disability and HealthFunctioning, Disability and Health). ). illustrates a clear shift from the 1980 illustrates a clear shift from the 1980 version of ICIDH which describe version of ICIDH which describe disability, impairment and handicap disability, impairment and handicap in terms of diminishment to a model in terms of diminishment to a model which describes body structure, which describes body structure, functioning, activities and functioning, activities and participation in a positive way. participation in a positive way.

Health condition Health condition

(Disorder or disease)(Disorder or disease)

Body functions and structures

(Impairment)

Activities (Restrictions)

Participation (Limitations)

Environmental Factors

Personal factors

Health condition, personal factors Health condition, personal factors and environmental factors are all and environmental factors are all considered as influences on body considered as influences on body functioning, performance of activities functioning, performance of activities and participation in social life. and participation in social life.

What is CBR?What is CBR?

CBR is what the people say it is…CBR is what the people say it is…

(in Wolffers and Finkenflugel, 1993)(in Wolffers and Finkenflugel, 1993)

CBR is a philosophy with diverse CBR is a philosophy with diverse applications that reflect the variety applications that reflect the variety of cultures and levels of development of cultures and levels of development (Peat, 1997)(Peat, 1997)

Definitions of CBRDefinitions of CBR

CBR involves measures taken at the CBR involves measures taken at the community level to use and build on community level to use and build on the resources of the community, the resources of the community, including the impaired, disabled and including the impaired, disabled and handicapped persons themselves, handicapped persons themselves, their families and their community as their families and their community as a whole a whole (WHO, 1984)(WHO, 1984)


CBR is more than a method; it is a CBR is more than a method; it is a philosophy aimed at working in the philosophy aimed at working in the struggle for human rights and more struggle for human rights and more specifically the rights of disabled specifically the rights of disabled people people (Alexandra township South (Alexandra township South Africa, 1991)Africa, 1991)


CBR is a strategy within community CBR is a strategy within community development for the rehabilitation, development for the rehabilitation, equalisation of opportunities and social equalisation of opportunities and social integration of people with disabilities integration of people with disabilities (UN, (UN, 1994)1994)

It is achieved through the combined It is achieved through the combined efforts of people with disabilities, their efforts of people with disabilities, their families, and communities and the families, and communities and the appropriate health, education, vocational appropriate health, education, vocational and social servicesand social services

Term CBR, UsagesTerm CBR, Usages

1.1.Home based services provided by families to Home based services provided by families to their disabled members in their homes.their disabled members in their homes.

2. 2. Self help projects run by disabled persons.Self help projects run by disabled persons. 3. 3. Out-reach projects run by rehabilitation Out-reach projects run by rehabilitation

institutions.institutions. 4. 4. NGO projects run by paid CBR workers.NGO projects run by paid CBR workers. 5. 5. An ideology, which promotes inclusion of An ideology, which promotes inclusion of

disabled persons in developmental projects.disabled persons in developmental projects. 6. 6. Institutional programmes located in villages.Institutional programmes located in villages. 7. 7. A term to describe anything related to A term to describe anything related to

rehabilitation of disabled persons.rehabilitation of disabled persons.

Classification of Classification of Rehabilitation ProjectsRehabilitation Projects

4 dimensions / objectives4 dimensions / objectives• Restoration of quality of liveRestoration of quality of live• Locus of PowerLocus of Power• Commitment to involve othersCommitment to involve others• Range of ActivitiesRange of Activities

Individual model Social model

Classification of Rehabilitation ProjectsClassification of Rehabilitation Projects

Individual SocialIndividual Social

Restoring physical

functioning

Social & Economic

rehab.

Equalityof

rights

PPhysical

PWWell-being

WAAdvocacy

A

Restorationof qualityof life



Clients asreceivers

Clientsmakelimitedchoices

Clientshave full

ownership

Coompliance

OLLim. choice

LEEmpowerment

E

Locus ofpower



Focus onlyon people

withdisabilities

Involvingfamilies

Communityparticipation

BBeneficiary

BFFamily

FCCommunity

C

Involvementof others



Range of Range of activitiesactivities

Single resource /

service

Multipleservices

Multisectoral collaborationInformation

sharing

SSingle

SVVariety

VRReferral

R



Restoration Restoration of quality of of quality of lifelife

PP WW AA

Locus of Locus of powerpower OO LL EEInvolvement Involvement of othersof others BB FF CCRange of Range of activitiesactivities SS VV RR

What CBR isWhat CBR is FlexibleFlexible Active involvement of families and Active involvement of families and

communitiescommunities A partnership approach with disabled people A partnership approach with disabled people

and parents of disabled childrenand parents of disabled children Capacity building of disabled people and their Capacity building of disabled people and their

families, in the context of their community and families, in the context of their community and cultureculture

Holistic in its approach to disabled people; Holistic in its approach to disabled people; addressing social, employment, educational, addressing social, employment, educational, and other needs not just physical ,multi-sectoraland other needs not just physical ,multi-sectoral

An approach which uses centres/ institutions to An approach which uses centres/ institutions to respond to the needs of disabled people and respond to the needs of disabled people and their familiestheir families

A system which is based in the community, but A system which is based in the community, but which uses district level and national level which uses district level and national level services for referralservices for referral

An approach which aims to enable around 80% An approach which aims to enable around 80% of disabled people’s rehabilitation needs to be of disabled people’s rehabilitation needs to be addressed in the communityaddressed in the community

Integrated into existing services and promoting Integrated into existing services and promoting the social inclusion of disabled peoplethe social inclusion of disabled people

An approach with a broad concept of An approach with a broad concept of rehabilitation’rehabilitation’

A long term strategyA long term strategy

What CBR is notWhat CBR is not Rigid or a blue-printRigid or a blue-print An approach which only focuses on the An approach which only focuses on the

physical or medical needs of a personphysical or medical needs of a person Long-term residential careLong-term residential care Delivering a service to disabled people Delivering a service to disabled people

as passive recipientsas passive recipients Only outreach from a centreOnly outreach from a centre Rehabilitation training in isolationRehabilitation training in isolation Surveys on disability with no actionSurveys on disability with no action Limited to one sectorLimited to one sector An approach which is determined by the An approach which is determined by the

needs of an institution or group of needs of an institution or group of professionalsprofessionals

An approach which requires that An approach which requires that disabled people have to travel to a disabled people have to travel to a remote centre or institution to meet remote centre or institution to meet their needstheir needs

Segregated and separate from services Segregated and separate from services for other peoplefor other people

An approach with a narrow concept of An approach with a narrow concept of rehabilitation’rehabilitation’

A short-term fixA short-term fix

Starting PointsStarting Points

Improvement of physical, social and Improvement of physical, social and psychological function of the person with a psychological function of the person with a disabilitydisability

Solidarity with those who are denied their Solidarity with those who are denied their rights and working for adaptation of rights and working for adaptation of societysociety

Working for integration and equality of Working for integration and equality of rights of those people with disabilities rights of those people with disabilities within the mainstream of societywithin the mainstream of society

Starting PointsStarting Points

Rehabilitation should where possible Rehabilitation should where possible be part of community developmentbe part of community development

Rehabilitation is achieved through Rehabilitation is achieved through multi-sectoral collaborationmulti-sectoral collaboration

CBR Core ObjectivesCBR Core Objectives

InclusionInclusion of people with disabilities in civil, of people with disabilities in civil, social, political and economic structures of social, political and economic structures of society.society.

People with disabilities playing a People with disabilities playing a full part full part as citizens or equal members of the as citizens or equal members of the communitycommunity with the same rights, with the same rights, entitlements and responsibilities as others, entitlements and responsibilities as others, while contributing tangible benefits to the while contributing tangible benefits to the whole community. whole community.

Twin Track ApprochTwin Track ApprochMainstreamingMainstreaming The equalisation of opportunities and The equalisation of opportunities and

integration of disabled people in societyintegration of disabled people in society

Disability specificDisability specific The interventions that may take place at The interventions that may take place at

the individual level in order to improve the the individual level in order to improve the quality of lifequality of life

It is important to recognize the particular It is important to recognize the particular needs of people with disabilities, needs of people with disabilities, especially their rehabilitation especially their rehabilitation interventions needs , in order to ensure interventions needs , in order to ensure that inclusion in mainline development that inclusion in mainline development schemes does not lead to further schemes does not lead to further marginalization of people with disabilities marginalization of people with disabilities and their issues.and their issues.

The twin track approach to disability and The twin track approach to disability and development, which promotes inclusive development, which promotes inclusive development while addressing particular development while addressing particular needs of people with disabilities is an needs of people with disabilities is an increasingly accepted strategy. increasingly accepted strategy.

The twin track approach is becoming The twin track approach is becoming evident in current CBR trends, where evident in current CBR trends, where CBR projects address the special CBR projects address the special needs of people with disabilities, and needs of people with disabilities, and promote their inclusion in all promote their inclusion in all mainstream development processes mainstream development processes and activities. and activities.

The New The New Community Community

Based Based RehabilitationRehabilitation

CBR as Inclusive Development

Strategy in order to Alleviate Poverty

The need for strengthening CBR The need for strengthening CBR programmes: “Inclusive programmes: “Inclusive

Communities”Communities” Joint position paper of ILO, UNESCO, UNICEF and WHO (2002)Joint position paper of ILO, UNESCO, UNICEF and WHO (2002)

“We present this joint paper because, despite the progress made in the past two decades, there are still many individuals with disabilities who do not receive basic rehabilitation services and who are not enabled to participate equally in school, training, work, recreation or other social activities. We recognise that women and girls with disabilities often have fewer opportunities than others. Efforts must continue until all adults, youth and children with disabilities achieve equal rights and thereby have the same opportunities as other citizens in their societies.”

CBR Key methodsCBR Key methods

Involving the whole communityInvolving the whole community Involving local government and leadersInvolving local government and leaders Meeting basic needsMeeting basic needs Building capacityBuilding capacity Creating opportunities for livelihood, health, and Creating opportunities for livelihood, health, and

educationeducation Organizing disabled people and involving disabled Organizing disabled people and involving disabled

people’s organisations [DPO’s]people’s organisations [DPO’s] Collaborating across sectors - PARTNERSHIPSCollaborating across sectors - PARTNERSHIPS Using the legislation, judicial and political systemsUsing the legislation, judicial and political systems

CBR is a CBR is a strategystrategy within within community development for community development for rehabilitation, equalisation of rehabilitation, equalisation of opportunities and social opportunities and social integration of all people with integration of all people with disabilities.disabilities.

WHO, ILO, UNESCO Definition of CBRWHO, ILO, UNESCO Definition of CBR

WHO- CBR GuidelinesWHO- CBR Guidelines

CBR as Inclusive Development CBR as Inclusive Development Strategy in order to alleviate povertyStrategy in order to alleviate poverty

CBR MatrixCBR Matrix

This matrix has been developed to give This matrix has been developed to give a framework for a coherent CBR a framework for a coherent CBR programme. programme.

It consists of five components It consists of five components (domains), each divided into five (domains), each divided into five elements (sectors).elements (sectors).

Launch: 3 December 2008

CBR MatrixCBR Matrix

The 4 working principlesThe 4 working principles ParticipationParticipation: how do different stakeholders : how do different stakeholders

participate in decision making in and about the participate in decision making in and about the programme?programme?

InclusionInclusion: how does the programme enable disabled : how does the programme enable disabled people to join in the operation of the mainstream people to join in the operation of the mainstream institutions in each of the 5 domainsinstitutions in each of the 5 domains

SustainabilitySustainability: : how is the programme embedded in the surrounding community how is the programme embedded in the surrounding community

and how does it draw on local resourcesand how does it draw on local resourcesIs the organization able to adapt to changing circumstances?Is the organization able to adapt to changing circumstances?

Self-advocacySelf-advocacy: how are disabled people and other : how are disabled people and other participants in the programme enabled to speak out for participants in the programme enabled to speak out for their own needs.their own needs.

CBRCBR NetworkNetwork

Education

EmpowermentInclusion

RehabilitationHealth

Religion, Social

Livelihoods, SED

CBR Manager

CBR Facilitator

CBR Working Group

DPO

CBR Project

Ministry of Health, Min. of Social welfareMinistry of Education

•Rehab Services,•Mobility Aids •Surgery •Medical Treatment

•Special Education•Inclusive education •Vocational Training

Agriculture,Income GenerationMainstream Employment

Indian senarioIndian senario

Who benefits???Who benefits???

How effective???How effective???

How far possible??How far possible??

What effect on What effect on PWDs ???PWDs ???

PWD actPWD act National trust actNational trust act RCIRCI ConcessionsConcessions DRCDRC Inclusion(SSA)Inclusion(SSA) Community Community

Participation Participation India Has signed India Has signed

the UN convention the UN convention

Stakeholders’ ActionStakeholders’ Action

DiscussDiscuss

Be awareBe aware

Unite Unite

Advocate Advocate

Sharing Sharing

InformedInformed

StrengthenedStrengthened

Get the rightsGet the rights

Thanks Fr Thomas Chirackal