d i s a b i l i t y a n d r e h a b i l i t a t i o n , 1999; v o l . 21, n o s . 10± 11, 522± 528

Community-based rehabilitation: thegeneralized model

REG MITCHELL*

Department of Behavioural Sciences, Faculty of Health Sciences, University of Sydney, PO Box 170,

Lidcombe, NSW 2141, Australia

Summary

This article presents an overview of a generalized approach torehabilitation services which have come to be known ascommunity-based rehabilitation (CBR). The various admin-istrative and government organizationsthat may be involved inthe delivery of rehabilitation services are identi® ed. Speci® cattention is given to the various forms of medical referralsystems that might exist. In general, rehabilitationservices areprovided at the community level but more di� cult cases, whichrequire more sophisticated approaches, are referred toinstitutions more closely allied to a central government. Thisreferral system also gives the disabled person access to morespecialized personnel and services. The sources of informationin this article consist of fundamental and formative primaryreferences from documentationprovided by the World HealthOrganization (WHO). These sources provide a valuable set ofhistorical documents detailing the idealized concept of CBR.

Introduction

There are several hundred million people in the world

who have permanent disabilities resulting from move-

ment, hearing, seeing, or mental impairments. The

precise number of disabled people is not known, but the

inability of current services to meet their needs is well

recognized. In developing countries basic services and

equipment are lacking. In developed countries people

with disabilities may have access to medical and

educational services, but they do not have equal

opportunities to participate in social and work activities.

The impact of disability on the individual is not

questioned. The impact of disability on a nation has been

analysed in developed countries where the cost of

rehabilitation is less than the cost of long-term support

for the disabled, particularly when the productivity of

the rehabilitated person is taken into account. In

developing countries the ® nancial cost to the nation has

not been analysed in the same way. However, there is no

doubt that disability has an impact on families who have

* e-mail: R.Mitchell! cchs.usyd.edu.au

a disabled member. Families bear much of the cost of

treatment for their disabled member. This cost often

includes transportation to take the disabled member to a

centre for treatment, appliances and } or equipment. In

addition, there is often a loss of income for the family

because one member remains at home to care for the

member with the disability.

Countries which take action to assist their citizens with

disabilities are motivated not only by economic loss, but

also by the belief in equality. All citizens, whether they

are disabled, elderly, or very poor, have the right to

health. This right includes the right to grow physically,

psychologically, and socially in the most normal way

possible. To provide for the rights of all citizens a nation

must provide for the healthy development and well-being

of its disabled citizens.

Rehabilitation is a process which assists people with

disabilities to optimize the use of their physical, mental,

and social abilities. This means that rehabilitation is

multi-faceted. For example, at one point in the life of a

child with a movement disability the most crucial need is

for training and equipment for mobility. For a child who

cannot hear, the ® rst priority would be training for

communication. Both children, at a later period in their

lives, will need education or training for work inside or

outside the home. Both want to participate in the social

activities of their families and communities. The total

rehabilitation process will require diŒerent types of

services, as well as community action.

To provide the variety of rehabilitation services is not

an easy task in any country. The health-care services ® nd

it necessary to provide special personnel for services to

people with disabilities. The eduction system ® nds that

many disabled children can be integrated into their local

schools, but often the teachers require special infor-

mation in order to provide these children with a

meaningful education. Some people with disabilities can

have occupational training alongside the non-disabled.

However, others need special training and adapted work

places.

Disability and Rehabilitation ISSN 0963± 8288 print} ISSN 1464± 5165 online # 1999 Taylor & Francis Ltdhttp:} } www.tandf.co.uk} JNLS } ids.htm

http:} } www.taylorandfrancis.com} JNLS } ids.htm

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CBR: the generalized model

To coordinate and to distribute services to all parts of

a country poses further di� culties. Perhaps one type of

rehabilitation service is more readily available within a

country than other services. For example, an

organization may be prepared to develop vocational

training programmes, but people with movement dis-

abilities are unable to obtain the necessary equipment,

such as braces or wheelchairs, to assist their mobility

between home and work. Likewise, medical rehabili-

tation services may be provided within a few centres, but

these services reach very few of the disabled in isolated

and rural communities. Even those who live in urban

communities may have services only within centres, and

not have the assistance necessary to make adaptations in

their homes and local communities.

The idealized CBR model

Most CBR programmes have developed along a three-

tier manpower structure. This type of structure appears

to be the most eŒective method of carrying out the

various activities in an integrated CBR programme.

Training of manpower varies from country to country

and depends upon the availability of resources such as

money, technology, expertise, materials, scope of the

CBR programme, coverage of management, and co-

ordination.

The three tiers that have emerged in the model are

directly associated with various levels of government."

These tiers, a simpli® ed organizational model and the

management structure are presented in table 1. The

model presented in the table assumes that there are in

place integrated national (central), regional (district) and

local (community) policies regarding CBR. While the

various Ministries listed in the above structure are

Table 1 Organizational model for community-based rehabilitation

Location O� ce Collaborators

Central Ministry of Health,

Primary health-care

system, national CBR

coordinator

Other ministries such as

Education, Labour,

Agriculture,

Economic, Planning,

etc.

District Ministry of Health,

PHC team, CBR

district team

Education, etc. as

above

Community Community health

workers, family

trainers, disabled

person, community

members

Health centre

essential to the operation of CBR there are essentially six

key players in the CBR. First and foremost are the

disabled persons themselves, and although presented as

second-last in the table this is, in fact, the person who

should be at the top of the model.

The focal person in the CBR programme is the

disabled person. There are many roles that the disabled

person will play in the rehabilitation process and among

these will be :

(1) the right to self-determination;

(2) to be self-motivated to become an active and

responsible family member ;

(3) to enjoy the bene® ts of family membership ;

(4) to be an active and responsible community

member ;

(5) to enjoy and use the same opportunities that are

available to all community members such as access

to education, skills training, work and recreational

activities;

(6) to give serious consideration to becoming a family

trainer for another disabled person, but at least be

prepared to play a signi® cant role in the CBR

programme ;

(7) to participate in the organizations which cater for

disabled persons, acquire leadership skills, con-

tribute to the achievement of community, regional

and national health goals, and act as a lobbyist for

the disabled and their families.

Services in CBR

The services considered to be medical rehabilitation

are those which: (1) promote normal development for

babies and small children with disabilities, (2) provide

training and equipment for self-care and mobility for

those with movement disabilities, and (3) provide

language and speech training for individuals with

neurological impairments. # Hence, medical rehabilitation

services may follow some individuals with movement

disabilities throughout their lives. Education services

provide training for cognitive and language development

for older children with learning, hearing, or visual

impairments.

Each Ministry of Health (MOH) should have a

national plan for medical rehabilitation services. In some

countries it is not feasible for the MOH to provide all of

the services because of government policy regarding

implementation of services, or because of ® nancial

restrictions. Nonetheless, the MOH provides a national

rehabilitation plan and then coordinates government

and non-government services so that they both con-

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R. Mitchell

tribute to the expansion of medical rehabilitation services

throughout the country. The MOH can also use the

national plan as a basis for seeking donor funds to

support the development of the medical rehabilitation

services. In particular, donor funds can be sought for

capital costs, while the MOH sustains the running costs

of the programme.

In this description oΠthe medical rehabilitation

components it is suggested that the rehabilitation

workers at district and community levels be within the

health-care system. However, these workers may be

personnel from another ministry, such as Social AŒairs

or Community Development, or from a non-government

organization (NGO). Then it is important to coordinate

medical rehabilitation services with the other services at

district and community levels.

The development and distribution of services can be

done eŒectively and e� ciently when they are expanded in

response to needs at the community level. CBR provides

a framework for developing and distributing all types of

rehabilitation and for ensuring that services reach

disabled people in their communities.

Resources in CBR

CBR has as its unique feature the use of family and

community resources for the rehabilitation of people

with disabilities. Knowledge and skills for basic training

of disabled people in functional activities are given to the

families of disabled people, to disabled adults, and to

community members. $ A resource person for rehabili-

tation is available at the community level. Disabled

children attend the local school. Within local work

settings, community members provide occupational

training for disabled adults. Community groups assist

the families of disabled people by providing child care,

transport, or loans to start an income-generating project.

Community leaders provide opportunities for disabled

people to participate in the social and political activities

within the community. These resources for the disabled

are supported by referral services within the health,

education, labour, and social services systems. Personnel

skilled in rehabilitation technology train and supervise

community workers, and provide the necessary skilled

interventions for speci® c individuals when basic training

techniques are not su� cient.

The process of rehabilitation provides disabled indi-

viduals with the opportunity to develop their physical,

mental and social skills. The goal of rehabilitation is

disabled people’ s participation in normal roles within

their families and communities. Fragmented rehabili-

tation services which do not reach the community level

are less likely to either provide or stimulate the necessary

opportunities for disabled people to participate in normal

roles. The development of services at the community

level through the mobilization of community resources

provides disabled people with the variety of assistance

they require, and does so in the setting where the goal of

rehabilitation can be achieved in the home and the

community.

Both the mobilization of community resources and the

provision of referral services are needed to achieve the

goal of rehabilitation. In developed countries, where

many referral services are provided, the use of com-

munity resources may need to be strengthened. In

developing countries the mobilization of community

resources and the expansion of referral services can be

simultaneously strengthened. The community cannot

meet all of the needs of people with disabilities, so some

referral services should be available in a region before the

development of the CBR programme is initiated.

What is essential to support the community eŒorts will

vary from country to country. However, there are some

conditions which will facilitate the implementation of

CBR. These conditions include:

(1) community leaders and organizations will support

the programme with the understanding that they

will contribute to it;

(2) a cadre of community workers will be available for

rehabilitation;

(3) personnel who will train and supervise this

community workforce will be available;

(4) resources will be available to train and post

personnel in referral services ;

(5) referral services will be able to provide basic

appliances and equipment.

Government involvement in a CBR programme

Plans for a national CBR programme may be initiated

by one or more ministries. In some countries this will be

the ® rst step in establishing CBR. In other countries

national planning may be stimulated by the existence of

CBR projects which have been initiated at the com-

munity level by NGO’ s. In either situation it is ideal to

have joint planning at the national level by all Ministries

involved in rehabilitation, although one may take the

lead as initiator and co-ordinator of the national

programme. % ± ’

Each Ministry that provides rehabilitation services will

have its own plan for the distribution of services from

central to community levels. Depending on the country,

and on the Ministry, this may include central, provincial,

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CBR: the generalized model

district and community levels. At the central level each

Ministry may have a service staŒed by specialists, e.g.

medical, educational, or vocational. Specialists may also

work at the provincial level. At district level rehabili-

tation staŒwith less training than the specialists may

oŒer some technical services and coordinate the services

between the community and the referral system. The

description below refers to developing countries, where

there is a need to develop referral services for all aspects

of rehabilitation.

However, in both developing and developed countries

there is concern about the rights of disabled people.

Many disabled people lack the opportunity to participate

in education, work, or social activities. This may be the

result of many factors, including negative attitudes and

lack of expectations about what disabled people can do,

lack of necessary appliances or equipment, and physical

barriers preventing access to buildings.

Although developed countries may have adequate

medical rehabilitation services, many of them do not

have active community components in their rehabili-

tation programmes. The lack of community awareness

and involvement in rehabilitation contributes to the

continued restriction of opportunities for disabled

people.

The Ministry of Health may have a medical re-

habilitation centre, or a rehabilitation service located at

a large central hospital. There may also be a university or

private hospital which oŒers rehabilitation services.

Within these services there are physicians with specialities

related to rehabilitation, such as orthopaedic, neurology

and psychiatry ; physical, occupational and speech

therapists ; and prosthetists } orthotists.

Within a national CBR programme the Ministry of

Health has a team at national level that takes re-

sponsibility for managing the distribution of medical

rehabilitation services at all levels. The team would

include a physician, therapist, and prosthetist } orthotist.

Their responsibilities include planning for services

throughout the country, training staŒ, and organizing

the system for supervision of staŒand referral of clients

for services. In addition, there are staŒat the central level

who provide specialized services to disabled people

referred from the provincial level. The services within the

central facility should be coordinated. If services for a

particular type of disability exist in several centres, it

would be preferable to develop only one of the centres as

a referral service in order to avoid duplication of

equipment and training. For example, services for people

with amputations might be expanded at one centre, while

services for children with cerebral palsy are expanded at

another centre.

The Ministry of Education may have special schools

for children with mental retardation, blindness or

deafness. In some countries the special schools are not a

government service, but are provided by NGO’ s. The

schools are often located in urban areas. Many are

residential because the lack of transport makes it

impossible for children with disabilities to travel each

day between home and school. Within these schools

there may be a few teachers who are special educators,

trained to teach children with a speci® c type of disability.

The other teachers may have had training on the job

from the special educators. There may be no service in

the regular school system for children with disabilities.

Within a national plan for CBR the Ministry of

Education promotes the integration of disabled children

into the local schools and provides specialists as resources

for the regular school system. This provides more

disabled children with the opportunity to attend school,

and also allows them to stay with their families rather

than in an institution. The specialists train teachers in

methods which can be used for teaching visually, hearing

or mentally impaired children within the regular school.

These special teachers may also be available to assess

children with impairments and make speci® c recom-

mendations to the teachers in the local schools. The

Ministry of Education may also organize the distribution

of some special schools for children with various types of

disabilities. This may be done by working with NGO’ s

and encouraging them to place schools according to a

national plan.

The Ministry for Labour or for Social AŒairs may be

responsible for vocational training for people with

disabilities. This task may be carried out within the

training programmes available to non-disabled indi-

viduals. Sometimes NGO’s provide this service for

disabled people who require special training or an

adapted workplace. Often vocational training centres are

located in urban areas, and are not readily available to

people from rural areas.

Within a national plan for CBR, the Ministry

responsible for vocational training will coordinate the

expansion of government and non-government

vocational training programmes so that eventually they

are available to people with disabilities throughout the

country. This will include orienting staŒin all vocational

training centres to the needs of people with disabilities. It

will also include training community organizations

involved in job training or income-generation projects so

that they can include the disabled in their programmes.

The Ministry of Social AŒairs or Social Welfare may

also be responsible for social support programmes for the

disabled, such as disability payments or the provision of

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funds for special equipment. These services will be

available through the social welfare o� cers, who may be

posted at national, provincial, and district levels.

Within each Ministry involved in rehabilitation, the

services provided are specialized, with a focus on speci® c

types of disabilities, or on particular aspects of disability.

Within these specialized services there may be little

attempt to coordinate all aspects of rehabilitation needed

by one individual. If the individual, or family, pursues

each type of service independently, the person’ s needs

may be met. However, very often it is only the most

obvious needs that receive attention. For example, a

child is provided with a brace for walking, but no-one

explains to the family what opportunities might be

availablewhen the child is older so that the young person

can have training for income production. This lack of

coordination may be particularly marked within the

central services, based in large urban areas where the

staŒand location of each type of service is geographically

separated from all other services. At district level there

may be more communication, and hence more referrals,

among staŒof health, education and social services.

The concept of CBR must be applied within the

central services as well as at provincial, district and

community levels. This requires the coordination of

services, and the activation of the community within

urban as well as rural areas. The central services cannot

coordinate services only for other levels; they must also

coordinate their own work so that people with disabilities

in the urban areas also have assistance for the complete

process of rehabilitation.

Government or non-government organizations Ð the

provincial level

In this article there is reference to only one level of

health services between central and district. The term

`provincial ’ is used to refer to the services immediately

under the central level, although many countries use

diŒerent terms such as regional or state to refer to this

level.$ , ( , )

In a CBR programme the provincial medical, edu-

cational and vocational services will each be distributed

as equally as possible. StaŒbased in provincial centres

will have the responsibility to provide direct services to

people with disabilities, and also to supervise the services

at the district and community levels.

Within the medical services, routine procedures for

rehabilitation will be carried out by physicians, therapists

and prosthetists } orthotists. Disabled people with com-

plicated or unusual conditions will be referred to the

central facilities. Provincial services will be provided to

clients referred from the district-level services. An

important role for some of the rehabilitation staŒwill be

the training and supervision of rehabilitation workers at

district and community levels.

A few special schools and vocational training centres

for the disabled may also be located in provincial

capitals. These are likely to be managed by NGO’s, but

located according to a national plan for distribution of

the services. Children or adults who wish to bene® t from

education or training, and who do not live in the larger

cities, have to reside at the school or training centre.

District level

The word `district ’ does not have the same meaning in

all countries. In larger nations it may encompass a

population of one million people, while in a smaller

country a district may have a population of 100000. In

this article the discussion of `district ’ refers to the area

covered by the ® rst referral level hospital.# , * , " !

Within a CBR programme the district is a key point in

the delivery of rehabilitation services. District-level staŒ

for health, education, and social services can coordinate

their own work in order to support the community

eŒorts in rehabilitation. StaŒat district level can travel to

the communities within the area to supervise community

workers and to visit disabled people in their homes. A

district centre is geographically accessible to most people

in the area, including those with disabilities. This

provides ® rst referral level rehabilitation services to

people with disabilities.

For the provision of medical rehabilitation services,

some Ministries of Health are employing `mid-level ’

rehabilitation workers (MLRW) at the district level. This

level of personnel is often trained to carry out the basic

tasks associated with physical and occupational therapy.

Some countries call this cadre rehabilitation assistants,

or rehabilitation technicians. The MLRW work in the

district hospital, with periodic supervision from a

physical or occupational therapist from provincial level.

In a CBR programme the MLRW are trained to work

not only with people with locomotor disabilities, but also

with people who have sensory or mental impairments.

The interventions consist of early detection of these

impairments in children; assessment of impairments or

disabilities in children or adults; and recommendations

to disabled people, their families, and community

workers regarding training to improve mobility, com-

munication and learning.

In addition to technical training for CBR, the MLRW

are trained for management and supervision. The

management responsibilities include record-keeping and

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CBR: the generalized model

reporting on the community and district rehabilitation

services, and the coordination of referrals to other levels

of the medical rehabilitation services, and to other types

of services, i.e. educational, vocational, and social. The

MLRW also supervise the work of a person in the

community who is a contact for disabled people and

their families. This may be the community health worker,

a representative for another government programme, or

a volunteer. Depending on the background of the

rehabilitation worker at community level, and what

other responsibilities that person has, the MLRW may

also have to work with community leaders and

organizations who actively support the rehabilitation

process for people with disabilities.

Community level

In communities in developing countries, where few

referral services for rehabilitation exist, families take the

initiative to rehabilitate their children, or adult members,

who have disabilities. In many instances the activities

carried out by the family are eŒective in training a child

to do self-care activities, or to move around. However,

left alone in their eŒorts, the family may have di� culty

in training or communication, preventing deformities,

providing appliances or equipment to aid the disabled

person, and integrating the child into the local school, or

the adult into normal community activities.$ , " "

In a CBR programme, disabled people and their

families receive support and encouragement as the

disabled person goes through the rehabilitation process.

They can gain knowledge and skills from the community

worker, and also from the MLRW if the knowledge of

the community worker is insu� cient. Local school

teachers receive information about disabled children and

how to include them in their classes.

Most characteristic of a CBR programme is the active

role played by disabled people and the contribution of

community members to the rehabilitation process.

People with disabilities are active in their own re-

habilitation, rather than passive recipients of services.

They are active in their own rehabilitation because it

takes place in their own homes and communities, so they

can identify what services are needed to assist them there.

Individuals with disabilities can also be active in assisting

other disabled persons in their communities, and in

advocating for the needs of all people with disabilities.

Through education programmes, and seeing disabled

people become active, the community learns about

causes of disability, and understands better the abilities,

as well as the limitations, of people with disabilities.

Attitudes towards disabled people change. Community

members receive information about skills training and

income-generating projects which include people with

disabilities. Members and organizations of the com-

munity oŒer opportunities to the disabled to become

active participants in social, work, or political activities.

The community rehabilitation worker (CRW) may be

the community health worker, in which case the medical

rehabilitation services have the most direct link for

training and supervision. However, the CRW may be a

volunteer just for the purposes of rehabilitation; a

member of another organization, such as the Red Cross ;

or a worker from a Ministry other than Health (e.g.

Social AŒairs or Community Development). If the CRW

is not part of a Ministry related to rehabilitation, an

agreement should be made regarding the direct line of

supervision for rehabilitation. Also, when the MLHW is

part of the health services, this person is the best

prepared to supervise the CRW. While it is necessary to

have one supervisor for the CRW, it is also necessary to

recognize the variety of activities that this person may

carry out in the community, and the need to have

information from all rehabilitation services reach a

community through the CRW. A more comprehensive

description of manpower and manpower training in

CBR can be found in WHO publications." #

Conclusion

The material presented above outlines the idealized

model for the delivery of CBR. The WHO support for

CBR began in 1978 and they developed a manual for

CBR through a process of ® eld testing, revision and

further testing. The 1979, 1980, and 1983 editions of the

manual were translated and used in many countries in

Asia and Africa, either by government rehabilitation

programmes or non-government organizations.

The activities of the WHO and Member States re¯ ect

a priority on prevention rather than rehabilitation.

Within the WHO the number of primary prevention

programmes is greater than the number of programmes

concerned with rehabilitation. The WHO has not

assessed a number of aspects of rehabilitation, including

integration of disabled children into local schools, special

education, or vocational training for people with

disabilities. However, it appears that the momentum of

the activities begun in 1981 during the International Year

of the Disabled Person has not been maintained with

regard to any aspect of rehabilitation. The International

Year created public awareness about the needs of people

with disabilities. However, very few countries have

established CBR as a component of either primary

health care or an expanded medical referral service.

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Where CBR has been implemented there is clear

evidence that the majority of these programmes are still

in the pilot stage. There has been no comprehensive

evaluation of CBR programmes to identify its strategic

strengths and weaknesses. Despite the ideal model

presented in table 1 there has been a lack of coordination

among service providers, primary health-care pro-

gramme components, and between government and non-

government organizations.

However, all is not doom and gloom. The CBR

concept is and has become an excellent tool for

improving the participation of disabled persons in

decision-making and facilitating their integration into

society. CBR, where implemented, has made a signi® cant

social impact on the lives of disabled persons, particularly

those in remote and rural areas. Through the increase of

public awareness about disability there is an expectation

that there will be greater community support for the

disabled and that the community will mobilize resources

(manpower, materials, money) to support the disabled

person.

Many of the reported disadvantages and advantages

of CBR are based on anecdotal evidence and, apart from

bringing rehabilitation to all disabled persons, there is an

immediate need to comprehensively evaluate CBR.

Given the vested interests of governments and non-

government organizations such an evaluation should be

initiated and supported by organizations such as the

WHO or the World Bank.

References

1 Zhuo D. Response from Jim Hua Street to the challenging CBRtasks in the 1990’s. In Report: Intercountry Workshop on Planningand Management of Community-based Rehabilitation Programmes,Manila: World Health Organization, July 1991.

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