5.1 Concept, Definition and Scope of CBR

Disability refers to any form of restriction or lack of disability to perform an activity in the manner, or, within the range that is considered normal for a human being. A person with disability is an individual who is officially recognized by society as such, because of differences in appearance, behavior, communication and functional limitations (WHO,1980)1. Disability may be temporary or permanent and reversible or irreversible and may be described as progressive or regressive.

 

Rehabilitation includes all measures aimed at reducing the impact of disability for an individual, enabling him or her to achieve independence,social integration, a better quality of life and self-actualization. It includes not only training of persons with disability, but also interventions in the

general systems of society, adoptions of the environment and protection of human rights.

 

Community is defined as a group of individuals living together, with similar interests and having the same ideological, religious, cultural and economic aims.

 

Community Based Rehabilitation involves measures taken at the community level to use and build on the resources of the community,their families and the community as a whole. This means that CBR programmes should be planned and implemented with the participation of PWDs. This is different from the so-called community programmes, where the core phases and plans are done away from the actual community, often in the city.

 

Participation refers to the involvement of the beneficiaries in the programmes being initiated/ implemented in the community, in order to ensure ownership and sustainability of such programmes. This is based on the assumption that it is the beneficiaries who know their own problems the best.

 

Community based rehabilitation is a strategy for enhancing the quality of life the person with special needs in improving service delivery, by providing more equitable opportunity and by promoting and protecting their human rights.

"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”

Objectives of community-based rehabilitation:

·        Enhance mental and physical abilities of PwD.

·        Equal opportunities and Contribute positively to the development of their communities.

·        To promote and protect the rights of persons with disabilities.

·        To remove barriers and obstacles that disrupt participation.

·        Improve the functional capabilities of PwD.

·        Create public awareness.

CBR Matrix 26Dr. Ahmed Refat AG Refat

Components and principles of CBR

 

As mentioned earlier, the World Programme of Action (UN 1983) concerning the persons with disabilities, was worked out by the United Nations in order to guide the stakeholders in the field of disability. The Community Based Rehabilitation approach is part of the recommendation of the World Programme of Action.

It is increasingly accepted, that a good CBR programme is based on a holistic approach and will include many of the following aspects (O’Toole and McConkey 1995):

•        Understanding community needs;

•        Identifying community perceptions and beliefs;

•        Promotion of social integration;

•        Transferring knowledge to communities but also learning from the communities;

•        Empowering PWDs and community;

•        Encouraging PWDs reach their potential, mobility etc.;

•        Removal of physical barriers, social and physiological;

•        Building strategies for sustainability;

•        Changing negative attitudes;

•        Addressing human rights issues and information sharing, as

•        essential components of the CBR programme.

Some essential ingredients for sustainability which CBR programmes should consider are listed below.

 

5.2 Models of CBR – Advantages and Disadvantages

Models of Disability are tools for defining impairment and, ultimately, for providing a basis upon which government and society can devise strategies for meeting the needs of disabled people

The Religious Model

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The Religious Model views disability as a punishment inflicted upon an individual or family by an external force. It can be due to misdemeanors committed by the disabled person, someone in the family or community group, or forbears. Birth conditions can be due to actions committed in a previous reincarnation.

The Tragedy/Charity Model
This figure illustrates the Charity Model of disability and the associations persons have when adopting this model. In the Charity Model the disabled individual is seen as the cause of the problem. The associations in the figure are: "need to be looked af

The Tragedy/Charity Model depicts disabled people as victims of circumstance, deserving of pity. This and Medical Model are probably the ones most used by non-disabled people to define and explain disability.


The Medical Model

The Medical Model holds that disability results from an individual person’s physical or mental limitations, and is largely unconnected to the social or geographical environments. It is sometimes referred to as the Biological-Inferiority or Functional-Limitation Model.It is illustrated by the World Health Organization’s definitions, which significantly were devised by doctors:Impairment: any loss or abnormality of psychological or anatomical structure or function.Disability: any restriction or lack of ability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being.

The Social Model

The Social Model views disability as a consequence of environmental, social and attitudinalbarriers that prevent people with impairments from maximum participation in society. It is best summarized in the definition of disability from the Disabled Peoples’ International:

MODELS OF COMMUNITY BASED REHABILITATION:-

Social model:

People with disabilities in low-income countries are affected by the same factors which cause poverty for others, but also face added disadvantages. Children with disabilities face barriers to education; youth with disabilities face barriers to training; adults with disabilities face barriers to decent work. Most damaging of all, families and communities may think that people with disabilities are incapable of learning skills and working. By encouraging and facilitating work by women and men with disabilities, community-based rehabilitation (CBR) programmes can help individuals and their families to secure the necessities of life and improve their economic and social situations. By taking into consideration the needs and views of people with disabilities and making provision for their inclusion in national poverty reduction and other development programmes, opportunities for education, skills acquisition and work can be provided for people with disabilities and their families, enabling them to emerge from poverty. Accessing livelihood opportunities is one of the key factors in eliminating poverty.

Under this component CBR is to facilitate access for people with disabilities and their families to acquiring skills, livelihood opportunities, enhance participation in community life and self-fulfillment

·         Engaging vulnerable groups/individuals in economic activities (PWD’s and mental health clients in productive income generating ventures)

·         Microcredit for the vulnerable groups

·         Vocational skill training/ skill development for young disabled adults/persons with mental illness

·         Linking persons with disabilities/individuals to financial institutions for credit

·         Animal rearing/Credit in-Kind system(cashless system)

·         Handicrafts

 

Medical model

The Constitution of the World Health Organization (WHO) states that “enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” Unfortunately, evidence shows that people with disabilities often experience poorer levels of health than the general population and face various challenges to the enjoyment of their right to health. Community-based rehabilitation (CBR) programmes support people with disabilities in attaining their highest possible level of health, working across five key areas: health promotion, prevention, medical care, rehabilitation and assistive devices. CBR facilitates inclusive health by working with the health sector to ensure access for all people with disabilities, advocating for health services to accommodate the rights of people with disabilities and be responsive, community-based and participatory. Specific services include;

·         Advisory services in blindness prevention and sight restoration by way of referrals, medical treatment or surgery

·         Organizing health promotion talks through community durbars and radio programmes

·         Orthopaedic and Physiotherapy services

·         Audiological services

·         Mental health services (Management of epileptic seizures and other mentally related disorders)

·         Prevention of childhood disability activities through a multi-sectorial collaboration

·         Provision of rehabilitation services to persons with disabilities

·         Provision of basic assistive devices to persons with disabilities

·         Prevention of childhood disabilities using a multi-disciplinary team screening approach

Economic model

People with disabilities in low-income countries are affected by the same factors which cause poverty for others, but also face added disadvantages. Children with disabilities face barriers to education; youth with disabilities face barriers to training; adults with disabilities face barriers to decent work. Most damaging of all, families and communities may think that people with disabilities are incapable of learning skills and working. By encouraging and facilitating work by women and men with disabilities, community-based rehabilitation (CBR) programmes can help individuals and their families to secure the necessities of life and improve their economic and social situations. By taking into consideration the needs and views of people with disabilities and making provision for their inclusion in national poverty reduction and other development programmes, opportunities for education, skills acquisition and work can be provided for people with disabilities and their families, enabling them to emerge from poverty. Accessing livelihood opportunities is one of the key factors in eliminating poverty.

Under this component CBR is to facilitate access for people with disabilities and their families to acquiring skills, livelihood opportunities, enhance participation in community life and self-fulfillment

·         Engaging vulnerable groups/individuals in economic activities (PWD’s and mental health clients in productive income generating ventures)

·         Microcredit for the vulnerable groups

·         Vocational skill training/ skill development for young disabled adults/persons with mental illness

·         Linking persons with disabilities/individuals to financial institutions for credit

·         Animal rearing/Credit in-Kind system(cashless system)

·         Handicrafts

 

Educational model

Education is about all people being able to learn what they need and want throughout their lives, according to their potential. It includes “learning to know, to do, to live together and to be”. Education takes place in the family, the community, schools and institutions, and in society as a whole. The role of CBR is to work with the education sector to help make education inclusive at all levels, and to facilitate access to education and lifelong learning for people with disabilities. This include;

·         Referrals of Children with disabilities to special Schools from primary, secondary and tertiary

·         Provision of lifelong learning activities for the severely disabled persons

·         Early Childhood intervention

·         Integration of Children with mild disabilities into the regular school system

Advocacy and Empowerment Model;

While the first four components of the matrix relate to key development sectors (i.e. health, education, livelihood, and social sectors), the empowerment component focuses on the importance of empowering people with disabilities, their family members and communities to facilitate the mainstreaming of disability across each sector and to ensure that everybody is able to access their rights and entitlements. Empowerment begins to happen when individuals or groups of people recognize that they can change their situation, and begin to do so. It is a process that involves things like awareness and capacity-building leading to greater participation, to greater decision-making power and control, and to action for change Having a say and being listened to promotes a self-power to make decisions which allows people with disabilities to live free and independent with the ability to fight for their own rights and gain recognition as equals.

Under this component CBR seeks to assist persons with disabilities to develop advocacy and communication skills and, to ensure that their environment provides appropriate opportunities and support to allow them to make decisions and express their needs and desires effectively.

Currently the CBR programme has established forty five (45) Disable People Organisations (DPOs) and twenty three (23) Self-Help-Groups of persons with mental illness

·         Awareness creation on rights based issues on disabilities

·         Establishment of Disable People Organisations (DPOs)

·         Establishment of Self-Help-Groups in working communities

·         Establishment of community Development Committees to spear head development at the community level.

·         Social mobilization at the community level for development.

·         Provision of training on group dynamics

5.3 Types of Community Resources and their mobilization

Community mobilization is the process of bringing together as many stakeholders as possible to raise people's awareness of and demand for a particular programme, to assist in the delivery of resources and services, and to strengthen community participation for sustainability and self-reliance. A lot can be achieved when people from different parts of the community share a common goal and actively participate in both identifying needs and being part of the solution. Community mobilization helps to empower communities and enable them to initiate and control their own development.

Little progress will be made towards mainstreaming disability until community support is built up and the different sectors of society become actively involved in the process of change. CBR programmes can use community mobilization to bring together stakeholders in the community, e.g. people with disabilities, family members, self-help groups, disabled people's organizations, community members, local authorities, local leaders, decision- and policy-makers, to address barriers within the community and ensure the successful inclusion of people with disabilities in their communities with equal rights and opportunities.

This element focuses on how CBR programmes can bring people together to act and bring about change in the communities in which they operate.

Mobilize and manage resources

Financial resources

Fundraising: It is essential to seek financial resources for the development of new programmes or to enable existing programmes to continue their work. Finance for CBR programmes may be mobilized from many different sources. Where possible, the emphasis should be on community-based funding, as this will contribute to the longer-term sustainability of programmes. Possible sources of funding in the community may include:

If sufficient resources are not available locally, fundraising may be required at regional, national or international levels to develop and implement CBR programmes.

Financial management: It is important to establish a transparent system for managing finances. This will ensure that the programme is accountable to stakeholders, including funding bodies, community members and people with disabilities themselves. Financial management is a key role of the programme manager, but others may be involved, particularly when programmes are large and involve large amounts of money. Financial management involves:

 

Funding and sustainability financial support to the programme is provided by the Royal Government of Bhutan and WHO. Under the decentralization policy of the government, all developmental activities and programmes to be implemented in communities are now decentralized. Funds from the central programme are released for implementation at districts by the district health officials

Accessibility

 This is one of the major areas addressed in the CBR programme. If there are accessibility issues related to public buildings, toilets or houses, a certain amount of funds (depending on the problem) is dispersed by the National Fund from the Ministry of Social Services and Social Welfare. Community contribution is expected in the form of voluntary labour. This increases community ownership and ensures sustainability. Amendments to Disabled Persons (Accessibility) Regulations, No. 1 of 2006 are also under way. Several awareness programmes are conducted on access to public buildings and places to create awareness among government institutions at district, provincial and divisional levels.

Community Participation    

The new partner agencies already had acceptance and credibility in the community for other services given. The community became interested in the additional services and became involved in identification and motivation of the visually impaired in accepting services. The community leaders, who were impressed by the visibly dramatic improvement in mobility, daily living and social skills developed by the visually impaired, actively assisted in obtaining other facilities and concessions from the community, Government and financing organisations, all for the improvement of economic rehabilitation for the visually impaired. The process also involved gifted clients as motivators and facilitators, advising families of the visually impaired, community leaders and other rural service organisations in NGO and occasionally Government sectors.

As part of the project development, refresher courses were organised periodically for one week or two week durations. The participating agencies were encouraged to contribute to the agenda by sharing case studies, special aspects of their areas and specific and common difficulties. The refresher courses were planned to be interactive so that issues and projects were analyzed and solutions evolved. The nearby Government officials, blind welfare organizations and eye care institutions were also invited as guest faculty.

Strategies and role of government in promoting participation in CBR

 

In order to improve and strengthen implementation, the Government must set up management structures to facilitate the smooth operation of CBR programmers’. This includes policy-making and planning, appropriate administration structures, provision of resources, decentralization, training personnel, onward referral systems and monitoring and evaluation.

 

Policy formulation, review and promotion

 

Today, various governments have laid down a number of strategies to promote participation of marginalized groups. Governments have policies applicable to vulnerable groups in general, but there is a need to design policies, which adequately address issues of PWDs. This may require formulating new ones, promoting or reviewing existing ones, so that any deficiencies in particular sectors such as health services, schooling and employment opportunities that affect PWDs are corrected. By formulating a detailed policy statement, the government points out what is to be achieved, how to implement change, who is responsible, when can change be made and a commitment to provide the resources. In Uganda, the affirmative strategy has been used to promote participation.

 

Putting up appropriate administrative structures

 

The Government has set up the necessary structures to ensure Community participation in CBR programmes. This includes the Department of Disability and Elderly in Ministry of Gender, Labour and Social Development to coordinate disability issues. This Department has also set up a National CBR steering Committee, which consists of the key stakeholders to monitor the activities of the CBR programmes. Due to decentralization, a similar structure has been duplicated at district and lower levels.

 

Mobilization of resources

 

Funds, personnel, equipment, transportation, physical structures, statistical services, research and information are some of the resources that have to be mobilized. Central and local government bodies, communities and non-Government organisations provide these resources. The government role here is to identify with the communities the available resources, and to point out to the community what it has to do, such as, provide local management and some of its resources. The government can then fill the missing components through training, technical supervision, administrative support and referrals.

 

Decentralizing to encourage community participation

 

One of the key features of CBR programme development is decentralization. However, this in itself is not enough, as there is no guarantee that this process can lead to higher levels of participation in the community based rehabilitation programmes. Decentralization must be followed by a change of attitudes.

 

Training and sensitization

 

This component is important, for building a competent workforce at all levels. In Uganda, training of CBR workers is carried out at UNISE,COMBRA and Makerere University (Makeree University 1994). Sensitization is another key activity. All stakeholders have been involved insensitisation of technical personnel.

 

Building and maintenance referral options

Referral options are looked at as places where PWDs can be referred for treatment, education, employment and legal advice. In most cases, these cannot be handled by communities, so it is the role of the government to ensure that these services are operating efficiently.

 

Monitoring and evaluation

The Government monitors and evaluates the progress of all the programmes relating to people with disabilities. This serves as a check and contributes to the quality of the programmer’s development. High levels of participation are encouraged and where this is not achieved, action is taken to increase the level of participation and the range of stakeholders involved.

 

CONSTRAINTS

 

Inadequate funding

 

The Government would like to extend the CBR programme to the whole country, but due to inadequate funding, CBR is still limited to 10 out of 56 districts.

 

Lack of statistical data

 

The magnitude of disability prevalence is not known due to lack of reliable data. It is hoped that the next Population and Housing Census will come up with better disability statistics for ease of planning and resource allocation.

 

RECOMMENDATIONS

 

Empowerment

 

Even though some measures have been undertaken by the Government to eradicate poverty among PWDs and promote access to employment, this is an area, which still needs greater focus. For example, more PWDs need accessibility to micro-finance schemes in the community. Through this, the government will have ensured that PWDs are engaged in productive ventures for an improved standard of living. There is also a need to promote cultural values and languages, including sign language, which is used by the deaf to preserve and enhance dignity of all.

 

Gender balance

 

Emphasis should be laid on gender balance, fair representation of disadvantaged groups and a call for society to respect the rights of PWDs, particularly the girl child and women. There needs to be better educational opportunities for the girl child, whether she is able-bodied or not.

 

Health care system

 

Since the leading causes of disability are communicable and preventable diseases, an improved health care system is a pre-requisite for reducing the rate of disability.

 

Removing physical and environmental barriers

 

The Government should be able to be more vigilant and avoid activities that increase disability, such as wars and motor accidents. Laws should be enforced to punish careless drivers and those involved in domesticviolence. Work places should be conducive to productivity and repetitive straining influences should be avoided.

 

Institutional rehabilitation

 

Everyone is well aware that community based rehabilitation does not provide all skills to PWDs. There are those who are severely handicapped, and, who still need the services of institutions. Governments should therefore continue to fund Institutions, so that they work hand- in- hand with the CBR programmers'.

 

Coordination

 

As has already been discussed, CBR is implemented by different stakeholders. In order to avoid duplication, the government should be able to coordinate the activities together with the stakeholders and monitor and evaluate them.

 

5.4 Organizing services for PwID in the community

Community organizing involves mobilizing a group of people to address common issues and concerns and enabling them to take action. It focuses on collective action; the power derived from the synchronized actions of people in unity, as opposed to separate individuals. Quite akin to the common saying, ‘United we stand, divided we fall.’

From fighting social injustice to inequality, community organizing finds its roots in movements of the past such as the suffragettes and the trade union movements, among others. To put it simply, community organizing consists of these five steps:

§  Listening to people

§  Clarifying common goals

§  Framing strategies for action

§  Helping build leaders

§  Mobilizing the community

There are four fundamental strategies available to neighborhood groups to address community problems: community organizing, advocacy, service delivery or development.

Community organizing is characterized by the mobilizing of volunteers. Staff roles are limited to helping volunteers become effective, to guiding the learning of leaders through the process, and to helping create the mechanism for the group to advocate on their own behalf. Community organizing almost always includes confrontation of some sort. The people who want something get themselves together to ask for it, often the people who could give them what they want get jumpy. Community organizing strategies include meeting with corporate or government decision makers to hold them accountable for their actions, designing programs for others (not the group) to implement that meet the needs of the community, and aggressive group action to block negative developments or behaviors (highway construction that leads to neighborhood destruction, etc.).

Advocacy and Service Delivery are both characterized by doing FOR people. Often professionals like lawyers or social workers will attack a problem on behalf of those perceived as unable to speak for themselves. Job referral services, social work, training for job readiness, homeownership counseling, business plan preparation training - these are methods which fit into the Advocacy or Service Delivery strategy.

Development is a strategy that gets the group directly into the business of delivering a physical product. Generally, groups select a development strategy because the normal course of events is not meeting the areas needs. The profit motive either does not bring private developers into the area - they can't make enough money - or it brings them in to do the wrong thing - they are converting moderate cost rental units into yuppie condos. Development could mean housing or commercial or even industrial development. Development methods require, like the other two strategies, particular skills. Many groups have struggled to achieve good results in housing development with staff whose training, experience and interests are in community organizing, causing pain and suffering for the group and the staff. This is unfair. If we understand the distinction between the strategies, we can see the different resources needed for the methods that fit within them.

Community organizing is the process of building power through involving a constituency in identifying problems they share and the solutions to those problems that they desire; identifying the people and structures that can make those solutions possible; enlisting those targets in the effort through negotiation and using confrontation and pressure when needed; and building an institution that is democratically controlled by that constituency that can develop the capacity to take on further problems and that embodies the will and the power of that constituency.

5.5 Role of Special Educator, Family, Community and PwID in CBR

FAMILY IN COMMUNITY BASED REHABLITATION:-

•        For parents of children with special needs, initially, acceptance becomes the main concern.

•        The education of the child with special needs.

•        Family think disabled child as burden on them. As they have to take care of all the needs of the child.

•        family don't provide education facilities to these children as they have attitude that these children can't do productive in their lives.

TEACHER IN COMMUNITY BASED REHABLITATION:-

•        Teachers have inadequate training in inclusive education.

•        Teachers ignore children with disabilities because of the extra attention that children with disabilities.

•        Teachers‟ frustration and negative attitudes affected academic performance of students with disabilities.

•        Teachers‟ expectations of students with disabilities are low and they spent less effort and time teaching these students.

•        Teacher’s favourable and unfavourable feelings towards the students with disabilities had a significant effect their educational attainment.

ROLE OF CO-WORKERS IN COMMUNITY BASED REHABLITATION:-

•        Capacity building and the enablement of CBR’s partner organisations is enhanced by further training by CBR co-workers.

•        The quality of services is ensured in accordance with the latest developments in CBR's policies.

•        Recognizing and providing equal opportunities is ensured throughout recruitment, policy formulations and administration of activities.

PEER GROPU IN COMMUNITY BASED REHABLITATION:-

•        Low acceptance by peers, few friendships, loneliness and even being rejected and/or bullied.

•        Young students with disabilities, resulting in difficulties in joining groups and activities.

•        Avoid and  labelled  people with disabilities

•        Faced difficulty engaging in a personal interaction with the child with disabilities.