By: Sangeetha Loganathan

and

Angeliza Arciaga

The emergence of the concept of Community Based Rehabilitation

If you give a person a fish, hell eat for a day;

if you teach him to fish,

hell eat for a lifetime.

Definition:
CBR (Community Based Rehabilitation)
is a systematized approach within general community development whereby Persons with Disabilities are enabled to live a fulfilling life within their own community, making maximum use of local resources and helping the community become aware of its responsibility in ensuring the inclusion and equal participation of PWDs.(Persons With Disabilities)In the process, PWDs are also made aware of their own role and responsibility, as they are part of the community.

A strategy within community development for the rehabilitation, equalization of opportunities and social integration of all people with disabilities (UN definition) CBR is a strategy for enhancing the quality of life of disabled people by improving service delivery, by providing more equitable opportunities and by promoting and protecting their human rights (E. Helander ).

 Impairment (is) lacking part of or all of a limb, or having a defective limb, organ or mechanism of the body; Disability (is) the disadvantage or restriction of activity caused by contemporary organization which takes no or little account of people who have physical impairments and thus excludes them from the mainstream of social activities.
The Union of the Physically Impaired Against Segregation, 1976

Cerebral Palsy
is the commonly used name for a group of conditions characterized by motor dysfunction due to non-progressive brain damage early in life. is an umbrella term encompassing a group of non-progressive, noncontagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement.

What do we see in the picture?

Mainstream

Your Boat

What if you are in the Mainstream? What if you are in the Side stream?

Mainstreaming and inclusion

Mainstreaming and inclusion is seen as an effective way: (a) to include persons with disability (b) to give equal opportunities and (c) to provide a non-discriminative environment for their growth and development. In practical terms this means persons with disability are included in the programmes and schemes formulated by the government and others, not as mere beneficiaries but as equal members who can participate with full recognition and exercise their rights.

Introduction
Evolution I 1970s Concept was very new, but was medically orientated Einer Helander Strong medical model influence top-down power relations No effective involvement by disabled people 1980s/1990s Shift of emphasis away from medical towards Empowerment and community development Increasing influence of social model Consensual power relations.

Evolution II 2000 onwards CBR perceived in terms of human rights Increasing influence & involvement of Disabled people, Bottom-up power relations Rights-based approaches to development

What do we do in CBR???
The idea of CBR is that disabled people should have the right to a good life. The help they need should be available to them, at a low cost. It should be offered to them and their family in a way that suits their usual way of living, whether in a village, a town or a city. They should have education like everybody else. They should be able to take up jobs and earn their living. They should be able to take a full part in all the activities of their village, or town or city.

The idea of CBR is that, even if people learn very slowly, or have problems seeing or hearing, or find it hard to move about, they should still be respected for being men and women, girls and boys. Nobody should be looked down on, or treated badly just because they have a disability.

Houses, shops and schools should be built in such a way that everyone can easily go in and out and make use of them. Information should be given to people in a way they understand, not only in writing, which is hard for people who cannot read or have problems seeing it. Information should be given in spoken forms as well, so that everyone has a fair chance to use it.

Who Initiates CBR ?

Community action for CBR is often initiated by a stimulus from outside the community, most likely ministries or NGOs. Following initial discussions with representatives from outside the community, ideally it is the community which decides whether CBR will become part of its ongoing community development activities.

COMPONENTS NEEDED TO BEGIN A PROGRAMME FOR THE REHABILITATION OF PWDs

Look out for.

1. 2. 3. 4.

An action area where the need is apparent. A community which is receptive. A resourceful and creative outside agency. Persons with Disabilities who need the services of an external agency as well as the community for mainstreaming themselves, in order to set themselves up as contributors and not just recipients of service.

In 1994 the International Labour Organization (ILO), United Nations Educational Scientific and Cultural Organization(UNESCO) and World Health Organization (WHO) produced a Joint Position Paper on CBR in order to promote a common approach to the development of CBR programmes.

Major Objectives
The major objectives of CBR as listed in the joint position paper are:

To ensure that PWDs are able to maximize their physical and mental abilities, to access regular services and opportunities, and to become active contributors to the community and society at large. To activate communities to promote and protect the human rights of PWDs through changes within the community, for example, by removing barriers to participation.

CBR in Qatar:
Initiated in Qatar on September 2001 introduced at the beginning of 2003 The main interventions were training for involvement in life situations, job site training and providing family counseling and support. The project was introduced to develop and implement the CBR concept across Hamad Medical Corporation (HMC) and the community of Qatar, encompassing the WHO principles of CBR. The available structures within PM&R and GD were used as a platform to develop a new service of CBR.

BASIC PRINCIPLES OF A CBR PROGRAMME

HOW

The prin ciple over s ar lapp e com ing, plim enta inte r-de ry a pen nd cann den ot b tt one e se para hey from ted the othe r.
Source: World Health Organization: Meeting Report on the development of guidelines for Community Based Rehabilitation (CBR) programmes : (1 st and 2 nd November 2004, Geneva, Switzerland)

Inclusion
Inclusion means the removal of all kinds
of barriers which block PWDs from access to the mainstream.

Inclusion means placing disability issues

and PWDs in the mainstream of activities, rather than as an after-thought.

Inclusion means including all forms

of impairment.

Participation
Participation means the involvement of PWDs as active contributors to the CBR programme from policy making to implementation and evaluation, for the simple reason that they know best what they need.
Participation also means PWDs being a critical

resource within any CBR programme providing training, making decisions etc.

It covers the participation of women in all

processes and decision-making, and that of other groups who are typically not listened to or excluded.

Sustainability
The benefits of the programme must be lasting. The activity initiated through the CBR programme
must be sustainable beyond the immediate life of the programme itself able to continue beyond the initial intervention and thrive independently of the initiating agency.

Strong links between GOs, NGOs, CBOs and DPOs will contribute towards sustainability. This means that DPOs and SHGs are the hub of any CBR activity.

Empowerment

Empowerment means that local people, and specifically PWDs and their families, make the programme decisions and control the resources. It means PWDs taking leadership programmes. any programme. roles within

The empowerment of women is central to Empowerment necessitates capacity building that is,
the developing and using of the skills necessary to act with authority and responsibility, independent of the initiating agencies and CBR programme managers.

Advocacy
Advocacy means the central and consistent involvement
of PWDs and their families defining for themselves the goals and processes for poverty alleviation.

Advocacy is a collective notion not an

individualistic one. It means selfdetermination.

It means mobilizing, organizing,

representing, creating space for interaction and demands.

GOAL: HUMAN RIGHTS ~ SOCIO-ECONOMIC DEVELOPMENT ~ POVERTY ALLEVIATION COMMUNITY BASED REHABILITATION
PRINCIPLES: PARTICIPATION ~ INCLUSION ~ SUSTAINIBILITY ~ SELF ADVOCACY

HEALTH

EDUCATION

LIVELIHOODS

EMPOWERMENT

SOCIAL

PROMOTIVE

EARLY CHILDHOOD DEVELOPMENT NON-FORMAL

SKILLS DEVELOPMENT INCOME GENERATING ACTIVITIES ACCESS TO FINANCIAL SERVICES OPEN EMPLOYMENT
ECONOMIC CONTRIBUTION & SOCIAL PROTECTION

SELF-HELP GROUPS DISABLED PEOPLE'S ORGANIZATION SOCIAL MOBILISATION

LEGAL PROTECTION CULTURE & RELIGION SPORTS & LEISURE RELATIONSHIP MARRIAGE & FAMILY PERSONAL ASSISTANCE

PREVENTIVE

CURATIVE

FORMAL SCHOOL

REHABILITATIVE

HIGHER

POLITICAL EMPOWERMENT LANGUAGE & COMMUNICATION

ASSISTIVE DEVICES

SPECIAL/ TRANSITORY

WHO MATRIX

ESSENTIAL COMPONENTS OF A CBR PROGRAMME

1. 2. The programme should cover all types of PWDs who need rehabilitation services. The programme should be part of mainstream development and have a multisectoral approach : including social integration interventions, health, education and economic programmes. The programme should have access to or generate a good and effective referral system. The programme should aim at full integration of the PWD into his / her community. The programme needs to have committed and well trained community members as service providers. The programme should have gender and disability focus and balance. The programme should strike a balance between provision of service delivery and empowering the PWD, family and community through regular transfer of skills. The programme should facilitate the formation and strengthening of the disabled peoples movement to ensure that the rights of the PWDs are not denied through advocacy at local, state and national level.

3. 4. 5. 6. 7.

8.

Challenges of CBR
Lack of understanding of concept. Rapid turn over of civil servants. Acceptance of CBR as a valid intervention. Finance / Prioritization. Poor Management / planning of CBR Inter Ministerial Rivalry - Lack of communication Evidence based facts not made available Lack of co-ordination between the Government and NGOs Absence of a coherent community level strategy Limited competence and capacity of decentralizing services Limited models of good practices Social welfare department often has a weak structure at community level Government is preoccupied with basic needs Governments do not include disability as a cross cutting issue.

Rehabilitation of Cerebral Palsy

In working with the child having CP we have 4 goals to remember:

Specific Activities for children with CP

Play with child Lying on stomach 1st stage: encourage them to raise head, support themselves on elbows

 2nd Stage: swing the child slowly

Child reaching to play

 2nd and 3rd stage: first hold the hips then the legs

Creeping

Crawling

 4th stage: creep and crawl under, up, down through round things

Child supports on hands and feet

 Playing with child lying on back 1st stage: encourage child to raise head

 2nd stage: at first help the child lift their hips

2nd to 4th stage: roll and swing child in a blanket slowly

 Playing with a child in sitting position

 1st stage: try different positions

2nd stage & 3rd stage:

 3rd & 4th stage:

 Playing with the child in standing 1st stage:

2nd stage:

 3rd & 4th stage:

Home Visit

Bad

Good
The R.W. did not behave as if she was high up She explained who she was and why she was there She was understanding and empathetic about the amount of work the mother had to do She was patient, kind and friendly

Architectural Barriers
Any architectural feature of a home or a public building that limits the access and mobility of disabled persons. Why??? Remove environmental barriers in order to improve the physical accessibility and inclusion of everybody in the community. How??? By building ramps leading to classrooms, homes, health centers and places of worship. By widening doors for wheelchair and walker access.

Outdoor Accessibility

American with Disabilities Act (ADA) requires 1:12 slope for wheelchairs and scooters for business and public use.

 Any part of an accessible route with a slope greater than 1:20 shall be considered a ramp. The least possible slope shall be used for any ramp. The maximum slope of a ramp in new construction shall be 1:12. The maximum rise for any run shall be 30 in (760 mm) .

Hand Rails

Outdoor stairs and their approaches shall be designed so that water will not accumulate on walking surfaces.

Hallway accessible for 2 wheelchairs

Space needed for a smooth U-turn in the wheel chair

Universal parking Design

Home Accessibility:
Modifications for bathroom accessibility -bathroom door: 32 inches door for a straight in approach -if the doorway is located in the typical hallway and requires turning a wheelchair, youll need a 36 inches door. -swing away door hinge is also an option and will increase the door width by 2 inches.

Diagonal Approach

Side Approach

 Bath tubs: many people find it difficult to use and can be replaced with showers. Toilet seat usually between 17" to 19". Toilets can be replaced with special units or raised seats can be installed. Toilet grab bars can be installed for balance and support and to allow individuals to safely transfer from a wheelchair.

Sinks can be installed to allow wheel chair access

Shelf height:

We look forward to a tomorrow

that does not side stream PWDs

that includes PWDs in the mainstream as equal partners

References:

http://www.adaptiveaccess.com/home_changes.p http://www.oikoumene.org/fileadmin/files/wcc-main Global-help.org http://CBR\Environmental Barriers.mht www.tdlr.state.tx.us/AB/abtas4a.htm http://www.hmc.org.qa/qmj/qmj2006/JUNE200 6/original_studies/org10.htm Sunders Textbook of Rehabilitation.