Cbr Sangli Seminar

1. Community Based Rehabilitation: New perspectives 2. Outline <ul><li>Origin & development </li></ul><ul><li>What is CBR…
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  • 1. Community Based Rehabilitation: New perspectives
  • 2. Outline <ul><li>Origin & development </li></ul><ul><li>What is CBR </li></ul><ul><li>Models of CBR </li></ul><ul><li>New WHO CBR Guide lines </li></ul>
  • 3. Community <ul><li>“ A community consists of people living together in some form of social organization and cohesion. Its members share in varying degrees, political, economic, social and cultural characteristics, as well as interests and aspirations, including health. Communities vary widely in size and socio-economic profile, ranging from clusters of isolated homesteads to more organized villages, towns and city districts”. (Helander (1993 ) </li></ul>
  • 4. Community <ul><li>Currently, the term “community” has two general meanings. </li></ul><ul><li>The first refers to ‘actual groupings of people’ or ‘ geographical groups ’. </li></ul><ul><li>The second refers to ‘social ideals of </li></ul><ul><li>solidarity, sharing and consensus’ or ‘ affinity groups’ . </li></ul>
  • 5. Rehabilitation <ul><li>Rehabilitation is a dynamic multidisciplinary process, that, in partnership with a client, often combines interventions of medical, social, educational and vocational disciplines to maintain, or obtain and secure, for a person who is experiencing certain problems related to a health condition or disorder, a respected and satisfying place in society. (JW Brandsma, 2004) </li></ul>
  • 6. Historical Development Rehabilitation services Traditional Institutions Community-based reh. Resource centers Information-based 1950 1980 1990 2000
  • 7. <ul><li>Charity approach- </li></ul><ul><li>Institutions to take care of the disabled </li></ul><ul><li>Medical Model only </li></ul><ul><li>Urban centered </li></ul><ul><li>Expensive </li></ul><ul><li>Not empowering </li></ul><ul><li>Segregation </li></ul><ul><li>Reaching out to very few </li></ul>
  • 8. Why Community Based Rehabilitation? <ul><li>Institutions are </li></ul><ul><li>expensive </li></ul><ul><li>(Helander, WHO, 1976) </li></ul><ul><li>Institutions require high tech </li></ul><ul><li>personnel </li></ul><ul><li>(Helander, WHO, 1976) </li></ul><ul><li>Institutions are reaching only </li></ul><ul><li>2% of disabled population in </li></ul><ul><li>developing countries (Helander, WHO, 1976) </li></ul><ul><li>Institutions segregate/isolate instead of integrate </li></ul>
  • 9. IBR versus CBR debate: <ul><ul><li>Rehabilitation can be done in most cases without specific expensive equipment </li></ul></ul><ul><ul><li>IBR does use a medical model </li></ul></ul><ul><ul><li>While costs of IBR are high, specialised services may be more effective and efficient </li></ul></ul><ul><ul><li>Community services can also be specialised </li></ul></ul><ul><ul><li>Complementary models and services </li></ul></ul><ul><ul><li>Risks: CBR as second rate, under-funded services </li></ul></ul>
  • 10. <ul><li>Following the Alma Ata Declaration1 (1978) &quot;Health for all&quot; and considering the limitation of specialized medical rehabilitation services, the World Health Organization introduced the concept Community Based Rehabilitation (CBR). CBR was designed to enhance the quality of life for people with disabilities through community initiatives. It was also introduced to ensure that rehabilitation services reached those in developing countries where the majority of disabled people live. The focus was on training a person with disability to carry out daily activities such as going to school, playing with others, joining in family and community activities and making a living, mainly by using local resources. </li></ul>
  • 11. Community Based Rehabilitation <ul><li>Delivering rehabilitation with limited and local available resources to as many people as possible is at the core of CBR </li></ul>
  • 12. <ul><li>The original concept of CBR was an extension of PHC system, which expanded services to reach underprivileged people who had no access to services till then. This was to be done through the use of manual based training of community volunteers and family members The key element was the transfer of minimum and essential rehabilitation intervention skills to families and other volunteers in the community. In the early eighties, CBR was conceptualized and evolved primarily as a service delivery method with a medical focus, following the WHO recommendation that CBR be integrated into the PHC system, which was already well established in many developing countries </li></ul>
  • 13. <ul><li>The International Classification of Impairments, Disabilities and Handicaps (ICIDH) published in 1980 by WHO also contributed to a medical approach. </li></ul><ul><li>ICIDH defines a model that progresses from disease, impairment and disability to handicap in a linear fashi on. </li></ul><ul><li>disease impairment disability handicap </li></ul>
  • 14. <ul><li>Impairment is defined as abnormality of structure or function of the body or an organ. </li></ul><ul><li>Disability is defined as a restriction or lack of ability as a result of impairment. </li></ul><ul><li>Handicap is defined as a social disadvantage faced by an individual resulting from either impairment or disability. </li></ul>
  • 15. <ul><li>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. </li></ul>
  • 16. The Medical Model of Disability <ul><li>Disability is individualised. It is regarded as a disease state that is located within an individual. Thus, the problem and solution may both be found within that individual </li></ul><ul><li>Disability is a disease state, a deviation from the norm, which inherently necessitates some form of treatment or cure </li></ul><ul><li>Being disabled , a person is regarded inherently as biologically or psychologically inferior to an able bodied person </li></ul><ul><li>Disability is viewed as a personal tragedy . It assumes the presence of a victim </li></ul>
  • 17. Community Based Rehabilitation <ul><li>Developments in eighties in the West </li></ul><ul><ul><li>Mainstreaming </li></ul></ul><ul><ul><li>Attention for the social model </li></ul></ul><ul><ul><li>Decade for Disabled People </li></ul></ul><ul><ul><li>(1980-1990) with International </li></ul></ul><ul><ul><li>Year of the Disabled in 1981 </li></ul></ul><ul><ul><li>Rise of Disabled Peoples </li></ul></ul><ul><ul><li>Organisations and focus on </li></ul></ul><ul><ul><li>rights issues </li></ul></ul><ul><ul><ul><li>1981 launch of DPI in Winnipeg </li></ul></ul></ul><ul><ul><ul><li>National and regional DPOs </li></ul></ul></ul>
  • 18. Social Model of Disability <ul><li>Human rights principles are at the core of the social model </li></ul><ul><li>A person’s impairment is not the cause of restriction of activity </li></ul><ul><li>The cause of restriction is the organisation of society </li></ul><ul><li>Society discriminates against disabled people </li></ul><ul><li>Attitudinal, sensory, architectural, and economic barriers are equally, if not more, important than health barriers </li></ul><ul><li>Less emphasis is placed on the involvement of health professionals in the life of a person with disability </li></ul>
  • 19. <ul><li>The social model focuses on the strengths of the person (and not on her limitations as in the medical model) and values her potential . This model frames disability as part of human diversity. Fear, ignorance and prejudice create barriers and cause discrimination which increases disability. The issue becomes an attitudinal one requiring individuals to change their perceptions in order to ensure full participation of people with disabilities in society. </li></ul>
  • 20. <ul><li>The ICF( the International Classification of Functioning, Disability and Health ). illustrates a clear shift from the 1980 version of ICIDH which describe disability, impairment and handicap in terms of diminishment to a model which describes body structure, functioning, activities and participation in a positive way. </li></ul>
  • 21. <ul><li>Health condition </li></ul><ul><li>(Disorder or disease) </li></ul>Body functions and structures (Impairment) Activities (Restrictions) Participation ( Limitations) Environmental Factors Personal factors
  • 22. <ul><li>Health condition, personal factors and environmental factors are all considered as influences on body functioning, performance of activities and participation in social life. </li></ul>
  • 23. What is CBR? <ul><li>CBR is what the people say it is… </li></ul><ul><li>(in Wolffers and Finkenflugel, 1993) </li></ul><ul><li>CBR is a philosophy with diverse applications that reflect the variety of cultures and levels of development (Peat, 1997) </li></ul>
  • 24. Definitions of CBR <ul><li>CBR involves measures taken at the community level to use and build on the resources of the community, including the impaired, disabled and handicapped persons themselves, their families and their community as a whole (WHO, 1984) </li></ul>
  • 25. Definitions of CBR <ul><li>CBR is more than a method; it is a philosophy aimed at working in the struggle for human rights and more specifically the rights of disabled people (Alexandra township South Africa, 1991) </li></ul>
  • 26. Definitions of CBR <ul><li>CBR is a strategy within community development for the rehabilitation, equalisation of opportunities and social integration of people with disabilities (UN, 1994) </li></ul><ul><li>It is achieved through the combined efforts of people with disabilities, their families, and communities and the appropriate health, education, vocational and social services </li></ul>
  • 27. Term CBR, Usages <ul><li>1. Home based services provided by families to their disabled members in their homes. </li></ul><ul><li>2. Self help projects run by disabled persons. </li></ul><ul><li>3. Out-reach projects run by rehabilitation institutions. </li></ul><ul><li>4. NGO projects run by paid CBR workers. </li></ul><ul><li>5. An ideology, which promotes inclusion of disabled persons in developmental projects. </li></ul><ul><li>6. Institutional programmes located in villages. </li></ul><ul><li>7. A term to describe anything related to rehabilitation of disabled persons. </li></ul>
  • 28. Classification of Rehabilitation Projects <ul><li>4 dimensions / objectives </li></ul><ul><ul><li>Restoration of quality of live </li></ul></ul><ul><ul><li>Locus of Power </li></ul></ul><ul><ul><li>Commitment to involve others </li></ul></ul><ul><ul><li>Range of Activities </li></ul></ul>Individual model Social model
  • 29. Classification of Rehabilitation Projects Restoring physical functioning Social & Economic rehab. Equality of rights P hysical P W ell-being W A dvocacy A Restoration of quality of life Individual Social
  • 30. Classification of Rehabilitation Projects Clients as receivers Clients make limited choices Clients have full ownership C o mpliance O L im. choice L E mpowerment E Locus of power Individual Social
  • 31. Classification of Rehabilitation Projects Focus only on people with disabilities Involving families Community participation B eneficiary B F amily F C ommunity C Involvement of others Individual Social
  • 32. Classification of Rehabilitation Projects Single resource / service Multiple services Multisectoral collaboration Information sharing S ingle S V ariety V R eferral R Individual Social Range of activities
  • 33. Classification of Rehabilitation Projects Individual Social Restoration of quality of life P W A Locus of power O L E Involvement of others B F C Range of activities S V R
  • 34. <ul><li>What CBR is </li></ul><ul><li>Flexible </li></ul><ul><li>Active involvement of families and communities </li></ul><ul><li>A partnership approach with disabled people and parents of disabled children </li></ul><ul><li>Capacity building of disabled people and their families, in the context of their community and culture </li></ul><ul><li>Holistic in its approach to disabled people; addressing social, employment, educational, and other needs not just physical ,multi-sectoral </li></ul><ul><li>An approach which uses centres/ institutions to respond to the needs of disabled people and their families </li></ul><ul><li>A system which is based in the community, but which uses district level and national level services for referral </li></ul><ul><li>An approach which aims to enable around 80% of disabled people’s rehabilitation needs to be addressed in the community </li></ul><ul><li>Integrated into existing services and promoting the social inclusion of disabled people </li></ul><ul><li>An approach with a broad concept of rehabilitation’ </li></ul><ul><li>A long term strategy </li></ul><ul><li>What CBR is not </li></ul><ul><li>Rigid or a blue-print </li></ul><ul><li>An approach which only focuses on the physical or medical needs of a person </li></ul><ul><li>Long-term residential care </li></ul><ul><li>Delivering a service to disabled people as passive recipients </li></ul><ul><li>Only outreach from a centre </li></ul><ul><li>Rehabilitation training in isolation </li></ul><ul><li>Surveys on disability with no action </li></ul><ul><li>Limited to one sector </li></ul><ul><li>An approach which is determined by the needs of an institution or group of professionals </li></ul><ul><li>An approach which requires that disabled people have to travel to a remote centre or institution to meet their needs </li></ul><ul><li>Segregated and separate from services for other people </li></ul><ul><li>An approach with a narrow concept of rehabilitation’ </li></ul><ul><li>A short-term fix </li></ul>
  • 35. Starting Points <ul><li>Improvement of physical, social and psychological function of the person with a disability </li></ul><ul><li>Solidarity with those who are denied their rights and working for adaptation of society </li></ul><ul><li>Working for integration and equality of rights of those people with disabilities within the mainstream of society </li></ul>
  • 36. Starting Points <ul><li>Rehabilitation should where possible be part of community development </li></ul><ul><li>Rehabilitation is achieved through multi-sectoral collaboration </li></ul>
  • 37. CBR Core Objectives <ul><li>Inclusion of people with disabilities in civil, social, political and economic structures of society. </li></ul><ul><li>People with disabilities playing a full part as citizens or equal members of the community with the same rights, entitlements and responsibilities as others, while contributing tangible benefits to the whole community. </li></ul>
  • 38. Twin Track Approch <ul><li>Mainstreaming </li></ul><ul><li>The equalisation of opportunities and integration of disabled people in society </li></ul><ul><li>Disability specific </li></ul><ul><li>The interventions that may take place at the individual level in order to improve the quality of life </li></ul>
  • 39. <ul><li>It is important to recognize the particular needs of people with disabilities, especially their rehabilitation interventions needs , in order to ensure that inclusion in mainline development schemes does not lead to further marginalization of people with disabilities and their issues. </li></ul><ul><li>The twin track approach to disability and development, which promotes inclusive development while addressing particular needs of people with disabilities is an increasingly accepted strategy. </li></ul>
  • 40. <ul><li>The twin track approach is becoming evident in current CBR trends, where CBR projects address the special needs of people with disabilities, and promote their inclusion in all mainstream development processes and activities. </li></ul>
  • 41. The New Community Based Rehabilitation CBR as Inclusive Development Strategy in order to Alleviate Poverty
  • 42. The need for strengthening CBR programmes: “Inclusive Communities” 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 d
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