Community-based rehab evolves
IN AN effort to bring rehabilitation to persons with disabilities in their homes and communities as opposed to receiving rehabilitation services in institutions, community-based rehabilitation is a strategy that has developed since the early 1980s.
The World Health Organisation (WHO) initiated the concept of community-based rehabilitation following the Declaration made at the primary health care conference of Alma-Ata in 1978, the aim was to improve the quality of life of persons with disabilities and their families, particularly in low and middle-income countries.
However, as evidenced by the publication of the Joint Position Papers on CBR (ILO, UNESCO & WHO, 1994 and 2004) and the CBR Guidelines (WHO, 2010), community-based rehabilitation has evolved to become a multi-sectoral approach, which promotes community-based inclusive development that seeks equal opportunities for people with disabilities, thereby fighting against the vicious cycle of poverty and disability (Rule, 2015, WHO, 2017).
Community-based rehabilitation has now taken a comprehensive approach, focusing on five key areas, health, education, livelihoods, social aspects and empowerment (WHO, 2017). Each key area has a number of principles that are assigned to it, and the idea is to practically translate these principles into tangible ways of working, that are visible in community development activities.
Whilst the community-based rehabilitation matrix is composed of five key areas (health, education, livelihoods, social aspects and empowerment) it does not mean that every community-based rehabilitation initiative should tackle all of them at once or in any particular order, but a community-based rehabilitation initiative can select what it deems as the most practical entry point.
For example, in relation to education, an initiative can choose to organise parents of children with a diverse range of disabilities using for example, the model taken by the Tamiranashe Centre in Norton or the Ngonidzaishe Care Centre in Rusape, or the initiative may choose to tackle early childhood development of children with disabilities as exemplified by the Nzeve Deaf Children Centre in Mutare.
Taking the above approach, does not mean that a community-based rehabilitation programme should be stuck at the same level but from there, the same initiative can move to tackle primary healthcare as it continues to build up the community-based rehabilitation programme, until a logical programme which consists of the five key elements (health, education, livelihoods, social aspects and empowerment) is formed and supported by a strong linkage of multi-sectoral partnerships and alliances (WHO, 2017).
Focus could be on preventive measures, for example, “a handful of green vegetables every day would be enough to save the eyesight of some 250 000 children who go blind every year because their diet lacks vitamin A, proper sanitation can eliminate the spread of contagious and disabling diseases” (Boylan, 1991).
A serious community-based rehabilitation initiative is implemented through the combined efforts of people with disabilities, their families and communities, and relevant government and non-government health, education, vocational, social and other services.
The concept of community-based rehabilitation has for many years been prevalent in the region particularly in countries like Zimbabwe, South Africa, and Botswana. In South Africa a number of programmes use grass-roots community-based rehabilitation workers and midlevel rehabilitation workers (Rule et al, 2006). Some community-based rehabilitation programmes rely in part, on the services of volunteers who may have other occupations such as teachers, farmers or unemployed housewives.
Many people may wonder about how and from where they can get information and knowledge about community-based rehabilitation training, planning and implementation. WHO provides community-based rehabilitation guidelines which give direction on how to develop and strengthen community-based rehabilitation initiatives, and promote community-based rehabilitation as a strategy for community-based development. In part, the strategy seeks to involve and empower persons with disabilities, support their basic needs and enhance their quality of life.
For example, in order to avoid incurring travel and other costs to visit rehabilitation centres, local volunteers and family members are trained to provide basic rehabilitation such as daily living skills training for people with disabilities (WHO).
In turn, a person with a disability is trained to perform daily activities such as eating, dressing, communicating, moving around and taking part in school, work and social activities (Boylan, 1991).
The advantage of training family and community members is that such people are closest to the person with disability, hence their participation in improving the conditions of their lives is both strategic and important.
Community-based rehabilitation encourages the use of low cost resources that are available locally. For example, Ngonidzaishe Care Centre in Rusape uses locally grown timber to make walking frames for children with disabilities as opposed to pursuing expensive imports whose repairs may constantly require parts or professional skills which they may be unable to pay for or which may be unavailable.
The community-based rehabilitation concept proves that the establishment of large rehabilitation centres may not always be the answer, the centres may turn out to be very expensive to run and in some instances they are designed in such a way that they may not necessarily facilitate the participation of people with disabilities in society and in the economy. In any case, “dumping” people with disabilities in rehabilitation institutions can only serve to isolate them from their families and communities, relegating them to institutions whose practices may not be compatible with their family traditions (Boylan, 1991).
Some people have criticised community-based rehabilitation and argued that it is a sub-standard type of service which is designed for poor people. However, research has indicated that 70 percent of people with disabilities in developing countries could possibly have their concerns addressed and their needs met at community level rather than at institution-based programs (Boylan, 1991).
The reality is that some people, particularly those who live in remote rural areas may never, throughout their whole lives be able to get any form of assistance, in the absence of community based rehabilitation programmes.
Within CBR, volunteers and family members are also encouraged to promote inclusive education for children with disabilities, thereby addressing the misconception that investment in education is the preserve of non-disabled children who are likely to be breadwinners in their adulthood; yet non-disabled children also grow into the same adulthood, which demands that they provide for their own families just like everyone else. For example, “it has been estimated that in Southern Africa there are about one million women with disabilities who have a total of about 4 million dependants” (Boylan, 1991).
Way forward
By highlighting some of the tenets of community-based rehabilitation above, I do not mean to say that community-based rehabilitation is the only solution to all problems that are faced by people with disabilities, it is clear that for community-based rehabilitation to be successful other resources may also need to be present within communities.
However, it is not useful for us to make “noise” about human rights, whilst we do nothing on the ground to make a positive difference in the lives of persons with disabilities within families and communities.
The United Nations Convention on the Rights of Persons with Disabilities (2008), highlights the need for people with disabilities to have access to support, participation and inclusion in the community in all aspects of society, ensuring that they are as close as possible to their communities including in rural areas. If implemented properly and with sincerity, community-based rehabilitation plays a critical, practical and strategic role in ensuring that equal rights for all have been achieved.
Why should the realisation of human rights be for the urban elite who can address their concerns through the courts? There are people out there who know nothing about national legislation or the UN Conventions whose realization of human rights needs to be facilitated.
It is such people that we should aim to reach with good quality community-based rehabilitation programmes that seriously take community-based rehabilitation guidelines and principles into account (Harley and Okune n.d.). Dr Christine Peta is a Public Health Care Practitioner who, among other qualifications, holds a PhD in Disability Studies. Be part of international debate on how best to nurture a society which is more accessible, supportive and inclusive of disabled people. Partner with Disability Centre for Africa (DCFA): whatsapp, 0773-699-229; website; www.dcfafrica.com; e-mail; dcfafrica@gmail.com