COMMUNITY BASED REHABILITATION(CBR)

DEFINITION
Community-based rehabilitation(CBR) is a strategy within the community for the rehabilitation, poverty
reduction, equalization of opportunities and social integration of people with disabilities in low-income and
middle-income countries, by making optimum use of local resources.

HISTORY
CBR was initiated by the World Health Organization(WHO) following the Declaration of Alma-Ata in 1978. In
recognition of this, the ESCAP (Economic and Social Commission for Asia and the Pacific) had declared the
decade 1993-2002 as the Asia and Pacific decade for the disabled. Later key recommendations were made in
2003 at the International Consultation in Helsinki to review Community-based Rehabilitation.

OBJECTIVES
 Supporting people with disabilities to maximize their physical and mental abilities.
 Helping them access regular services and opportunities, and to become active contributors to the
community and society at large.
 Activating communities to promote and protect the rights of people with disabilities by removing barriers
to participation, improve awareness about disability and lobby for their inclusion in society.
 Prevent disability by providing proper nutrition, detection of disability in young children and intervention
early in their development.
 Empowering PWD and their families.

PRINCIPLES
The following principles should be included in a CBR program. The principles are overlapping,
complementary and inter-dependent.
 PARTICIPATION
CBR focuses on abilities, not disabilities. It depends on the participation and support of people with
disability, family members and local communities. It also means the involvement of people with disabilities as
active contributors to the CBR programme, from policy-making to implementation and evaluation.
 INCLUSION
Inclusion means placing disability issues and people with disabilities in the mainstream of activities. CBR
works to remove all kinds of barriers which block people with disabilities from access to the mainstream of
society.
 EMPOWERMENT
Local people – and specifically people with disabilities and their families, ultimately may make the
programme decisions and control the resources. It means ensuring that CBR workers, service providers and
facilitators include people with disabilities and that all are adequately trained and supported.
 EQUITY
CBR emphasizes equality of opportunities and rights – equal citizenship. Interaction with other members
of the community, without being neglected or discriminated.
 SELF-ADVOCACY
It means self-determination. CBR consistently involves people with disabilities in all issues related to their
well-being.
 FACILITATION
CBR requires multisectoral collaboration to support the community and to address the individual needs of
people with disability.
 PARTNERSHIPS
CBR depends on effective partnerships with community-based organizations, government organizations
and other organized groups.

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  SUSTAINABILITY
CBR activities must be sustainable beyond the immediate life of the programme itself. The benefits of the
programme must be long-lasting.

CRITERIA
The development and implementation of CBR program should be based on the following criteria:
 People with disabilities must be included in CBR program at all stages and levels, including initial program
design and implementation
 CBR program activities should improve the quality of life of people with disabilities
 CBR program activities are working with the community to create positive attitudes towards people with
disabilities and to motivate community member to support and participate in CBR activities.
 CBR program is providing assistance for people with all types of disabilities (Physical, sensory,
psychological and mental); for people of all ages including older people; for people affected by leprosy; for
people affected by epilepsy, and for other people who may be identified by the communality as needing
special assistance.
 All activities in CBR program must be sensitive to the situation of girls and women. This is because in
many communities throughout the Asian and Pacific region women are not treated equally. When they are
disabled, the problems that they face in life are doubled. Furthermore, women are usually the primary family
caregivers for all people with disabilities.
 CBR programs must be flexible, so that they can operate at the local level and within the context of local
conditions. There should not be only one model of CBR because different social and economic contexts and
different needs of individual communities will require different solutions. Flexible, local programs will ensure
community involvement and result in a variety of program models which ae appropriate for different places.
 CBR program must coordinate service delivery at the local level. Community members should understand
their specific different roles that are part of providing assistance to people with disabilities.

MODLES OF CBR
 WHO MODEL
This model uses trainers and distributes booklets on health conditions
 NEIGHBORHOOD MODEL:
A resource center in the community adopts another center, trains the personnel, and in due course this
becomes another resource center
 DRC MODELS:
The District Rehabilitation Scheme (DRC) was launched by the Government of India in January 1985. The
DRCs surveys disabled population, and works on all aspects of rehabilitation like prevention, early detection,
and medical intervention. Deformities are corrected surgically; physiotherapy occupational therapy and
speech therapy are given, and amputees are provided with artificial limbs. The entire gamut of socio-
vocational rehabilitation like training, job placement, and self-employment opportunities is also catered to
under this scheme.

CBR MATRIX
CBR matrix is a framework for CBR programmes.
The matrix has been developed to help CBR managers visualize the range and depth possible in a CBR
program. CBR matrix gives an idea on which sector should be focused for the effective CBR programme.
It has five key components: Health, Education, Livelihood, Social and Empowerment and within each
component there are five elements. The following table shows the components of the CBR matrix along with
its elements.

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HEALTH EDUCATION LIVELIHOOD SOCIAL EMPOWERMENT
Promotion Early childhood Skills development Personal assistance Advocacy and communication
Prevention Primary Self-employment Relationships, Community mobilization
marriage, and family
Medical care Secondary and higher Wage employment Culture and arts Political participation
Rehabilitation Non formal Financial services Recreation, leisure, Self-help groups
and sports
Assistive lifelong learning Social protection Justice Disabled people's organization
devices

CBR PROJECT VS CBR PROGRAM

CBR PROJECTS CBR PROGRAMMES
Small in scale large in scale
Focused on achieving very specific outcome in one More complex than projects
component of the CBR matrix
Short term with set start-point and end point. Usually long term with no set completion dates
If the government support is limited, it can be started by local The successful project may be expanded to the
community groups and nongovernmental organizations. program level

ASPECTS OF CBR
CBR has four important aspects.
1. MEDICAL
The medical aspect usually starts with evaluation of the disability by a group of professionals. A
comprehensive program is charted out, which is followed up by diligent grassroots level trained personnel.
Usually the relatives of the patient are also trained
2. EDUCATIONAL
Whenever required, education is imparted to those who need basic knowledge and skills. This gains
more significance in children suffering from cerebral palsy.
3. ECONOMICAL
The educational vocational and avocational skills imparted will provide a springboard for the patient to
register himself for a job, or open up opportunities for self-employment, and avenues for economic
betterment.
4. SOCIAL
The success of any CBR program depends upon factors like cost effectiveness, individualized values as
well as social acceptability of the program.

RESOURCES OF CBR
All communities have resources. It helps to build a CBR program. The following resources should be
considered-
 HUMAN RESOURCES
It includes the types of personnel needed to implement the programme, e.g. Doctors, Nurses, Health
worker (Male and Female), Health Assistant (Male and Female), Pharmacists, Lab technician etc.
 MATERIAL RESOURCES
It includes the types of facilities and equipment needed to implement the programme, e.g. office
space, furniture, computers, mobile phones, vehicles, audiovisual equipment, and rehabilitation equipment.

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  MONEY RESOURCES
Cost can be a major limiting factor for new programs, so it is important to think carefully about the
amount of money that is needed. The best way to do this is to prepare a budget. It does not matter whether a
CBR programme is using existing funds or funds from a donor , it is always important to prepare a budget.
Currently India is spending 3% of GDP on health and family welfare. Govt expenditure on Health 18% of GDP
in developed countries & 1-2% of GDP in developing countries.
 TIME RESOURCES
Time is money and it is an important dimension in health care services. WHO survey reveals ANM
(Auxiliary nurse midwife, commonly known as ANM, is a village-level female health worker in India who is
known as the first contact person between the community and the health services) spends 45% of her time in
giving medical care, 40% in travelling, 5% in paper work, and only 10% field work duties for which she has
been trained.

STEPS OF CBR
1. Identification of person requiring rehabilitation services
2. Assessment of disabilities and various needs for rehabilitation of identified person
3. Provide the basic services through primary Health care such as drugs, dressing, materials.
4. Refer to secondary/tertiary care centers
5. Facilitating the accessibility to socio-economic rehabilitation services
6. Review meetings by all stake holders, to discuss progress.

CBR VS IBR
CBR IBR
DEFINITION In this type, rehabilitation is In this type, rehabilitation is performed in the institute
performed within the community by that may be regional rehabilitation, district
utilizing the local resources and rehabilitation or research rehabilitation centre or in
contribution of local people the special education institute i.e. deaf and dumb
school, school for MR children etc.
ACCESSIBILITY OF SERVICES Accessible to all Only few institutions are accessible to all
DURATION OF TRAINING 3 months to 1 year 4-year degree
COST OF TREATMENT Cheaper Costly
EXTENSION OF SERVICES Can be done without of much cost Not possible
SOCIAL REHABILITATION Possible Not possible as patient is away from family
PSYCHOLOGICAL Much Possible as they have support Not much possible
REHABILITATION of family
SKILLED PERSONAL CARE Not given Given
APPLICATION OF ADVANCED Not possible Possible
TECHNIQUE
QUALITY OF SERVICE Not good Good
ACTIVE PARTICIPATION Possible Not possible
PROMOTION OF Yes Not
AWARENESS
COMMUNITY INTERACTION Done Not done

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ADVANTAGES  Wide coverage service can be achieved • Research programs
 Community interaction and the empowerment • Statistics generated
 Affordability • Rare conditions can be treated
 Build up of manpower and resources • Systematic program initiated and carried out
 Comprehensive and holistic development by professionals
 Awareness and acceptance
 Sustainability
 Wise use of local resources
 Need based planning
DIS-ADVANTAGES  Improper care due to lack of specialized trainee • Prohibitively costly
 Difficulties with evaluation • Patients are mostly admitted; hence they are
 Reducing the importance of professional services cut off from society
 Unreliability of community involvement • No follow up when patients are discharged
 Limitation of local resources
 Difference in large scale co-ordination and co-
operation

EVALUATION OF CBR
Evaluation means assessment. Evaluation of CBR refers to make objective judgements on the relevance,
efficiency, effectiveness, impact and sustainability of the programme.
Evaluation is different to monitoring because it is not carried out continuously. Evaluation only takes place
at specific points in the project cycle – an evaluation may be carried out midway through the implementation
of the programme, immediately after its completion, or some time afterwards (e.g. a couple of years).
Evaluations can be carried out following way-
 SELF-EVALUATION- The evaluators are said to be those who are inside the program or know the
program very well. For example: program administers, executors, target people, service consumers etc.
 MUTUAL EVALUATION- The evaluation is made between (or among) two (or more) CBR programs. The
evaluators come from outside their own community. They can exchange experiences, draw on each other’s
advantages and avoid disadvantages
 HIGHER AUTHORITIES- EVALUATION- The evaluation is made by superior level departments that are in
charge of the program. Therefore, the program can get the understanding support and suggestion from their
higher authorities directly.
 EXTERNAL EVALUATION- The evaluation is carried out by organizations and persons from outside the
country or the community. Outsiders can take a fresh look at the program and will not be personally involved,
so the evaluation may be more objective.
The following is a list of the kind of information needed for evaluation.
 General information of disabled person: Name , age, gender, occupation, address.
 HISTORY OF DISABILITY: The type and degree of disability, the causes of disability, rehabilitation or
medical measures accepted and the assessment of abilities for living, learning working and social activity of
disabled person.
 REHABILITATION NEEDS: It includes needs that the disabled people may have in medical care,
rehabilitation service, education, employment, participate family’s life and social activities of disabled person.
It is necessary to judge the priority among all the rehabilitation needs.
 SOCIAL ASPECTS: It includes marriage status, family composition, source of income, employment
status, attitude from family members and disabled person himself or herself etc.
 COMMUNITY PROFILE: It provides basic information of a community such as general description,
ethnic, culture, religious, situation on socioeconomical development, environment, quality life of disabled

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people, health, and social activities etc. People may think that they are familiar with their own community and
know it very well, but they may lack of information, which is essential for a CBR program.

CBR TEAM
 THE PATIENT
He has to be involved in all decision-making processes, because he is the recipient of the services. It
reduces the sense of isolation and loneliness.
 FAMILIES OF PEOPLE WITH DISABILITIES
They contribute essential understanding and empathy, which cannot be obtained by any other strategy.
Their involvement also serves to improve the quality of life of PWDs as it gives them confidence and improved
self-esteem.
 COMMUNITY MEMBERS
Community members know the local environment conditions, the economy, political situation and how to
work with them.
 REHABILITATION PROFESSIONAL
The rehabilitation professional, whether he is medical, paramedical or socio-vocational, is seen as a
leader, teacher and guide instead of as a health provider. He imparts training, demystifies the rehabilitation
concepts, solves specific problems, organizes the set up and generally functions as an advisor.
 EDUCATIONAL SECTOR
This sector assist community schools and change their methods of teaching in order to provide quality
education of all children. Within the school system there are many people with knowledge and skills that
could be shared with community schools. For example, there are schools that only child with special needs
and the teachers from those school can serve as resources to teachers in community school.
 GOVERNMENTS & NON-GOVERNMENTAL ORGANIZATIONS
Governments & a variety of non-governmental organizations (NGOs, relief and development
organizations, faith-based organizations) and groups( Local Clubs, Women’ and health groups) can contribute
to a CBR program. Some of these may provide services to people with disabilities, while others can make
special efforts to include them in their activities.
 EMPLOYMENT AND LABOUR SECTOR
Employment services organized by the sector help job seekers with disabilities to find employment
opportunities in the open labour market. In addition, the civil service can set a good example by employing
workers with disabilities.
 CORPORATE SECTOR
The corporate sector, comprising of profitable companies and industries have recently coined a term
corporate social responsibility (CSR), implying an obligation to plough back some of the benefits of its
operations to the community, in which it operates.
 SKILLED WORKERS
The locally available skilled workers, e.g. carpenters who could be trained to make appliances and aids,
local leaders who can try for barrier free environment can include in a CBR team.

ROLE OF PHYSIOTHERAPY IN CBR

 Preventing disability and deformity
 Improve movement of disabled people
 Functional training
 Promoting self-care
 Consultancy, advice, support, and supervision to other health care professionals
 Advice to governments, NGOs and local communities on establishing CBR programs.

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