COMMUNITY BASEDREHABILITATION AND
INCLUSIVE DEVELOPMENT
Maya Thomas
Editor, Disability, CBR and Inclusive
Development
Bangalore, India

Background• Experience of over 25 years in CBR promotion– training, evaluation, strategy development,
research• Mainly in south and south-east Asian region• Mainly associated with NGO projects, some ofgovernment

CBR Origins• “Failure of conventional system, and need foralternative” (Helander, 1993)• Initiated in early 80s, based on PHC principles• Focus on coverage of rehabilitation services forpersons with disabilities in rural areas indeveloping countries, with limited resources• Transfer of skills to local people, including families(WHO, 1989)• Emphasis on individual focused interventions –medical, surgical, therapies, education,
vocational trainingCBR in the initial years – late 80s to
mid-nineties• Vertical CBR project implementation, a few
integrated into development projects• Focus: how many registered with project, howmany covered and benefited from different
services: medical rehabilitation (mobility, ADLS,communication, home based rehabilitation);education (school enrolment, special education);social security; some livelihoods activities; somesocial activities (participation in community,acceptance by friends/neighbours)

Joint Position Paper, 2004
• “The major objectives of CBR are• To ensure that people with disabilities are able tomaximise their physical and mental abilities, toaccess regular services and opportunities, and tobecome active contributors to the communityand society at large.
• To activate communities to promote and protect
the human rights of people with disabilities
through changes within the community, forexample, by removing barriers to participation.”

Changes in project activities• Scope of activities broadened from medical andeducation to:• more focus on poverty and livelihoods,• self help groups, family associations, focus oninclusion, participation,• awareness raising, partnerships and networking,• inclusion of marginalised groups – women,
persons with intellectual or multiple disabilities,
psychosocial disabilities, HIV,• inclusion in general development and poverty
reduction programmes, not just disability-specificentitlements

Changes in CBR understanding andpractice• CBR practice has changed from an often single
sector, service delivery approach, to acomprehensive, multi-sectoral, rights-based one.
• Recognition that persons with disabilities havethe same rights, and need access to the same
services and opportunities, as others in theircommunities.
• CBR is understood today as a strategy to ensure
inclusion, rights and equal opportunities for
persons with disabilities.

CBR Today• WHO 2007 survey: 92 countries had CBR projects
and programs : 35 in Africa, 26 in Asia, 24 in Latin
America and 7 in Europe (Khasnabis, HeinickeMotsch (2008).
• 1st World CBR Congress in 2012 in Agra with morethan 1000 delegates.
• Regional and Global CBR Networks• CBR Guidelines of WHO, released November
2010• UN CRPD : Articles 19, 25 and 26

CBR Today• Specific reference to CBR is found in thenational level policies of Bhutan, India,Indonesia, Myanmar, Pakistan,Philippines, Sri Lanka, Thailand and TimorLeste.
• In Burkina Faso in Africa, CBR has been
adopted as national strategy to support
persons with disabilities.

UN CRPD Support for CBR• Article 26 : “Support, participation and inclusionin the community and all aspects of society arevoluntary, and are available to persons withdisabilities as close as possible to their own
communities, including in rural areas.”• Article 25: “Provide these health services as close
as possible to people’s own communities,including in rural areas”.
• Article 19: “the equal right of all persons withdisabilities to live in the community, with choices
equal to others”.

WHO CBR Guidelines, 2010
• An attempt to address the felt need for a documentthat would synthesise experiences from across theworld and provide a unified understanding of theconcept and principles of CBR.
• Provides a structure for CBR planners and practitioners,
based on which they can develop activities according
to their local context, needs and resources.
• Not a prescriptive document and does not advocate
any particular ‘model.
• Not presenting ‘a new way of doing CBR’, but asynthesis of CBR experiences to illustrate existing andnew concepts, to endorse and strengthen field level
practice.

CBR and CBID (IDDC, 2012)• Community based inclusive development is agoal – of making communities inclusive of all
marginalised groups, including persons withdisabilities.
• The rationale is that no one should be
excluded from development for any reason.
• CBR is the tool or strategy to achieve the goalof community based inclusive development
for persons with disabilities

CBR Guidelines and CRPD
• CBR Guidelines:“CBR is a multi-sectoral, bottom-up
strategy which can ensure that the Convention makes adifference at the community level. While theConvention provides the philosophy and policy, CBR isa practical strategy for implementation. ”• “CBR activities are designed to meet the basic needs ofpeople with disabilities, reduce poverty, and enable
access to health, education, livelihood and social
opportunities – all these activities fulfil the aims of theConvention”• IDDC, 2012 : Link between CRPD and CBR GuidelinesWhat difference can CBR make –evaluation findings (2013)• After 5 years of implementation in an NGO
project in India:• 63% of those who needed rehabilitation andtherapy, showed between 75-100%
improvement. Rehabilitation and therapy
interventions led to increased mobility,communication skills, daily living skills, andaccess to education, income generation andsocial participation.

CBR effectiveness• Accessibility improved in homes and a number ofpublic places in the community.
• The incidence of preventable disabilities came down in
the project area, with fewer numbers of children withdisabilities being identified below the age of 5 years. Inaddition, the project was successful inpreventing/correcting secondary disabilities in anumber of persons.
• A majority of persons with disabilities in the project
area were able to access government schemes andentitlements.
• Better awareness and knowledge led to improved
health and hygiene.

CBR effectiveness• A majority of the family members trained
continued to carry out home based rehabilitationand look after their children. They ensure thatassistive devices are maintained and used
regularly. They follow the advice given on where
to go for specialist assistance. They support theirchildren in education, in income generation
activities; and in getting married. Parents ofchildren with severe intellectual/ multiple
disabilities now take them out for family andsocial functions.

CBR effectiveness• 92% of the identified 114 children with disabilities
were enrolled in inclusive education. 96% of thoseenrolled, continued in the education system.
• 14 Schools in the project are made accessible, 3 with
contributions from the project and the community, andthe rest done by the local government and school
management committees.
• 305 teachers/school authorities (Government andPrivate) were trained, along with 60 early childdevelopment centre teachers.

CBR effectiveness• 88% of those who underwent skills training continued
in the same trade.
• While all those who accessed livelihoods support
showed a marked increase in their family income as aresult, 91% those who accessed livelihoods support
were able to improve their income by 45%.
• 33 SHGs are operating in the project area, with 521
members: 142 men and 379 women.
• As a result of SHG membership, the situation of
persons with disabilities is the same or, in some cases,
better than that of others in the community.

CBR effectiveness• One of the significant achievements is sensitising andmobilising support from the local government units atvillage and district levels. All 8 village level government
units in the project area include disability issues in theiragenda and action plans, and utilise the prescribed 3%budget allocation for persons with disabilities.
• Two of the local government offices were made accessible.
• The district commissioner (administrative head of thedistrict) and other officials are sensitised and supportive.
• The local government units follow the CBR Matrix
components of the WHO CBR Guiidelines for their plansand budgets for persons with disabilities. The Matrix-basedplan is prominently displayed outside their offices.

Case studies• P is a 6 year old girl, with 2 elder sisters and 1
younger brother. She was born prematurely,following complications. She is severely disabled
and undersized, looking half her age. The motheris unable to go out much and cannot join the SHG
because she has to look after the child full-time.
• CBR has helped to get some of the government
schemes and entitlements for the child. The local
SHG members visit the family and help out withmedicines; they also took the family for a day’souting with the SHG members.

Case studies• Mr. T, a trained horticulturist, lost his leg due to gangrene 3 years
ago. He is married, and has a daughter who has intellectual andspeech difficulties. When identified after his amputation, when he
was depressed, jobless, had loans to repay and worried about his
family’s future. CBR provided him with an artificial leg (prosthesis),wheelchair and walker; and motivated him to join the SHG. After
joining the group, he was encouraged to think that he was notalone in facing problems. He started a candle making business in his
home with the help of a grant; and also got a contract from 2 local
industries for garden maintenance. With the help of a loan from theSHG, he started this work. Today he employs 8 persons in hisbusiness.
• CBR assisted his daughter to get access to the government
schemes and entitlements. She now helps her father in candlemaking.
• Mr T is a resource for his SHG, he provides training to the members
on kitchen gardening and has also donated books to children withdisabilities and children from poor families.

Lessons from CBR practice in Asia(WHO,2012)• Importance of a nodal ministry to coordinate national
coverage of CBR and to promote multi-sectoral collaboration;• Collaboration between government and civil society inpromoting comprehensive CBR programmes• Linking of community level rehabilitation activities to existing
primary health care systems• Awareness raising and advocacy across different stakeholder
groups at the time of inception of CBR programmes• Promotion of self help groups and associations of persons
with disabilities• Effective supervision, guidance and training of CBR staff at thecommunity level• Need for national plans for coverage of CBR in a country.

Other lessons from recent evaluations• Need based planning, and ensuring quick access toschemes and benefits from government helps tomobilise and motivate persons with disabilities andfamilies.
• Advocacy for inclusion of CBR into local government
plans and budgets; supplementing/strengthening thework of government; and utilising existing structuresand systems instead of setting up parallel systems
helps in sustainability.
• Capacity building of key stakeholders like government
and persons with disabilities, and ensuring localisation‘ of international concepts and terminology, forexample, ‘empowerment’ or ‘rights based approaches’
leads to better acceptance,Lessons• Establishment and building capacity of a structure
like a ‘disability working committee’ that has
representation from government and civil society,including local self-help groups or disabled
persons’ organisations helps in sustainability.
• Going beyond disability issues to address otherissues of concern (health, water and sanitation,child rights for example) to the generalcommunity; and including other marginalised
groups in the programme also helps insustainability.

How relevant is CBR today? (Thomas,2013)• The World Report on Disability acknowledges
that “CBR pro­grammes have been effective indelivering services to very poor and underserved
areas“• CBR Guidelines summarise outcomes of CBR:
“increased independence, enhanced mobility,and greater communication skills for people withdisabilities; increased income for people withdisabilities and their families; increased self
esteem and greater social inclusion”

Relevance of CBR• The World Report on Disability (2011): persons withdisabilities lag behind in education and employment,
have less access to health care, tend to be isolated
from social, cultural and political participation, andfamilies with a disabled member experience higher
rates of poverty.
• WHO(2012): in many developing countries, themajority of persons with disabilities continue to live inareas that have limited coverage of health andrehabilitation services. Poverty and the resultant poor
health care, lack of access to health care, lack ofawareness, poor hygiene and sanitation, andcommunicable diseases, continue to be the largest
contributors to the causation of impairment anddisability in these countries.

Emerging challenges to be addressedin Asia-Pacific region (Yuenwah, 2012)• rapid urbanisation• increased incidence of non-communicablediseases• disasters and climate change• demographic transitions leading to increasing
numbers of elderly persons• economic challenges that can have an impact
on poverty and food security.

Future of CBR• Factors that provide a favourable environment forcontinued CBR promotion:• international frameworks like CBR Guidelines andCRPD• recognition of the need to include disability into all
development concepts and programmes• partnerships with key stakeholders likegovernments and DPOs
• renewed interest in networking and sharing
through national, regional and global CBR networks• focus on monitoring and evaluation and evidencebased CBR practiceConclusion• CBR continues to be relevant and needed,
especially in low and middle income countries.
• CBR can be an appropriate response andstrategy to deal with some of the emerging
needs and challenges in these countriesReferences•

Helander E (1993). Prejudice and Dignity. UNDP, New York.

•IDDC (2012). Community based Rehabilitation and the Convention on the Rights of Persons with Disabilities.
Brussels, Belgium.

•ILO, UNESCO, WHO (2004). CBR : A Strategy for Rehabilitation, Equalization of Opportunities, Poverty Reduction and Social
Inclusion of People with Disabilities. Joint Position Paper, Geneva.

•Khasnabis C, Heinicke-Motsch K (2008). The Participatory Development of International Guidelines for CBR. Lepr Rev; 79: 1729.

•Thomas M. Community Based Rehabilitation as a Strategy for Community Based Inclusive Development, Disabilityand International Development. 2013, Issue 1, 15-20•

United Nations (2006). Convention on Rights of Persons with Disabilities.

•WHO (1989). Training in the Community for People with Disabilities. WHO, Geneva.

•WHO, UNESCO, ILO, IDDC (2010). Community Based Rehabilitation: CBR Guidelines. Geneva.

•WHO, World Bank (2011). The World Report on Disability. Geneva•WHO Regional Office for South East Asia (2012). Situational Analysis of Community-based Rehabilitation in South-East AsiaRegion. New Delhi.

•Yuenwah, S. Relevance of CBR for the Asia-Pacific Region. Disability, CBR and Inclusive Development, 2012; 23 (1): 7-13