Satya Bhushan
Nagar
Coordinator DCBR Program, Department of Physiotherapy
Head Department of Community-based rehabilitation
Ex-Coordinator Department of Physiotherapy Coordinator, Community Activities of Medical Field Janardan Rai Nagar Rajasthan Vidyapeeth Deemed University
Udaipur,
Rajasthan,
India
Member, Rajasthan Paramedical Council Government of Rajasthan,
India
Forewords
Umasankar
Mohanty
Indumathi
Rao
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Essentials of Community-based Rehabilitation
First Edition: 2017
9789386261229
Printed at
fm5
Dedicated to
My Grand Parents
Late Pandit Sh Damodar Prasad Nagar
and
Foreword
fm7I have immense pleasure in forewording this book titled Essentials of Community- based Rehabilitation brought out by my close professional associate Dr Satya Bhushan Nagar, a renowned physiotherapy academician and rehabilitation professional.
Community-based rehabilitation (CBR) was initiated by WHO following the Declaration of Alma-Ata in 1978 in an effort to enhance the quality of life for people with disabilities and their families, meet their basic needs, and ensure their inclusion and participation. While initially a strategy to increase access to rehabilitation services in resource-constrained settings, CBR is now a multisectoral approach working for the equalization of opportunities and social inclusion of people with disabilities while combating the perpetual cycle of poverty and disability. CBR 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. CBR is changing, and it has to change. Even today, CBR focuses on taking rehabilitation services to the population in many parts of the world where it has not yet reached!
Dr Nagar has given an overview to concepts, principles, components, and other aspect of CBR. This book also includes disability evaluation or assessment criteria, professional ethics regarding physiotherapy, ergonomics at workplace. This book aims at the students of physiotherapy, occupational therapy, and rehabilitation studying in various colleges or universities all over the country. Since it conforms to the syllabus of undergraduate physiotherapy and rehabilitation program laid down by several universities, I am sure that this book would definitely benefit physiotherapy students and rehabilitation professionals. In my opinion, essential of CBR lives up to the promise of its title. I am delighted that the author has found the time and dedication needed to write this semper excelsius masterly fm8 book which will enable him to share his experience as an author and teacher to wider audience.
I am sure the content of the book will cater to the needs of students and physiotherapy professionals in community-based rehabilitation. I congratulate Dr Nagar for his intense effort to provide a textbook of CBR with essential contents and I wish him great success.
Umasankar Mohanty
BPT (Hons), MPT (Manual Therapy) PhD MISEP MIAP FAGE
PhD Guide, Department of Physiotherapy
Lovely Professional University
President
Manual Therapy Foundation of India
President
The Indian Association of Physiotherapists
Member
International Society of Educators in Physiotherapy
Foreword
fm9The Constitution of India has included disability and aging in its state list. Disability is also a Panchayat Raj subject as per PRI Act. Further, India has signed and ratified UN convention on persons with disabilities in 2006. Indian Parliament passed a legislation titled Equal Opportunities Act in 1995 in the winter session of Parliament.
The goal of a national or state level policy is to promote an inclusive, community-based, barrier-free opportunities for fullest actualization of potential in every individual with a rights-based vision for persons with disabilities with a clearly defined goals/objectives and strategies relevant to diverse socioeconomic-geographic diversities in India.
Persons with disabilities have potential and right to the enjoyment of the full range of civil and political, educational, health and socio-economic and cultural rights embodied in the Indian constitution.
India straddles two worlds simultaneously: It is both a developed and developing nation. It is the fourth largest economy in terms of purchasing-power parity, in the top ten most industrialized countries, and a global leader in information technology. It is the world’s largest democracy and a rising power.
The Constitution of India ensures equality, freedom, justice and dignity of all individuals and mandates an inclusive society, including persons with disabilities. India is a signatory to the declaration on the full participation and equality of people with disabilities in the Asia Pacific Region and Biwako Millennium Framework for Action towards an inclusive, barrier-free and rights-based society. Further, the Eleventh Five Year Plan of India (GOI, 2008) and now Twelfth Plan (2012–2017) have marked “Inclusive Growth” as its focus and have earmarked substantial financial provisions to make this inclusion a reality. Strategy also puts us all on similar grounds.
India has signed and ratified the UN Convention for Persons with Disabilities in 2006. In India, the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act 1995 defines disability as one or more of the following: blindness, low vision, fm10 leprosy cured, hearing impairment, locomotor disability, mental retardation and mental illness. A new draft comprehensive bill on disability, which is based on UN convention on the right of persons with disabilities (UNCRPD) principles, is waiting for the Parliament approval in India.
There is no universally agreed definition of disability. Historically, disability is understood to be a medical condition—a problem located within the individual. Since then, disability activists who have conceptualized disability as primarily a social phenomenon have challenged this medical or individual model. This social model draws a clear distinction between “impairments” and “disability”. It argues that it is the society that disables people with impairments, by failing to recognize and accommodate difference, and through the attitudinal, environmental and institutional barriers that it erects against people with impairments. Disability thus arises from a complex interaction between social, economic and health conditions.
Social inclusion is a multidimensional and cross-sectional concept, which needs to be, mainstreamed into various areas at national, regional and local levels. It does not lie, not only within one tier or section of society, nor does it rely on only one area of policy to exact changes. There is a larger and infinitely more comprehensive aim to social inclusion that encompasses many areas of society and humanity.
Understanding how the dimensions of inclusion are structured and realizing its diverse nature in diverse cultures and socioeconomic threshold is necessary for this. As inequality and exclusion are produced systematically, and they can be tackled. It is necessary to distinguish inequality from being different. While we can be different, we all need to be provided with equal opportunities and access. Accommodating people with diverse needs to build a common future is a core value of an inclusive society. Developing a concept of inclusion in which people get together are interconnected, and sharing a sense of belongingness as well as sense of responsibility is necessary.
If this concept of social inclusion is promoted, cycles of exclusion and traditional blockades, structural and perceived, will begin to dismantle. This would constitute an important step towards an inclusive society. Equally, while the actual fiscal responsibilities involved in creating inclusive societies may initially present a challenge, the viewpoint should be promoted that the investment fm11 in motivating participation in all sectors of society is an investment in a successful and sustainable future and a more balanced society, meeting the needs of all its members, where investment in inclusion and the resulting change in society are actually beneficial to all.
A majority of persons with disabilities live in rural areas
The country’s disabled population has increased by 22.4% between 2001 and 2011. The number of disabled, which was 2.19 crore in 2001, rose in 2011 to 2.68 crore—1.5 crore males and 1.18 crore females. Rural areas have more disabled people than urban areas. In Maharashtra, Andhra Pradesh, Odisha, Jammu and Kashmir and Sikkim, the disabled account for 2.5% of the total population, while Tamil Nadu and Assam are among those where the disabled population is less than 1.75% of the total population.
According to World Bank Report 2009 titled “From Commitment to Outcomes” which states that while official estimates of disability are low (around 2%), alternative estimates using better methods and more inclusive definitions suggest a higher incidence of disability (of at least 5–8%). Many systematic studies of NGOs in Karnataka shows the prevalence of disability in 0–14 age group children is around 4–6%.
Poverty and disability link
Persons with disabilities are most disadvantaged group of people in a community. Though they have immense talent like any other person unless there is a positive attitude to include them in the mainstream development they would remain poor, illiterate, unemployed and dependent in their life. But if we include them in the development program with a positive attitude they can contribute to the community–nation building.
A society for all
Disability centered/friendly policy initiatives taken by NDA government to enable persons with disabilities in India in 2014–2016. CBR helps include persons effectively in the national development program.
- Accessible India Campaign—2015
- HRD Ministry’s National Education Policy—2014
- National Health Policy—2016
- National Bill on Allied and Health Professionals—2015
- National Youth Policy which includes Sports—2015
- National Skill Development Framework—2014
- Rural Development and Panchayat Raj (RDPR) on mandatory inclusion of person with disability in all the development program.
CBR is a proven strategy to achieve the goals of inclusion of All—leaving none behind.
“Sabka Saath Sab Ka Vikas” is the vision of India. Hon’ble Prime Minister of India, Sri Narendra Bhai Modi Ji urges to use the word “Divyang”. The community has a major role to play in the rehabilitation process. In order to get the Vision to Action, we need CBR and trained human resources for CBR, resource manuals on CBR.
One of the major barriers to rehabilitation is the attitude of the community. The participation of the community will ensure that all attitudinal and social barriers to the rehabilitation process are minimized.
The role and inherent potential of the family to overcome problems of disability must be recognized as a basic building block of the rehabilitation process.
The ultimate goal in rehabilitation is empowerment of persons with disabilities. Empowerment comes from enjoying the equity in the community. Empowerment of a person with disabilities has several dimensions. Equal opportunities and active participation in the family, community and development program continues to be a major focus for the community based-rehabilitation program. Economic independence is one of the key factors that lead a person to achieve the goal of empowerment.
The conventional approaches in rehabilitation, such as special schools, social and vocational rehabilitation centers, special employment schemes, residential schools, hostels, etc. are expensive models. It would be impossible to find the financial and human resources required to reach all disabled people in India through this approach.
There are several accepted political goals, such as the universalization of elementary education, mass literacy programs, poverty eradication programs, health for needy people and other developmental programs. These are aimed at improving the quality of life of underprivileged groups, such as people with disabilities. Yet, it is a common experience that disabled people seldom participate in such mainstream programs. Hence, it is important to develop a plan for people with disabilities aiming at a large coverage with good quality services in a sustainable manner, by optimal utilization of resources fm13 available at the state level. For these reasons, it is imperative to adopt an efficient and cost-effective approach such as community-based rehabilitation (CBR).
CBR strategy is an effort to design a system for change—for improving service delivery in order to reach all in need, for providing more equal opportunities and for promoting and protecting the human rights of disabled people”.
Inclusion is accepted globally and locally as the underlying principle on which rehabilitation programs should be built on. However, there is a need for some exclusive measure to achieve the goal of inclusion. The exclusive measures are required because people with disability not only belong to poorer of the poorest sections in the society, but they are also fighting the social images about them. Self- image elevating activities are necessary in addition to image boosting activities in the community. A sense of belonging is intrinsically vital, as most feel isolated and neglected.
Democratization at grassroots has picked up tremendous momentum in the last decade. Panchayath Raj System is one example of decentralization of policy decision-making and implementation of all development programs.
In India, Mahatma Gandhi emphasized the need for self-reliance and self-sustainable villages as early as the beginning of last century. The concept of Self-help and Gram Swaraj are not foreign concepts to us. The ancient village management system was also based on the principle of “sharing and caring”.
Somewhere along the line, after independence, people started playing the role of “recipient of services and benefits" and became beneficiaries. This passive role of the community did not help in the long run.
Neither government nor the community can afford to start separate services for separate sets of people. The District CBR Society is to help meet different needs of the community without disintegrating families from their communities.
There has been an increasing realization that the chances of sustaining programs without the community’s participation at all levels of implementation are close to nil. The decentralization of power structures/increased number of grassroots NGO projects has strengthened the learning that community should be involved right from project conceptualization to implementation/evaluation stage. Various project-planning skills, such as rural appraisals/logical fm14 framework analysis, etc. have been developed to ensure community participation in planning of projects.
The second resource book on CBR by Dr Nagar fills a major deficit in our society. The book is comprehensive with 28 Chapters, with illustrations which makes reading easy.
I recommend this book Essentials of Community-based Rehabilitation, to all professionals working in the field of disability, inclusive development and health sectors.
I hope to see more books from Dr Nagar in future.
Indumathi Rao
Regional Advisor
CBR Network
South Asia, Bengaluru
Karnataka, India
Preface
fm15Community-based Rehabilitation (CBR) brings rehabilitation know-how to villages and urban slums, and CBR personnel facilitate people to take responsibility for their own lives. CBR 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. In the process, PWDs are also made aware of their own role and responsibility, as they are part of the community. People with disabilities are estimated to form 7–10% of the population in any country, and around 2% would need some form of rehabilitation services. Yet, only 0.01–0.02% of the population in developing countries actually get such services. There are presently about 200 million moderately and severely disabled people in developing countries, where disabilities are mostly poverty related. The incidence of disability has always been on the increasing trend and about 60% of disabilities. In order to further promote the development of CBR in coordination with the social and economic development of this region, there is a need to develop a set of comprehensive guidelines for CBR evaluation. Such guidelines should be scientific, practical, easy to use, and should cover various aspects and stages of the practice. CBR is strategy within community development for rehabilitation, equalization of opportunities and social inclusion of all children and adults with disabilities. A disability is an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations. Thus, disability is a complex phenomenon, reflecting an interaction between features of a person’s body and those of the society in which he/she lives. Where rehabilitation is community-based, then the decision making and responsibility for the habilitation of those disabled individuals are in the community, and do not originate outside the community.
fm16“The community-based rehabilitation strategy is an effort to design a system for change for improving service delivery in order to reach all in need, for providing more equal opportunities and for promoting and protecting the human rights of disabled people” (Helander, 1993, page 5). WHO has developed community-based rehabilitation program designed to integrate with programs for primary health care. Since then CBR as a tool for government and non-government intervention has been expanding very rapidly all over the world. People with disabilities, their families, and their communities have benefited from CBR.
CBR practices in countries with vast differences in race, culture, language, socioeconomic-political development, and religious belief have provided a collection of diversified and rich experiences. This book has been launched to meet a specific need of undergraduate student of physiotherapy and rehabilitation it will give overview of concept, principle, criteria, components and aspects of community-based rehabilitation.
CBR evaluation and its practical significance. It will help Rehabilitation professional to assess disability and to implement CBR program. The first edition of the book will bring about to design a system for change for improving service delivery in order to reach all in need, for providing more equal opportunities and for promoting and protecting the human rights of disabled persons.
I am extremely thankful to supreme power, who by his immeasurable infinite grace enabled me to write this book, No venture of this kind is possible without the blessing of my Parents Smt Daya Devi and Shri Krishna Chandra Nagar. To whom I shall remain ever indebted.
I also wish to express my thanks to my brother Dr Satish Nagar and his wife Smt Sadhna Nagar and their wards Ayush and Aryan, who has helped me in each and every step of preparation of this book. I will be failing in my duty if I do not mention the name of my wife Mrs Sonal and my Dear son Aman and daughter Anushree and my in-laws Smt Girish and Suryakant Nagar for their understanding and unstinted support during the long months of collecting the material and writing of the book. I would like to be grateful to my teachers who made me able to do such kind of work. It is a pleasure to acknowledge the valuable suggestions and kind support received from professor SS Sarangdevot, Hon’ble Vice Chancellor Janardan Rai fm17Nagar Rajasthan Vidhyapeeth Deemed University, Udaipur, Rajasthan, India, Dr Indumathi Rao, Regional Advisor CBR Network, Professor Umasankar Mohanty President IAP, Professor Sanjeev Jha, Advisor IAP, and Professor Jagmohan Singh, Professor NS Rao, and my colleagues and my dear friends and Students. May this book give an effective stimulus to physiotherapy students and rehabilitation professionals to gain knowledge of CBR and disability.fm18
Satya Bhushan Nagar
fm19Abbreviations
AA :
Alcoholics anonymous
ADHD :
Attention deficit hyperactivity disorder
ADL :
Activities of daily living
AHRTAG :
Appropriate health resources and technologies action group
CBR :
Community-based rehabilitation
CHA :
Community health aide
CP :
Cerebral palsy
CW :
Community worker
DPI :
Disabled People’s International
EEC :
European Economic Community
GDP :
Gross domestic product
IAP :
Indian Association of Physiotherapists
IBR :
Institution-based rehabilitation
IDA :
International Development Association
ILEP :
International Federation of Anti-Leprosy Associations
ILO :
International labour organization
ILS :
Intermediate Level Supervisor
IYDP :
International Year of Disabled People
LS :
Local supervisor
MR :
Mental retardation
MRT :
Mapnet Resource Teacher
NDLRP :
National district level rehabilitation program
NGO :
Non-governmental organization
OAS :
Organization of American States
OAU :
Organization of African Unity
PHC :
Primary health care
PHW :
Public health worker
RDP :
Declaration on the Rights of Disabled Persons
RI :
Rehabilitation International
RMR :
Declaration on the Rights of Mentally Retarded Persons
TCPD :
Training in the Community for People with Disabilities (a Manual published by WHO, 1989)
TP :
Training package
UDHR :
Universal Declaration of Human Rights
UK :
United Kingdom
UN :
United Nations
UNCSDHA :
United Nations Centre for Social Development and Humanitarian Affairs
UNDESD :
UNDP :
United Nations Development Programme
UNESCO :
United Nations Educational, Scientific and Cultural Organization
UNHCR :
United Nations High Commissioner for Refugees
UNICEF :
United Nations Children’s Fund
UNOV :
United Nations Office at Vienna
USA :
United States of America
US$ :
United States of America, dollars
WCPT :
World Confederation for Physical Therapy
WHO :
World Health Organization
WPA :
World Programme of Action Concerning Disabled Persons