Box 2: Community Based Rehabilitation

The objectives of the new CBR guidelines are: Inclusion of people with disabilities in the civil, social, political and economic structures of the community. Full citizenship and equal opportunities for people with disabilities in the community. The key strategies for achieving inclusive development are: Meeting basic needs (i.e. employment, health and education). Involving local government and leaders. Social mobilization (involving the whole community). Building capacity and empowering people with disabilities, their families and the wider community Using the legislation, judicial and political systems to include disability issues in development policies.

What will the guidelines contain? The guidelines will recommend strategies for facilitating equal access to health care, education, livelihood opportunities, skills training and employment, for improving personal mobility and for ensuring adequate standards of living and participation in public and cultural life. Selected examples of good evidence-based practice to help practitioners build on the positive experience of others will also be provided.

1. United Nations Standard Rules: The UN General Assembly adopted the Standard Rules on the Equalization of Opportunities for Persons with Disabilities in 1993. The rules represent a strong moral and political commitment from governments to take action to attain equalization of opportunities for persons with disabilities. The rules that serve as direct foundation for WHO's work are, Rule 1. (awareness-raising), Rule 2. (medical care), Rule 3. (rehabilitation), Rule 4.(support services as preconditions for equal participation) and Rule 19 (which addresses in part issues related to training of personnel providing health and rehabilitation services).
2. WHA Resolution (WHA58.23) "Disability, including prevention, management and rehabilitation": WHO's work is based on the mandate it receives through resolutions from its governing bodies. In May 2005, the 58th World Health Assembly approved a Resolution on "Disability, including prevention, management and rehabilitation" that calls upon Member States to strengthen implementation of the United Nations Standard Rules on the Equalization of Opportunities for Persons with Disabilities; promote the rights and dignity of people with disabilities to ensure their full inclusion in society; promote and strengthen community-based rehabilitation programs; and include a disability component in their health policies and programs. Through the Resolution, the WHO Director-General is requested to intensify collaboration within WHO by including gender-disaggregated statistical analysis and information on disability in all areas of work and provide support to Member States in strengthening national rehabilitation programs and collecting more reliable data on all relevant aspects. The draft resolution also requests the WHO Director-General to produce a world report on disability and rehabilitation based on the best available scientific evidence.

• Identify the partners and resources needed for developing it.
• Collect data and evidences of good practices
• Identify a core group to produce it
• Draft the World Report and conduct review by the experts
• Finalize and publish the world report in different languages

• World report on disability and rehabilitation

• Create a comprehensive website on disability and rehabilitation *
• Develop and disseminate advocacy materials, including fact sheets *
• Actively influence the media

• Website on Disability and Rehabilitation
• Fact sheets, newsletters, posters, documentary and other advocacy materials
• Articles on disability and rehabilitation in electronic and print media including scientific journals/publications

• Prepare a glossary of terminology related to disability and rehabilitation*
• Issue Guidelines on appropriate data collection methods in collaboration with other relevant UN agencies and partners.
• Support collection of country-level data on disability and implementation of the UN Standard Rules related to health, rehabilitation and support services.*

• Glossary of terminology on disability and rehabilitation *
• Guidelines on appropriate data collection methods
• A web-based country by country profile on disability and rehabilitation

• Support Member States to promote access to rehabilitation services by integrating rehabilitation into Primary Health Care, strengthening specialized rehabilitation centres, linking these services with Community Based Rehabilitation (CBR)
• Develop the guidelines to strengthen medical rehabilitation services *
• Develop "Multi-country Action-Learning Research Initiative - A new Paradigm of Medical Care for Disabled Persons" to promote opportunities for persons with disabilities to become more knowledgeable and empowered

• Guidelines on strengthening medical rehabilitation services
• Report on "Multi-country Action-Learning Research Initiative - A new Paradigm of Medical Care for Disabled Persons"
• Programmes in countries

• Develop CBR Guidelines*
• Conduct regional/country workshops for promotion of CBR and Guidelines
• Support Member States to initiate CBR and/or strengthen existing CBR*

• Guidelines on CBR
• CBR country/regional progress report and database of national and international resource organizations working in the field of CBR
• Programmes in countries

• Support Member States to develop national policies on assistive technology
• Support member states to train personnel at various levels in the field of assistive technology especially in prosthetics and orthotics.
• Promote research on assistive technology and facilitate transfer of technology Products:
• Guidelines to develop national policies on assistive technology such as wheelchairs and prosthetics/orthotics*
• Distant learning package in prosthetics and orthotics and other assistive technology for different level of personnel in different languages

• Include a chapter on disability and Rehabilitation in the existing TEACH.VIP package.
• Support Member States to develop training on disability and rehabilitation

• Updated TEACH-VIP that includes a chapter on disability and rehabilitation
• Curriculum on disability and rehabilitation for schools of public health, medical schools, and other institutions training personnel for work in broader public services

• Participate in the preparatory work for the United Nations "Comprehensive and integral international convention on promotion and protection of the rights and dignity of persons with disabilities".*
• Support Member States to develop multisectoral and multidisciplinary policies at local, regional and national levels

• Comprehensive and integral international convention on promotion and protection of the rights and dignity of persons with disabilities" with adequate mention about need for greater access to all supports services and assistive technology required the health and well-being of people with disabilities.
• Collection of best practices in policy development and implementation in the field of disabilities and rehabilitation
• Country projects on policies on Disability and Rehabilitation.

• Organize a meeting of partners every alternate year to report on DAR activities and discuss DAR’s future plan of activities
• Organize regular meetings with other UN Agencies, Member States, academia, private sector, organizations of people with disabilities (DPO) and non governmental organizations (NGO), to strengthen collaborative work and to promote WHO’s objectives on disability and rehabilitation
• Develop a network of a dozen of active Collaborating Centres

Phase		Action
Preparatory		Hold in house consultations with a wide range of stakeholders Establish an Editorial Committee to coordinate the development of the report and ensure the highest possible quality of its content Recruit lead authors and report contributors Advocate and fund-raise Create an Advisory Committee to lend political support to the launching and implementation of the Report
Drafting		Consult among technical and editorial contributors Draft each chapter Hold regional consultations with local experts to verify the proposed contents of the report, obtain “grey” data and get "buy in" from practitioners and policy-makers. Obtain information on disability and rehabilitation and good practice from "model" countries Carry out an extensive review process Finalize the text
Production		Edit stylistically Develop the graphic design and Layout Translate in official UN languages Print and disseminate Launch the report globally and nationally

Partnerships
An underlying principal of this report is the building of partnerships for disability and rehabilitation efforts. The partners involved in this initiative bring in enormous technical and political weight ensuring the best quality of information and the widest possible dissemination. WHO and the World Bank will jointly produce the report in collaboration with a wide variety of institutions who are already involved in disability, rehabilitation and mainstreaming initiatives. A strong interdisciplinary and geographic orientation will thus be reflected in the report, drawing knowledge and experience from a diverse constituency of scholars and practitioners. These include; Disabled People's Organizations such as International Disability Alliance and its members, professional NGOs such as World Confederation of Physical Therapists, World Federation of Occupational Therapy, International Society for Prosthetics and Orthotics, International Society of Physical and Rehabilitation Medicine, IPC; Non government organizations that belong to the International Disability and Development consortium and work in over 100 countries globally; International Paralympics committee, UN Agencies such as ILO, UNESCAP, UNESCO, UNFPA, Ministries from various governments, etc. Additional partners will be explored.

CBR

Introduction
Community-based rehabilitation (CBR) promotes collaboration among community leaders, people with disabilities, their families, and other concerned citizens to provide equal opportunities for all people with disabilities in the community. The CBR strategy, initiated two and a half decades ago, continues to promote the rights and participation of people with disabilities and to strengthen the role of their organizations (DPOs) in countries around the world.

In 1994 the International Labour Organization (ILO), United Nations Educational Scientific and Cultural Organization (UNESCO) and World Health Organization (WHO) produced a “Joint Position Paper on CBR” in order to promote a common approach to the development of CBR programmes. Despite the progress made since then, many people with disabilities still do not receive basic rehabilitation services and are not enabled to participate equally in education, training, work, recreation or other activities in their community or in wider society. Those with the least access include women with disabilities, people with severe and multiple disabilities, people with psychiatric conditions, people living with HIV, persons with disabilities who are poor, and their families. Following on from the CBR Strategy, efforts must continue to ensure that all individuals with disabilities irrespective of age, sex, type of disabilities and socio-economic status, exercise the same rights and opportunities as other citizens in society - “A society for all”.

The need for renewed efforts to address these issues was highlighted at the International Consultation to Review Community- Based Rehabilitation in Helsinki, Finland, 2003. The Consultation was organized by WHO in collaboration with UN Organizations, Non-Governmental Organizations and Disabled People’s Organizations. The recommendations agreed at the Consultation are incorporated in this paper.

The purpose of this Joint Position Paper 2004 is to describe and support the concept of CBR as it is evolving, with its emphasis on human rights and its call for action against poverty that affects many people with disabilities.

WHO, ILO and UNESCO view CBR as a strategy that can address the needs of people with disabilities within their communities in all countries. The strategy continues to promote community leadership and the full participation of people with disabilities and their organizations. It promotes multi-sectoral collaboration to support community needs and activities, and collaboration between all groups that can contribute to meeting its goals.

Community Based Rehabilitation (CBR)

Concept of CBR
CBR is a strategy within general community development for the rehabilitation, equalization of opportunities and social inclusion of all people with disabilities.

CBR is implemented through the combined efforts of people with disabilities themselves, their families, organizations and communities, and the relevant governmental and non-governmental health, education, vocational, social and other services.

Major Objectives
The major objectives of CBR are:

• To ensure that people with disabilities are able to maximise their physical and mental abilities, to access regular services and opportunities, and to become active contributors to the community and society at large.
• To activate communities to promote and protect the human rights of people with disabilities through changes within the community, for example, by removing barriers to participation.

Evolution of Concepts in CBR
Although its definition and major objectives have not changed, there has been an evolution of concepts within CBR and of stakeholder involvement. This evolution is around the concepts of disability and rehabilitation, the emphasis placed on human rights and action to address inequalities and alleviate poverty, and on the expanding role of DPOs.

Disability and Rehabilitation
Disability is no longer viewed as merely the result of impairment. The social model of disability has increased awareness that environmental barriers to participation are major causes of disability. The International Classification of Functioning, Disability and Health (ICF) includes body structure and function, but also focuses on ‘activities’ and ‘participation’ from both the individual and the societal perspective. The ICF also includes five environmental factors that can limit activities or restrict participation: products and technology, natural environment and human-made changes to it, support and relationships, attitudes, and services, systems and policies. No nation has eliminated all of the environmental barriers that contribute to disability.

Rehabilitation services should no longer be imposed without the consent and participation of people who are using the services. Rehabilitation is now viewed as a process in which people with disabilities or their advocates make decisions about what services they need to enhance participation. Professionals who provide rehabilitation services have the responsibility to provide relevant information to people with disabilities so that they can make informed decisions regarding what is appropriate for them.

Human Rights
CBR promotes the rights of people with disabilities to live as equal citizens within the community, to enjoy health and well being, to participate fully in educational, social, cultural, religious, economic and political activities. CBR emphasizes that girls and boys with disabilities have equal rights to schooling, and that women and men have equal rights to opportunities to participate in work and social activities. The UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities address the steps needed to ensure these rights. Hence they form a guide for all CBR programmes.

To strengthen the UN Standard Rules further, the UN General Assembly has decided to develop a Convention on the Protection and Promotion of the Rights and Dignity of Persons with Disabilities. A CBR strategy can set up an ideal framework to implement the provisions of the Convention.

Poverty
There is a strong correlation between disability and poverty. Poverty leads to increased disability, and disability in turn leads to increased poverty. Thus, a majority of people with disabilities live in poverty Studies show that they have higher rates of unemployment compared to non-disabled people even in industrialised countries. In developing countries, where the majority of people with disabilities live, their rates of unemployment and underemployment are undoubtedly higher. Lack of access to health care  and rehabilitation, education, skills training, and employment contributes to the vicious cycle of poverty and disability.

In 2000, the UN Member States adopted the Millennium Declaration and set eight Millennium Development Goals (MDGs) to guide the implementation of the Declaration. All the goals are relevant to disability and three goals are of particular concern to people with disabilities and their families:

• Eradicate severe poverty and hunger.
• Achieve universal primary education.
• Promote gender equality and empower women.

With regard to poverty reduction, countries were invited to develop strategies relevant to their needs and capabilities and to request assistance from international banks, donors and aid agencies.

It is essential that national strategies to address the MDGs and tackle poverty include measures to ensure the participation of people with disabilities. CBR itself can be viewed as a poverty reduction strategy within community development.

Efforts at community level to ensure education for children with disabilities, employment for youth and adults with disabilities, and participation of people with disabilities in community activities can serve as a model for national strategies and policies for development. Agencies and organizations that work to reduce poverty have recognised the importance of specific programmes for women, who contribute significantly to the health, education and welfare of their children. But these specific programmes do not routinely include women with disabilities. CBR programmes can be effective in promoting the inclusion of women with disabilities in programmes aimed at poverty reduction among women in general.

Inclusive Communities
The term ‘inclusive’ is now commonly used with reference to educational provision that welcomes all children, including those with disabilities, to participate fully in regular community schools or centres of learning. The principle of ‘inclusion’ is also being applied to policies and services in health, skills training and employment and to community life in general.

The concept of an inclusive community means that communities adapt their structures and procedures to facilitate the inclusion of people with disabilities, rather than expecting them to change to fit in with existing arrangements. It places the focus on all citizens and their entitlement to equal treatment, again reinforcing the fact that the rights of all people, including those with disabilities, must be respected. The community looks at itself and considers how policies, laws, and common practices affect all community members.

The community takes responsibility for tackling barriers to the participation of girls, boys, women and men with disabilities. For example, many people in the community may have beliefs or attitudes that limit the kinds of opportunities that are open to people with disabilities. Policies or laws may contain provisions which work to exclude them. There may be physical barriers such as stairs rather than ramps or inaccessible public transport. Such barriers may also reduce access to work opportunities.

CBR benefits all people in the community, not just those with disabilities. For example, when the community makes changes to increase access for people with disabilities, it makes life easier for everyone in the community too.

Role of Organizations of Persons with Disabilities (DPOs) Today DPOs are prepared to take meaningful roles in the initiation, implementation and evaluation of CBR programmes. At the same time, they strive to reach more people with disabilities and to be more active in representing them. DPOs need to be recognized as a resource to strengthen CBR programmes.

In almost all countries, DPOs and organizations of parents of children with disabilities have been established and strengthened. Women with disabilities have started to form their own branches within existing DPOs, or to form their own organizations. This has led to a significant increase in the participation and influence of both women and men with disabilities at local, national and international levels.

The role of DPOs includes educating all people with disabilities about their rights, advocating for action to ensure these rights, and collaborating with partners to exercise rights to access services and opportunities, often within CBR programmes. Two major types of DPOs have become active participants in CBR programmes: cross-disability organizations representing people with disabilities without regard to the type of impairment; and single-disability organizations representing only those individuals who have a disability related to a specific impairment, such as seeing or hearing.

Both types of organizations have a role in CBR. The cross-disability organizations have an essential role to play from national to community level and in influencing leaders and policy makers about rights including equal access. The single-disability organizations also make an important contribution at all levels by advising on the needs of people with specific types of impairments.

It is essential that CBR and other disability-related programmes are planned and implemented with disabled people and their representatives. DPOs have the right and the responsibility to identify the needs of all people with disabilities to make their needs known and to promote appropriate measures to address those needs. Where DPOs are weak, CBR programmes can empower them to enhance their capacity to promote individuals’ rights and access to services and their full participation in the development of their communities.

In order to participate fully in CBR programmes, some people with disabilities require services such as sign language interpretation, Braille equipment, guides or transport. Lack of transport, lack of accessible information and communication difficulties are significant barriers to the development of DPOs and to their participation in CBR.

Who Initiates CBR ?
Community action for CBR is often initiated by a stimulus from outside the community, most likely ministries or NGOs. Following initial discussions with representatives from outside the community, it is the community which decides whether CBR will become part of its ongoing community development activities. Various partners in the community, such as the community development committee, organizations of people with disabilities and other non-governmental organizations can provide leadership and take responsibility for the programme. Once a community chooses to initiate a CBR programme, the CBR programme management provides the necessary support, including training, access to referral services and the mobilisation of resources.

4. Essential Elements of CBR CBR requires community and DPO involvement. But communities and DPOs cannot work alone to ensure equal opportunities for people with disabilities. National policies, a management structure, and the support of different government ministries, NGOs and other stakeholders (multi-sectoral collaboration) are also needed.

Country approaches to implementing CBR vary a great deal, but they have some elements in common that contribute to the sustainability of their CBR programmes. These include:

• National level support through policies, co-ordination and resource allocation.
• Recognition of the need for CBR programmes to be based on a human rights approach.
• The willingness of the community to respond to the needs of their members with disabilities.
• The presence of motivated community workers. To address these important elements of CBR, action is needed at national, intermediate/district and local levels.

National Level
National policies and support, along with intermediate level management and local government involvement, are essential elements of CBR programmes. The manner in which communities are linked to the national level varies, depending on the administrative structure of the country and the particular ministry that promotes and supports the CBR Programme. In all situations, however, national policies are needed to guide the overall priorities and planning of a CBR programme. National level co-ordination and allocation of adequate resources are other elements identified with successful CBR programmes.

National Policies The national government is responsible for the formulation of policies and legislation for the rehabilitation, equalization of opportunities and the social and economic inclusion of people with disabilities. Such policies may include specific reference to CBR as a strategy.

International instruments and declarations relevant to disability can guide the formulation of national policies: the UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities, the UN Convention on the Rights of the Child (Articles 2 and 23), the ILO Convention No.159 concerning the Vocational Rehabilitation and Employment of Disabled Persons and the associated Recommendation No. 168, the UNESCO Salamanca Statement and Framework for Action ‘Education for All’, on Special Needs Education, the WHO Declaration of Alma-Ata establishing rehabilitative care as part of primary health care, and the Beijing Platform for Action for the Advancement of Women (paragraphs 60, 82, 175, 178, 232).

National policies may also take account of regional proclamations concerning disability, such as the Proclamations of the Asian and Pacific Decades of Disabled Persons, the African Decade of Persons with Disabilities, and the Arab Decade of Disabled Persons, as well as the Inter-American Convention on the Elimination of All Forms of Discrimination against Persons with Disabilities.

National Co-ordination of CBR
Many countries have found that a national level co-ordinating body is necessary to ensure the multi-sectoral collaboration needed for an effective CBR programme. The mechanism for co-ordination will vary depending on the approach preferred by government. There may be, for example, a national co-ordinating committee consisting of representatives from the various ministries that collaborate to support CBR; or one ministry may take responsibility for coordinating support for the CBR programme.

Management Structure for CBR
In national CBR programmes, government takes a leading managerial role. One ministry usually takes the lead and then provides the organizational framework. While it is possible for any ministry to initiate CBR, this is often done by the ministry responsible for health, social affairs, or other ministry such as education or labour.

Although one ministry initiates and may co-ordinate the CBR programme, the involvement of the ministries for labour, social affairs, education, and health is essential to its success. These ministries collaborate not only with each other, but also with all ministries that deal with access issues relevant to the participation of disabled people, e.g. ministries for housing, transport, and rural development. Involvement of the ministry for finance is important to ensure financial support for CBR.

Collaboration among all of the sectors that support CBR is essential. This is particularly important at the intermediate/district level where referral services are provided in support of community efforts.

It is very important for all ministries, as well as non-governmental organizations to work in partnership. Although one ministry provides the organizational structure, all sectors play an important role in ensuring that communities participating in the CBR programme have access to support services and resources.

Allocation of Resources
National resources can be allocated to CBR in a variety of ways. One is the direct allocation of funds to support aspects of the CBR programme, such as training or the strengthening of support services. Another method is to include a disability component in all developmental programmesinitiatives especially in aimed at poverty reduction strategy programmes. Government can also encourage NGOs, businesses and the media to support CBR.

CBR Programmes without National Support A CBR programme with strong links to governmental structures usually has a greater impact than a CBR programme working in isolation. In the absence of governmental support, small CBR projects started by local community groups or NGOs can exist, but their impact may remain limited. If small projects can be linked to governmental services, they are more likely to be sustainable.

Intermediate/District Level Each country decides how to manage its CBR programme at different levels. Some countries have co-ordinators, and in some cases committees at each administrative level. Experience has shown that the intermediate/district level is a key point for coordination of support to communities. It is, therefore, particularly important to have CBR managers and perhaps intermediate/ district committees responsible for CBR.

CBR Managers
CBR programme managers usually work in the ministry that provides the organizational framework for the programme. For example, if the ministry for social affairs is in charge of CBR, social welfare officers will probably have CBR as one component of their work. If the ministry for health is in charge, the primary health care personnel may be responsible for CBR. Ideally, some of the CBR managers will be men and women with disabilities. The duties of a CBR programme manager include implementing and monitoring of the programme, supporting and supervising the training of community workers, linking various community committees and liaising between the communities and other resources.

Community Level Because CBR belongs to the community, representatives of the community must be involved in the planning, implementation and evaluation of CBR programmes.

Recognition of the Need for CBR Community awareness of the need for CBR is essential before a programme starts. When a CBR programme is initiated from outside the community, the community may not believe that it needs such a programme. The programme manager from the intermediate/district level works with each community to raise awareness about the need for and benefits of a CBR programme. The manager will ensure that people with disabilities themselves, and their families, define their needs. During community meetings, needs can be discussed and the community can decide whether it wants to address the needs in a co-ordinated way through a CBR programme.

Community Involvement
If the community decides to address the needs of people with disabilities, the process of establishing a CBR programme can begin. One approach to implementing CBR is through the leadership of an existing community development committee or other structure headed by the chief of the village or the mayor of the town. This committee guides the development activities of the community. Such a committee is well suited to act as co-ordinator of the many sectors, governmental and non-governmental, that must collaborate to sustain a CBR programme. For example, the community development committee can collaborate with the educational sector to promote inclusive education, with the ministry of transport to develop a system of accessible transport for people with disabilities, and with voluntary organizations to form a group of volunteers willing to take care of children with disabilities so their parents can do errands outside the home.

Community action for equal participation of both children and adults with disabilities varies a great deal between countries and also within a single country. Even with the guidance of a national policy encouraging communities to take responsibility for the inclusion of their citizens with disabilities, some communities may not identify this as a priority. Or, the members of the community development committee may decide that CBR requires special attention and so may establish a separate CBR committee. Such a committee might comprise representatives of the community development committee, people with disabilities, family members of people with disabilities, teachers, health care workers and other interested members of the community.

The CBR committee takes responsibility for responding to the needs identified by people with disabilities in the community: raising awareness of their needs in the community; obtaining and sharing information about support services for people with disabilities that are available outside the community; working with the sectors that provide support services to create, strengthen and co-ordinate the required services; working within the community to promote the inclusion of people with disabilities in schools, training centres, work places, leisure and social activities. In addition to these tasks, the committee mobilizes funds to support its activities.

The CBR committee members may know how to solve many of the problems in the community, but will sometimes require additional information from experts in the education, labour, health, social and other sectors. For example, family members may seek information about how to improve the activities of daily living of a disabled person in the home; volunteers and community workers may need training on assisting people with disabilities and their families; teachers and vocational instructors may need training on including children and youth with disabilities in their classes; and business people may need advice on how to adapt workplaces for people with disabilities.

Hence, information exchange is a key component of CBR. All sectors should support CBR by sharing information with the community, collaborating with each other, and strengthening the specific services they provide to people with disabilities.

Community Workers
Community workers form the core of CBR programme. They are usually volunteers who give some time each week to carrying out activities that assist people with disabilities. People with disabilities and their family members can make significant contributions as CBR workers. Sometimes teachers, health care workers, or social workers donate their time to this role. Other interested members of the community can also be encouraged to give their time.

CBR workers provide information to people with disabilities and their families, including advice on carrying out simple tasks of daily living or making simple assistive devices to improve independence, such as communicating in sign language or using a white cane to move around outdoors. The community CBR worker also acts as an advocate for people with disabilities by making contacts with schools, training centres, work places and other organizations to promote accessibility and inclusion. In addition, the CBR worker provides information about services available outside the community, and acts as liaison between the families of people with disabilities and such services.

Based on the description of CBR worker responsibilities, it is clear that women and men with disabilities and their family members are excellent candidates for this role. As the participation of DPOs has increased within CBR programmes, the number of CBR workers with disabilities has also increased. Nonetheless, there is a need for many more people with disabilities to become involved as CBR workers.

The recruitment and training of CBR workers, maintaining their motivation and coping with turnover are among the major challenges of community leaders and CBR programme managers. Some incentive, such as regular in-service training, an annual award for the best worker, certificates of appreciation, or the provision of uniforms, may be offered to CBR volunteers. This will depend on the customs of the country and the community.

Multi-sectoral Support for CBR

In CBR a multi-sectoral collaboration is essential to support the community, address the individual needs of people with disabilities, and strengthen the role of DPOs. In addition to collaboration between government ministries, collaboration is needed between these ministries, non-governmental organizations and the private sector. It is needed between the community and the referral services at local and intermediate levels, and also between the various referral services at local, intermediate and national levels. Collaboration between national, intermediate and community levels within a sector can ensure that appropriate referral services are developed and delivered.

Support from the Social Sector
Although the allocation of responsibility for social affairs varies from country to country, matters commonly addressed include disability pensions, technical aids and adaptations, housing, vocational training and employment, and co-ordination of referrals for individuals who require services from other sectors. If the social affairs ministry initiates CBR, social welfare officers may be managers of the programme.

A ministry for social affairs may not have personnel at local level, but it is common that personnel posted at district/intermediate level are familiar with social and economic conditions and knowledgeable about resources within the district/intermediate level including those in the non-governmental sector. This information is very useful in a CBR programme, particularly for identifying vocational skills training and work opportunities for women and men with disabilities. Personnel from the social affairs ministry can advise individuals with disabilities and family members as well as personnel from other ministries regarding community resources.

Support from the Health Sector
The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The Declaration of Alma Ata (1978) states that Primary Health Care (PHC) is the key to attaining health for all. It also states that PHC needs to address the main health problems in the community, providing promotive, preventive, curative and rehabilitative services.

The health care system is usually responsible for providing medical care and rehabilitation services, including assistive devices. Most basic rehabilitation activities can be carried out in the disabled person’s own community using local resources. PHC can play a major role in this context both as a provider and supporter. Many people with disabilities need to be referred to specialised rehabilitation services outside their own communities. PHC personnel can facilitate links between people with disabilities and specialised services, such as physical, occupational and speech therapies; prosthetics and orthotics; and corrective surgeries.

PHC also supports CBR activities. At community level, there are usually no specialised personnel in either health or rehabilitation. Therefore, PHC personnel are responsible for carrying out the early identification of impairments and providing basic interventions for people with disabilities. In addition, they can transfer basic knowledge and skills in rehabilitation to the community, especially to CBR workers.

The health sector needs to make serious efforts to ensure that rehabilitation is part of PHC and to provide training to PHC personnel on disability and rehabilitation. The health sector can also strengthen specialised services so that they are a better support to PHC personnel and CBR workers. To be most effective, the rehabilitation services must collaborate with all the other services within the health care system. It is also necessary to collaborate with the sectors for education, labour and social affairs to ensure equal citizenship for people with disabilities.

Support from the Educational Sector
Good co-operation between communities and the education sector is imperative if the goals of Education for All are to be met. With more than 90 per cent of children with disabilities in developing countries not attending school, it is evident that steps must be taken to ensure access to education for all of these children. The community school plays a central role in this work.

The educational sector can make an important contribution to CBR by assisting community schools within the regular school system to become more inclusive. This involves, for instance, adapting the content of the curriculum and methods of teaching to meet the needs of all children rather than expecting them to adapt to a rigid curriculum. Schools may require assistance to change their methods of teaching in order to provide quality education for 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 teach only children with special needs and the teachers from those schools can serve as resources to teachers in community schools. Schools that are already inclusive can help other schools learn how to respond to the needs of all learners, treat all children with respect, and be model schools.

The regular school system must take responsibility for the education of all school-aged children. This includes focusing on the girl child with disabilities, often overlooked in some communities. To do this, communities are essential partners because that is where inclusive schools - open to all children - have their rightful place. Children with multiple or severe disabilities who require extensive additional support may be taught within special units, depending on the existing level of external support being provided. Special schools are important partners in the school system and may be used as a resource for regular schools in promoting inclusive education.

To promote Education for All, the educational sector should adapt the initial and in-service training of both regular and specialised teachers in response to the new roles in the inclusive school, as well as ensure that classrooms, facilities and educational materials are accessible. The education sector must take responsibility for the quality of education and for the educational assessment of children with disabilities. In some countries this is viewed as a medical responsibility. It must be emphasised that children with disabilities should not be treated as sick children. Their needs and aspirations are the same as those of all children.

Support from the Employment and Labour Sector
Productive and decent work is essential for the social and economic integration of individual women and men with disabilities. A gainful livelihood provides an individual with income, self esteem and a sense of belonging and a chance to contribute to the larger community. Collaboration between a CBR programme and the employment and labour sectors is essential to ensure that both youth and adults with disabilities have access to training and work opportunities at community level. The employment and labour sectors promote vocational training, employment and good working conditions. Ministries responsible for vocational training, employment, labour as well as social services can facilitate social and economic integration by  providing vocational rehabilitation services, vocational guidance and skills training through both mainstream training institutions and through specialised training centres and programmes. The employment and labour sectors encourage equal employment opportunities through national policies and legislation. 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.

At community level, informal apprenticeships with master trainers or local businesses can provide individuals with disabilities opportunities to learn employable skills and gain practical experience. The business community can provide valuable support to CBR by providing on-the-job training, hiring workers with disabilities, mentoring entrepreneurs with disabilities and providing advice on current and emerging skills requirements to vocational training centres. Micro and small enterprise development programmes can provide business skills training and advisory services. They can provide access to credit to assist women and men, including people with disabilities, to start their own businesses and become self-employed. Such programmes are often operated by the ministry responsible for trade and industry or by a separate government agency, as well as by NGOs. Special efforts are often required by a CBR programme to ensure the inclusion of youth and adults with disabilities in such programmes.

Support from NGOs
Most communities have a variety of non-governmental organizations (NGOs) and groups that can contribute to a CBR programme. These may include relief and development organizations, faith-based organizations, and service clubs as well as women’s and youth groups. Some of these may provide services to people with disabilities, while others can make special efforts to include them in their activities.

In the framework of governmental policy, national and international NGOs can also make significant contributions to the development of CBR, by initiating programmes in local communities and then scaling it up, by training CBR programme managers and other personnel, and by helping to strengthen the services within the various sectors that contribute to CBR.

Support from the Media
Newspapers, radio, television and the internet can provide the public with information about disability issues, and also present a positive image of individuals with disabilities at school, work or in social settings. All CBR stakeholders should work closely with the media to identify priorities and to provide relevant information.

Collaboration for Support to the Community
CBR will not work if the sectors mentioned above work in isolation. The following example illustrates the types of collaboration that can work well.

A CBR worker contacts a social welfare officer with information about an older child who has never been to school and who has difficulty with mobility and with learning. The officer and the CBR worker collaborate to encourage the family to contact the health services and the school. The health services assess the situation to see if something can be done to improve the child’s mobility. The teachers at the school assess the child’s learning needs. If the child needs a wheelchair, for example, and there are no resources to pay for one, the social welfare officer requests assistance from other sectors, including NGOs.

The support service that considers the holistic needs of the person, and not just the focus of its own service, is more likely to collaborate with other services. Collaboration with other resource groups in the community is necessary because government services alone cannot provide women and men with disabilities with employment or social inclusion.

Further Development of CBR
CBR is now recognised by many governments as an effective strategy for meeting the needs of people with disabilities especially who live in rural areas. Some rural communities in these countries have established CBR programmes. There is a need, however, to encourage existing CBR programmes to expand their activities to other communities, to pay due attention to gender equality and to include people with disabilities from all age groups. The expansion of programmes requires training for the people who will be involved in the management and delivery of services.

Expansion and Scaling up of CBR Programmes
Existing CBR programmes tend to be found in communities that have access to support services or in communities where NGOs have promoted the establishment of programmes. There is a need to expand CBR to rural communities that have very limited access to district/intermediate level support services from the health and social sectors. There is also a need to expand CBR to large cities to reach people with disabilities living in slums.

New settings may also include locations where the community is not well developed, such as refugee camps. Even in these settings, community leaders may be identified and encouraged to make the needs of their groups known. These groups will include people with disabilities, who may be identified for rehabilitation services, but who are not sharing in other programmes provided for refugees, such as skills training and placement programmes.

Gender Equality
Many CBR programmes recognise that girls and women with disabilities require education, work and social opportunities just as boys and men do. Yet, the distribution of resources for education and training frequently favours males. CBR workers may have to make special efforts to persuade families and local schools that girls with disabilities should have access to education. Women with disabilities may require special training by other women. Programmes that provide loans or financial aid to women for small businesses may ignore women with disabilities. DPOs and CBR implementers have a special role to play in promoting the full participation of girls and women with disabilities.

CBR programmes can also promote the integration of women with disabilities in local women’s groups and activities. In addition to providing women with disabilities more contacts and resources within the community, the interaction may result in non-disabled women changing their attitudes and expectations about people with disabilities.

Inclusion of All Age Groups
CBR programmes often focus on children and young adults who require support to complete their education and to develop work skills, and rarely serve middle-aged and older adults with disabil- ities, including those with chronic conditions such as heart disease, diabetes or HIV. People with disabilities in middle age may wish to continue working. Older people with disabilities may want to continue socializing with family and friends. Assistive devices, support services or training may be required to enable adults with disabilities to maintain their quality of life. CBR programmes should be expanded to cater to such needs.

Training for CBR
The experience of CBR programmes is that formal training is needed in order to ensure effective management of programmes, meaningful participation of DPOs, and satisfactory delivery of services from CBR workers and professionals who provide referral or support services.

Management Training
CBR management usually has a focal point at the intermediate or district level. The ministry responsible for CBR may train the personnel who manage the CBR programme so that they are able to carry out tasks such as identifying the people who need services, co-ordinating with the community and sectors that provide services, and keeping records.

Training for DPOs
DPOs may also need training to function as liaisons between the community and the national and intermediate/district levels. They will need skills, for example, in advocacy, co-ordination, planning and evaluating programmes, and fund raising.

Training for Service Delivery
Two groups of people are involved in service delivery: the community CBR workers and the professionals who provide specialised services.

CBR workers need to learn the skills used in training people with disabilities, and they need to learn how to provide this training in a competent manner. They also require training for their role in facilitating contact between people with disabilities and their families on the one hand, and the community leaders and specialised service providers on the other.

The investment in training of the CBR workers is a significant aspect of CBR programmes, and is a factor that should motivate the managers to do what they can to minimise the turnover of workers.

Professionals who provide specialised services in the health, education, social and vocational sectors also need training to sensitize them to the rights of people with disabilities and their families. Some service providers may not be skilled in providing the information that people need to make decisions about which services they wish or do not wish to have. They may also need training in how to communicate with people who have different types of impairments such as hearing, seeing, mobility, understanding or behaving.

These aspects of training should be included in the basic training of professionals, but until that is done, special training programmes should be provided.

Conclusion
CBR is an effective strategy for increasing community level activity for equalization of opportunities for people with disabilities by including them in programmes focused on human rights, poverty reduction and inclusion. The WHO, ILO and UNESCO emphasise the importance of the participation of people with disabilities in the planning and implementing of CBR programmes, the necessity of increased collaboration between sectors that provide the services used by people with disabilities, and the need for government support and national policies on CBR. All countries and sectors are invited to :

• Adopt Community-Based Rehabilitation as a policy and strategy relevant to human rights and poverty reduction for people with disabilities;
• Provide support for nation-wide CBR programmes;
• Create the conditions for multi-sectoral collaboration to advance CBR within community development.

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GLOBAL PROGRAMMING NOTE 2006-2007 call for resource mobilisation and engagement opportunities

Promoting access to healthcare services for persons with disabilities
80% of people with disabilities live in developing countries and most have no access to healthcare services

WHO’s proposed Medium-term Strategic Plan 2008-2013 and the WHO’ two-year programme budget 2006-2007 build on WHO’s work over recent bienniums, and set out new and emerging areas of global concern. The latter is implemented through operational plans prepared by country and regional offices and headquarters, which define the results to be achieved and draw up their work plan on the basis of products needed to achieve those results. These work plans form the basis for corporate and coordinated resource mobilization aimed at increasing non-earmarked budgetary support. This global programming note highlights activities which are included in the work plan, but lack critical voluntary resources. AND REHABILITATION GLOBAL PROGRAMMING NOTE 2006-2007 call for resource mobilisation and engagement opportunities

Achieving results

WHO’s strategy to promote access to healthcare services for persons with disabilities Raise awareness Raising awareness about the magnitude and consequences of impairments and disabilities Build national capacities Building capacity among health and rehabilitation policy makers, service provides and Disabled Peoples Organizations (DPOs) Mainstream objectives into national plans Supporting national efforts to promote and strengthen health and rehabilitation services for people with disabilities and their families Promote community-based strategies Promoting and strengthening Community Based Rehabilitation strategies Produce assistive devices Promoting the development, production, distribution and servicing of assistive devices Foster partnerships and networks Fostering multisectoral partnerships and networks

• WHO World Report on Disability and Rehabilitation. The process for developing and disseminating the World Report will include regional consultations as well as country-led advocacy strategies
• Guidelines to assist developing countries in preparing national policies to improve access to rehabilitation services. Initially a “core group” meeting will be organized to produce a report and initiate the process for the development of the contents of the guidelines. Following the Meeting, information will be collected, analyzed, processed and articles will be developed. Guidelines will be disseminated, field test and finalized for implementation in interested countries.
• Guidelines on Community Based Rehabilitation (CBR). Considering the experiences learnt in the past 25 years while implementation CBR, and to respond to the present and future needs, guidelines will be developed by forming a core group to draft various components and producing draft guidelines. The guidelines will be field-tested prior to finalization.
• Guidelines on production, distribution and servicing of wheelchairs. Considering the huge need of quality wheelchairs, WHO will produce Wheelchair Guidelines to clarify and raise awareness of various key issues related to wheelchair user in developing countries especially , establishment of recommendations for different products, its service provision and training of personnel.

• Promote development, production and servicing of assistive devices. Meetings and workshop on wheelchairs, orthotics and other assistive devices will be organized in collaboration with the International Society of Prosthetics and Orthotics, USAID, international NGOs, DAR partners and the local producers. This will facilitate a greater access to assistive devices for persons with disabilities and elderly.
• Build capacity among health, rehabilitation policy makers and service provides. Partner countries will be supported to develop their knowledge base to promote the rights and dignity of persons with disabilities and ensure their full inclusion in society. Different levels of training programmes will be developed in the field of rehabilitation for health and rehabilitation personnel.
• A research study on the role of assistive devices in poverty reduction. This study will be conducted in collaboration with DAR partners. Studies will be carried out in 18 countries of Asia and Africa to highlight the role of assistive devices to reduce poverty and the need for greater allocation of resources to assistive devices.
• A web-based country-by-country profile on disability and rehabilitation, which will include country data on impairments and disabilities. WHO will provide guidance and support to assist Member States in data collection. WHO will also support data collection and analysis of existing data on disability and rehabilitation. The web site will also contain all data at regional and global level, and will be a multilingual disabled-friendly website.
• Universal tool on early identification of impairments and disabilities. A protocol will be developed, field tested, finalized, published and disseminated for its use by primary health and CBR workers.

• Awareness raising. Both the general public and policy decision makers are often unaware of the great number of persons living with disabilities around the world and the challenges they face in participating fully in their societies. People with disabilities are often isolated and discriminated against - not due to their impairments, but as a result of society’s attitude towards them. WHO will raise awareness with an aim to change attitudes. Various events will be organized and advocacy material will be developed