CBR- Role of Physiotherapy &

Physiotherapist

Ankita Chitre (M.P.Th III)

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 LECTURE OVERVIEW
• Definition of Community & CBR
• Evolution of CBR
• Foundation of CBR
• Principles of CBR
• Advantages & Disadvantages of CBR
• Framework of CBR
• Value of Physiotherapy in CBR
• PHC & CBR
• CBR personnel
• Role of a Ptist as a CBR manager
• Difference between CBR & IBR
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WHAT IS COMMUNITY?

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• A community consists of people living together in some
form of social organization & cohesion

• Its members share varying degrees of political, social,

economic & cultural characteristics including health

• Vary widely in size and economic profile

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WHAT IS CBR?

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• Strategy based on community development for the
rehabilitation, equalization of opportunities & social
integration of all people with disabilities themselves,
their families & the appropriate health, education,
vocational & social services

• Empowers persons with disability to take action to

improve their own lives, rather than drain or deplete
whatever scarce resources that are available and
thereby benefiting all the community

(UNESCO, WHO, 1994)

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 Evolution of CBR
 Medical care Health care

 The World Health Organisation (WHO) introduced the

Community-Based Rehabilitation (CBR) strategy as part of
its goal to accomplish health for all by the year 2000

 The Alma-Ata Conference and Declaration of 1978 on

Primary Health Care (PHC) created a new vision for
providing promotive, preventive, curative and rehabilitative
services for main health problems in the community

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 The Declaration of Alma-Ata states that people have the
right and duty to participate individually and collectively
in planning and implementation of their health care.

 This concept led to development of the first CBR model

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 CBR: Foundation
 In 1950, the World Health Assembly (WHA) called for
development of rehabilitation programmes for people
with disabilities.

 It was not until 1966 that the WHA adopted a resolution

stressing the importance of rehabilitation, whereby it
urged member states to develop their rehabilitation
services as an integral part of the national health system.

 Thus
(a) conceptualisation,
(b) components, and
(c) principles of CBR came into existence 9
 Conceptualization
 CBR is a strategy within general community development
for rehabilitation, equalization of opportunities, and social
inclusion of all children and adults with disabilities

 The CBR concept is both simple and complex in nature.

 The simplicity has to do with its origins, i.e., delivery of

rehabilitative services to people with disabilities in their
communities

 CBR’s complexity is the result of the current concept of

CBR programmes as multi-disciplinary 10
 Components
The primary component of CBR is that community
members are willing and able to mobilize local resources
and provide appropriate services to people with disabilities.

Other components :
(a)Creating positive attitudes towards people with disabilities,
(b)providing functional rehabilitation services,
(c)providing education and training opportunities,
(d)creating micro and macro income generation,
(e)providing care facilities,
(f) preventing causes of disabilities, and
(g)managing, monitoring, and evaluation of CBR programmes 11
PRINCIPLES OF CBR?????

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1. Equality

2. Social justice

3. Solidarity

4. Integration

5. Dignity

(SSIDE) 13
 Equality
• All human beings are of inherently equal
worth, are entitled to equal rights and share
the same responsibilities.

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 Social justice
• Social justice implies that services and opportunities provided
for disabled people should be at the disposal of all and not be
reserved for a numerically small group among them.

• It stands to reason that the ultimate goal is to make

individualized care, training, schooling, and access to
employment and income generation available to all disabled
people.

• Reach to integrated living

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 Integrated Living
1. Family life
2. Shelter
3. Food
4. Schooling
5. Education and training
6. Leisure time
7. Public services
8. Association
9. Economic opportunities
10.Political participation
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 Solidarity
The responsibility for fostering human life is shared by all

Solidarity should be shown toward those among us who

are dependent and need help - children, the elderly, and
those who have a disability

Solidarity of purpose and efforts toward this end should

be seen as a privilege of all and not as charity for some

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 Integration
All members of the society should join in the mainstream
of community life

Disabled people are often excluded from the activities of a

particular society because they are looked upon as
"special" or "strange."

There is a clear correlation between the policy of providing

special, segregated services and the attitudes of most non-
disabled people in favoring the segregation of disabled
people 18
 Dignity

 The final guiding principle is dignity. All disabled

people should live a life in dignity.

 The term "dignity“ may be defined as follows: "the

quality that earns or deserves respect."

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Advantages & Disadvantages of CBR
Advantages of CBR Disadvantages of CBR

• Wide service coverage • Lack of specialized

• Interaction & training
empowerment • Difficulties with
• Cost effective evaluation
• Holistic development • Limitation of resources
• Promotion of awareness • Reducing imp of
• Sustainability professional services
• Needs based planning • Difficulties in large scale
co-ordination
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 Framework of CBR
• Factors defining CBR programmes:

1. Aims

2. Beneficiaries

3. strategies

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• AIMS:
Individually focused-
• Direct service- PWD & families
• Family support- to caregivers
• Empowerment- gather awareness

Community focused-
• Attitude change
• Sustainability
• Advocacy- to influence policy
• Education of existing & future professionals
• Research 22
• BENEFICIARIES:
• Individuals with disabilities
• Families of PWD

• They include-
• Community as a whole
• Multisectorial programmes that include a variet of
professionals

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• STRATERGIES:

Strategy Individual oriented Community oriented

Providing information Training families in easy Field work training- eg:
rehabilitation technique referrals
Developing organizations All work together to meet To help community to find
the same goal what are the needs &
continue the designed
programs
Accessing resources Finding support groups Involving NGOs, & for
communities to generate
their own funds
Providing technological For PWD & families -
aids

Developing leadership - Creating a positive role

models of PWD

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 Top down

Bottom up
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 Link between PHC & CBHC
• The hope of primary health care was that it would
address the economic reality of health care with an
increasing shift to primary disease prevention and
health promotion and promoting self-reliance

• Community-based health care, by and for the

community, encompassing traditional health care
combined with basic health services, controlled and
financed by the government or private institutions,
were seen as the integrated systems by which
primary health care could be achieved 26
 Primary Health Care
• Focuses on:
• Maximum use of local resources, including traditional healers
and trained community health workers

• Participation of the individual and the community.

• Affordable and accessible care

• Integration of prevention, promotion, treatment and

rehabilitation

• Co-ordination between the health care sector and other

aspects of society, such as housing and education 27
 CBR
• It involves:
• Partnerships with disabled people, both adults and children, their
families and caregivers

• Capacity building of disabled people and their families, in the

context of their community and culture

• An holistic approach encompassing physical, social, employment,

educational, economic and other needs

• Promoting the social inclusion of disabled people in existing

mainstream services

• A system based in the community, using district and national 28level

 CBR personnel
• Three levels of service personnel required for CBR who need to
be overseen by a CBR manager to ensure coordination of services

• Level one: grass roots workers delivering services in a community

- CBR workers

• Mid-level: workers who organize and support level one workers:

Mid-level rehabilitation workers (MLRW), therapy assistants or
supervisors

• Level three: professionals who refer users to the community or to

whom referrals can be made from the community, such as
physical therapists
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 Physical therapy provision
• The difficulties in realizing a primary care orientated vision
are numerous

• In terms of physical therapy, many developing countries

have insufficient numbers of physical therapists to operate
at a local level and they are mainly located in national or
provincial centers and, to a lesser extent, district services

• For example, in developed countries the average physical

therapist to population ratio is 1:1400 compared to an
estimated average of 1:550,000 in developing countries
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 IMPLICATIONS FOR PHYSICAL THERAPY-WCPT

• If physical therapists want to protect their

domain of expertise and see themselves as
required to be the primary care givers in direct
contact with those with disabilities, then they
risk mystifying rehabilitation and making it
inaccessible to those most in need, especially in
developing countries

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 Professional autonomy & status
• The emphasis is on professional skills and expertise
lying with the professional

• This contrasts with the way in which community

based physical therapists are conferred with a lower
status and a focus on transferring skills to empower
other workers and families

• In addition, emphasis in urban centres is primarily

on cure rather than rehabilitation or maintenance,
so the health gains and improvements achieved by
the health professionals are perceived to be greater
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• Primary health care may not have been embraced
by some health care professionals, who potentially
see it as providing negative incentives for them
professionally

• Especially, if the focus is on prevention, when their

skills and main business have been curative, often
with the opportunity for additional private income

• However, physical therapists have always had a

focus on prevention and are keen to develop this
area of practice further 33
 Roles aRole
Ptist plays
a Ptist asa CBR
plays as a CBR manager
manager
• Physical therapists undertake, or have the potential to
undertake, a number of roles in primary health care and CBR,
dependent on local cultural and socio-economic circumstances.

• The roles are as follows:

1. Preventing disability and deformity
2. Educating / training disabled people to move around
3. Promoting self-care
4. Educating, training and transferring skills to other staff
5. Consultancy, advice, support and supervision to other health
care personnel 34
6. Health promotion and disease prevention
7. Curative and rehabilitation services
8. Invistigators of CBR services
9. Team leaders and managers
10. Providers of direct care
11.Advocates for disabled people, local
communities as well as the profession
12.Advisers to governments, NGOs and local
communities on establishing CBR
programmes
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DIFFERENCE BETWEEN IBR & CBR???

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Difference between IBR & CBR

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Thank you!!! 38
 References
• Books:

1. CBR by Malcolm Peat

2. Understanding public health (health promotion) by Maggie Davis

• The value of PT in CBR: Asia Pacific Disability journal
• Primary health care & community based rehabilitation:
implications for physical therapy: Tracy Bury: Asia Pacific Disability
Rehabilitation journal, vol 16,no. 2, 2005

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