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The WHO Newsletter on Disability and Rehabilitation PDF Print E-mail
Monday, 05 September 2011 12:15

The WHO Newsletter on Disability and Rehabilitation

This is the first issue of a new WHO newsletter dedicated to disability and rehabilitation and aimed to keep you abreast of WHO’s activities in this area. It will be produced three times a year and distributed via e-mail. Subscription/unsubscription requests should be sent to WHO’s Disability and Rehabilitation Team at the following e-mail address: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Editorial

The challenges facing WHO at "the dawn of a new era"
Etienne Krug, Director Violence and Injuries Prevention


ImageThe landmark United Nations Convention on the Rights of Persons with Disabilities heralds the need for a major shift in the way people with disabilities are treated. It is widely recognized that disability has yet to be given the attention it deserves, both as a development issue and as a human rights issue. As the lead United Nations agency for public health, WHO occupies a unique position and thus has a specific contribution to make in terms of raising the profile of disability. We intend to focus our contribution on those areas where we can make the greatest difference, namely, in strengthening community based and medical rehabilitation (and access to it), improving data collection, and supporting policy development in accordance with the principles of the Convention. Disability will need to become a higher priority in all WHO’s programme areas and also progressively crosscutting. There is much to be done but our resources, both human and financial, are modest. We will therefore look to deepening collaboration with all our partners in order to achieve these goals.

It is hoped that WHO’s current activities, outlined in the Plan of Action 2006–2011, will provide the impetus to bring about change. For instance, the planned World report on disability and rehabilitation will help to increase attention and document the shifts in policy and practice needed to address the gaps in approach and attitude. The new guidelines on community based rehabilitation are intended to assist development of community-level action that equalizes opportunities for people with disabilities through programmes targeted on human rights, poverty reduction and inclusion. Reports on both of these activities feature in this first WHO newsletter devoted to disability and rehabilitation issues, which we hope, in addition to the website will keep you informed of key initiatives within WHO.

World report on disability and rehabilitation

FEATURES
World report on disability and rehabilitation 
Produced jointly by WHO and the World Bank in cooperation with organizations of persons with disabilities, professional associations, non government organizations, experts and other UN agencies

In May 2005, the World Health Assembly requested WHO to produce a status report on disability and rehabilitation (Resolution WHA58.23 on Disability, including prevention, management and rehabilitation). One of the key functions of such a report, which will draw on the best available scientific evidence from around the world, is to provide governments and civil society with a comprehensive description and analysis of the significance of disability and the responses to it and make recommendations for action. The availability of this knowledge will play an important role in awareness creation, intensifying networks and shaping policies in line with the United Nations Convention on the Rights of Persons with Disabilities. Above all, this report represents the first step in a longer term process aimed at enhancing collaboration and the complementariness of actions across sectors to promote respect for the inherent dignity of persons with disabilities and to ensure their full participation in every facet of life. The Editorial Committee, comprising nine external experts from different world regions, met in early December 2006 in Geneva to elaborate the report’s objectives (see Box 1), its target audience, a process for its development, as well as a draft structure and contents. Chapter teams (i.e. small groups of individuals with  responsibility for drafting the text of each chapter) are currently being selected. Every effort is being made to draw knowledge and experience from a diverse mix of persons with disabilities, scholars, health-care professionals and other experts to ensure as broad a disability, interdisciplinary and geographic perspective as possible. The next key date in the report’s production timetable is the review of the detailed chapter outlines, scheduled for 18–19 June 2007.

Box 1: Objectives of the World report on disability and rehabilitation
  • To summarize existing information on the status of
    disability, rehabilitation, inclusion and the lived
    experience of persons with disabilities.
  • To document the evidence base demonstrating the
    gap between what exists and what is required.
  • To issue a call to action, and to propose a path
    forward that is set in an evidence-based framework

A first draft of the complete report will be available at the end of 2007 for review by the Editorial and Advisory Committees. The report will then be reviewed by many stakeholder in regional consultations in early 2008 to assess the proposed content and to further develop collaboration with those who will be responsible for follow-up activities in the field. A peer review process will be undertaken before finalization. The Advisory Committee includes representatives from organizations of persons with disabilities, professional associations, nongovernmental organizations (NGOs), experts and various United Nations agencies who will, in addition to reviewing the content of the report, lend political support for its launch and implementation.

Improving wheelchair provision in developing countries
A joint initiative of WHO, the International Society for Prosthetics and Orthotics (ISPO) and USAID

For many people who have mobility impairments, a wheelchair offers personal mobility and is often the "first step" towards greater inclusion and participation. Currently, an estimated 1% of the world’s population, or just over 65 million people, need a wheelchair. This need is increasing due to the combination of population growth, ageing, and higher prevalence of chronic conditions, injuries and conflicts.

Personal mobility is a fundamental human right that has been reinforced by article 20 of United Nations Convention on the Rights of Persons with Disabilities, which asks State Parties to facilitate production and access to quality mobility aids, devices and assistive technologies at affordable cost. In many developing countries, however, access to wheelchairs and other aids is woefully inadequate. Most people cannot afford to buy a wheelchair, and although it is the State's responsibility to provide a wheelchair in such cases, due to limited availability, many find themselves relying on donated wheelchairs, which are often of poor quality and fail to meet an individual’s particular needs. The lack of wheelchair availability, coupled with a lack of awareness, means that many people believe that any chair with wheels is worthy of distribution.

ImageTo facilitate greater access to quality wheelchairs, a Consensus Conference on Wheelchairs for Developing Countries was organized in Bangalore, India (6–11 November 2006). The conference was attended by over 70 participants from all over the world and provided a unique opportunity for professionals, wheelchair users, service providers, donors, manufacturers and academics to meet and discuss wheelchairs and allied issues 

The conference also gave participants the chance to review the first draft of new guidelines on the provision of manual wheelchairs in less well resourced settings, which are being developed by WHO in partnership with the International Society for Prosthetics and Orthotics (ISPO) and USAID. Several international NGOs, including Motivation, Whirlwind Wheelchair, the Centre for International Rehabilitation and Disabled Peoples International are also taking an active part in developing these guidelines. The guidelines will be presented at the forthcoming ISPO World Congress in Vancouver, Canada, and formally published at a launch event in December 2007. Box 1: Objectives of the World report on disability and rehabilitation To summarize existing information on the status of disability, rehabilitation, inclusion and the lived experience of persons with disabilities. To document the evidence base demonstrating the gap between what exists and what is required. To issue a call to action, and to propose a path forward that is set in an evidence-based framework.

Community Based Rehabilitation
United Nations agencies work with civil society to draw up guidelines for implementing community based rehabilitation programmes

ImageSeveral United Nations agencies, including WHO, the International Labour Organization (ILO) and the United Nations Educational, Scientific and Cultural Organization (UNESCO), are in the process of drafting new guidelines that will provide clear direction on how community based rehabilitation (CBR) initiatives can work to ensure the rights of persons with disabilities and promote respect for their inherent dignity. The work is being done in collaboration with various international NGOs and disabled people’s organizations. It is hoped that a draft version of the guidelines will be available for review by the end of 2007. Final publication is scheduled for the end of 2008.

Background to the guidelines
In 1978, recognizing the limitations of existing specialized medical rehabilitation services, WHO introduced its CBR programme to enhance the quality of life for people with disabilities through community initiatives. Since then, the CBR concept has evolved and is now widely perceived as being community action to ensure that people with disabilities have the same rights and opportunities as all other community members, i.e. equal access to health care, education, skills training and employment, a family life, social mobility and political empowerment. In 2003, at an international consultation held in Helsinki to review 25 years of CBR, it was agreed that CBR needed to become more holistic in its approach. Greater multisectoral involvement – to facilitate the meeting of basic needs (e.g. for food, shelter, health, education and livelihood), to reduce poverty, and to ensure community ownership and the active involvement of disabled people and their organizations – is considered pivotal to further development of CBR. The Helsinki consultation was followed, in November 2004, by the publication of a joint WHO/ILO/UNESCO position paper that depicted CBR not simply as a strategy for the rehabilitation and social inclusion of people with disabilities, but as a multisectoral mechanism for reducing poverty, advancing socioeconomic development, and fulfilling national obligations in terms of equal opportunities and human rights.

Building on the recommendations of the CBR position paper, and responding to an expressed need for practical guidance on CBR in the wake of the adoption of the United Nations Convention on the Rights of Persons with Disabilities, a core group of experts met in Geneva in December 2006 to lay the foundations for the development of a set of guidelines on CBR. The planned guidelines will follow mainstream multisectoral approaches to ensure the holistic development of CBR in an inclusive society (see Box 2).

How will the guidelines be structured? A CBR “matrix”, which reflects the different sectors that contribute to a holistic CBR strategy, will be used to guide the structure and content of the guidelines. The matrix itself comprises five key components (i.e. health, education, livelihood, social, empowerment), each of which is further divided into five elements. Each of these 25 elements will form the subject of a chapter in the guidelines. The guidelines will also cover topics such as mental health, leprosy, HIV/AIDS and disaster management.

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.

ANNOUNCEMENTS

ImageDr Federico Montero left his position as Coordinator, Disability and Rehabilitation (DAR), on 27 February to return to his home country, Costa Rica. Dr Montero is warmly thanked for his unfailing support and great commitment to WHO's activities during his time with the DAR Team. Dr Etienne Krug, Director of WHO’s Violence and Injuries Prevention Department, is currently acting as Coordinator.


RESOURCES

Access to "Rehab in Review" now available to all users of the WHO web site

Thanks to the cooperation of Harvard Medical School, you can now view their journal, Rehab in Review online. The journal provides concise readable summaries of current, pertinent articles from 70 distinguished journals. The journal is available in three languages: Chinese, English and Spanish. Contact page: http://www.rehabinreview.com/contactform.aspx
Login name: who
Password: rehabwho

The definition of disability: what is in a name?
Current perceptions about the definition of disability are the subject of an article published in the Lancet.

Leonardi M, Bickenbach J, Ustun TB, Kostanjsek N, Chatterji S on behalf of EU MHADIE Consortium. The definition of disability: what is in a name?. Lancet, 2007; 368: 1219-21.

UPCOMING EVENTS
June
World Report on Disability and Rehabilitation.
2nd meeting of the Editorial Committee,
WHO, Geneva (18–19 June)
Contact: Alana Officer
This e-mail address is being protected from spambots. You need JavaScript enabled to view it

July
The 12th ISPO World Congress, Vancouver,
Canada (29 July – 3 August 2007)
Contact: Chapal Khasnabis
This e-mail address is being protected from spambots. You need JavaScript enabled to view it

October
African CBR Congress
Birchwood Centre, Johannesburg
South Africa
(30 October – 2 November 2007).
Jointly organized by CBR Africa Network and the WHO Regional Office for Africa
Contact: Olive Kobusingye
This e-mail address is being protected from spambots. You need JavaScript enabled to view it  

Image
For further information please:
contact: Disability and Rehabilitation Team Violence and Injuries Prevention Department World Health Organization (WHO),
20 Avenue Appia CH-1211 Geneva 27 Switzerland
E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
visit our web site: http://www.who.int/disabilities

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Disability and Rehabilitation Who Action Plan 2006-2011

An estimated 10% of the world’spopulation experience some form of disability or impairment1. The number of people with disabilities is increasing due to population growth, ageing, emergence of chronic diseases and medical advances that preserve and prolong life. The most common causes of impairment and disability include chronic diseases such as diabetes, cardiovascular disease and cancer; injuries such as those due to road traffic crashes, conflicts, falls, landmines, mental impairments, birth defects, malnutrition, HIV/AIDS and other communicable diseases. These trends are creating overwhelming demands for health and rehabilitation services. This document provides the overview of WHO's future plan of activities, which will be carried out or coordinated by the Disability and Rehabilitation team (DAR) located in the Department of Injuries and Violence Prevention, in the Noncommunicable Diseases and Mental Health (NMH) Cluster.

VISION:
All persons with disabilities live in dignity, with equal rights and opportunities

MISSION:
To enhance the quality of life for persons with disabilities through national, regional and global efforts to:

  • Raise awareness about the magnitude and consequences of disability
  • Facilitate data collection and analyse or disseminate disability-related data and information
  • Support, promote and strengthen health and rehabilitation services for persons with disabilities and their families
  • Promote community based rehabilitation (CBR)
  • Promote development, production, distribution and servicing of assistive technology
  • Support the development, implementation, measuring and monitoring of policies to improve the rights and opportunities for people with disabilities
  • Build capacity among health and rehabilitation policy makers and service providers
  • Foster multisectoral networks and partnerships

GUIDING DOCUMENTS:
WHO activities are mostly based on two guiding documents: the UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities and the World Health Assembly (WHA) Resolution on "Disability, including prevention, management and rehabilitation".

  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.

KEY ACTIVITIES: (Those with *are identified as priorities)

To produce a world report on disability and rehabilitation *

The WHO Resolution on "Disability, including prevention, management and rehabilitation", requests the WHO Director General to produce a world report on disability and rehabilitation based on the best available scientific evidence. The world report will contribute to raise the profile of disability and rehabilitation issues globally by providing up to date information and propose a number of concrete recommendations. WHO will:

  • 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

Product:

  • World report on disability and rehabilitation

Advocacy - to raise awareness about the magnitude and consequences of disability:
The general public and decision makers are often unaware of the great number of persons living with disabilities and impairments around the world, the challenges they face in participating fully in their societies and their difficulty in accessing healthcare and rehabilitation services and other supports and services necessary for their health and well-being. The additional challenges faced by women with disabilities are also often ignored. DAR's primary target audiences for its advocacy work are Ministries of Health and other government organizations, development organizations, private sectors, the media and the general public. WHO will:

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

Products:

  • 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

To facilitate data collection, analysis, and dissemination of disability-related data and information.
Resolution WHA 58.23 invites WHO to support Member States in collecting more reliable data and to promote studies of incidence and prevalence of disabilities as a basis for the formulation of strategies for prevention, treatment and rehabilitation; WHO recognizes the urgent need for collecting disaggregated gender specific data on disability. One of its departments, Measurements and Health information Systems (MHI) is actively engaged in collection of some data related to disability. The UN Statistics Division and the Washington Group on Disability Statistics are also collecting data on disability.

WHO will complement the work of both groups by carrying out the following activities:

  • 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.*

Products:

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

To support national, regional and global efforts to promote health and rehabilitation services for persons with disabilities and their families
WHA 58,23 invites WHO to provide support to Member States in strengthening national rehabilitation programmes and implementing the United Nations’ Standard Rules on the Equalization of Opportunities for Persons with Disabilities. UN Standard Rule 2 on Medical Care describes that “States should ensure the provision of effective medical care to persons with disabilities”. Similarly, Rule 3 mentions that, "States should ensure the provision of rehabilitation services to persons with disabilities in order for them to reach and sustain their optimum level of independence and functioning". WHO will work towards strengthening health care and rehabilitation services for people with impairments and disabilities. WHO will:

  • 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

Products:

  • 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

Promoting Community Based Rehabilitation (CBR):
25 years ago, considering the great need and limited resources, WHO introduced a new approach in providing rehabilitation services known as Community Based Rehabilitation (CBR). Today, CBR is being implemented in more than 90 countries and has evolved into an effective comprehensive multi-sectoral strategy in creating access to health care, education, livelihood opportunities and participation/ inclusion. After 25 years of use, it is the time to take stock and update the strategies where needed. WHO will work in the following areas:

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

Products:

  • 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

Promoting development, production, distribution and servicing of assistive technology
Even today, in many developing countries only 5% - 15% population can access assistive technology. This technology is highly needed among people with impairments and disabilities, especially for mobility, hearing and low vision. Considering the huge need, UN Standard Rule 4 stated that "States should ensure the development and supply of support services, including assistive technology for persons with disabilities, to assist them to increase their level of independence in their daily living and to exercise their rights". To contribute to the implementation of UN Standard Rules 4 and part of 19, WHO will:

  • 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

Build capacity among health/rehabilitation policy makers and service providers
Rehabilitation is rarely included in the curriculum of public health, medical schools or other parts of the education system. This hampers the strengthening of disability and rehabilitation projects and activities. Considering this, WHO needs to support capacity development programmes for personnel whose work will affect the health and well-being of people with disabilities. WHO will:

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

Products:

  • 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

Contribute to the development of local, national and international public health policies on disabilities and rehabilitation
In many countries plans of action and legislation addressing issues related to disability and rehabilitation already exist. However these documents are often fragmented and inadequate and their implementation is often incomplete.. A UN “Comprehensive and integral international convention on promotion and protection of the rights and dignity of persons with disabilities” currently discussed, will provide impetus for improving the situation. WHO will:

  • 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

Products:

  • 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.

To foster multisectoral networks and partnerships
Considering the limitation of resources available and the value of collaboration with other stakeholders, WHO has always carried out its activities in close collaboration with its partners, which include: Collaborating Centres, Organizations of professionals, NGOs/civil society, Disabled People's Organizations (DPOs) and many others. This strategy proved a very useful one in the past and needs to be nurtured further to achieve greater success. WHO will:

  • 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

Products:

  • Network of partners
  • Network of Collaborating Centres

CONTACT:
Disability And Rehabilitation (DAR) Team
Department of Injuries and Violence Prevention (VIP)
Noncommunicable Diseases and Mental Health (NMH)
Cluster World Health Organization
20, Avenue Appia, CH-1211 Geneva 27, Switzerland
Tel: (+41 22) 7913403 Fax: (+41 22) 7914874
Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
Website: www.who.int/disabilities/


World Report on Disability and Rehabilitation

Background and Justification

Magnitude:
An estimated 10% of the world’s population - approximately 650 million people, of which 200 million are children - experience some form of disability. The most common disabilities are associated with chronic conditions such as cardiovascular and chronic respiratory diseases, cancer and diabetes; injuries, such as those due to road traffic crashes, falls, landmines and violence; mental illness; malnutrition; HIV/AIDS and other infectious diseases. The number of people with disabilities is growing as a result of factors such as population growth, ageing and medical advances that preserve and prolong life. These factors are creating considerable demands for health and rehabilitation services. Furthermore, the lives of people with disabilities are made more difficult by the way society interprets and reacts to disability which require environmental and attitudinal changes.

Box 1: Key developments in disability legislation

  • Adoption of action plans or policies on disabilities at international level such as UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities
  • Emergence and evolution of Community-based Rehabilitation (CBR)
  • Creation of organizations by people with disabilities and their families
  • Paradigm shift from “medical model” to “social model” of disability
  • Approval of new International Classification of Functioning Disability and Health (ICF): by the World Health Assembly
  • Adoption of the United Nations Comprehensive and integral international convention on promotion and protection of the rights and dignity of persons with disabilities.

Poverty and Health: Disability is both a cause and a consequence of poverty. About 80% of the world's population of people with disabilities live in low-income countries and experience social and economic disadvantages and denial of rights. Poverty limits access to health and rehabilitation services. Health policies, programmes and practices impact on the rights of people with disabilities. Most of the developmental initiatives ignore the need of people with disabilities. The UN convention on the rights of persons with disabilities emphasizes the importance of mainstreaming disability issues for sustainable development. Attention to health and its social determinants are essential to promote and protect the health of people with disabilities and for greater fulfilment of human rights.

Need for strong and evidence based information: Despite the magnitude of the issue, awareness of and scientific information on disability issues are lacking. There is no agreement on definitions and little internationally comparable information on the incidence, distribution and trends of disability or impairments. Despite the significant changes over the past two decades in the field of disability and rehabilitation (see box 1) there is no comprehensive evidence base. There is no global document that compiles and analyses the way countries have developed policies and the responses to address the needs of people with disabilities. Considering the aforementioned issues, the World Health Assembly Resolution 58.23 (May 2005), on "Disability, including prevention, management and rehabilitation", requests the WHO to produce a World Report on disability and rehabilitation based on the best available scientific evidence. This report will increase access to and promote the utilization of evidence-based research. The availability of this knowledge will play an important role in shaping policy and enhancing the lives of people with disabilities.

Building on past successful experiences: The production and dissemination of World reports by WHO and its institutional partners have proven to be a most valuable exercise. For example the World report on road traffic injury prevention and the World report on violence and health have generated a large number of follow-up activities including increased political support, augmented advocacy and media attention, enabled countries to develop national plans of action, generated resolutions by other organizations, been the catalyst for numerous prevention programmes (Government and Non governmental) and new legislation and ultimately contributed to saving and protecting human lives.

Objectives of the Project
To provide governments and civil society with a comprehensive description of the importance of disability, rehabilitation and inclusion, an analysis of the responses provided and recommendations for action at national and international level based on the best available scientific evidence.

Detailed project activities
The Report will be developed between the end of 2006 and mid 2009 in three phases as outlined below. The focus will be on broad consultation and the inclusion of a large number of experts from around the world. The processes recognize the advisory role of organizations of persons with disabilities in decision-making on disability matters and ensures that organizations of persons with disabilities represent persons with disabilities at regional and global levels.

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
Concept of CBRCBR 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
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.

Inclusive CommunitiesThe 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.

CBRIt 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.

National LevelInternational 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
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.

Community WorkersBased 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.

Support from the Health SectorThe 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.

Support from the Educational Sector 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
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.

Support from NGOsIn 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
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

An estimated 10% of the world’s population, some 650 million people, experience some form of impairment or disability. The number of people with disabilities is increasing due to population growth, ageing, emergence of chronic diseases and medical advances that preserve and prolong life. The most common causes of impairments and disability include chronic diseases such as diabetes, cardiovascular disease and cancer, injuries such as those due to road traffic accidents, war and conflicts, falls, landmines, mental impairments, birth defects, malnutrition, HIV/AIDS and other communicable diseases. These trends are creating overwhelming demands for health and rehabilitation services.

About 80% of people with disabilities live in developing countries. The majority are poor and experience difficulties in accessing basic health services, including rehabilitation services. This causes immobility, isolation, dependency, inequality, often premature death and increased poverty. With proper health care and rehabilitation services, this picture could be significantly changed and people with disabilities would become important contributors to society.

Indeed, people with disabilities are equal members of society and it is their fundamental right to access health care, rehabilitation and support services as mentioned in the United Nations’ Standard Rules on the Equalization of Opportunities for Persons with Disabilities (December 1993).

WHO’s response
There is a need to accelerate the development and implementation of national action plans to promote appropriate integration of people with disabilities. These plans should include coordination mechanisms and actions that address healthcare needs of people with disabilities and their family members, rehabilitation services, early identification and intervention to reduce the impact of disabilities, data collection, as well as advocacy to promote societal changes that facilitate inclusion and participation of people with disabilities. The aim of WHO is therefore to provide assistance to developing countries in their efforts to strengthen national programmes, policies and strategies for the implementation of the United Nations’ Standard Rules.

Image 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

The next step
An important next step will be the development and publication of a World Report on Disability and Rehabilitation, as requested in the Resolution on Disability, including prevention, management and rehabilitation, which was approved by WHO’s World Health Assembly in May 2005. WHO’s long-term objective is that by the end of 2010, partner countries will have accelerated progress in the implementation of operational frameworks (planning, budget, and performance assessment frameworks) aimed at providing persons with disabilities with more equal opportunities and rights, and to live with dignity through enhanced health care and rehabilitation services and barrier free environment. WHO’s immediate objective is that by the end of 2007, WHO and partner countries will have resolved to take far-reaching and monitorable actions to consolidate ways to promote access to healthcare including rehabilitation services for persons with disabilities in developing countries.

Providing guidance and technical support
As a first output, WHO will ensure that guidance and technical support is provided to partner countries in designing, implementing and monitoring multi-stakeholder national policies and programmes to enhance the quality of life of person

  • 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.

Scaling up public health responses
As a second output, WHO will ensure that effective tools will be made available to assist all partners countries in scaling-up public health responses to promote access to medical care including rehabilitation and assistive devices for persons with disabilities, in accordance with national circumstances. Activities will include:

  • 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.

Creating a favorable international environment against discrimination
Creating a favorable international environment against discrimination As a third output, WHO will take international leadership in trying to create a favorable environment to reduce discrimination towards the disabled and increase awareness that the disabled can lead a positive life by benefiting from having access to healthcare and rehabilitation services. Activities will include:

  • 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

Financial needs
WHO is seeking the following critical voluntary resources:

2006-2007 US$
Training and scholarships 970,000
Personnel 918,000
Partnerships 330,000
Advocacy materials 255,000
Printing and dissemination of World Report 170,000
Equipment 85,000
Support costs 354,600
Total 3,082,600


Further information
For additional information, please do not
hesitate to contact WHO, as follows:
Dr Catherine Le Galès-Camus
WHO Assistant Director-General
Noncommunicable Diseases and
Mental Health
+41.22.791.2999
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Dr Etienne Krug
WHO Director
Department of Injuries and
Violence Prevention
+41.22.791.3535

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Additional information is available on
www.who.int/nmh

WHO’s Noncommunicable Diseases and Mental Health (NMH) is charged with the group of diseases and conditions that afflict the most people: 70% of the world’s population die from noncommunicable diseases and conditions. They present the largest and fastest growing health burdens worldwide and are the major looming global health issue of today and tomorrow.
Last Updated on Friday, 17 February 2012 12:49
 
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