Overcoming the Barriers for Participation by the

Disabled: An appraisal and global view of

community-based rehabilitation in community
development
Olaogun, M.O.B., Nyante, G.G.G., Ajediran, A.I.
Department of Physiotherapy, School of Allied Health Sciences, College of Health Sciences, University of Ghana

Correspondence
Matthew O.B. Olaogun, School of Allied Health Sciences, University of Ghana, PO Box KB-143, Korle-Bu,
Accra, Ghana • Email: [email protected]

SUMMARY
The discipline of rehabilitation developed after the Second World War. Some disabled people were reintegrated
into the society due to advances in technical aids, appliances and assistive technology. The transfer of these aids
and technology to developing countries was facilitated by the United Nations Organization (UNO). The results,
however, did not get to the rural communities. The number of people with disability worldwide, and
particularly in the developing countries, is increasing due to wars, conflicts, vehicular accidents, chronic
diseases, mental impairment, birth defects and malnutrition. Many of these people face participation-restriction
in activities of life. This paper appraises the emergence and the global view of community-based rehabilitation
(CBR). The review and remodelling of CBR in developing countries, and its inclusion in community
development will enhance the reintegration of the disabled individuals into the society.

KEY WORDS: disabled, community based rehabilitation, reintegration, community development

INTRODUCTION specialists and technicians as a professional team and

support for the construction of large urban-based
At the end of W orld W ar II, many countries had large
rehabilitation centres. By the end of the 1960s, it was
numbers of servicemen who had sustained various forms
observed that this approach had only resulted in minimal
of disability. Since then, the number of people with
rehabilitation service delivery in the capital cities, but was
disabilities has been increasing worldwide. Some other
not reaching the vast numbers of disabled children and
causes of disability include falls, vehicular accidents and
adults living in villages and slums.
chronic diseases. The participation of individuals with
disabilities in activities and community participation is In 1978, following a series of reviews and meetings, the
limited. Some disabled individuals, however, are able to W orld Health Organization (W HO) adopted the Alma
reintegrate into their communities due to advances in Alta Declaration, shifting support from city-based hospitals
technical aids, appliances and assistive technology. and institutions to the community. The community-based
rehabilitation (CBR) initiative eventually evolved
A new specialty – rehabilitation, rapidly developed in
(W HO/Disability, 2007). The W orld Health Organization
the decades after the Second W orld W ar, and became the
has been very effective in developing guidelines for CBR,
subject of substantial international research, development
conducting regional and national workshops to promote
and technical assistance by governments and international
CBR guidelines, and supporting member states to initiate
non-government organizations. In 1951, the UNO
CBR and/or strengthen existing CBR programmes. Some
established a Rehabilitation Unit, with the aim of
member countries are, however, yet to embrace the
facilitating the transfer of these new medical and technical
guidelines of W HO-CBR. In countries like Nigeria,
advances to developing countries. The main aspects of the
rehabilitation services are either institution-based, within
international assistance were training of rehabilitation
the cities or suburban communities, or form part of active

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Community-based Rehabilitation and Reintegration of the Disabled

outreach services to rural communities, supported by attitudes and beliefs (W aldie, 2002; Tomlinson and Abdi,
international agencies. 2003).
Community rehabilitation services in any form are yet This paper explores the evolution of community-based
to take off in many developing countries (Tinney et al, rehabilitation into a community development model, that
2007). The consequences of civil wars, political upheavals offers the hope of a good quality of life to the physically-
and strife, in addition to poverty, as in Liberia, Sierra challenged, by providing or ensuring full participation in
Leone, Rwanda, the Democratic Republic of Congo, have their rehabilitation affairs and in the society.
also increased the incidence of disabilities in the
developing countries of Africa. There is, therefore, the
The Meaning of Rehabilitation
need to explore a workable model for the rehabilitation of
Rehabilitation is not only concerned with physical or
disabled individuals in the community as a means of
functional restoration/compensation of individuals disabled
overcoming the limitations imposed by the handicap. Full
by injury or disease. Attention is also given to the total
participation of the physically-challenged has been part of
quality of life in terms of wellness, happiness and
the United Nation’s Standard Rules on the Equalization of
satisfaction in fulfilling the demands needs capacities of
Opportunities for Disabled People, which states under the
human existence in orientation, freedom of movement,
Principles of Equal Rights that, the needs of each and
independence, expression of self (with respect to age, sex
every individual are of equal importance, and that those and culture), relationship and ability to ensure
needs must be made the basis for the planning of societies. independent economic existence. After a serious injury,
In addition, all resources must be employed to ensure that illness or surgery, one needs to recover slowly. There is the
every individual has equal opportunities for full need to regain strength, to relearn skills or find new ways
participation (United Nations, 1993). M any developing of doing things one did before. This is the process of
nations are signatories to the UN position. Ghana, for rehabilitation.
instance, came out with the National Disability Policy
Children who are born with disabilities need
Document, which seeks to ensure the inclusion and full
stimulation for development and adaptation – habilitation
participation of disabled people in all spheres of social life
(W innick, 1979), and those who acquire disabilities also
(National Disability Policy Document, 2000). In spite of need rehabilitation. Technically, therefore, rehabilitation
the policy, there are still many public facilities which are is a creative procedure that includes the cooperative efforts
designed without consideration for people with disabilities. of various medical specialists, and associates in other
These include schools, offices, libraries, hospitals and other health, technical and environmental fields, to improve the
public facilities (Annor, 2002). Also roadside infra- physical, mental, social and vocational aptitudes of the
structures, such as open gutters, and inaccessible vehicles disabled, with the objectives of preserving and improving
further restrict their mobility. In a study conducted by their ability to live happily and productively on the same
M ock et al (2003), 33% of the participants whose long- level, and with the same opportunities as their neighbours
term injuries resulted in disability, had fallen into open (Krusen et al, 1971; Olaogun, 2007). In other words, it is a
street gutters. process of decreasing the dependence of the disabled
In some developing nations, disability is often person, by developing to the greatest extent possible, the
considered to be a punishment for wrong doing, witchcraft, abilities needed for adequate functioning in his individual
an evil eye, the wrath of God/ the gods, or the ancestors’ situation in the community (Helinder, 1984).
anger. Such a belief is a major cause of participation-
restriction. It affects marriages, interpersonal relationships, Related Community-Based Disciplines
mobility, employment, access to treatment and care,
Lucas and Giles (2003) identified 4 dimensions of public
education, and attendance at social and religious functions health – preventive medicine, social medicine, community
(van Brakel et al, 2006). health and community medicine.
The cultural and traditional norms, societal beliefs and
Community health deals with the services that aim at
values which perpetuate prejudice, discrimination and
protecting the health of the community. The intervention
unequal opportunities constitute another major barrier to
ranges from public sanitation, environmental hygiene,
the participation of the physically-disabled in the African
diseases vector control, health education, immunization
community. Some researchers contend that the primary
and so on. Community rehabilitation deserves a niche in
problems facing disabled persons are the negative societal
the scope of community health. Surveillance, monitoring

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 Olaogun, Nyante, Ajediran

of community health needs and the assessment of the physical disability, e.g., Atanda Olu School, Surulere,
impact of interventions are also part of community health Lagos and Cheshire Home Oluyole, Ibadan, all in Nigeria.
practice. Rehabilitation Centre, M oniya, Ibadan, is also an
institution-based rehabilitation center, with active
Com munity medicine is synonymous with primary health
rehabilitation services and vocational training for spinal
care (PHC), which is the lowest level of health care
cord injury victims. The institute also provides out-patient
delivery. This refers to health services that are provided at
and in-patient services, and long-term boarding. An
the community level. There are guides for primary and
example of this is M odupe Cole H ome for the Handicap,
clinical diagnosis, care and administration of medicines.
Akoka, Lagos. There are regular physiotherapy services for
There are no facilities for surgery. Referrals are made to
the cerebral palsy children in this home.
the comprehensive health centres (CHCs) or state/regional
hospitals for advanced care and surgery. Community
physicians, community health officers, nurses, community Outreach Services for Rehabilitation Professionals from
physiotherapists and other health care personnel are foreign or local-based institutions advise the local
involved in providing care at the primary health care clinics authorities about the environmental, vocational and
(PHCs), comprehensive health centres (CHCs) and in old educational problems that can be dealt with, in order to
peoples’ homes. ameliorate the situations/conditions facing people with
disabilities. Decentralization of professional services to the
community level, as far as the resources allow, are
Evolution of Rehabilitation Services
delivered locally. In Nigeria for instance, this has been
A situation-analysis on prevalence and incidence of done through mobile teams, camps and day-clinics, using
disability revealed a lower prevalence of disabilities in the comprehensive health centers or schools as contact points
developing countries, due to the short life span of disabled (Abereoje and Olaogun,1990). Some religious institutions
people (Helinder, 1984). The factor contributing to death on outreach programmes are also offering rehabilitation
is not the disability per se, but infectious diseases and services in several states of the country.
diarrhoea. There is therefore a global need for improved
W ith the analysis and definitions above, only very few
rehabilitation services. Rehabilitation services, where
disabled will receive rehabilitation services, particularly of
available, have been active or passive, institution-based or
IBR. In some developing countries, there are no
on outreach programmes (Helinder, 1984; Olaogun, 1986;
rehabilitation services at all. W here they are available,
and Lucas and Giles, 2003).
rehabilitation services in the institutions do not provide
social integration. Services provided were far from ideal.
Types of Rehabilitation Services An alternative approach to IBR was then declared by
W HO in 1978 - Community Based Rehabilitation (CBR)
Active Rehabilitation Services imply functional training,
(Helinder, 1984, W HO, 2007). CBR has the notion that:
schooling and vocational training, which lead to an
independent and better social integration. Examples of a. If rehabilitation is to reach all those in need in the
where it is offered in Nigeria include the Children developing countries, there must be a large-scale
Development Centre, Surulere, Lagos and the Stella transfer of knowledge about disabilities and skills in
Obasanjo Child Trust Foundation, Abuja. the rehabilitation of people with disabilities to their
families and members of the community.
Passive Rehabilitation Services signify those which do not
aim at independent and better social integration. These are b. For rehabilitation to be successful, communities must
offered in rehabilitation homes and care institutions, where recognize and accept that people with disabilities have
people with disabilities are given shelter and food, but do the same rights as other human beings. Rehabilitation
not undergo any training programme (Olaogun et. al, therefore needs to aim at bringing about this required
1992). attitude- change in communities. It has been found
that this change in attitude is most effectively brought
about when communities themselves take on the task
Institution-Based Rehabilitation (IBR): In this category,
of rehabilitating their members who have disabilities.
general or specialized services are offered in an institution
or home for the disabled. General institutions include CBR is a strategy that seeks to ensure that people with
centres that provide services for people with all types of
disabilities are involved in the development of their
disability. Specialized ones include homes for children with

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Community-based Rehabilitation and Reintegration of the Disabled

community by having equal access to rehabilitation and the blind and the deaf); long-term vocational training and
other services and opportunities – health, education and provision of standard orthopaedic appliances.
income; as do other members of the society.
At the national/federal level, there should be referral, as at
The targets of the CBR programme are: people with
the state level, for more complex medical diagnosis and
disabilities, families of people with disabilities,
very specialized medical services, complex rehabilitation
organizations of people with disabilities, local, regional
services like spinal fusion and physiotherapy, educational
(state) and national (federal) governments, international
services at institutions of higher learning for people with
organizations, non-go vernm ent o rga niza tions,
disabilities and vocational services (training in special
professionals in health sciences and other fields and the
vocational subjects unavailable at local and state levels).
private sector (business and industry)
Professionals will be involved in the delivery of
The system components of the CBR include:
complex rehabilitation services as well as in the training
technology, service delivery and community involvement
and supervision of personnel for district, provincial and
and close cooperation with organizations of people with
national levels. There is therefore the need for the review
disabilities and parents of disabled children.
of the present training curricula of various professional
In a CBR programme, all the interventions that can be groups in order to prepare the graduands better for the
effectively done should be done, then referral services at additional responsibilities they will have in the referral
higher levels should have professional inputs. Three levels system of a CBR programme.
of referrals were proposed: district, provincial and
It is suggested that the CBR programme be started
national. These can be translated to local, state and
from the district level, rather than from the national level,
national levels, respectively.
which can be wasteful. At national institutes, well-trained
professionals are often occupied with simple levels that
At the district/local government level, diagnostic services could be done by someone with less training.
should be available. If circumstances allow, each client in The activities in CBR at the three levels include:
the CBR programme should be seen by a physician. The
• Promotion of positive attitudes towards people with
purpose is to confirm diagnoses and make sure that no
medical treatment is neglected. In other words, co- disabilities.
morbidity should not be neglected. There should be • M aking public utility and offices accessible.
educational services for children and provision of resource • Preventing causes of disabilities.
teachers, vocational services for adults, vocational
• Providing rehabilitation services.
assessment and guidance, skill acquisition and short-term
vocational training and job placement. • Facilitating education and training opportunities.

There should be provision of simple orthopaedic • Supporting local initiatives.

appliances and other adapted equipments. There is a need • M onitoring and evaluating CBR programmes.
for an intermediate–level supervisor or a CBR manager, • Supporting micro and macro income-generation
who can train the local supervisors, guide and supervise opportunities.
their work, manage referrals, maintain communications
will all levels of service and manage the CBR programme.
Community Involvement
Integrating CBR into Primary Health Care (PHC) may
be considered, but CBR must be given due attention to A rehabilitation programme based in the community must
make it effective. The PHC is the lowest level of medical have its roots there. The community must be involved in its
service delivery in many developing countries, but it has planning, implementation and evaluation. A community
not given the desired attention to CBR. committee should be involved as a management group.
The local government should provide the personnel and
At the state level, CBR involves referral for: diagnostic financing for it. The W H O rehabilitation unit does not
services for more complex medical conditions; medical provide consultancy services for periods longer than 3
services for corrective surgery, e.g., ear-drum perforation, months (Helinder, 1984).
eye surgery, complicated fractures; drug treatment of In CBR programmes, it is important to have community
therapy- resistant diseases; complex rehabilitation therapy organizations and informally involve som e people with
for those not improved through community services; disabilities in an advisory capacity.
educational services, such as special education (schools for

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 Olaogun, Nyante, Ajediran

Opinion leaders such as the religious leaders and CONCLUSION

traditional rulers should champion the demystification of
The physically-disabled in most developing countries still
our traditional norms and practices pertaining to
face a lot of obstacles or barriers to full participation in
disabilities.
their affairs and in the society. M ost governments need to
revisit the principles of W HO-CBR to provide equal
The CBR Global Review opportunities for their citizens. The community-based
Twenty years after its introduction, a global consultation rehabilitation principles should be involved as components
forum to review the state of CBR was called by W HO, in of community development, which is essential for any
collaboration with the UNO, NGOs and disabled people’s meaningful government. Aside involving the disabled in
organizations. The consultation was hosted by the the running of CBR, developing a strong disabled
government of Finland, in Helsinki on M ay 25-28, 2003 community network will also go a long way in sustaining
(W HO, 2007). the project and making the disabled part of the solution of
The theme paper for the meeting noted that : overcoming the restriction in participation in all areas of
human endeavour. Public offices and utilities should
i. Because all communities differ in socioeconomic
conditions, terrain, culture and political systems, there include provisions for accessibility. Aside the benefits of
cannot be one model of CBR for the world. physical rehabilitation, the CBR encourages the
participation of the physically-challenged in social
ii. The focus of CBR has evolved from medical
rehabilitation. ‘Bionic’ vehicles can be provided and
rehabilitation towards more comprehensive multi-
restricted for the use of the aged and the physically-
sector approaches such as access to health care,
challenged. The community-based approach in reducing
education, vocational training, income generation
the barriers for participation by the physically- challenged
programmes, community participation and inclusion.
is modifiable without neglecting the goals of the
components of health, education, livelihood, social and
The New Model empowerment.
There are five key components which show the different CBR can play a significant contribution to the overall
sectors of the CBR strategy as a component of community development of the country if politicians, administrators
development. They are health, education, livelihood, and professionals pay attention to the infrastructure and
social and empowerment. training needs which are necessary to fulfill the potential of
In health, attention is focussed on wellness promotion, the programme.
disease prevention, medical care rehabilitation and use of
assistive devices. The subsets of education are early
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