The COVID-19 pandemic has more than ever before highlighted the need to strengthen rehabilitation services for the most vulnerable sections of society, which include the elderly and persons with disabilities. While communities have come forward and offered support, the pandemic has also exposed grave limitations in several low- and middle-income countries where there are little to no health or rehabilitation services available for those living in poverty.
From 1979, the World Health Organization has advocated Community Based Rehabilitation (CBR) as an integral component of heathcare.
Balakrishna Venkatesh, Voluntary Convenor, Indian Forum for Rehabilitation and Assistive Technology (IFRA), says that CBR is the only comprehensive United Nations model that has stood the test of time to reach persons with disabilities in remote areas using barefoot and community development approaches. The recent exclusion, therefore, of CBR from two important WHO policy documents is worrying.
IFRA has initiated an advocacy petition to co-promote a World Health Assembly Resolution on Rehabilitation, including CBR, said Venkatesh in an interview, adding that this is important in the global context as CBR runs the risk of being forgotten. Excerpts:
How did CBR come about in the context of global health?
In 1978, shortly after the Alma Ata Declaration, the WHO came up with the concept of community-based rehabilitation after extensive interaction with persons with disabilities living in slums and rural areas across the world. CBR is essentially people-centric and focuses on how ordinary citizens can be trained in rehabilitation skills, which includes identification, assessment, and providing requisite services. It is an excellent model as it creates an environment for the community to take responsibility. CBR is also a bridge between the family of the person with disability, the PHC, and other government and civil society agencies. This is rehabilitation at the doorstep.
In 1979, a manual on ‘Training disabled people in the community’ was published and endorsed by UNICEF, UNDP, UNESCO and UNCHR. Twenty-five years later, CBR was reviewed in Helsinki in 2003 and a CBR Joint Position paper was published. CBR was updated in 2004 as a multi-sectoral strategy for rehabilitation, equalisation of opportunities, poverty reduction, and social inclusion of people with disabilities.
To operationalise this in 2010, the WHO published the CBR guidelines in collaboration with UNESCO, ILO and 33 civil society organisations. Today, more than 100 countries, mostly low- and middle-income, practise CBR. A 2019 WHO study estimated at least 2.4 billion people benefit from rehabilitation at some stage and that one in three people needs rehabilitation due to reasons ranging from accidents and non-communicable diseases to pregnancy and ageing.
Why is the exclusion of CBR from recent policy documents worrying?
According to the WHO, in many developing countries, including ours, with huge populations, there are only 10 trained rehabilitation professionals for every 1 million people, besides a shortage of 20 million doctors and nurses across the world.
In 2017, WHO launched ‘Rehab 2030: Call for Action’ under the new leadership of their disability unit, and CBR was found to not have a central focus here. Additionally, the absence of CBR in the World Health Assembly Resolution in January 2021 on ‘Highest attainable standard of health for persons with disabilities’ is not only conspicuous, but of grave concern. In the last 43 years, CBR has been central in all WHO and WHA discussions and documents concerning disability. The absence of CBR will be detrimental to people living in poverty and the impact on disabled persons will be even greater. If we allow this to continue, CBR will be forgotten. There will be no government support and aid agencies will not step in with financial assistance for such rehabilitation programmes.
How has the pandemic emphasised the need to bring back focus on CBR?
In the post-COVID era, the need for community-based or home-based rehabilitation is most appropriate and urgent. The most effective way to provide services is to put people at the centre, as part of the system. Developing countries spend less than 1% to 3% of their GDP on health. The pandemic has exacerbated the frailty of healthcare systems across the world. In India, we saw how persons with disabilities had difficulty getting assistance, including pensions, during the pandemic. Food security was also affected. Some 150 million people are estimated to have fallen back into poverty and hunger and whatever was gained through poverty alleviation and literacy programmes in the last 20 years has been wiped out by the pandemic. Then there is the long-term impact of climate change, migration, and conflict. .
The need for rehabilitation has increased by 63% from 1992 to 2019 and will continue to rise further due to population growth, global health trends, including fallout from COVID-19. We believe it is time to strengthen commitments on rehabilitation, including CBR, and respond to the huge unmet need globally.
We saw communities stepping up and coming together to help the vulnerable sections globally...
Yes. People and communities have become the first port of call for help during the pandemic. Neighbourhood groups or individuals have helped persons with disabilities by providing dry rations, financial assistance, getting them tested, and ensuring access to welfare schemes such as pensions.
Tell us about the advocacy petition that IFRA has initiated.
As India is a member of the WHO Executive Board, IFRA has written to the health ministry to join a core group of WHO member states presenting a request to include a resolution on rehabilitation in the agenda of the World Health Assembly 2022. The purpose of this resolution is to make rehabilitation an integral part of health systems at all levels. IFRA’s appeal is also to include CBR as a central strategy in this resolution. Countries such as Columbia, Rwanda, Israel and Australia have already submitted the request to the WHO’s Executive Board. Our petition is supported by around 4,000 people across India and this is an indicator of the awareness of the need for rehabilitation and CBR.
How has CBR been adapted in India over the decades? Have there been any standout initiatives that can be studied as an effective model?
There are several civil society organisations implementing CBR programmes across the country. The Rural Development Trust in Anantapur district, for instance, has a CBR worker in every village and habitation, numbering over 2,000. The worker creates awareness in the community, encourages persons with disabilities to form self-help groups to advocate for their needs and rights, and facilitates service delivery for rehabilitation, education and livelihood. For instance, if parents want to admit a child with disability in school, the CBR worker will interact with the parents and the school, and act as a bridge.
Karnataka, at the panchayat level, has a village rehabilitation worker, and almost every worker is a person with disability. Andhra Pradesh has a nodal person in the district administration to promote inclusion of persons with disabilities in NREGA. There are several such models across the country, which can be replicated by all States.
The District Disability Rehabilitation Centre (DDRC) is an initiative by the Ministry of Social Justice and Empowerment to facilitate comprehensive services for persons with disabilities in rural areas. There is a lot of scope for improvement and adaptation. For the country to effectively implement CBR, adequate, trained human resources, financial investment, and effective infrastructure are absolutely necessary.
poorvaja.sundar@thehindu.co.in
