理学療法士と地域基盤リハビリテーション

NII-Electronic Library Service

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The

Physiotherapist

andCommunity-BasedRehabilitation"

PadmaniMendis*"

Introduction

Ina sample of 51 countries scattered in

the,West-ern-Pacific Region,

South

Asia

and Africa,25

coun-tries

are reported

to

have

initiated

Community-Based

Rehabilitation

_(CBR)

_projectsor _programmes,

In

13

of

these

ceuntries

CBR

ispart of the

govern-ments plan

for

rehabilitation2]. Increasingly,

reha-bilitation

publications

include

literature

and

discus-sion on

CBR.

Today

several newsletters on the

subject of CBR are being published in different

partsof the world, and have a wide _global

distribu-tion. Also increasingly,CBR iseither the subject

of, or a topicon,

the

agenda of international

meet-ings and symposia. Keeping inmind thatitisonly

just

over a

decade

thatthephrase "CBR"

came

into

use tedescribe a new concept forthe development

of _programmes

for

_people who have

disability,

all

these would

indicate

the

degree

of

it's

acceptance

globally.

Three

major

factors

appear toconstrain

the

gen-eration and extension of

CBR,

and are relevant to thesubject of thispaper;

1)The

first

isthe lack of understanding of the

CBR concept, and consequent implementation

'

of too many approaches which are

CBR

only

in

name;

2) The second relates to this,and

is

the

failure

to

recognize the role inCBR, of _people who have

disability;

3} The. third is the inadequacy of manpower

* _vaYesiil

±ttnnjgma Uii lf' b)t- V, i y

" _{Consultantin Rehabilitation}

C

_{rPN lf}

Vr- ViJ y

･

=

)it±IL,S ;/F)

cadres essential for supporting communities.

The term inadequacy refers not so much _to

numbers, but more importantly, to

appropriate attitudes and

lack

of appropriate

skills

for

CBR.

The

Cornmunity

"Base"

By

the very nature of

being

a"concept", that

is,

"a

set of

ideas",

the term

CBR

does

have

a special

meaning, CQnsequently those

planning,

im-plementing and managing CBR approaches must

conform to

this

set of ideas,or not call those

ap-proaches CBR. The use here of the word "special"

does

not

limit

its

application,

but

indicates

rather

that the concept _gives a

broad

direction

as tohow

the aspirations of _peeple who

have

disability

(as

stated

for

example, inthe

UN

World

Programme

of

Action

Concerning

Disabled

Persens), can be

achieved.

The

rationale

for

the development of

CBR

is

the

situation of _people with

disabilities,

faced

by

in-equalities in all aspects of life.These inequalities

and disadvantages are _primarily the result of

society's attitudes towards

disability

and people

who have disability.

CBR

takes into account that

the

situation can thgreforeonly

be

corrected

by

a

radical social change towards _the acceptance of the

humanity

and

the

equality of people who

have

dis-ability.

Social

change cannot

be

enforced from outside

if

itisto be deep and iasting. People in whom the

change isrequired must accept thatchange is nec-essary, and

take

responsibility

for

bringing

about

NII-Electronic Library Service

450

mp\tsth\

CBR concept. The _primary responsibility for

change lies with the imrnediate community in

which individualswho have disabilitylive.Hence

the

term

"community-based".

At

the

same

time,

all

sectors of society, at alladministrative levels,must

participate

in

the

change

if

society

is

to

open all

its

doors

to

_peeple

who

have

disability.

CBR

thus sees thatthe needs of _people with

disa-bility

are met through the country's engoing

sys-tems and structures for socio-econornic

J

ment. This

begins

at

the

_grass-rootsIevels,with as

many of the needs as _possible being met in the'

in-dividuals

own home and community environment.

Social interaction must take _place here, as must

also

ADL,

mobility ana communication training,

and early stimulation ef children who

have

disabiii-ty;

income

generating activity for adults and

edu-cation

for

children often need _greater community

involvement tomeet special needs.

Needs that cannot

be

met at community

level

are

rneL by referral _toother levels-vocational training

in

specialised areas,

for

instance,

or specialised

ther-apy and medical and surgical

interventions.

The

CBR

system thus

builds

upwards, through special needs

being

met

in

integrated

environments.

No

･more

_{justification}

_for

_{services which}

_isolate

_and

SERVtCE COMPONENTS Home-BasedTrain]ng detectlen/ eariystimulatien/ breastteeding/ SERVICE

fi

2o

igee

7

e

segregate individualswho have

disability.

Figure 1illustratessome aspects of the

CBR

de-liverysystem.

Employment

of

Communities

There

are two aspects toempowerment

in

CBR.

The

first

is

empowerrnent of communities to take

responsibility

for

impreving

.the

_quality of

life

of

their

members with

disabMty.

The

_primary

requi-site forempowerment isinformtation.

Information

in

the

form

of

knowledge

and skills which can

be

used toovercome consequences of

disabiity.

Information

must

be

in

the

hands

of communities

and individuals and not

just

doled

out

by

profes-sionals and other

health

workers. Itmust be inthe

possession of not only _people who

have

disability,

theit familiesand rehabilitation workers,

but

also

of neighbours and

friends,

formal

and

informal

community leaders,school teachers,

health

workers,

and also of community workers and community

groups.

Knowledge

is

power,

This

was the principleunderlying the

develop-ment of the

WHO

Manual

"Training in the

Com-munity for People with Disabilities"i).The Manual contains

information,

knowEedge

and skills that ctin

be

used by individuals who have disability;their

LEVEL Fig.

1

M'ANPOWER INVOLVED ina]viduaFsvrithdisabUtrv: femilymenlbefs/ ): disabilby; tatf/ rrvadicalspacla11s ±

,socialwqkers/

vocetionalspe:iailsts/ orthotists,presthetists/ mlnistrigs,depanmenls,medie:

Some

Aspects

of the

CBR

Delivery System

NII-Electronic Library Service

The Physiotherapist and

Community-Ba$ed

Rehabilitation

family

members, and community members

(leader-ship, school teachers,community workers).

The

Manual

is

not merely a

documentation

of

simplified technology. Itistechnology integrated

inthe context of social change and community

de-velopment.

Unfortunately,

some western

profes-sionals have in the _past tended to see itmerely as

"technology

which

is,

at

the

most,

too

simple", In

doing

so,they have missed the wood forthe trees.

The

unique significance of the

Manual

is

that a

problem solving approach

is

used

from

the

perspec-tiveof the consumer, and not

from

theperspective

of the _professionaL

To

appreciate the

Manual,

pro-fessionalsrequjre not only a familiarityof the

socio-cultural ethos and an understanding of the root

causes of

handicap

in

developing

cQmmunities; it

calls

for

a willingness to see things

from

beyond

the confines of theirprofessions; to realize

that

al-ternative soLutions to the same _problem may

be

more appropriate

for

people

in

different

circum-stances; and tosee thatinthedevelopment of these

new approaches the role of the

few

rehabilitation

profe$sionals

in

developing

countries

becomes

even

more valuable.

The

development

of

the

WHO

Manual

has

been

based

on 2

fundarnentals:

'

_information

_{dissemination,}

_{utilizing a set of}

proaches

designed tochange

family

and

nity attitudes towards greater acceptance of the

potentialabilities of _people with

clisability

and of

theirright todevelop these abilities tothe

mum.

'

_description

of both a rehabilitation system that

builds

upwards

from

the community, and

ures to

be

taken

by

the familyand community to

enable their members with

disability

to

pate

in,

and to contribute to,the

life

of their

munity instead of livinginisolationor

tion.

There

can

be

no empowerment without

knowl-edge,

Hence

the use of

the

Manual

for

gmpower-ment.

451

Empowerment

of

People

Who

Have

Disability

Empowerment brings topeople the right to make

decisions

_<or,

as inmany of our cultures, _participate

in_group

decision-making),

in

matters which affect

themselves

as

individuals,

and as members of

fami-lies,communities and society at

large.

Without

empowerment we cannot

fulfi1

ourselves as

human

beings;

we cannot achieve self-realization.

This

is

an

inherent

right of every

human

being,

but

yet

even as we

draw

to theend of the twentieth

centu-ry, denied to most people who have disability.

Denial of

this

basic

human right makes for

oppres-sion.

There

are many

individuals

with

disability

who

say thatone of the areas where this"oppression"

is

very prevalent

is

in

rehabilitation.

This

can

hardly

be

denied,

because

conventional rehabilitation

pro-fessional

education tends to project people who

have

disability

in

sick roles, as patients, and

there-fore _{prepares professionals}to be _providers of

serv-ices

and _primary decision-makers.

CBR inverts the conventional health _pyramid.

The

base

cornes on top, with individuals,families and communities

being

the primary

decision-rnakers and controlling their own lives. Basic

knowledge

and skills that they need

for

handling

day-to-day

_problems

ismade available to them in

the

WHO

Manual.

In

CBR,

theirinformation _gaps

are fiIledand decision-making thereby supported

by _{professionals.} In rny own view thisincreases

the value of professionals,rather than

the

reverse.

The inverted pyramid provides empowerment

for

Organizations

of

People

who

have

Disability

by

providing opportunity

for

them to

_participate

in

the planning, monitoring and evaluation of CBR.

This isa challenge which, with

few

exceptions,

has

not _yet

been

_taken up

by

Disability

Organizations.

Manpower

Requirements

for

CBR

As

shown

in

Fig.

1,

the

CBR

delivery

system calls

for

the

deployment

of specific manpower categories

NII-Electronic Library Service

452

ve\taza\

at the

different

levelsof the CBR system. It'sfocus

within community

development

and

it's

multi-sectoral nature

both

demand

that any categories

workjng within theseareas should

have

orientation/ education in

CBR

related to theirarea of activity.

At

the same time,a "core"

group of technical

manpower takes specific respensibility formaking

the system work:

'

individual

who

has

disability

f

trainer-family member

]

local

supervisorH]ommunity worker

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concept as technicalcadres at the community level,

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has

called

for

specific

full-time

re-habilitationworkers. CBR to

date

has used a

varie-ty of categories, oriented to

CBR

through special

courses to

fi11

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(Myanmar),

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(Argentina),

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NII-Electronic Library Service

The

of _qualityand coverage has increased

(Viet

Nam).

Itisthe lack of appropriately educated middle

levelworkers that _presents one of the major

barri-ers to CBR development today. Many developing

countries educate physiotherapists, and a

few

coun-triesalso educate occupational therapists. These

cadres are usually employed at tertiarylevel

insti-tutions,out ef reaeh of most communities. Besides,

theircurricula _prepare them to rneet the

therapeu-ticreferral needs of conventional rehabilitation, which

is

inadequate

for

CBR.

It

would

be

not

exag-geration to state that the greatest manpower

re-quirernent

for

CBR

today are middle level

rehabili-tationworkers.

Possibilities

for

Physiotherapists

CBR,

having

two

levels

of services, narnely the

community level and the supportlreferral level,

offers physiotherapists a choice.

One isto continue theirconventional role in in-stitutions. This isthe rore they are currently being

educated for,to _provide therapy mainly fer

im-pairments of the locomotor, respiratory and

cardio-vascular systems and mobility disability.As CBR expands the number of referrals toinstitutionswill

increase,

and

there

will

be

an increasing

demand

for

physiotherapy. Inthisrole they could also

un-dertake

toteach other

health

workers some aspects

of physiotherapy,

The second

is

toassume a more dynamic role

in

CBR-to

be

active inthe

forefront

of

CBR,

stimulat-ing

and supporting the social change that will

bring

about the recognition and realization of the

rights of peoplewho have

disability.

With

the second choice therapistsmove out

into

a central role

in

rehabilitation; _they move out to

widen theirsphere of

infiuence

in

society-at-large,

from

within the confines of physiotherapy services.

Physiotherapist and Community-Based Rehabilitation

453

The second choice calls for a reappraisal of

the

role of _{physiotherapists} tofirstfunction as a

gener-alists at middle levelsand

then

as specialists at

ter-tiarylevels.Itthus widens theirscope.

Our

experi-ence inCBR has demonstrate that_{physiotherapists,}

with adequate CBR educatoin, can rnost easily

assume these new roles and _perform thenew tasks

required of CBR.

The experience of Viet

Nam

is

of

interest,

and

theirmanpower

development

is

summarised

in

Fig.

2.

Through

participation

in

CBR,

realising the

con-tribution they could make, conventional

physio-therapists now callthemselves rehabilitation

thera-pistsand

have

adopted a new curriculum fortheir

education. A

30･-month

trainingprepares them to

meet the middle Levelsupport and referral needs of

individuals

who

have

disability,

theirfamiliesand

communities. They will have skMs to meet not

only the needs of mobility disability,

but

aLso of

visual, communtcation, intellectualand behavioural

disability.They will lateracquire more specialized

skills.

The

fact remains that CBR will not

be

able te

meet the _goal of "Rehabilitation _For

All"

without a

well defined middle levelrehabilitation cadre.

Few

countries have such a cadre

today.

Given

their

pre-vailing economic situations, such countries are not willing tocreate cadres.

In

such situations would physiotherapists

be

will-ing

to

fi11

the gap? The opportunities forthe

pro-fessionare

immense.

References

1)WHO: Traininginthe Community forPeoplewith

Disabilities,Geneva 1989.

2)PupulinE:CBR

---Where

are we now. Paper_presented