1 Publications on Community-based Rehabilitation Management series 1 A Service Delivery System For Community-Based Rehabilitation Programmes Guidelines for the design and organisation of services and of training programmes for the personnel By Einar Helander UNITED NATION DEVELOPMENT PROGRAMME; GENEVA SWITZERLAND
2 2 Einar Helander, 2003 Lisbon, Portugal All rights reserved. Without limiting the rights under Copyright reserved above, no part of this book may be reproduced, stored in or transmitted in any form or by any means, electronic or mechanical, including photo-copying, recording, or by any information storage and retrieval system, without the written permission of the Copyright owner of this book. To get permission to copy or translate parts or the entire text of this book for non-commercial purposes, please contact the author: Avenida Casal Ribeiro 12 4 A, Lisbon, Portugal CONTENT Page Background and Executive Summary 3 Introduction 5 1. Prerequisites for a CBR programme 6 2. General strategy for the development of human resources for CBR 7 3. Planning the training of CBR personnel 8 4. Prerequisites for training and choice for training organisation How many personnel are needed? CRFs ILCs Timetable for development of the services delivery system Policy regarding use of public services and access to mainstream opportunities by persons with disabilities Financing of the programme Approaches to referral services Upgrading of personnel Support from a National Rehabilitation Institute Co-operation with Organisations of persons with disabilities and their families Evaluation of the CBR service delivery system 22 Books and documents about CBR 22 Annex I Detailed programme design 25 Annex II Expected outcome and performance of the students to be intermediate level coordinators 35 Annex III Detailed course plan for the intermediate level rehabilitation co-ordinator (ILC) 55 Annex IV Training the community rehabilitation facilitator (CRF) 63 Annex V Guidelines for district CBR societies 81
3 3 BACKGROUND AND EXECUTIVE SUMMARY The global number of persons with a moderate or severe disability by the year 2000 are estimated at 335 millions. This number is growing by about 10 million a year, or over 25,000 a day. By the year 2035 the global prevalence is estimated at 667 million. People with moderate and severe disability are at present (year 2000) about one out of six of those close to 1,400,000,000 people, who live in poverty in the developing countries. Little is done today to provide any meaningful level of services needed by disabled people in the developing countries. Until now, non-governmental organisations have been the main deliverers of services in most countries. However, they have never been equipped to handle the more than a tiny proportion of the needs for functional training, education, ability and vocational training, income-generation, protection of human rights and security and care. These needs can only be met through large-scale service delivery system. For the organisation and maintenance of those governments must take responsibility. This Guide outlines the concepts of how a service delivery system built on the strategy of Community-based rehabilitation (CBR) can be set up. It also includes examples of training programmes for the field personnel. The Introduction (p. 5) outlines the general design of the service delivery. The objective is to eventually provide equal opportunities, protection of rights and full participation for all the persons with disabilities. This document includes a proposal for a design (p.6 and Annex I) of such a system and for the management support needed to plan, implement, monitor, evaluate and create the conditions for its sustainability. The system is based on the community-based rehabilitation (CBR) strategy and conforms to international policy recommendations. It is unfortunately common to see that in the past the majority of the professionals working with persons with disabilities have not been sufficiently trained. After 20 years of CBR experience the most common solution for the setting up of a sustainable field programme in a developing country is to start by training the basic personnel. The most cost-effective and efficient entry-point for action (p.8) is the training of two categories of field personnel: the Intermediate Level Co-ordinator (ILC) and the Community Rehabilitation Facilitator (CRF). In order to design their training requirement an analysis in 12 steps (p. 8-16) has been made. This goes out from a review of the needs of persons with disabilities. Based on this the field technology has been developed, using models of successful, local examples of training programmes in developing countries. The process used for the formulation and testing of simple training packages is described elsewhere. Families and community members can successfully perform a very large proportion of the rehabilitation tasks, if properly motivated and guided by the personnel. These include functional training, inclusive education, ability and vocational training, income generation, action to protect rights and security; and to effectively engage persons with disabilities and their organizations in community activities. It is - as a part of this new paradigm - necessary to open up the opportunities for participation of persons with disabilities in mainstream community development programmes. The tasks for the ILCs and CRFs are described (p.12-13), as are the reasons for the competence level proposed (p ). The document outlines the desired performance and competence of the ILCs (Annex II) and CRFs (Annex IV), and the training programme for them (Annex III and IV). In this Guide, a detailed model is provided for an ILC course lasting 18 months, but alternatives can be developed. Similarly, a CRF course for 12 weeks is described; two alternatives are given. The requirements for organisations to train ILCs appear on p.16.
4 4 Calculations of how many personnel are needed have been made (p.16-17). To meet the very high demands from under-served persons with disabilities at the start (the peak phase), a system for phasing in the CBR programme is proposed. With this, the long-term needs are for one full-time ILC for a population of about 100,000 and one full-time CRF for a population of about 5,000, in areas with a population density of about 20 to 30/sq.km. or higher. The policy regarding the use of public services and mainstream opportunities for persons with disabilities is reviewed on p. 20. a review of the financing of the programme and the approaches to referral services appear on p The technical and managerial support from a National Institute/Foundation for community-based rehabilitation (p.21) will be needed to assure the quality of the development of the implementation of the national CBR programme. Close co-operation should be established with persons with disabilities and their families. (p.21). They should be engaged in the evaluation of the service delivery system; to ensure this, it is proposed to set up in each District a CBR Society with wide representation of these persons and their local originations. (p and Annex V). A list of CBR books and documents appears on p This book was last revised in September Readers are welcome with proposals. Lisbon 20 September 2003 Einar Helander
5 5 A SERVICE DELIVERY SYSTEM FOR COMMUNITY- BASED REHABILITATION. Guidelines for the design and training programmes for the personnel INTRODUCTION.
6 6 INTRODUCTION. 1. Prerequisites for a CBR programme. The setting up of a system to provide services for people with disabilities should be based on a set of Government policies and plans. There are in many instances several phases in the development of policies and plans, such as: Simple declarations of intentions, for instance, made by politicians or parties at the time of ongoing elections or in political programmes. Acts/legislation, approved by the parliament, the congress or similar bodies. Official public plans and decisions Commitments for financing over a period, such as those of a 5-year national economic plan. Directives and rules by the Cabinet, or individual Ministries. Availability of funds for local authorities The country may already have Institutions and Centres, which provide specialised care, services, and training of professional personnel and research. These may concern different sectors, such as Health, Education, Labour and Welfare. In all developing countries, their quantitative capacity to assist individuals with disabilities is insufficient. NGOs are in most countries still the main providers of services for persons with disabilities. However, NGOs have only been able to cover an estimated 2-3 per cent of the global needs. NGOs are, largely, based in urban areas - the rural population is barely reached - and their resources are limited. One cannot expect NGOs to cover the 97 per cent of the needs of those who are now totally under-served. To implement the service delivery system needed by persons with disabilities is necessary major extension is needed. The role of the State Governments is to provide the administrative and technical backbone (for policy background see U.N. Standard Rules on the Equalization of Opportunities for Persons with Disabilities, 1993). The Community- Based Rehabilitation (CBR) strategy has been shown to be effective, sustainable and affordable. The CBR has the following features: 1) it involves families and local community encouraging their own initiatives and using local resources, based on a technology built on indigenous and thoroughly tested methods 2) it is multisectoral and operates with a multi-level system 3) it addresses the needs of the target population: functional training, education opportunities for incomegeneration and protection of rights and security The CBR strategy works best in a participatory environment. In one country (India: 73rd Constitutional Amendment Act of 1992) this has been expressed as follows: To place more and more power in the hands of the rural people to determine their own destiny; to enhance the capabilities of the rural people to involve themselves in the planning from below; to decentralize execution of all kind of development activities with effective participation of peoples; and to orient development administration based on the philosophy of popular participation. The increase of services and efforts to provide equal opportunities, protect rights and promote full participation can only be implemented, if the required number of competent personnel is added. An expanded programme needs to engage persons with disabilities, their families and communities, as well as concerned non-governmental organizations, existing institutions and professionals in a joint commitment towards co-operation and support. Only through combined efforts of solidarity, a willingness to promote inclusion and access to mainstream opportunities will the dignity of disabled people be restored. Guidelines for planning, recruiting, training and managing educational programmes for personnel in order to create the service delivery system needed to implement a national CBR programme are reviewed in this document.
7 2. General strategy for the development of human resources for CBR. 7 No major change in the quality of life and in the protection of rights of persons with disabilities can be achieved without an appropriate and effective service delivery system, eventually reaching all in need. This system should for reasons of costs and optimal use of resources be unified at the local level and specialised at higher referral levels. Fig. 1 provides a draft overview, with a general programme design, including the system for management support. A specific programme and detailed design is provided in Annex I. FIG 1.Draft of general programme design: service delivery and management system for CBR Level Community (5,000 pop.) County (100,000 pop.) District (300,000 pop.) Province (1 million pop.) State Persons Responsible Disabled person Families Community members Community Rehabilitation Facilitator Intermediate Level Coordinator District Rehabilitation Technical Officer Province Rehabilitation Director Province Commissioner Province Rehabilitation Technical Officer Ministers Secretaries Chief Commissioner Management Support and Responsibilities Organisations of persons with disabilities and family members (DPOs): planning, promotion, and activities to implement the community level services. Community Rehabilitation Committee (micro-management planning, evaluation, provision of resources, sustainability.) County Committee (evaluation, coordination, supervision, reporting and planning, protection and promotion of rights, some referrals, co-operation with NGOs.) District Rehabilitation Society (planning, evaluation, full monitoring of ongoing activities, contacting and arranging referral services, co-operation with NGOs.) Province Coordination Committee (planning, training of personnel, evaluation and monitoring, cooperation and coordination, specialized referral services, cooperation with NGOs and DPOs.) Legal questions, promotion and protection of rights, monitoring of social justice and empowerment. Technology, technical training of staff, supervision of field activities. Central Co-ordination Committee Policies and Legislation. Supervision of rights protection. Monitoring of all activities to comply with existing legislation Financial support Technical support, training of professionals and managers, educational materials, development and research, co-ordination etc. through a National Institute/ Foundation. Co-operation with NGOs, DPOs and professional organisations The levels above are to see as one example and needs to be adapted to each country. The principle to provide general services at the peripheral levels, and the specialised services at the more central levels is consistent with the strategy for other national services, such as health and education. The costs to deliver highly specialised services for persons with disabilities directly in the community are unaffordable even in the highly industrialised countries. The peripheral levels of the public service delivery system would for these reasons - and in accordance with internationally accepted polices and recommendations - consist of multipurpose/multisectoral personnel. These personnel will be provided at two levels: a) at the community level - a Community Rehabilitation Facilitator: CRF b) at the county level an Intermediate Level Co-ordinator (ILC)
8 8 This proposed choice of personnel strategy is important. ILCs are seen as the entry-points for the major expansion of service delivery system. ILCs will, once their training is finished - initiate the mobilisation of the communities through an awareness/sensitisation programme, then train and supervise the CRFs and set the whole system in progress, starting from the grassroots (see Box 3). Organisations that deliver services for persons with disabilities should employ only personnel that meet the requirements for competence. The ILC should receive a training that is at least 6 months. It would be more cost-effective to give a period of training that is 12 to 18 months. If it is shorter, the competence of the ILCs will be lower. As a result the number of referrals will be much higher and much more costly. (See Box 3). In this Guide a model for 18 months training of ILCs will be outlined in detail. The ILC will in our model be employed initially for a population of some 100,000 people. The CRFs will receive 12 weeks of training and work in a community of some 5,000 people. Modifications of this model are required id the population density is less than 30 per sq.km or if the environment is difficult to access because of rough terrain, mountains, rivers and sever road conditions. There are other strategic alternatives for a service delivery system. It is often proposed to add the responsibilities for persons with disabilities to an already existing category of personnel. For instance, health workers or social workers have been used on a part-time basis. This has been tried out in several countries. Unfortunately, the experience of this option is rather negative for these reasons: the personnel is already overburdened with their existing responsibilities and has no time for providing services for persons with disabilities. When the work load related to the original duties increases, the activities for persons with disabilities decrease or cease to be carried out, the personnel chosen from one sector will most often be ignorant of how sectors outside of their own should be engaged to meet the needs of disabled people, the costs are substantially higher, as often 8-10 times more personnel will have to be trained, and there are no savings to compensate for these extra costs (it is also common that the personnel asks for salary increases to carry out the extra responsibilities), there is most often a lack of clear responsibility and dedication to the holistic approach, which includes wide responsibilities for the rehabilitation programme, the personnel will mostly not acquire sufficient experience, thus quality is reduced, the recording, reporting, monitoring and evaluation are frequently insufficient. There are no such problems should a Government choose to give existing health or social workers sufficient additional training to become full-time CBR personnel. There may be exceptions to this rule, for example (see p.17) in areas of low population density or with inaccessible geography. 3. Planning the training of CBR personnel The planning of the training of ILCs and CRFs has followed twelve analytical steps (fig 2). Each of these steps is commented below. Step 1. Setting of Objectives Objectives should be clearly formulated. In general, one could express the goal of a CBR programme as follows: to promote a development that eventually will allow all persons with disabilities to live in dignity. To achieve this end requires actions aimed at, among others: * providing the rehabilitation services and care needed; * reducing or eliminating environmental barriers; * compensating persons with disabilities for loss in their standard of living caused by disability; * promoting social inclusion and self-actualisation; * * protecting and promoting the human rights and security of persons with disabilities; and empower them through adequate representation and influence in their society.
9 9 Fig 2. Analytical steps in the planning of the training of ILCs and CRFs. 1. Objectives 2. Surveys of persons with disabilities 3. Description and calculation of needs 4. Development of appropriate culture - compatible and people - oriented technologies 5. Programme design 6. Task list and detailed description 7. Task distribution 8. Descriptions of responsibilities 9. Desired performance and competence 10. Course evaluation 11. Design of course activities and length of course 12. Detailed course plan Step 2. Surveys of disabled people
10 10 A large number of surveys of the prevalence of disabilities have been made. Survey techniques have varied considerably, for this reason it is difficult to assess all data combined. Using an international data basis (see E. Helander: Prejudice and Dignity, UNDP 1999) for the estimation of the prevalence of moderate and severe disability in the less developed regions will provide the following outlook. Prevalence of disability in less developed regions by age group TABLE 1. Prevalence of disability million Total % of total population 4.8% 7.7% Total population 4,904 7,468 As seen in Table 1 the prevalence is expected to increase from about 4.8% in 2000 to 7.7. % in Persons with disabilities will increase from 234 million to 525 million. The major reasons are: a general population increase and redistribution between the age groups towards the elderly. The most important increase is among those aged above 65 years. In one generation, the number of persons with moderate and severe disability in the developing countries will more than double. The average annual increase over the period 2000 to 2035 is 8.3 million or close to per day. The annual incidence of persons needing a CBR programme - and this is a more important information for the planner - may be assessed (using international data) to about 0.5 per cent. The data used are, however, based only on indirect observations and may change when better methods become available. Step 3. Description and calculation of needs The specific needs related to persons with disabilities are well known: functional training, education, ability and vocational training, jobs and opportunities for income, participation and inclusion in mainstream family and community activities, empowerment and participation programmes for persons with disabilities, protection and promotion of human rights and security, environmental access, information, etc. (For details see Annex I). Besides, the needs related to rehabilitation, there are large needs for care. Persons with disabilities, like all citizens, need access to mainstream public services (see below p. 16). The global needs should be better researched so in the future the quantitative aspects will be better known. Using international data the following estimations of the specific service needs related to persons with disabilities in the developing regions have been calculated: functional training, services need to be organised for about 45 million disabled people in 2000 and 120 million in 2035; education, (based on a schooling period of seven years) one would expect at least 20 million children with disabilities to attend regular schools in 2000 and 22 million in ability and vocational training, jobs and opportunities for income, about 5 million moderately or severely disabled adults will need to enter the labour market in 2000; this number will increase to 7 million in Besides a number of persons with slight disabilities may need some service or action.
11 11 In addition, there will be a large number of persons with disabilities, who acquire a disability in their adult years. Most of them have already been engaged in income generation and a large proportion will continue - they may need some assistance and monitoring. participation and inclusion in mainstream family and community activities, this applies to all 234 million at present and to growing numbers in the future; empowerment and integration programmes for persons with disabilities, protection and promotion of human rights and security, environmental access, information, etc. this applies to all 234 million at present and to growing numbers in the future. Besides the needs related to rehabilitation, some disabled persons (who may not achieved full independence through rehabilitation) need care. This estimated to concern about 1.5 per cent of the total population (or at present some 75 million); and will increase as the ageing process continues. Step 4. Development of appropriate culture-compatible and people- oriented technologies The CBR technology is described in the WHO manual Training in the Community for People with Disabilities (TCPD). This manual is based on observation and description of indigenous, spontaneous technology and is people-oriented. Much of the material has been compiled and adapted during testing periods carried out by field personnel involved in CBR programmes. One must, however, continuously evaluate, adapt and upgrade the technology, taking into consideration the diverse cultures, social systems and environments in different parts of the world. Step 5. Specific programme design The specific programme design includes examples of the analysis of the following main components (See Annex I). 1. identification and medical treatment of disabled people; 2. functional training; 3. education; 4. ability training; 5. interventions to improve the environment; 6. legal questions and representation; 7. development of personnel; 8. management. Step 6. Task list and descriptions Based on the programme design an example of a list of detailed tasks is shown in Annex I. Step 7. Task distribution A proposal for how to distribute the tasks listed to the personnel of the various level services is shown in Annex I. These are: a) the Community b) the County c) the District d) the Province e) the State The most frequent and simple tasks are to be carried out at the community level, less frequent and more complex at central levels. The task list should be revised in each country to reflect local conditions.
12 12 Step 8. Descriptions of responsibilities Based in the above, job descriptions and rules on responsibilities are needed for all personnel and organisations engaged, such as: a) CRFs (See Box 1), b) ILCs (See Box 2), c) District Rehabilitation Technical Officer, d) Province Rehabilitation Director, e) State Rehabilitation Director and the State Commissioner, f) Community Rehabilitation Committee, g) County Committee, h) District Rehabilitation Society, i) Province authorities responsible for rehabilitation and care of persons with disabilities and for disability prevention, j) State Ministries, officials and personnel of existing public services including national existing institutes and specific centres, and others responsible for all aspects of disability including rehabilitation, care, human rights, full participation and prevention, co-ordination and cooperation. k) Personnel from other sectors: health, education, community development etc. l) Non-governmental organisations For c) to l) specific recommendations, directives/rules and educational materials will be required. BOX 1. EXAMPLE OF TASKS OF THE CRF The CRF is a community worker chosen by the community and under the management of its leaders; is trained and subsequently technical supervised by the ILC; and who 1) undertakes tasks related to the identification of PWDs, followed by locating, motivating and preparing a trainer for each of them; 2) is able to use the Manual Training in the Community for People with Disabilities and to transfer skills and knowledge of rehabilitation and disability to the family and to community members; 3) teaches and assists the family and others concerned functional training and other related activities and in the production of simple rehabilitation appliances; 4) meets regularly with family members of PWD; contacts community members with a view of arranging self-help groups and other support activities carried out by volunteers; 5) contacts the local educational services to provide inclusive schooling and other education, 6) arranges ability and vocational training with the assistance of the community rehabilitation committee, participation in locally available development programmes, such as those related to poverty alleviation, jobs, legal protection, transport, etc.; 7) initiates social contacts and participation with the aim of fully integrating persons with disabilities; 8) encourages and gives initial guidance to disabled people, family members and others, who will set up and maintain a local interest organisation to represent and empower them and to extend their influence and participation in society, and 9) keeps records, monitors, and reports the progress of the programme to all those concerned. BOX 2. EXAMPLE OF TASKS OF THE ILC The ILC is a professional, who preferably is recruited from the area of assignment and is under the management of the County administration and the District CBR Society, and who
13 13 1) initiates contacts with communities and provides the information requested on the CBR programme. 2) visits communities and advises them on the practical aspects of the CBR programme, including the selection of the CRF. 3) designs, conducts, and evaluates courses to train CRFs. 4) supervises programmes carried out in the communities under the management of local rehabilitation committees and the CRF. 5) assists in the development of multi-sectoral contacts, so PWDs will be involved in mainstream rural development schemes, receive health care, educational and ability training, social benefits etc. 6) contacts and interacts with personnel in referral services, public authorities, or NGOs, regarding PWDs in need of, for example, diagnostic, therapeutic or rehabilitation services, and/or opportunities for further assessment, schooling, vocational training, jobs, environmental interventions, support to self-employment, which are not provided at the community level. 7) monitors all aspects aimed at the legal protection and security of PWDs to ensure observance of their human rights and adequate representation of these persons and their families in all community affairs that are of special interest to them. 8) ensures appropriate monitoring of the CBR programmes and takes steps to correct problems that become apparent on monitoring; reports monitored information and data to higher levels, and responds to directives aimed at reprogramming or at other changes. 9) assists, in co-operation with the local and district administrations, with necessary administrative action to ensure smooth functioning of the programme. Step 9. Desired performance and competence The details of this step are reviewed in Annex II. ILC students must at the end of the course have (for reasons see Box 3.) a sufficient level of competence by acquiring well defined: practical skills communication skills knowledge/mental skills BOX 3. REASONS FOR THE COMPETENCE LEVEL PROPOSED FOR THE FIELD PERSONNEL ENGAGED IN THE IMPLEMENTATION OF CBR At a low level of competence, the experience is that the major and often only action taken by the field personnel will be to refer all persons with disabilities to a centre or institution for diagnosis, rehabilitation and follow-ups. The problems are: the costs will be very high, the services will only be accessible for small groups of PWDs, as many cannot or will not travel for reasons of reduced mobility, lack of a person to accompany them, other duties that will not allow them to leave their homes and/or costs, major parts of the functional training programme should be carried out at home the level of competence and skills transferred to the family and community will be insufficient for sustainability, the ability of the personnel to solve problems locally and engaging the community in self-help groups, encourage voluntary action and local initiatives for job creation and responsibility for care will suffer, personnel with low level of competence and those not residing in the community will be less able to enhance the process of full participation and inclusion, the monitoring and evaluation system will be incomplete. The length of the CRF and ILC training should be set to a level that will lead to the desired performance and competence to make them able to meet the daily challenges reducing the need to arrange for costly referrals. Step 10. Course evaluation The Community Rehabilitation Committee and the District Society will undertake the course evaluation of the CRFs. The State Executive Committee or the National Rehabilitation Institute or an equivalent body evaluate the course for the ILCs.
14 14 Step 11. Design of course activities and length of course As the exit point of the ILC training has been defined (see Annex II and III), the course activities are dependent on the entry point. Who are the students accepted for the course? (See Box 4). Uniformity of students entering the course will facilitate the education. Some countries have a quota of places reserved for groups, who in the past may have been underprivileged, such as women, ethnical or tribal groups. Reservations for these groups should be made. There could be an entrance examination with interview to guide the choice of students. Assuming that the ILC students graduated from high school or university, the course length has in our example been set to 18 months (see Annexes II and III). Other options are shorter. (see Annex IV). BOX 4. PROPOSED REQUIREMENTS FOR ENTRY TO THE ILC COURSE * High school or university education, such as bachelor s degree. (If CRFs, NGO personnel or others without the proposed background education enter as students, they might need a preparatory course to close possible knowledge gaps.) * Fully competent to speak, write and read the local language, (knowledge of an international language such as Arabic, English, French, Portuguese or Spanish is useful if a large number of books, guides and other information are available in that language) * Preferably recruited from the District where they will work, so they are familiar with the social and cultural conditions and with the local language, and have the confidence of the population in the areas, in which they will serve. * Committed to community work. * Positive attitudes and behaviour towards persons with disabilities and their families. * Drivers license for scooter/motorcycle. Details of the design of the course drafted for CRFs appears in Annex IV. Step 12. Detailed course plan A proposal for the details of an example of an 18-month ILC course plan appears in Annex III Below follows a review of the scheduling of subject groups and time requirements. This is based on a training time of three terms, equivalent to 66 weeks with 40 hours per week; the total time is 2640 hours. Total time for subjects groups listed below: 2430 hours. Reserve time and holidays 210 hours. Subject Group 1: CBR, Introduction hours Subject Group 2: CBR for persons with moving difficulties hours Subject Group 3: CBR for persons with seeing difficulties - 40 hours Subject Group 4: CBR for persons with hearing/ speech difficulties - 80 hours Subject Group 5: CBR for persons with learning difficulties -100 hours. Subject Group 6: CBR for persons with other difficulties - 80 hours Subject Group 7: Income-generation, and participation in community development -40 hours Subject Group 8: Public organisation and services - 90 hours Subject Group 9: Pedagogy and communication hours Subject Group 10: CBR Management hours Subject Group 11: Group work and individual projects with presentations - 60 hours Subject Group 12: Field practice hours Subject Group 13: Examinations hours
15 BOX 5. COMMENTS ON THE LENGTH OF THE ILC COURSE. 15 The courses for ILCs can have a different length and content than the one in our example. It should be useful to consider the following: 1) In a shorter course the number of hours will be reduced. This can be done either through an overall reduction (by one third, for instance, if the length will be 12 months instead of 18) of each of the subject groups. Alternatively, it can be done by reduction of subjects, which are given less priority. The list of skills should be carefully scrutinised and content removed to the same extent as the hours are reduced. Some time may be gained by a reduction of holidays and use of Saturdays. Simply substituting one subject (with less priority) with another (given higher priority) can mostly be done without adding time. Such changes should be based on a course evaluation, undertaken after with the students after for instance, 2 years of fieldwork. 2) If a longer course than 18 months is chosen, skills and/or theory can be added. Many course principals and teachers have the ambition to add one subject after the other and in this way prolong the courses. It is common to see courses for certain categories of professionals being prolonged from a beginning of 18 months to become 3 to 4 years after a ten-year experience. This is very costly and often has negative implications: technical personnel, who have received too much training have a tendency of being less willing to spend their time working in the community, as they rather stay in their offices. 3) It is sometimes seen that a course that was initiated a very long time ago, has remained unchanged. The teachers have become used to a pedagogic standstill, they prepared everything many years ago and do not want to have the trouble to change. Change is necessary to update technology, to adapt to new information and to the varying background and expectations of the students. Pedagogy is also undergoing rapid development. Audiovisual aids such as video films and PowerPoint presentations are becoming more easily available. More elaborate and active group sessions with participation of students and outsiders are becoming common. Students, who are exposed to modern school education, are often able to work more independently. 4) The number of hours is hours of study. Teachers can provide some of these; others can be devoted to self-study under the guidance of the teacher. See also comments in Annex III. The details of a 12-week course for the CRF appear in Annex IV. Suggestions for a modular approach and other alternatives are discussed. It is, unfortunately, often seen that courses for CRFs are totally insufficient. There are countries that train community personnel for CBR in courses lasting 2 to 3 days, and have no technology manual (such as TCPD) available; the results of such training is nil. BOX 6. COMMENTS OF THE CHOICE OF PEDAGOGY APPROACHES. CBR personnel should preferably be trained using modern problem-solving pedagogy methods. Education should be a continuous process, involving the students and using their own resources. Many teachers have realised that the most underused resource for any course is the students themselves. The initiatives of the students should right from the beginning be encouraged to self-study through a series of group works and individual projects. Students should also seek information by themselves, rather than relying on teachers (during the course) and others (after the course). For this access to a library of resource material and to Internet is very valuable. Students should methodically be guided to find the answers themselves to the examination questions, and they should be trained to present subjects on their own. This will be very helpful for their future jobs, as they will be working in conditions that will not allow for much supervision or control. Having learnt how to take initiatives and how to induce selfdevelopment among community members will greatly contribute to the progress of CBR. It may be surprising for many teachers to see that Annex III contains a draft list of all examination questions (additions and subtractions from this draft can be made by the teachers prior to the course or as a result of course evaluation). The recommendation is to give the students this list on the first day. It should also be useful to provide the students with a copy of the examination questions given at the previous course and how the answers were evaluated. Most of us are used to a system, where students are afraid of examinations, because they do not know what is required of them. It is commonly observed that students see the whole examination system as a way of trying to cheat or trap them with questions they never heard of or have not seen as important. It is better to have a transparent system. The requirements should be well known, and the process of examination seen as fair. It is clear that the number of questions given in our example is very large. If the students know the right answers to all of them, they can be regarded as having the required amount of knowledge. Another advantage is that it will better focus the teachers activities. The alternative chosen by some course principals has been to give lengthy descriptions of what to do within a given period. The teachers, knowing the
16 16 evaluation can be better relied on to not stray into unnecessary matters outside the subject, as the students are unlikely to pay much attention. Finally, this system can also be used as a tool for self-study. The students may very well, having a library and other adequate means of information, be able to find the answers to the examinations questions though self-activity. The role of the teachers will then be to listen to the students presentations and make sure that the subject is well understood and correctly presented. 4. Prerequisites for training and choice of training organisation The choice of training organisations could be guided by the conditions listed in Box 7. The training of ILCs can either be carried out at a government institution (such as a national institute, a training centre for rural development workers) or by an NGO; close access to an ongoing CBR rural programme is needed. For the CRF there are many alternatives. Cost-efficiency calculations have shown that it is less costly and more effective to let the ILC train the CRFs in small groups of 4 to 8, directly in the field. Training CRFs at a Central Training Centre is much more costly, less realistic and has no specific advantages. BOX 7. REQUIREMENTS FOR ORGANISATIONS THAT TRAIN ILCS The most important requirements are: availability and a long-time experience of a CBR field programme pedagogic and technical competence of the teachers The practical training is a very great importance. Students must be able to work in a community, where there is a real CBR programme: decided and managed by the people; executed and evaluated by a local rehabilitation committee; with all components available: function training, inclusive education, ability training, access to development opportunities, special projects for women, promotion and protection of human rights, empowerment of persons with disabilities and their families; the teachers should include specialists, therapists, social development workers, multidisability resource teachers, communication specialists, NGOs, teachers with extensive experience of modern, problem-solving pedagogic methods. In the fieldwork experienced supervisors are necessary. 5. How many personnel are needed? 5.1. CRFs. Calculations of needs of CRFs should be based on samples of existing communities. One should make maps of the geography (such as size of area, roads and their conditions, rivers, hilly or mountainous areas, bridges, location of community buildings such as offices, schools, health centres, religious places, changes that may occur during varying weather conditions). To this should be added information about household distribution and location of PWDs, time required for each visit, availability of self-help groups and volunteers, etc. An example is shown in Box 8. Another factor is the peak demand, see Box 9. BOX 8 REQUIREMENTS OF PERSONNEL BASED ON MAPPING. The annual incidence of PWDs to participate in CBR is assumed to be 0.5 per cent of the population. If the CRF covers a population of 5,000, there will each year be 25 new PWDs involved. The estimated number of PWDs to require follow-ups (from previous years) is about 1 per cent of the population, or 50 people.
17 17 In areas with a population density of 20 to 30 per sq. km, 5,000 people will live in an area of about 16 kms x 16 kms and 13 kms X 13 kms respectively. In the first case (2o/ sq.km), the average one-way distance to the home of a PWD will be about 5 Kms. In the second case (30/sq.km) be about 4 kms. The time required for a home visit should be about minutes at start, a later on 15 to 30 minutes. Visits may require less time, if efficiently arranged using self-help groups, visits to schools and work places for follow up. Families can attend joint meetings to discuss the training programme and other concerns. In areas with this population density or higher, such as marginal urban or semi-urban settings, one CRF/5,000 is quite enough. If there is a lower population density or rough, inaccessible geography, specific calculations have to be made. If the population density is very low, such as 1-5 person per sq. Km, another strategy for service delivery should be considered. It would preferable to use personnel in other sectors, such as health, education or social services as CRFs on a part-time basis. BOX 9 PHASING IN THE CBR PROGRAMME. At the peak of service demand - which is at the start of CBR - there are many PWDs requiring attention, because of the neglect. Needs will for this reason be about two to three times higher, than later on when the programme has matured. After 2 years or so, the demand for services will be reduced to what was calculated above. At that time, more volunteers and self-help groups will also be available. For this reason, the ILC could slowly phase in the programme. Illustrations appear in Fig 3 and fig 4. Fig 3 shows that the requirements of personnel are very high, if the entire area is surveyed at the start and the personnel makes an effort to provide all persons with disabilities the services that have until now have been unavailable. It is unlikely that enough skilled personnel can be provided to meet such peak demands. Fig 4 shows that, if the CBR programme is slowly phased in (by dividing up the community in three parts and separately surveying each of them with a time schedule spread out over some 2-3 years) the resource needs will be more even. This is natural, as communities will first go through a phase of awareness and decision-making. This takes different times in different communities and the CRF and ILC can start with the programme, when the community is ready ILCs. If the population density is 30 per sq. km, 100,000 people (from e.g. one county) will live in an area of 3,300 sq. Km. This equals a square of about 60x60 Kms. Within such an area, there will (in our example) be about 20 CRFs, and the annual incidence of disability concerns 500 new persons, or about 10 per week. About twice as many, or a total 1,000 are estimated be in follow-up. A realistic exercise with map-making and reviewing transportation conditions, shows that it should be possible for one ILC to carry out the technical supervision of about 20 CRFs, and other duties required (monitoring and reporting included). The ILC need a motorcycle for their travel. BOX 10. HOW MANY PERSONNEL TO RECRUIT? Personnel should be recruited based on: the requirement of the mature phase of the programme (and not for the peak, which appears at the start, because of the large number of neglected PWDs, see Fig 2 and Fig 3). During this phase there would be about 0.5 per cent of newly disabled persons joining CBR each year and follow-ups will be needed for about of 1 per cent of the population. Care for persons with disabilities is likely to be needed for about 1.5 per cent of the population, and this should be organised. the time required for the delivery of services (at home, in the community, with the assistance of the family, self-help groups, the community committee etc.) including travel time. Based on this it is proposed to start (where the population density is 20 per sq. or higher) with: one CRF for a population of 5,000 one ILC for a population of 100,000, which includes the technical supervision of about 20 CRFs At lower population density, more personnel are needed, and special calculations should be made. In areas with very low density or difficult environment, another strategy (see Box 8) might be preferable.
20 Timetable for development of the service delivery system To develop a CBR programme that meets the needs of all (or the vast majority) PWDs will take time. Most countries will find it reasonable to implement CBR over a period of 10 to 15 years. With this, budgets can be phased in at an annual increment rate of 6 to 10 per cent of the final costs. The plans for training of personnel should include details for how many students to train and the requirements of teachers each year to reach the Government targets, and an estimate of the budget requirements. 6. Policy regarding use of public services and access to mainstream opportunities by persons with disabilities. Segregated institutions have in the past mainly provided delivery of public services for persons with disabilities. The cost of resources for these institutions, such as personnel, equipment and facilities has proven to be high and inefficient. This approach has contributed to the isolation and segregation of persons with disabilities; in the rural areas services have rarely been available. There is an international consensus (UN Standard Rules adopted in 1993) about the strategy. It is recommended that mainstream public services be used to meet the needs of PWDs. This includes the primary and district health care, the regular local pre-schools and schools, the community development programmes, ability and vocational training, access to incomegeneration, special programmes for literacy, women s programmes, etc. To achieve an optimal level of preparation for participation of persons with disabilities in mainstream services and opportunities is an important objective of the CBR programme. Once the phase of functional training and individual preparation through CBR has been successful, the persons with disabilities should join the mainstream development programmes. The costs for arranging access to and effective participation by persons with disabilities are low in comparison with the segregated alternatives. Staffs working in public services need supplementary training; the ILCs need to be educated for these tasks. 7. Financing of the programme In order to be financially sustainable the costs for the CBR programme, such as salaries and other costs for service delivery, could be met partly by public funds, partly by contributions from the community. Financing could also be given for the training and equipment components of the programme. Examples of cost calculations appear elsewhere (See E. Helander: Prejudice and Dignity, chapter 12). Public funds can either be provided by the State or by local authorities. Funds for community development, whether supplied by the Government or by outside donors should be used to prepare PWDs for their participation in all the community development schemes. Communities in countries, which have a system with local tax collection and local decision-making of spending, should set aside funds for the implementation of the CBR programme. 8. Approaches to referral services The conventional system has often started with the setting up of a national centre or similar, in the belief that later on the centre would develop ramifications and decentralised functions. In reality, this has very rarely been the case. The CBR system endeavours to start development from below, by first setting up the community services and later on linkages with a referral system. The referral system should be created when -and not before - the community needs for referrals are known, after a period of implementation. In a system built from below, the objectives for professional staff at referral centres will be formulated in response to local requirements; it would be needs-generated and not supply-oriented. It is a common experience that the setting up of referral services before the basic ones are in place, has - more often than not - been based on vested interests by professionals than on an experience of what the
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