Regional Strategic Framework On Community-Based Rehabilitation (CBR) in The South-East Asia Region 2012-2017

Regional Strategic Framework on
Community-Based Rehabilitation (CBR) in the

South-East Asia Region 2012–2017
Regional Office for South-East Asia

SEA-Disability-4
Distribution: General
Regional Strategic Framework on

Community-Based Rehabilitation (CBR) in the
South-East Asia Region 2012–2017

© World Health Organization 2012
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Printed in India
Contents
Page
1. Background..................................................................................... 1
2. Community-based rehabilitation (CBR)........................................... 2
3. Principles ........................................................................................ 5
4. Vision .............................................................................................. 6
5. The goal of the regional framework................................................. 6
6. Objectives and action areas............................................................ 6
7. Appendix ....................................................................................... 30
8. References.................................................................................... 32
iii
1. Background
Disability is an evolving concept and an umbrella term for
impairment, activity limitation or participation restriction, which
result from interaction between persons with health conditions
and environmental factors (e.g. physical environment, attitude)
and personal factors (e.g. age or gender)1. The World Report on
Disability estimates that 15%-18% of the world’s population have
disabilities2. The causes include birth defects; injuries resulting
from road traffic accidents, conflicts, falls and landmines;
noncommunicable diseases (NCDs) such as diabetes,
cardiovascular diseases and cancer; mental illnesses and
intellectual impairment; ageing; and communicable diseases.3
The WHO South-East Asia Region also has a significant number
of people with disabilities due to polio, leprosy and tuberculosis.
Persons with disabilities are some of the most disadvantaged

and marginalized people worldwide. About 80% of them live in
developing countries.4 The majority of those with disabilities live in
chronic poverty. With good health care and rehabilitation services
and the provision of barrier-free environments, people with
disabilities can contribute to society instead of being passive
recipients of charity. In 2006, a UN study found that 62 countries
in the world had no national rehabilitation services and almost all
of these countries were developing or underdeveloped nations5.
Only 5%-15% of persons with disabilities in developing countries
can access assistive devices6. People with disabilities in
developing countries often depend on the support of carers who
assist with activities of daily living, transport and social support,
and provide emotional support and assist with decision-making.
They are usually women, mostly unpaid, family members, friends
or neighbours. They too may suffer ill-health due to their caring
role.
Poverty is both a cause and consequence of disability.7

Children with disabilities are less likely to attend a school than
other children.8 Persons with disabilities have higher
1
Regional Strategic Framework on Community-Based Rehabilitation (CBR) in the South-East Asia Region 2012–2017
unemployment and have lower earning than persons without

disability.9 The cost of medical treatment, physical rehabilitation
and assistive devices, contribute to the poverty and disability
cycle. The Millennium Development Goals (MDGs) adopted by
the UN in 2000 will not be achieved without the inclusion of
people with disabilities, as they are disproportionately
represented among people who live in poverty with limited access
to education, health and social benefits. Solutions focus on
ensuring social change, creating equal access to services and
removing barriers that exclude people with disability. There is
recognition of the need for community-based approaches and
community-driven initiatives to ensure sustainable and inclusive
development that benefits all.
This is not just an issue of the vicious cycle of disability and

poverty. The present situation constitutes a violation of human
rights. On 13 December 2006, the UN General Assembly adopted
the landmark Convention on the Rights of Persons with Disability
(CRPD).10 The Convention complements existing human rights
frameworks and builds upon UN standard rules on equalization of
opportunities for persons with disabilities (1993)11 and the World
Programme of Action Concerning Persons with Disabilities
(1982).12 The main purpose of CRPD is to promote, protect and
ensure the full and equal enjoyment of all human rights and
fundamental freedoms by all persons with disabilities and to
promote respect for their inherited dignity (Article 1). The
Convention has not created any new rights, but ensures that
existing rights are available to persons with disabilities.
The present approach to disability is based on the

participation of persons with disabilities, a movement which
began in the 1960s and adopted the slogan “nothing about us
without us”.13
2. Community-based rehabilitation (CBR)

Community-based rehabilitation (CBR) was introduced in 1978,
after the Alma-Ata Declaration of Health For All by WHO,14 as a
strategy to improve access to rehabilitation services for people
2
Regional Strategic Framework on Community-Based Rehabilitation (CBR) in the Sout-East Asia Region 2012–2017
with disabilities. Current concepts of CBR are based on various

international conventions, protocols, commitments and learning
from more than 30 years of practice. These are given in detail in
Appendix 2. CBR has now evolved into a multisectoral strategy to
improve the quality of life of people with disabilities and ensure
their empowerment, participation and inclusion in society.
The new CBR guidelines released in 2010 are based on the

principles of CRPD.15 They incorporate fundamental principles of
empowerment, the mainstreaming of disability in the
developmental agenda, human rights and social justice. They
show how to make key development initiatives/programmes such
as health, education, livelihood and social sectors inclusive of
people with disabilities and their families. The guidelines were
produced jointly by World Health Organization (WHO),
International Labour Organization (ILO), United Nations
Educational, Scientific and Cultural Organization (UNESCO) and
civil societies, such as, the International Disability and
Development Consortium (IDDC). The guidelines were approved
on 19 May 2010 and shall remain valid till 2020.
These guidelines are supported by evidence that CBR

significantly improves the quality of life of persons with disability,
especially in less-resourced settings. Training of community
workers in CBR is feasible and can be replicated across
communities and countries. In high-income countries too, it brings
positive social outcome, attitudinal change and improved social
inclusion of persons with disability.
The CBR Guidelines are based on the CBR Matrix, a

comprehensive framework for all sectors to work together with an
inclusive and empowerment approach. This needs a twin-track
approach of inclusion of disability in mainstream development
policies and programmes and disability-specific programmes such
as assistive devices, personal assistance, vocational training and
job coaching, etc.
3
HEALTH EDUCATION LIVELIHOOD SOCIAL EMPOWERMENT
EARLY SKILLS PERSONAL ADVOCACY &

PROMOTION
CHILDHOOD DEVELOPMENT ASSISTANCE COMMUNICATION
RELATIONSHIPS
PREVENTION SELF- COMMUNITY
PRIMARY MARRIAGE &
EMPLOYMENT MOBILIZATION
FAMILY
MEDICAL CARE SECONDARY & WAGE CULTURE & POLITICAL

HIGHER EMPLOYMENT ARTS PARTICIPATION
REHABILITATION FINANCIAL RECREATION

SELF-HELP
NON-FORMAL SERVICES LEISURE &
GROUPS
SPORTS
DISABLED
ASSISTIVE LIFE-LONG SOCIAL
JUSTICE PEOPLE'S
DEVICES LEARNING PROTECTION
ORGANIZATIONS
CBR is currently being implemented in more than 90

countries in the world and in all countries of the WHO South-East
Asia Region in varying forms, different degrees and with varying
national commitments. Specific reference to CBR exists in laws
and policies of Bhutan, India, Indonesia, Myanmar, Sri Lanka,
Thailand and Timor-Leste. The responsibility for disability affairs
rests with differing nodal ministries such as health, social
affairs/justice/welfare, etc. in SEAR Region member countries.
They also have differing coordinating mechanisms and varying
financial commitments. Civil societies also play an important role
in promoting and supporting CBR. These have resulted in
different models of CBR in different countries. In all countries
there is scope for improvement and further development of CBR,
and also consensus that CBR needs to be multisectoral with the
inclusion of key sectors, such as, health, education and livelihood
with a participatory approach. Improvement of the quality of life
and empowerment of people with disabilities and their families are
the essence of the CBR Guidelines.
A situation analysis of CBR in the South-East Asia Region in

2011 was undertaken to develop the strategic framework. A
compilation on “CBR Practices in the SEA Region” was also
developed.
The “South-East Asia Regional Strategic Framework for

Action on Community-Based Rehabilitation 2011-2020” was
4
formulated during a Regional Expert Group Meeting held on 3-4

November 2011 in Faridabad, India. A group of experts, including
persons with disability, from Member States and partner
organizations provided invaluable inputs regarding the situation
analysis of CBR in the SEA Region and the development of the
Regional Strategic Framework.
The framework will guide in strengthening policy and action

at the regional and national level. The framework focuses on the
areas under WHO’s mandate as a technical agency for health
while acknowledging the multisectoral nature of CBR. The action
areas focus on “doable and achievable actions” and Member
States and partners are encouraged to go beyond this framework
according to the availability of resources. Implementation of the
action strategy will help in coordinated action by all stakeholders
to reduce the burden of disability in the South-East Asia Region.
3. Principles
The Regional Strategic Framework is based on the principles of:
(1) a rights-based approach to CBR based on CRPD;
(2) inclusion and participation of persons with disabilities
and their families at all levels – “Nothing about us
without us”;
(3) empowerment of people with disabilities and their
families;
(4) inclusion of a disability focus in all development policies
and programmes;
(5) a barrier-free accessible Region; and
(6) Partnerships, networking and convergence among the
key stakeholders.
5
4. Vision
The creation of a barrier-free Region for disability where persons with
disabilities and their families are empowered, having equal rights and
opportunities.
5. The goal of the regional framework

The goal of the Regional Framework is to promote and strengthen
community-based rehabilitation (CBR) in order to improve the
quality of life of people with disabilities and their families through
access to health and rehabilitation services, with harmonized
actions among the Member States, the World Health Organization
and development partners.
6. Objectives and action areas

CBR is a multisectoral strategy aiming for an inclusive society.
The Strategic Framework focuses on the areas under WHO’s
mandate, particularly health and rehabilitation. It is recognized
that the action areas identified are not a complete list of all
actions needed but key areas for priority action. The importance
of concerted harmonized action by all stakeholders is recognized
and highlighted. Commitment and complementary action from
other sectors and stakeholders is needed to achieve the vision
towards which this framework is a stepping-stone. Close
coordination of all stakeholders–Member States, WHO, partner
organizations, collaborating centres and people with disability and
their representative organizations–is required for alignment and
harmonization of efforts. WHO will support and facilitate this and
also advocate at multisectoral and regional levels to engage other
sectors.
Five overall objectives with a number of specific objectives

and action areas under each have been identified for this
Framework. This will form the basis of development of an action
plan to be endorsed by the Member States of the WHO South-
East Asia Region.
6
Overall objective 1: Promote disability-inclusive health policies and

legislation
Specific objective Action areas
1.1 Strengthen  Advocacy to review, amend and develop
national legislation health-related legislation and policies in line
and health policy to with CRPD and CBR guidelines
be inclusive of  Increase awareness of CBR and CRPD and
disability and the World Report on Disability among health
rehabilitation policy-makers and planners
 Identify/establish and strengthen a focal point
1.2 Support within the ministry of health to coordinate
ministries of health disability-related activities
to play a leading
role in health-  Advocate for review of business allocation
related between ministries so that ministries of health
rehabilitation are responsible for health-related issues in
disability.
Overall objective 2: Promote access to quality health and
rehabilitation services in a barrier free environment
2.1 Enhance  Support the development of time-bound
allocation of national implementation plans for health and
financial resources rehabilitation-related disability issues (in
to increase access mission mode or a similar plan with dedicated
to health and budget and third party scrutiny of utilization);
rehabilitation  Increase financial allocation for CBR at the
district and sub-district level;
 Develop innovative mechanisms to implement
CRPD/CBR; encourage private investment in
public programmes.
7
2.2 Ensure the  Ensure that the specific needs of women and
availability of children with disabilities, stigmatized groups
quality, affordable and those with multiple disabilities and
and appropriate intellectual disabilities are met appropriately;
health and  Ensure that persons with disabilities have equal
rehabilitation access without discrimination to health
services at the
insurance and social protection schemes;
primary, secondary
and tertiary levels  Establish mechanisms for assessment,
for persons with evaluation and certification of disability
disabilities  Support early identification and early
intervention programmes for disabilities at the
community level;
 Ensure availability and utilization of appropriate
assistive devices and technologies at the
district and sub-district level;
 Ensure that public and private health facilities
are accessible to enable persons with
disabilities to access health services on an
equal basis with others.
2.3 Ensure  Amend curriculum to include disability and
adequate numbers rehabilitation issues in the training programmes
of competent of health personnel at all levels;
human resources
 Sensitize health professionals on disability and
for general health
the barriers faced by persons with disability;
and disability-
related intervention  Introduce or strengthen different levels of CBR
training in all countries of the SEAR Region;
 Develop measures to counter turnover of CBR
workers;
 Promote affirmative action for people with
disability to access higher education in health-
related fields.
8
2.4 Enhance  Increase coverage of CBR to ensure access to

capacity for rehabilitation for all persons with disabilities;
community-based  Develop and strengthen regional, national and
rehabilitation provincial or district resource centres for CBR;
 Increase capacity of CBR providers to deal with
multiple impairment, autism and other complex
disabilities.
2.5 Promote  Integrate and strengthen CBR in primary health
internal linkages care;
within the health  Strengthen health promotion and primary,
sectors to include
secondary and tertiary prevention of
disability.
impairments;
 Ensure inclusion of a disability focus in relation
to noncommunicable diseases, mental health,
leprosy, injury prevention and ageing;
 Hold regular coordination meetings within
health care and develop action plans for
disability in the health sector;
 Facilitate the convergence of IBR with CBR.
Overall objective 3: Promote participation and empowerment of
persons with disabilities and their families/communities in all
aspects of health care
3.1 Increase  Empower persons with disabilities to claim their
awareness and health rights;
participation among  Empower persons with disabilities and their
persons with
organizations to ensure their participation in
disabilities, families health service provisions;
and communities
on disability in  Persons with disabilities can participate actively
health promotion, as self advocates and promoters of healthy
prevention and lifestyle.
care
9
3.2 Enhance  Ensure participation of persons with disabilities

participation of and their families or caregivers at all stages of
persons with rehabilitation: planning programmes,
disability in implementing, monitoring and evaluation
Community- Based  Facilitate the establishment of disabled
Rehabilitation peoples’ organizations and promote linkages to
rehabilitation programmes;
 Increase community awareness on disability
issues.
Overall objective 4: Develop partnership with other sectors for CBR
4.1 Develop and  Development of regional, national, provincial
strengthen and district-level cross-sectoral coordination
multisectoral mechanisms;
coordination and  Establish partnerships, networks and linkages
partnership in line with other key development sectors in keeping
with the CBR
with the CBR matrix;
matrix
 Strengthen partnerships between government,
civil society (especially DPOs), private sector
and service providers (particularly health
service providers).
Overall objective 5: Develop and strengthen knowledge
management and information systems in the health component of
CBR
5.1 To promote  Improve disability data in the health system;
evidence-based  Build capacity for disability and rehabilitation
practices in research in the region;
disability, CBR and
inclusive  Include persons with disability in determining a
development research agenda and strengthen their
participation in research;
 Promote exchange of ideas and learning within
10
the Region by strengthening the CBR Asia-

Pacific network and national networks;
 Publication of good practices/lessons learnt for
sharing/replication among Member countries.
5.2 To monitor  Work towards the development of monitoring
implementation and tools and indicators for evaluation;
evaluate the  Conduct periodic updates of the country and
progress of CBR in regional situation of CBR.
the SEA Region
Overall objective 1: Promote disability-inclusive health

policies and legislation
Legislation and policy on health should be disability-inclusive and
rights-based in line with the UN Convention on Rights of Persons
with Disabilities (CRPD) and the CBR Guidelines. The CRPD
details the health obligations of State Parties. Ratifying countries
have to adapt their domestic legislation and adopt administrative
measures to fulfill the health obligations. CBR is a tool for
implementing the health obligations of Member States.
Specific objective 1.1: Strengthen national legislation

and health policy to be inclusive of disability and
rehabilitation
There should be active involvement of persons with disabilities
and their representative organizations in the development of
legislation and policies and other decision-making processes that
concern them.
Action areas:
 Advocacy to review, amend, and develop health-related
legislation and policies in line with CRPD and CBR
guidelines
11
 Consultation with organizations of persons with

disabilities;
 Advocacy at regional, national and subnational
levels.
 Increase awareness of CBR and CRPD and the World
report on Disability among health policy-makers and
planners
 Develop awareness and information material for
policy-makers and planners
 Conduct awareness sessions for policy-
makers/planners held by persons with disabilities;
 Translate CBR guidelines into national languages.
Specific objective 1.2: Support ministries of health

to play a leading role in health rehabilitation
The nodal ministry for disability issues in Member countries of the
WHO SEA Region may be health, social, empowerment or
justice. The role of the health sector in rehabilitation should be
strengthened and supported.
Action areas:
 Identify/establish and strengthen a focal point within the
ministry of health to coordinate disability-related
activities
 Advocate for review of business allocation between
ministries so that ministries of health are responsible for
health-related issues in disability
12
Overall objective 2: Promote access to quality health

and rehabilitation services in a barrier-free environment
Access to health and rehabilitation services is of paramount
importance for people with disabilities to be equal members of
society and live healthy and productive lives and must be ensured
in all health programmes. As the focal UN agency for health and
rehabilitation, WHO has the responsibility to support Member
States to fulfill the health obligations in the CRPD (Articles 25 &
26). This is a key objective. Until affordable health and
rehabilitation services are available and accessible, the majority
of people with impairments will lead an isolated nonproductive
life. Barrier-free or universally designed environments and the
availability of information, communication, assistive devices and
technologies enable persons with disabilities to participate on an
equal footing with others.
Specific objective 2.1: Enhance allocation of

financial resources to increase access to health and
rehabilitation
Adequate financial resources are needed at the national and sub-
national levels for the provision of health-related rehabilitation
services.
Action areas:
 Support development of time-bound national
implementation plans for health-related disability issues
in mission mode with dedicated budget and third party
scrutiny of utilization
 Advocacy for budgetary allocation and its
appropriate utilization.
 Increase financial allocation for CBR at the district and
sub-district levels
13
 Develop guidelines for local government to

implement or support CBR.
 Develop innovative mechanisms to implement
CRPD/CBR: encourage private investment in public
programmes
 Develop best practice models and pilot programmes.
 Involve local DPOs/NGOs in the implementation of
CRPD/CBR.
Specific objective 2.2: Ensure the availability of quality,

affordable and appropriate health and rehabilitation
services at primary, secondary and tertiary levels for
persons with disabilities
Health services need to be inclusive so that people with any kind
of impairment can access health services like all other citizens
close to the place they live or at the community level (Article 19,
25 and 26 of the CRPD). Article 20 stresses the right of people
with disabilities to live within the community and that services
should be available close to where they live. Many people with
disabilities currently have no access to basic health and
rehabilitation services.
Action areas:
 Ensure that the special needs of women and children
with disabilities, stigmatized groups and those with
multiple disabilities and intellectual disabilities are met
appropriately
Women with disabilities are particularly marginalized.
Children with disabilities also need particular attention. Certain
groups are particularly stigmatized, such as people with leprosy,
or those with mental illness and their caregivers. The burden of
multiple impairments appears to be increasing. Birth asphyxia,
accidents, injury, conflict and ageing may result in multiple
impairments. Some childhood conditions such as autism are
increasing throughout the Region.
14
Current CBR programmes often have expertise only in single

impairments. Capacity-building is needed both for rehabilitation
centres and CBR programmes for rehabilitation of those with
multiple impairments. The cost of treatment, rehabilitation,
assistive devices, and personal assistance can be significantly
higher for people with multiple impairments and these may have a
profound socioeconomic impact on them and their families. CBR
can help address these issues in a cost-effective way by making
services available at the community level and developing linkages
with the specialized referral services.
Suggested action points are:

 Develop policies and strategies for inclusion of
marginalized groups
 Ensure access to sexual and reproductive health
care for women with disabilities
 Promote and utilize existing policy papers (e.g.
technical papers on leprosy)
 Capacity building of CBR programmes for multiple
impairments
 Develop respite centres and home support
programmes
 Develop referral systems by establishing linkages
with specialized services
 Ensure that persons with disabilities have equal access
without discrimination to health insurance and social
protection schemes
People with disabilities are often excluded from current
health insurance policies and denied access to health care on the
grounds of their disability. This is also important in the context of
noncommunicable and other diseases.
 Review existing health policy on health insurance,
health costs reimbursement and social protection
schemes to ensure that people with disability have
15
equal access without discrimination (including for the

provision and repair of assistive devices).
 Establish mechanisms for assessment, evaluation and
certification on disability
With limited resources for disability benefits, countries need
to ensure that those in the greatest need receive the benefits
available. Available international and national tools will need to be
modified according to local situations.
 Develop and modify regional and national guidelines
and tools for assessment, evaluation and certification
of disability.
 Ensure easy access to disability certificates
preferably making it available for issue at the local
level.
 Support early identification of and early intervention for
disabilities at the community level
Early identification of disabilities and intervention results in
improved outcomes of rehabilitation in both congenital and
acquired impairments. This is particularly so for children with
disability, as early identification and appropriate rehabilitation
dramatically reduces developmental delay and fosters habilitation,
rehabilitation and inclusion. With the relentless increase in
noncommunicable diseases it is necessary to think beyond
traditional rehabilitation scenarios which include certain health
conditions and exclude others. For example, a child with cerebral
palsy, on account of delayed milestones, is included while an
older person with anaesthesia due to diabetes may not be
included. Early identification and intervention tools need to be
developed for emerging causes of disability. In addition early
intervention is important in the context of the growing burden of
disability due to injuries and violence.
Suggested action points are:

 Develop tools for early identification, particularly for
children;
16
 Capacity building of CBR and health care providers

for early intervention for children and new causes of
disability;
 Develop guidelines, information and linkages to
ensure disability prevention and early rehabilitation in
injury management for health services and accident
victims;
 Develop linkages with violence and injury prevention
surveillance programmes for data collection;
 Include early identification and intervention in
maternal and child health programmes and in home
based early childhood education programmes within
primary health care.
 Ensure availability and utilization of appropriate assistive
devices and technologies at the district and sub-district
levelS
 Ensure public and private health facilities are accessible
to enable Persons with disabilities to access health
services on an equal basis with others
Persons with disabilities are excluded from available health
care by a host of barriers, including physical, environmental,
attitudinal, limited access to information and communication,
financial constraints etc. Access of persons with disabilities to
health care at the primary, secondary and tertiary level must be
ensured.
 Develop and disseminate regional and national
standards and guidelines on accessibility; and make
the health centre facilities barrier-free.
 Increase availability and use of information and
communication assistive devices and technologies.
 Arrange and provide sign language interpreters
whenever needed.
17
 Ensure that health professionals need to develop a

positive attitude and treat persons with disabilities
with respect.
 Address barriers in homes and transport systems
that restrict movement and travel of people with
disability, and thereby limit or impede their access to
health facilities.
Specific objective 2.3: Ensure adequate numbers of

competent human resources for general health and
disability-related interventions
Health services are often the point of first contact with
rehabilitation services for people with disability. All health
personnel need to be aware of the rights-based approach to
disability. Health personnel of all cadres need to have training in
disability issues. Technical, management and other skills among
CBR stakeholders need to be improved. Training is particularly
required for CBR workers in the social and empowerment
domains of the CBR Matrix.
Action areas:
 Amend curriculum to include disability and rehabilitation
issues in the training programmes of health personnel at
all levels.
 Sensitize health professionals on disability and the
barriers faced by persons with disability.
 Introduce or strengthen different levels of CBR training
in all countries of the SEA Region.
 Strengthen and expand training in CBR, particularly
to support empowerment and participation issues
and management skills.
 Develop measures to counter turnover of CBR workers
including:
18
 Instilling and reviving the spirit of volunteerism.

 Promote community ownership of CBR programmes.
 Consider incentives for CBR workers.
 Promote affirmative action for people with disability to
access higher education in health-related fields.
Educational opportunities need to be opened to people with
disabilities so that they can be service providers also and not
always be restricted to being recipients of services. This will also
contribute to the sensitization of all health professionals and
awareness-building.
Specific objective 2.4: Enhance capacity for community-

based rehabilitation
The reach of Community Based Rehabilitation must extend to all
people with disabilities through increasing coverage and
strengthening of available CBR programmes. Capacity at all
levels needs to be strengthened.
Action areas:
 Increase coverage of CBR to ensure access to
rehabilitation for all persons with disabilities
 Assess capacity gaps at the regional, national and
subnational level.
 Develop urban CBR models.
 Develop and strengthen regional, national and provincial
or district resource centres for CBR
 Increase capacity of CBR providers to deal with multiple
impairment, autism and other complex disabilites
19
Specific objective 2.5: Promote internal linkages within

the health sector to include disability
It is important that disability is mainstreamed in all health sectors
to ensure access of people with disability to health services.
Areas of particular relevance are elaborated further.
Action areas:
 Integrate and strengthen rehabilitation in primary health
care
Outreach of CBR to all persons with disability can only be
ensured by integrating with primary health care, which strives to
reach out to all people at the village and community level. Primary
health care (PHC) is now increasingly community-owned with
good models of community participation in Sri Lanka, Thailand
and Bhutan, and to a certain extent in India with the National
Rural Health Mission. The transition in health care is an
opportunity for developing linkages between PHC and CBR. A
CBR programme as part of primary health care should ideally be
supported with national funding and have nationwide coverage.
Action steps to accomplish this are:
 Training of the primary health-care workforce in
disability;
 Collection of best practice models;
 Developing systems for access to aids and
appliances.
 Strengthening health promotion of persons with
disability and prevention of secondary impairments
Health promotion and prevention are areas which have not
had adequate emphasis in community-based rehabilitation.
Health promotion aims to increase control over health and its
determinants, and empower people with disabilities and their
families to enhance and/or maintain best possible levels of health.
20
Prevention–primary, secondary and tertiary–reduces the burden

of disability. Medical, surgical, psychosocial and other
interventions can prevent impairment and disability in various
health conditions. Simple interventions such as early detection,
proper exercises, along with judicial use of assistive aids and
appliances can prevent the development of secondary
impairment. For example the use of an appropriate wheelchair
can prevent development of pressure sores. In addition,
specialized services such as counseling, physiotherapy,
occupational therapy and prosthetic and orthotic services are also
needed to support people with disabilities in their communities for
the prevention of secondary impairment.
Action steps to accomplish this are:

 Inclusion of persons with disabilities in general health
promotion and prevention programmes
 Factsheets on health promotion for persons with
disability
 Training modules on prevention of avoidable
impairments
 Guidelines and tools for health workers and
rehabilitation workers in prevention of disability.
 Prevention of disability in injury and violence
prevention programmes
 Ensure inclusion of disability focus in relation to non
communicable diseases, mental health, leprosy, injury
prevention and ageing
The countries of the WHO South-East Asia Region have an
increasing burden of noncommunicable diseases. Late detection,
incomplete treatment, inadequate long-term medical supervision,
shortage of care providers, specialists and hospitals, and non-
availability of continuous finance mechanisms in the countries of
the SEA Region will gradually increase the burden of disability
due to NCDs.
21
Health promotion and prevention of NCDs is needed along

with mechanisms for meeting the cost of continued care of NCDs.
Leprosy programmes already include rehabilitation. General CBR
programmes should also include persons affected by leprosy.
Traditional CBR providers have often not included mental health
in their service provisions. Action Points include:
 To ensure persons with disabilities have equal
access to promotive and preventive therapy for
control of noncommunicable diseases;
 To build capacity of CBR programme managers on
noncommunicable diseases, leprosy and mental
illness and ageing;
 Promote capacity building of leprosy programme
workers for cross-disability rehabilitation;
 To develop training tools, and disseminate available
guidelines and tools for NCDs, leprosy and mental
disability;
 To develop innovative and sustainable models of
financing for treatment of NCDs in persons with
disabilities;
 To minute and archive documentation of case
studies and good practices in these areas;
 To ensure people affected by noncommunicable
diseases, leprosy and mental illness and adversely
affected by ageing are included in all CBR
programmes.
 Hold regular coordination meetings within health-care
systems and develop action plans for disability within
the health sector
 Convergence of IBR (Institution-Based Rehabilitation)
with CBR (Community-Based Rehabilitation)
CBR has developed as a community-based bottom-up
approach while IBR is often top down with poor community
22
involvement and participation. The transition in health-care

systems is an opportunity for developing linkages between IBR
and CBR. Present models of convergence are:
a. IBR centres with district or rural rehabilitation centres
implementing or linking up with CBR programmes;
b. CBR programmes linking to institutional rehabilitation
centres for specialist services;
c. Mobile camp approach or outreach activities from IBR,
including innovative approaches such as mobile
operation theatres and trains for specialized
rehabilitation, provide mainly corrective surgeries. Follow-
up is done through rehabilitation institutes or CBR.
Linking up with CBR will help mobile camp or outreach
services to ensure follow-up and better outcome. There
are still gaps in convergence and linkages between IBR
and CBR, partly due to lack of understanding, clarity and
trust. The available regional models need to be evaluated
and expanded to identify effective models based on the
CRPD and CBR guidelines. These need to become part
of national plans to ensure that persons with disability
have access to specialized rehabilitation services. Action
points include:
 Effect capacity building of institution-based
rehabilitation in CBR, particularly the social and
empowerment domains;
 To sensitize health professionals about the
importance of self-help groups and disabled peoples
organizations and develop guidelines for them as
well as training modules for institutions on their
formation;
 To promote linkages between Institutes and local
CBR programmes.
23
Overall objective 3: Promote participation and

empowerment of persons with disabilities and their
families/communities in all aspects of health care
The objective is to strengthen the inclusion and participation of
persons with disabilities and their representative organizations in
general health care and disability-specific programmes. They
should be involved in decision-making processes,
implementation, and monitoring and evaluation. Empowerment of
people with disabilities and their families makes programmes
effective and sustainable. It reinforces the commitment, “nothing
about us without us.”
Rehabilitation was traditionally practiced in a top-down

manner with persons with disability being passive receivers of the
medical/rehabilitation services. Article 3 of the UNCRPD
emphasizes respect for the inherent dignity, individual autonomy
and independence of persons with disabilities, including their
freedom to make their own choices.
Specific objective 3.1: Increase awareness and

participation among persons with disabilities, families
and communities on disability in health promotion,
prevention and care
For people with disability to participate in health programmes and
receive the benefits of health services, their awareness about
health and their rights needs to be increased. In addition, health
personnel should be sensitized to disability.
Action areas:
 To enhance capacity of persons with disabilities to claim
their health rights;
 To empower people with disability and their
organizations to ensure their participation in health
service provisions;
24
 Build awareness that persons with disabilities can

participate actively as self-advocates and promoters of
healthy lifestyle.
Specific objective 3.2: Enhance participation of persons

with disability in community-based rehabilitation
Raising the awareness of the community on disability issues is
crucial to full inclusion. For people with disability to participate in
rehabilitation, rehabilitation personnel who have traditionally been
care givers need to be made aware of the rights-based approach
to disability.
Action areas:
 Ensure the participation of persons with disabilities at all
stages of rehabilitation: planning programmes,
implementing, monitoring and evaluation
 To orient and train rehabilitation personnel in
UNCRPD and rights-based approaches;
 To train people with disabilities especially women, as
CBR personnel;
 Facilitate the development of disabled peoples
organizations and promote linkages to rehabilitation
programmes
 Increase community awareness On disability issues
 To develop community sensitization materials and
programmes
Overall objective 4: Develop partnership with other

sectors for CBR
Partnerships, networks, linkages and cross-sectoral collaboration
in support of CBR need to be strengthened. It is recognized that a
strong cross-sectoral coordination mechanism with inputs and
25
resources from all stakeholders is essential to implement CBR.

Such a mechanism should exist at all levels: community, sub-
district, district, provincial and national. In recognition of the role
of civil society in CBR in many countries of the SEA Region, the
partnership between civil society and governments must be
strengthened.
Specific objective 4.1: Develop and strengthen

multisectoral coordination and partnerships in line with
the CBR matrix
Action areas:
 To develop regional, national, provincial and district
level cross-sectoral coordination mechanisms;
 To establish partnerships, networks and linkages with
other key development sectors in line with the CBR
matrix;
 To strengthen partnerships between government, civil
society (especially DPOs), private sector and service
providers (particularly health service providers).
Overall objective 5: Develop and strengthen knowledge

management and information systems in the health
component of CBR
The objective is to develop the knowledge base for disability and
rehabilitation. The gaps in information on disability in the Region
require the strengthening of data collection systems. There are
also gaps in knowledge on CBR and outcomes of rehabilitation in
the Region. This is due both to a lack of research and a lack of
monitoring and evaluation.
26
Specific objective 5.1: To promote evidence-based

practices in disability, CBR and inclusive development
There is an urgent need for increasing the data and knowledge
base on disability. Disability statistics are predominantly collected
through censuses or using tools focused on a choice of
impairments. Currently available statistics are mainly based on
impairment-based definitions and not on social definitions which
include participation. Improved data collection is needed for
planning; the promotion of broader definitions and use of ICF as a
framework for data collection on persons with disability will
strengthen the data available for planning. Training in ICF
appropriate to CBR providers is needed. More evidence is
needed from the Region on the impact of Community Based
Rehabilitation to strengthen the case for promotion of CBR as a
strategy for all people with disabilities.
Action areas:
 To Improve disability data in the health systems:
 To develop appropriate data collection system for
CBR
 Provide training in ICF appropriate to CBR
 Ensure that management information systems at the
primary, secondary and tertiary health levels
maintain data on the number of persons with
disability accessing health services (add column on
Disabled Yes/No)
 To build capacity for disability and rehabilitation
research in the region
 To support training in research methodology with
collaborating centres, rehabilitation institutes and
CBR providers
27
 To develop an evidence base through impact studies

on community based rehabilitation
 To include persons with disability in determining a
research agenda and strengthen their participation in
research
 To promote exchange and learning within the region by
strengthening the CBR Asia-pacific network and national
networks
 To publish good practices/lessons learnt for
sharing/replication among member countries
Specific objective 5.2: Monitor implementation and

evaluate the progress of CBR in the SEA Region
The objective is to strengthen evaluation and monitoring of CBR.
An effective system for monitoring progress and evaluating
outcomes and impact will be critical in measuring a country’s
progress in addressing disability and rehabilitation and the
progress of CBR programmes at all levels. Monitoring will help
ensure that programs are implemented, will detect problems and
constraints, and support them to plan better for the future.
Evaluation of outcomes and impact periodically is needed to
document whether the planned strategies and activities have the
desired impact.
Critical areas in evaluation and monitoring of CBR

programmes are:
(1) Improvement in the health of the people with disability
and access to rehabilitation.
(2) Inclusion of disability and rehabilitation in health
systems
(3) Cross-sectoral linkages that need to be created and
reinforced at various levels
(4) Support and partnerships
28
The situation analysis conducted in 2011 serves as the

baseline information. This needs to be updated by detailed
country profiles and regular updates every four to five years. In
addition, State Parties are required to report on the UNCRPD
Framework every two years. The WHO SEA Region will lead
periodic reviews of Community Based Rehabilitation in the
Region and conduct evaluation of the Framework at the regional
level. It is hoped that national coordinating mechanisms will take
the responsibility of reviewing national programmes.
Action areas:
 Work towards THE development of monitoring tools and
indicators for evaluation :
 To work towards the development of output and
outcome indicators at the regional, national and
subnational level
 To ensure coherence of indicators in line with other
strategies for disability
 To work towards the development of monitoring and
evaluation frameworks in detailed national action
plans.
 Conduct periodic updates of country and regional
situation of CBR
 Conduct mapping and listing of organizations
implementing CBR in the Region on a continued
basis
29
7. Appendix
International declarations and commitments on

disability
The first CBR Joint Position Paper published by ILO, UNESCO
and WHO in 1994 described CBR as “a strategy for rehabilitation,
equalization of opportunities, poverty reduction and social
inclusion of persons with disability”.
The Second Joint Position Paper by ILO, UNESCO and

WHO in 2004 updated the first Joint Position Paper.16 It redefined
CBR as “a strategy within general community development for the
rehabilitation, poverty reduction, equalization of opportunities and
social inclusion of all people with disabilities” and promotes the
implementation of CBR programmes”... through the combined
efforts of people with disabilities themselves, their families,
organisations and communities, and the relevant governmental
and non-governmental health, education, vocational, social and
other services”. The paper recognized that persons with
disabilities should have the access to all services available in the
community; it emphasized protection of the human rights and call
for action against poverty for government support in development
of national policies.
UNCRPD
On 13 December 2006, the UN General Assembly adopted the
Convention of Right of Persons with Disabilities, a landmark
declaration on the rights of persons with disabilities. This built on
previous declarations and documents such as the Universal
Declaration of Human Rights adopted by all Member States of the
UN in 1948 and the UN Standard Rules on Equalization of
Opportunities of Persons with Disabilities (1993).
30
The purpose of the Convention is to promote, protect and

ensure full and equal enjoyment of all human rights and
fundamental freedom by all persons with disabilities and to
promote respect for their inherent dignity.
WHO documents
The World Health Assembly resolution 58.23 in 2005 urged
Member States “to promote and strengthen community based
rehabilitation programme”.
WHO published its “WHO Action Plan 2006-2011” in 2006,

“Human Rights, Health and Poverty Reduction Strategies” in
200817 and subsequently a report on the Community-Based
Initiative (CBI) in 2009.
Other UN documents
The UN General Assembly Resolution A/RES/64/131 in 2009 on
“Realising the Millennium Development Goals for Persons with
Disabilities”18
“Global Survey on Government Action on Implementation of

Standard Rule on Equalization of Opportunities for Persons with
Disabilities”19 (2006)
“Mainstreaming Disability in the Development Agenda”

(2008)
World Bank document on Community Driven Development

(CDD)
UNESCO “EFA Global Monitoring Report: Reaching the

marginalized” (2009) 20
ILO “Facts on Disability in the World of Work” (2007)21
International Disability and Development Consortiums

document on “Disability and the MDGs”22 (2009)
31
8. References
(1) International Classification of functioning, disability and
health (ICF), Geneva, World health Organisation,
2001(www.who.int/classfication/icf/en/)
(2) World report on disability
http://www.who.int/disabilities/world_report/2011/en/index.html
(3) Disability and rehabilitation: WHO action plan 2006-
2011, Geneva World Health Organisation, 2006
(www.who.int/disabilities/publications/dar_action_plan20
06to2011.pdf)
(4) ElwanA.Poverty and disability: a survey of the literature.
Washington, DC, The World Bank, 1999
(http://siteresources.worldbank.org/DISABILITY/Resourc
es/280658-1172608138489/povertyDisabElwan.pdf, ).
(5) Global Survey on government action on the
implementation of the Standard Rules on the
Equalization of Opportunities for Persons with
Disabilities. UN Special Rapporteur on Disabilty, 2006
(www.escwa.un.org/divisions/sdd/news/GlobalSurvey_R
eport_Jan30_07_ReadOnly.pdf).
(6) Assistive devices/technologies: what WHO is doing.
Geneva, World Health Organization (undated)
(www.who.int/disabilities/technology/activities/en).
(7) Disability, poverty and development.UK, Department for
International Development, 2000 (www.make-
development-
inclusive.org/doscen/DFIDdisabilityPovertyDev.pdf).
(8) EFA global monitoring report: reaching the marginalized,
Paris, United Nations Educational Scientific and Cultural
Organization, 2009
(http://unesdoc.unesco.org/images/0018/001866/18660
6E.pdf).
(9) Facts on disability in the world of work, Geneva,
International Labour Organization, 2007
32
(www.ilo.org/public/english/region/asro/bangkok/ability/d
ownload/facts.pdf).
(10) Convention on the Rights of Persons with Disabilities,
New York, United nations, 2006
(www.un.org/disabilities/default.asp?navid=12&pid=150)
(11) The Standard Rules on the Equalization of Opportunities
for Persons with Disabilities. New York, United Nations,
1993 (www.un.org/esa/socdev/enable/dissre00.htm).
(12) World Programme of Action Concerning Disabled
Persons.New York, United Nations, 1982
(http://www.un.org/disabilities/default.asp?id=23).
(13) Introductory Booklet – CBR guidelines, WHO, UNESCO,
ILO, IDDC, 2010.(page 15)
(14) Declaration of Alma-Ata: International conference on
primary health care, USSR, 6-12 September, 1978,
Geneva, World Health Organisation, 1978
(www.who.int/hpr/NPH/docs/declaration_almaata.pdf).
(15) Community-based rehabilitation guidelines
http://www.who.int/disabilities/cbr/guidelines/en/index.ht
ml
(16) CBR: A strategy for rehabilitation, equalization
opportunities, poverty reduction and social inclusion of
people with disabilities (Joint Position Paper 2004).
Geneva, International Labour Organization, 2004.
(www.who.int/disabilities/publications/cbr/en/index.html).
(17) Human rights, health and poverty reduction strategies,
Geneva, World Health Organization, 2008.
(http://www.ohchr.org/Documents/Publications/HHR_Po
vertyReductionsStrategies_WHO_EN.pdf).
(18) Realizing the millennium development goals for persons
with disabilities (UN General Assembly Resolution
A.RES/63/1313). New York, United Nations 2009
(www.un.org/disabilities/default.asp?id=36).
33
(19) Global Survey on government action on the

implementation of the Standard Rules on the
Equalization of Opportunities for Persons with
Disabilities. UN Special Rapporteur on Disability, 2006
(www.escwa.un.org/divisions/sdd/news/GlobalSurvey_R
eport_Jan30_07_ReadOnly.pdf).
(20) Mainstreaming disability in the development
agenda.New York, United Nations, 2008
(www.un.org/disabilities/default.asp?id=708).
(21) EFA global monitoring report: reaching the marginalized,
Paris, United Nations Educational Scientific and Cultural
Organization, 2009
(http://unesdoc.unesco.org/images/0018/001866/18660
6E.pdf).
(22) Facts on disability in the world of work, Geneva,
International Labour Organization, 2007
(www.ilo.org/public/english/region/asro/bangkok/ability/d
ownload/facts.pdf).
(23) Disability and the MDGs. Brussels, International
Disability and Development Consortium 2009 (
www.includeeverybody.org/disability.php).
34
This publication deals with the multisectoral strategy that
aims to promote and strengthen community-based
rehabilitation in the SEA Region in order to improve the
quality of life of people with disabilities and their families
through access to health and rehabilitation services in
Member States of the Region.
The strategy focuses on the key areas under WHO’s

mandate, particularly health and rehabilitation. It includes
promotion of disability-inclusive health policies and
legislation, promotion of access to quality health and
rehabilitation services in a barrier-free environment,
promotion of participation and empowerment of persons
with disabilities and their families/communities in all
aspects of health care, development of relevant
partnerships with other sectors for CBR and of knowledge
management and information systems in its health
component.

World Health House
Indraprastha Estate,
Mahatma Gandhi Marg,
New Delhi-110002, India SEA-Disability-4

Regional Strategic Framework On Community-Based Rehabilitation (CBR) in The South-East Asia Region 2012-2017

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Regional Strategic Framework on

Community-Based Rehabilitation (CBR) in the

Regional Office for South-East Asia

Regional Strategic Framework on

Regional Office for South-East Asia

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Requests for publications, or for permission to reproduce or translate WHO

The designations employed and the presentation of the material in this

The mention of specific companies or of certain manufacturers’ products does

Persons with disabilities are some of the most disadvantaged

Poverty is both a cause and consequence of disability.7

unemployment and have lower earning than persons without

This is not just an issue of the vicious cycle of disability and

The present approach to disability is based on the

2. Community-based rehabilitation (CBR)

with disabilities. Current concepts of CBR are based on various

The new CBR guidelines released in 2010 are based on the

These guidelines are supported by evidence that CBR

The CBR Guidelines are based on the CBR Matrix, a

HEALTH EDUCATION LIVELIHOOD SOCIAL EMPOWERMENT

EARLY SKILLS PERSONAL ADVOCACY &

MEDICAL CARE SECONDARY & WAGE CULTURE & POLITICAL

REHABILITATION FINANCIAL RECREATION

CBR is currently being implemented in more than 90

A situation analysis of CBR in the South-East Asia Region in

The “South-East Asia Regional Strategic Framework for

formulated during a Regional Expert Group Meeting held on 3-4

The framework will guide in strengthening policy and action

5. The goal of the regional framework

6. Objectives and action areas

Five overall objectives with a number of specific objectives

Overall objective 1: Promote disability-inclusive health policies and

2.4 Enhance  Increase coverage of CBR to ensure access to

3.2 Enhance  Ensure participation of persons with disabilities

the Region by strengthening the CBR Asia-

Overall objective 1: Promote disability-inclusive health

Specific objective 1.1: Strengthen national legislation

 Consultation with organizations of persons with

Specific objective 1.2: Support ministries of health

Overall objective 2: Promote access to quality health

Specific objective 2.1: Enhance allocation of

 Develop guidelines for local government to

Specific objective 2.2: Ensure the availability of quality,

Current CBR programmes often have expertise only in single

Suggested action points are:

equal access without discrimination (including for the

Suggested action points are:

 Capacity building of CBR and health care providers

 Ensure that health professionals need to develop a

Specific objective 2.3: Ensure adequate numbers of

 Instilling and reviving the spirit of volunteerism.

Specific objective 2.4: Enhance capacity for community-

Specific objective 2.5: Promote internal linkages within

Prevention–primary, secondary and tertiary–reduces the burden

Action steps to accomplish this are:

Health promotion and prevention of NCDs is needed along

involvement and participation. The transition in health-care

Overall objective 3: Promote participation and

Rehabilitation was traditionally practiced in a top-down

Specific objective 3.1: Increase awareness and

 Build awareness that persons with disabilities can

Specific objective 3.2: Enhance participation of persons

Overall objective 4: Develop partnership with other