Community based rehabilitation in India: who contributes to CBR programmes for the visually impaired?
Traditionally rehabilitation of the visually impaired used to be institution based and provided by organisations concerned with the welfare of the blind. With the development of the concept of Community Based Rehabilitation (CBR), Sight Savers International (SSI) commenced supporting CBR projects in India. However, the practice of CBR, in quite a few projects:
- had the cultural ‘hangover’ of traditional rehabilitation approaches
- started in geographic areas where organisations of/for the blind were strong leaving the under/unserved areas as they were
- was more ‘community-orientated’ than ‘community-based’ or ‘community involved’.
SSI’s India policy, developed since 1990, stressed the need for development of services to the visually impaired in the deprived parts and States of India – specifically in the central, eastern and northeastern states. Since traditional blind welfare organisations were not available (both in numbers and capacity), in these areas the SSI India programme had to look for alternative agencies for service delivery through CBR. This article attempts to share this experience as well as some suggestions for further expansion of well-developed and networked CBR projects.
Partner identification and development
While the blind welfare services were few in number with very limited capacity, the target States had a number of good agencies dealing with one or more community issues such as water management, rural sanitation, adult/female literacy, afforestation, etc. Discussions with these agencies were initiated to motivate them to add rehabilitation of the visually impaired as part of their objectives and activities. Awareness was created of the magnitude of the blindness problem in rural areas and support towards training, materials, funds, resource persons, etc. was offered and assured. Also, agencies with interest were shown running CBR projects to get the feel of the project content and accomplishment. Active networking between blind welfare organisations and the new community based organisations was developed. Thereafter, a memorandum of understanding was developed between the partner agency and SSI for a CBR project in the area, to cover a population of 500,000 over a period of five years.
Training and development: CBR coordinators
From the personnel of identified agencies, one person was selected to be trained as coordinator of CBR projects for the agency. Ten selected persons were given a 3-month training in the Blind Men’s Association at Ahmadabad in two modules, each of 6 weeks.
The first module introduced them to:
- the epidemiological, clinical, sociological and psychological aspects of blindness
- services that could be provided
- exposure to traditional methods and CBR methodology.
These trainees went back to their own area for two months to do a quick survey and study of blindness and develop an understanding of the problem and present level of services.
The second module addressed:
- issues seen by them in their area
- programme management
- record maintenance
- cooperation with other agencies and government assistance.
These persons became the core cadre for actual project developments with the current partner agencies and, as motivators, trainers and resource persons for further partner and project development.
Methodology of service delivery: clusters and fieldworkers
The service area was divided into clusters of about 25,000 population each. Eight clusters were chosen for the initial phase of the project. One fieldworker from each cluster was selected with suitable gender mix. The eight fieldworkers, and two extra persons (to allow for drop outs), were given a six-week training programme of two modules (two weeks and four weeks each). The training was organised by the partner agencies in their own project area, normally combining two or three projects for each training session (25-30 trainees). The trainers were drawn mostly from local development personnel supplemented by some experts with experience in rehabilitation and CBR. On completion of the training, the project was initiated.
The identified clients were screened for curable and incurable blindness. The curable were assisted in obtaining services from eye care agencies. The incurably blind were taken for rehabilitation services such as orientation, mobility and daily living skills. Each fieldworker normally dealt with five clients a quarter. The initial 200,000 population is normally covered within a period of two years. Thus the 500,000 population should be serviced in four to five years.
The new partner agencies already had acceptance and credibility in the community for other services given. The community became interested in the additional services and became involved in identification and motivation of the visually impaired in accepting services. The community leaders, who were impressed by the visibly dramatic improvement in mobility, daily living and social skills developed by the visually impaired, actively assisted in obtaining other facilities and concessions from the community, Government and financing organisations, all for the improvement of economic rehabilitation for the visually impaired. The process also involved gifted clients as motivators and facilitators, advising families of the visually impaired, community leaders and other rural service organisations in NGO and occasionally Government sectors.
As part of the project development, refresher courses were organised periodically for one week or two week durations. The participating agencies were encouraged to contribute to the agenda by sharing case studies, special aspects of their areas and specific and common difficulties. The refresher courses were planned to be interactive so that issues and projects were analysed and solutions evolved. The nearby Government officials, blind welfare organisations and eye care institutions were also invited as guest faculty.
In addition, seminars, workshops and social gatherings with blind clients were organised by partner agencies to increase awareness and thereby involvement of the community.
The projects, which were originally handled only by fieldworkers trained in rehabilitation, started involving general community based workers giving them basic training in orientation and mobility. This brought in continuity after the initial prevalent visually impaired population had been serviced. The provision of curative services developed links between eye hospitals and rehabilitation agencies. The case finding and mobilisation of patients for eye care to the hospitals became integrated into the programme, benefiting the community as well as the eye hospital.
There are a number of rural hospitals with eye care facilities that are little used due to lack of awareness, accessibility and affordability. A few eye care partners of SSI were encouraged to take on CBR as an add-on to their programme. At nine locations such linked projects are in place. This gives good outreach programmes from the base hospital and good eye care services to the community.
- The development of CBR projects in India complemented the activities of blind welfare agencies to include other community based service agencies
- Selected core staff of such agencies were trained in methodology as well as management of rehabilitation projects. They became useful in service delivery, training and proliferation of CBR projects
- Networking of CBR project partners geographically further expanded the movement
- Networking of blind welfare agencies and CBR project partners was implemented
- Linking eye care institutions to CBR partners and projects, as part of their outreach activities, became effective
- Motivation of general service providers in rural areas was encouraged to provide further services to blind clients.
- To cover the blind population throughout the country, it is necessary that CBR becomes a part of the national agenda in dealing with disability. The coordination between Government departments of Welfare and Health will be useful in providing comprehensive eye care services.
- As rural areas are at distances and populations scattered, providing training to general multipurpose workers in rehabilitation services would be useful.
- It would benefit eye care centres to link with CBR projects. Also they should be encouraged to add a CBR component to their outreach services.
- The facilities available for training of fieldworkers, project coordinators/managers, materials and literature available need to be enhanced by State funding. A proper syllabus, curriculum, faculty and authorised institutions need to be developed to standards appropriate to the countries concerned.
This report gives a brief outline of SSI’s programmes over the last nine years in enhancing services to remote areas in India. The concept of a comprehensive eye care programme also evolved out of these efforts. All these may need to be modified to suit local conditions, involving the clients, their families, the community and other agencies. Integrating rehabilitation into eye care programmes would be a right step forward in enlarging and enhancing services to the visually impaired in rural areas.
The author is grateful to a number of colleagues, experienced partners, rural organisations and rehabilitation professionals in the development and implementation of the above programmes.