New CBR Model on the West Bank?: Disability, poverty and human rights
By Marianne Ziesler, Norwegian Association of the Disabled (Marianne.zeisler@nhf.no)
The Norwegian Association of the Disabled/NAD has been involved in international development co-operation since 1981. Since 1991 we have concentrated our work on supporting governments in developing large scale community based rehabilitation programmes and to supporting organisations of disabled people to promote their rights. This article includes some lessons learned through two decades.
Discrimination and marginalisation.
Why are disabled people poor?
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Disabled people are highly over-represented among the poorest in any country all over the world.
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They are more likely to die early or get health problems
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They have a lower education
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Disabled people have lower income and are less likely to get access to poverty alleviation programmes
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They are very seldom a priority of the community or of the government
In other words, disabled people are not seen as a normal part of the mainstream society, but are easily marginalised through both indirect and direct mechanisms.
The common, basic understanding is that this exclusion is caused by the impairment itself and the following limited ability to meet with the demands/barriers caused by the dysfunction. It is, however, not that simple. The exclusion in any given country goes way beyond the practical limitations coming from the impairment. Indicators may be marriage rates, education level or income. As an example, just try your neighbour's understanding of the ability of disabled children to benefit from school compared to other children. Even if the impairment happens to be, for example, polio with no influence on learning ability, he will probably think of it as a waste of time and resources.
Marginalisation is the most serious threat to anybody. Lack of expectations from your family (that may love you and care for you), lack of social learning on an equal footing, and denial of access to education and work create high barriers for participation.
The relevance of Community Based Rehabilitation/CBR - for persons/families
Rehabilitation programmes should in our opinion be designed according to the above context of disabled people versus the society, and not limited to the treatment or compensation for the impairment - as is often the case. Strategies and actions taken to deal with disability issues will be very different according to how the problem is perceived. Measures taken to deal with disability within the perspective of marginalisation or discrimination will be very different from measures to deal with disability limited to the impairments of individuals:
Firstly, the aim of the rehabilitation process should be "social inclusion", and not as we often see, goals limited to the medical rehabilitation part. This means access to services and resources where you live - you should be able to grow up in a family and community setting. You should be part of the mainstream society. Needs and solutions should be identified according to this setting.
Secondly, the efforts should be directed both towards the individual disabled and the community. The rehabilitation programme used as an example below shows how the main efforts are directed towards the community. In addition, medical (re)habilitation; through training of family members, home adaptations, referrals to specialised services are part of the work.
Thirdly, CBR as it is usually practiced, (or any outreach or institution based program) targets disabled people exclusively. Action towards the individual, family and community may be part of the work, but still with a segregated approach, targeting a small minority within the community. Not easy to get support and recognition from the rest, is it? And examples of back-firing has been reported.
The present situation regarding CBR seems to be one of many scattered small projects, with no direction towards to large scale service delivery, and collapse of the project when external resources are withdrawn. More than 20 years after the presentation of the CBR concept and manual by the World Health Organization, disabled people are still not on the agenda for governments. So, there is a question whether CBR as most commonly practised today is relevant from the perspective of a government.
A community approach, benefiting not only a minority, but as well including other concerns may much more likely be sustainable because it would be recognised and supported by the majority of the community - and accordingly give better long term results for the target group.
For governments the situation for disabled people is of course only part of a much larger picture. Within limited economic resources (which increasingly seem to be the case as well within the rich countries) their responsibility is to secure the welfare for many different marginalized groups; children, elderly, refugees, ethnic minorities etc. These governments need socio-economical sensible solutions/models to be able to meet with the needs. They must find ways to organise services for the population that coordinate and utilise existing resources - governmental and private. They need large scale solutions. So, models that in an effective way address needs for all, that include marginalized sectors, and have the potential to become recognised and supported by the population would be much more of interest for any government.
An example of a better model
I'll briefly present another model - a community development approach with a focus on disability. This approach focuses the needs as prioritised by the community, but as well raises the issue of needs of disabled people in the community. It is an integrated approach, and relevant to approach any marginalised group in a community. Women have for example as a spin off effect been included as one such group in the programme referred to below.
This approach has been successfully developed in the programme NAD is supporting in Palestine. We have cooperated with the Palestinians to develop their rehabilitation sector since the beginning of 1990s. Palestinian partners include more than 20 NGOs. (At the start of the programme there was no government. After its establishment it has been gradually included).
The rehabilitation programme is not a service delivery project. The rehabilitation programme aims at mobilising and coordinating existing resources (governmental and private), at developing a structure at the three levels - community, intermediate and central level, and at capacity building and institution building at all levels. A lot of service delivery comes out of it - due to mobilisation of the existing resources at all levels, and an effective referral system linking community, intermediate and central levels.
Talfeet, a village on the West Bank
The village Talfeet is situated in Nablus, West Bank. Talfeet is very poor and the village authorities had not had much success in improving the welfare of its population. The organisation representing the rehabilitation programme in Nablus is a primary health care organisation, familiar to the village authorities. The first effort of the CBR team was to start a discussion with the village council. The lack of a health clinic, clean water and sufficient electricity were big issues. The team raised the issue of disabled people. It was agreed to make a survey. In cooperation the CBR team and the village council found ways to address the different needs. An article in the main newspaper highlighted the situation and its headline, "The forgotten village at the turn of the century," drew public attention to the village. The team helped the council to promote and connect with the Palestinian authorities regarding the electricity problem, with an organisation for water supply, and so on. Needs identified by the survey of disabled persons was discussed by the council and in open meetings.
After two years, some interesting results
Results after 2 years are:
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240 disabled children are included in the village school
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In the village school, an accessible toilet versus an extra classroom for girls is under discussion
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Women are working actively together
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Women groups have been formed - they are among other matters concerned about prevention of disability
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Homes have been adapted to be accessible
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Some persons have been referred to specialised rehabilitation services
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Clean water is available
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There is a better electricity supply
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There is a health clinic open once a week,
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The village council is more active and has better capacity,
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Disabled are on the on the joint agenda and marginalisation has been reduced.
This has been accomplished through networking, in a situation where both NGOs and the government has co-operated. Most countries even much poorer than the occupied territories of West Bank and Gaza have resources far beyond the governmental. Through coordination and cooperation between these existing resources there is a potential to increase service delivery substantially in most countries.
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