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Khasnabis C, Heinicke Motsch K, Achu K, et al., editors. Community-Based Rehabilitation: CBR Guidelines. Geneva: World Health Organization; 2010.

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Community-Based Rehabilitation: CBR Guidelines.

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Management

Introduction

The community-based rehabilitation (CBR) matrix, which was described in the introduction, consists of five components (Health, Education, Livelihood, Social and Empowerment) and their associated elements. It provides a basic framework which can be used to develop new CBR programmes. Even though a common matrix now exists, each CBR programme will continue to demonstrate unique differences because it is influenced by a wide range of factors, e.g. physical, socioeconomic, cultural and political factors. This chapter will be a guide for programme managers to provide a basic understanding of how to select the components and elements for a CBR programme, which are relevant and appropriate to local needs, priorities and resources.

While all CBR programmes are different, there is a universal sequence of stages that help to guide their development. These stages are usually collectively referred to as the management cycle, and comprise: Situation analysis (Stage 1), Planning and design (Stage 2), Implementation and monitoring (Stage 3) and Evaluation (Stage 4). This chapter will describe the management cycle in more detail to help programme managers understand the important aspects of each stage and to develop effective programmes that are inclusive of all key stakeholders and ultimately meet the needs of people with disabilities and their family members.

Please note that this chapter does not present a fixed approach which every CBR programme must follow. Because programmes are often developed through partnerships with others, e.g. governments or funding bodies, these may provide the necessary guidelines about how programmes are to be developed. In addition, while this chapter focuses mainly on the development of new CBR programmes, it will also be useful for strengthening existing ones.

BOX 8India

Mobilizing an inclusive society

Mobility India is a nongovernmental organization based in Bangalore, India. It has been promoting CBR since 1999, with the goal of achieving an inclusive society where people with disabilities have equal rights and a good quality of life. Mobility India carries out CBR programmes in three different locations; 1) the urban slums of Bangalore; 2) a periurban area (Anekal Taluk) about 35 km from Bangalore; and 3) a rural area (Chamrajnagar District) about 210 km from Bangalore.

While the CBR programmes in each of these areas carry out many common activities, such as facilitating the formation of self-help groups, facilitating access to health, education, livelihood and social opportunities, and community mobilization, they also display unique differences because of the different contexts in which they operate.

Through evaluation, Mobility India has learned a number of valuable management lessons over the years. These include the importance of:

  • Involving key stakeholders at all levels of the management cycle;
  • performing a proper situation analysis before starting a CBR programme;
  • making a solid investment in initial planning, ensuring that clear indicators are developed;
  • developing partnerships with key stakeholders, and ensuring there are clearly defined roles and responsibilities – partnerships with local government are essential;
  • initiating activities that benefit the whole community, not just a few disabled people;
  • recruiting CBR personnel from local communities and giving preference to people with disabilities, particularly women;
  • ensuring that capacity-building is an ongoing process and inclusive of everyone, e.g. people with disabilities, their families, community members, service providers and local leaders or decision-makers;
  • sharing successes and failures with others.

Key concepts

What is the difference between a CBR project and a CBR programme?

CBR projects and CBR programmes are being implemented around the world; however, many people are not sure of the difference between the two. CBR projects are usually small in scale and may be focused on achieving very specific outcomes in one component of the CBR matrix, e.g. health. They are short-term, with a set start-point and end-point. Where there is limited government support for CBR, projects are often started by local community groups or nongovernmental organizations, as in Argentina, Bhutan, Colombia, Sri Lanka and Uganda. If they are successful, it may be possible to expand them to the programme level, e.g. pilot projects have become national programmes in China, Egypt and the Islamic Republic of Iran. CBR programmes are a group of related projects which are managed in a coordinated way. They are usually long-term, have no set completion dates, and are larger in scale and more complex than a project. While projects and programmes have different characteristics, this chapter will use the term “programme” to refer to both. The management cycle that is discussed in this chapter and the outcomes, key concepts and suggested activities outlined in the other components of the CBR guidelines apply readily to both.

Getting started

CBR is usually initiated by a stimulus from outside the community, e.g. by a ministry or nongovernmental organization (1). Whether the interest originates from inside or outside the community, it is important to ensure that resources are available and the community is ready to develop and implement the programme (see Participatory management, below). It is neither expected nor possible for the ministry, department, local authority or organization that initiates a CBR programme to implement every component of the CBR matrix. It is essential that they develop partnerships with the different stakeholders responsible for each component of the matrix, to develop a comprehensive programme. Each sector should be encouraged to take responsibility for ensuring that its programmes and services are inclusive and respond to the needs of persons with disabilities, their families and communities. For example, it is suggested that the ministry of health and/or nongovernmental organizations working in the health sector take responsibility for the health component, the ministry of education and/or non-governmental organizations working in the education sector take responsibility for the education component, and so on.

Geographical coverage

CBR programmes can be local, regional or national. The type of coverage will depend on who is implementing the programme, what the areas of intervention are, and the resources available. It is important to remember that support is needed for people with disabilities and their families as close as possible to their own communities, including rural areas. Resources are limited in most low-income countries and concentrated in the capital or big cities. The challenge for CBR planners is to find the most appropriate solution to achieve an optimum quality of services, as close as possible to people's homes, given the realities of the needs and existing resources in the local situation (see Stage 1: Situation analysis).

Management structure for CBR

Each CBR programme will decide how to manage its own programme, so it is not possible to provide one overall management structure for CBR in this component. However, some examples of management structures which are based on existing programmes around the world have been provided at the end of this component (see Annex).

In many situations, committees may be established to assist with the management of CBR programmes, and these are encouraged. CBR committees are usually made up of people with disabilities, their family members, interested members of the community and representatives of government authorities. They are useful for:

  • setting the mission and vision of the CBR programme;
  • identifying needs and available local resources;
  • defining the roles and responsibilities of CBR personnel and stakeholders;
  • developing a plan of action;
  • mobilizing resources for programme implementation;
  • providing support and guidance for CBR programme managers.

Participatory management

One of the key threads running through all CBR programmes is participation. In most situations, CBR programme managers will be responsible for making the final decisions; however, it is important that all key stakeholders, particularly people with disabilities and their family members, are actively involved at all stages of the management cycle. Stakeholders can provide valuable inputs by sharing their experiences, observations and recommendations. Their participation throughout the management cycle will help ensure that the programme responds to the needs of the community and that the community helps to sustain the programme in the long term (see Stage 1: Stakeholder analysis).

Sustaining CBR programmes

While good intentions help to start CBR programmes, they are never enough to run and sustain them. Overall, experience shows that government-led programmes or government-supported programmes provide more resources and have a larger reach and better sustainability, compared with civil society programmes. However, programmes led by civil society usually make CBR more appropriate, make it work in difficult situations, and ensure better community participation and sense of ownership. CBR has been most successful where there is government support and where it is sensitive to local factors, such as culture, finances, human resources and support from stakeholders, including local authorities and disabled people's organizations.

Some essential ingredients for sustainability which CBR programmes should consider are listed below.

  • Effective leadership – it would be very difficult to sustain CBR programmes without effective leadership and management. CBR programme managers are responsible for motivating, inspiring, directing and supporting stakeholders to achieve programme goals and outcomes. Thus it is important to select strong leaders who are committed, excellent communicators, and respected by stakeholder groups and the wider community.
  • Partnerships – if they work separately, CBR programmes are at risk of competing with others in the community, duplicating services and wasting valuable resources. Partnerships can help to make best use of existing resources and sustain CBR programmes by providing mainstreaming opportunities, a greater range of knowledge and skills, financial resources and an additional voice to influence government legislation and policy relating to the rights of persons with disabilities. In many situations, formal arrangements, such as service agreements, memorandums of understanding and contracts can help secure and sustain partners' involvement.
  • Community ownership – successful CBR programmes have a strong sense of community ownership. This can be achieved by ensuring the participation of key stakeholders at all stages of the management cycle (see Empowerment component: Community mobilization.)
  • Using local resources – reducing the dependency on human, financial and material resources from external sources will help ensure greater sustainability. Communities should be encouraged to use their own resources to address the problems they face. The use of local resources should be given priority over national resources, and national resources should be given priority over resources from other countries.
  • Considering cultural factors – cultures vary, and what may be culturally appropriate for one group of people may not be the same for another group. To ensure CBR programmes are sustainable in different contexts, it is important to consider how they will affect local customs and traditions, what resistance to the programme may be expected and how this resistance would be managed. It is important to find a balance between changing inaccurate beliefs and behaviours related to people with disabilities and adapting programmes and activities to the local context.
  • Building capacity – building the capacity of stakeholders to plan, implement, monitor and evaluate CBR programmes will contribute to sustainability. CBR programmes should have a strong awareness-raising and training component to help build capacity among stakeholders. For example, building capacity among people with disabilities will ensure that they have the relevant skills to advocate for their inclusion in mainstream initiatives.
  • Financial support – it is important that all CBR programmes develop stable funding sources. A range of different funding options may be available, including government funding (e.g. direct financing or grants), donor funding (e.g. submitting project proposals to national or international donors for funding, in-kind donations or sponsorship), and self-generated income (e.g. selling products, fees and charges for services, or microfinance).
  • Political support – a national CBR policy, a national CBR programme, a CBR network and the necessary budgetary support will ensure that the benefits of the Convention on the Rights of Persons with Disabilities (2) and development initiatives reach all people with disabilities and their families. Inclusion of disability issues in government legislation and policies will also ensure lasting benefits for people with disabilities in terms of their access to services and opportunities in the health, education, livelihood and social sectors.

Scaling-up of CBR programmes

Scaling-up of CBR programmes means expanding the impact of a successful programme. This will have a number of benefits, for example, CBR will be extended to more people with disabilities who have unmet needs, it will contribute to a growing awareness of disability issues in society and may also increase support for changes in policies and resource allocation related to disability. Scaling-up requires (i) demonstration of programme effectiveness; (ii) acceptance by people with disabilities and their family members; (iii) acceptance by the community; (iv) sufficient financial resources; and (v) clear legislation and policies.

There are many different ways a CBR programme could be scaled up. One way is to increase the geographical coverage of the programme – that is, expand the programme beyond a single community to several communities or to the regional or even national level. However, in general, it is suggested that CBR programmes start small in areas that are easy to reach and show results before they consider scaling up. As many CBR programmes focus on people with a specific impairment, another way they could scale up is to accommodate people with different types of impairments.

The management cycle

When thinking about developing or strengthening a CBR programme, it is helpful to visualize the whole management process as a cycle (Fig. 2). This ensures that all the main parts are considered, and shows how they all fit and link with one another. In these guidelines, the management cycle consists of the following four stages.

Fig 2. Management cycle.

Fig 2

Management cycle.

  1. Situation analysis – this stage looks at the current situation in the community for people with disabilities and their families, and identifies the problems and issues that need to be addressed.
  2. Planning and design – the next stage involves deciding what the CBR programme should do to address these problems and issues, and planning how to do it.
  3. Implementation and monitoring – at this stage, the programme is carried out, with regular monitoring and review to ensure it is on the right track.
  4. Evaluation – this stage measures the programme against its outcomes to see whether and how the outcomes have been met and assess the overall impact of the programme, e.g. what changes have occurred as a result of the programme.

Stage 1. Situation analysis

Introduction

It is essential that CBR programmes are based on information that is relevant and unique to each community to ensure they respond to the real needs and are cost-effective and realistic. Often, before starting a CBR programme, planners think they have enough information about what is needed and what they should do. However, in many cases, this information is incomplete, so the first stage of the management cycle should be a situation analysis.

A situation analysis aims to answer the following question: “Where are we now?” It helps planners to build up an understanding of the situation (or context) in which people with disabilities and their families live, to determine the most appropriate course of action. It involves gathering information, identifying the stakeholders and their influence, identifying the main problems and objectives of the programme, and identifying what resources are available within the community. It is an important stage in the management cycle, as it provides essential information for the planning and design of the CBR programme (see Stage 2: Planning and design).

Steps involved

A situation analysis involves the following steps.

  1. Collecting facts and figures.
  2. Stakeholder analysis.
  3. Problem analysis.
  4. Objectives analysis.
  5. Resource analysis.

Collecting facts and figures

Collecting basic facts and figures helps identify what is already known about people with disabilities and the situation in which they live. It also provides baseline information which may be helpful for evaluation in the future (see Stage 4: Evaluation). Facts and figures can be gathered about the environmental, social, economic, cultural and political situation at the national, regional and/or local level.

For example, information could be collected about:

  • population, e.g. number of people with disabilities, age, sex, types of impairment;
  • living conditions, e.g. types of housing, water and sanitation;
  • health, e.g. mortality rates, causes of death and illness, local health services;
  • education, e.g. number of disabled children attending school, literacy rates;
  • economics, e.g. sources of income, average daily wage;
  • government, e.g. policies and legislation, level of interest in disability, ratification and implementation status of the Convention on the Rights of Persons with Disabilities, accessibility standards and regulations;
  • culture, e.g. cultural groups, languages, practices and attitudes towards disabilities;
  • religion, e.g. religious beliefs and groups;
  • geography and climate.

Fact-finding may involve talking to people, e.g. visiting the local government office and/or reviewing documents and data which may be found on the Internet, in government publications, in books and research papers.

Stakeholder analysis

It is important that all key stakeholders are identified and involved from the beginning of the management cycle to ensure their participation and to help establish a sense of community ownership. A stakeholder analysis helps to identify those stakeholders (individuals, groups or organizations) that might benefit from, contribute to, or influence a CBR programme. There are many different tools that can be used to identify stakeholders, document their levels of influence and map their activities. A SWOT analysis is one tool that can be used to analyse the strengths and weaknesses of a stakeholder group and the external opportunities and threats it faces.

Roles and responsibilities of key stakeholders

Many different stakeholders may be identified during a stakeholder analysis. These may include: people with disabilities and their family members, members of the community (including community leaders, teachers, etc.), civil society (e.g. nongovernmental organizations, religious organizations and women's groups), disabled people's organizations and government authorities (Fig. 3). It is important to remember that CBR personnel and CBR programme managers are also stakeholders. Each stakeholder will bring skills, knowledge, resources and networks and will have specific roles and responsibilities regarding the development and implementation of CBR.

Fig 3. CBR stakeholders.

Fig 3

CBR stakeholders.

People with disabilities and their families

People with disabilities and their families play an extremely important role within CBR. Their roles and responsibilities will become clear throughout the CBR guidelines, but in summary they may include:

  • playing an active role in all parts of the management of the CBR programme;
  • participating in local CBR committees;
  • being involved by volunteering and working as CBR personnel;
  • building awareness about disability in their local communities, e.g. drawing attention to barriers and requesting their removal.
Community members

CBR can benefit all people in the community, not just those with disabilities. CBR programmes should encourage community members to undertake the following roles and responsibilities:

  • participate in training opportunities to learn more about disability;
  • change their beliefs and attitudes that may limit opportunities for people with disabilities and their families;
  • address other barriers that may prevent people with disabilities and their families from participating in the life of their communities;
  • lead by example and include people with disabilities and their families in activities;
  • contribute resources (e.g. time, money, equipment) to CBR programmes;
  • protect their communities and address the causes of disability;
  • provide support and assistance where needed for people with disabilities and their families.
Civil society

The roles and responsibilities of civil society organizations and groups will vary depending on their level – international, national, regional or community. Their roles and responsibilities will also be influenced by their level of experience and involvement in disability and CBR. Historically, many nongovernmental organizations have been at the centre of CBR work, so they may be the driving force behind any new or existing CBR programme. Generally, roles and responsibilities may include:

  • developing and implementing CBR programmes where there is limited government support;
  • providing technical assistance, resources and training for CBR programmes;
  • supporting the development of referral networks between stakeholders;
  • supporting CBR programmes to build the capacity of other stakeholders;
  • mainstreaming disability into existing programmes and services;
  • supporting the evaluation, research and development of CBR.
Disabled people's organizations

Disabled people's organizations are a great resource for strengthening CBR programmes, and many currently play meaningful roles in CBR programmes (see Empowerment component: Disabled people's organizations).

Their roles and responsibilities may include:

  • representing the interests of people with disabilities;
  • providing advice about the needs of people with disabilities;
  • educating people with disabilities about their rights;
  • advocating and lobbying for action to ensure that governments and service providers are responsive to these rights, e.g. implementation of programmes in compliance with the Convention on the Rights of Persons with Disabilities;
  • provision of information about services to people with disabilities;
  • direct involvement in the management of CBR programmes.
Government

Disability issues should concern all levels of government and all government sectors, e.g. the health, education, employment and social sectors. Their roles and responsibilities might include:

  • taking the lead in the management and/or implementation of national CBR programmes;
  • ensuring that appropriate legislation and policy frameworks are in place to support the rights of people with disabilities;
  • developing a national policy on CBR, or ensuring CBR is included as a strategy in relevant policies, e.g. rehabilitation or development policies;
  • providing human, material, and financial resources for CBR programmes;
  • ensuring people with disabilities and their family members are able to access all public programmes, services and facilities;
  • developing CBR as an operational methodology or service delivery mechanism for providing rehabilitation services across the country.
CBR managers

Management roles and responsibilities will depend on who is responsible for initiating and implementing the CBR programme and on the degree of decentralization, e.g. whether the programme is based at the national, regional or local level. In general, some of the roles and responsibilities of a CBR programme manager may include:

  • facilitating each stage of the management cycle;
  • ensuring policies, systems and procedures are in place for management of the programme;
  • building and maintaining networks and partnerships both within and outside the community;
  • ensuring that all key stakeholders are involved in each stage of the management cycle and are kept well informed of accomplishments and developments;
  • mobilizing and managing resources, e.g. financial, human and material resources;
  • building the capacity of communities and ensuring disability issues are mainstreamed into the development sector;
  • managing day-to-day activities by delegating tasks and responsibilities;
  • supporting and supervising CBR personnel, e.g. ensuring CBR personnel are aware of their roles and responsibilities, meeting regularly with CBR personnel to review their performance and progress, and organizing training programmes;
  • managing information systems to monitor progress and performance.
CBR personnel

CBR personnel are at the core of CBR and are a resource for disabled people, their families and community members. Their roles and responsibilities will become clear throughout the CBR guidelines; however, they include:

  • identifying people with disabilities, carrying out basic assessments of their function and providing simple therapeutic interventions;
  • educating and training family members to support and assist people with disabilities;
  • providing information about services available within the community, and linking people with disabilities and their families with these services via referral and follow-up;
  • assisting people with disabilities to come together to form self-help groups;
  • advocating for improved accessibility and inclusion of people with disabilities by making contact with health centres, schools and workplaces;
  • raising awareness in the community about disability to encourage the inclusion of disabled people in family and community life.
Table 1. Viet Nam national CBR programme – roles and responsibilities of key stakeholders.

Table 1

Viet Nam national CBR programme – roles and responsibilities of key stakeholders.

Problem analysis

CBR programmes are set up to address existing problems in the community for people with disabilities and their family members. A problem analysis helps to identify what the main problems are, and their root causes and effects or consequences. The most important problems identified should then become the main purpose of the CBR programme (see Prepare a programme plan). In each component and element of the CBR guidelines, the potential purpose of the CBR programme is highlighted under the “Role of CBR”.

A problem analysis should be carried out with the key stakeholder groups identified above. Without stakeholders' views about an issue, the nature of the problem, the needs and the solutions will not be clear. A workshop is a useful way to carry out a problem analysis with stakeholders, and helps to build a shared sense of understanding, purpose and action. However, it should be noted that it may be necessary to carry out several workshops with different stakeholder groups to ensure that more vulnerable groups are able to express their opinions freely.

There are many different tools that can be used to carry out a problem analysis – a “problem tree” is probably one of the most common and widely used (3,4). A problem tree is a way to visualize the situation in diagram form. It shows the effects of a problem on top and its causes at the bottom.

Objectives analysis

An objectives analysis provides the starting point for determining what solutions are possible. An objectives tree is a useful tool to complete this analysis – it is similar to the problem tree mentioned above, except that it looks at the objectives rather than problems (3,4). If a problem tree has been used, it can easily be turned into an objectives tree. To complete an objectives tree the causes in the problem tree (negatives) are converted into objective statements (positives). The objectives identified during this analysis are important for the planning and design phase, as they form the basis of the programme plan. As many problems and objectives are usually identified during this stage of the programme cycle, it is important to prioritize key areas for the programme to focus on (see Planning and design).

Resource analysis

All communities have resources, even those that are very poor. The purpose of the resource analysis is to identify the current resources available in the community that a CBR programme could use or build on. It is also important during the resource analysis to identify the capacity (i.e. the strengths and weaknesses) of these resources to address the needs of people with disabilities. A resource analysis should identify: human resources, material resources (e.g. infrastructure, buildings, transport, equipment, financial resources and existing social systems) and structures, such as organizations, groups and political structures. It is often useful to map the location of these.

Stage 2. Planning and design

Introduction

Stage 1 should have provided CBR planners with enough information for Stage 2 –planning and design. Planners should begin this stage with a clear picture of the situation of people with disabilities and the context in which the CBR programme will operate; they should have information about the number of people with disabilities, the needs of people with disabilities and their families, possible solutions to problems, and the availability of community resources.

Planning helps you to think ahead and prepare for the future, providing guidance for the next stage in the management cycle (Stage 3: Implementation and monitoring). It ensures that all aspects of a CBR programme are considered – priority needs are identified, a clear map (or plan) towards achieving a desired goal is designed, monitoring and evaluation systems are considered and the resources necessary to accomplish the CBR programme plan are identified.

Steps involved

Plan together with key stakeholders

Holding a stakeholder forum is a good way to review and discuss the findings from Stage 1 to determine priorities, design programme plans and prepare budgets. It is important that people with disabilities and their family members are well represented at the planning stage; therefore, consideration should be given to the way in which the forum is held to ensure they are able to participate meaningfully. For example, information should be presented in formats that are accessible to people with different types of impairment. As mentioned in Stage 1, it may be necessary to hold separate forums for some stakeholder groups, e.g. people with disabilities and their family members, to ensure they are able to express their views easily and freely.

Set priorities

It is likely that many different needs will have been identified during Stage 1 which could all potentially be addressed by a CBR programme. Unfortunately, resources are not unlimited, and therefore priorities will need to be set. When deciding on priorities, it is helpful to consider where the need is greatest, where the greatest potential exists for change, and the availability of resources. Participation of key stakeholders in priority-setting is important to ensure that the programme is relevant and appropriate to their needs. Prioritization requires skill and an understanding of the realities – sometimes external facilitators can help prevent deviations from the programme goal.

Prepare a programme plan

The logical framework (“log frame”) is a planning tool that can be used to prepare a plan for the CBR programme. A log frame helps to ensure that all aspects needed for a successful programme are taken into consideration. It aims to answer the following questions:

  • what does the programme want to achieve? (goal and purpose);
  • how will the programme achieve this? (outcomes and activities);
  • how will we know when the programme has achieved this? (indicators);
  • how can we confirm that the programme has achieved this? (means of verification);
  • what are the potential problems that may be experienced along the way? (risks).

An understanding of the following steps is important to prepare a CBR programme plan using a log frame. Refer to Table 2 which shows the general structure of a log frame and Table 3 which shows an example of what a completed log frame may look like. Note that some of the log frame terms used below may be different to those used by other organizations, funding bodies, etc.

Table 2. The logical framework.

Table 2

The logical framework.

Table 3. Example of a log frame for the health component.

Table 3

Example of a log frame for the health component.

Determine the goal

Before thinking about what will be done, i.e. the activities, it is important to have a good understanding of what the programme hopes to achieve in the long term, i.e. the goal. The goal describes the intended ultimate impact of the CBR programme – the desired end-result whereby the problem or need no longer exists or the situation is significantly improved (see Stage 1: Problem analysis).

State the purpose

The purpose of the programme describes the change you want the programme to make towards achieving the goal. Usually, there is only one purpose, as this makes programme management easier. However, some CBR programmes may have more than one purpose because they may want to focus on several different components/elements of the CBR matrix, e.g. health and education. In this situation, separate log frames will be required, but these log frames should all share the same overall goal (see Stage 1: Problem analysis).

Define the outcomes

The outcomes are what the CBR programme wants to achieve. They are broad overall areas of work. There are usually no more than three to six outcomes for each log frame (see Stage 1: Objectives analysis).

Determine the activities

Activities are the work or interventions that need to be carried out to achieve the purpose and outcomes. Only simple, key activities are listed in the log frame. More detailed activities are considered later on in the management cycle, e.g. when the workplans are developed (see Stage 3: Develop detailed workplans).

Set the indicators

Indicators are targets that show the progress towards achieving the outcomes of the CBR programme and are important for monitoring (see Stage 3: Implementation and monitoring) and evaluation (see Stage 4: Evaluation). Indicators for a CBR programme may measure the following:

  • quality of services and promptness of service delivery;
  • extent to which programme activities reach the targeted individuals;
  • acceptability and actual use of services;
  • cost involved in implementing the programme;
  • extent to which the actual implementation of the programme matches the implementation plan;
  • overall progress and development of programme implementation and barriers to these.

It is important to remember when setting indicators that they should be SMART, that is:

  • Specific – when indicators are written they need to specify the extent of the change you hope to achieve, i.e. quantity (e.g. how much, or how many), the kind of change you are hoping to achieve, i.e. quality (e.g. satisfaction, opinions, decision-making ability or changes in attitude), and the timescale for the change, i.e. time (e.g. when or how often);
  • Measurable – will it be possible to measure the indicators realistically?
  • Attainable – will it be possible to achieve the indicators at a reasonable cost?
  • Relevant – are the indicators relevant to what they should be measuring?
  • Timely – will it be possible to collect information for the indicators when it is needed?
Determine sources of verification

After the indicators have been set, it is important to decide what information is needed to measure each indicator, i.e. the sources of verification. These may include reports, minutes of meetings, attendance registers, financial statements, government statistics, surveys, interviews, training records, correspondence or conversations, case-studies, weekly, monthly or quarterly programme reports, mid-programme or final programme evaluations. When deciding on the sources of verification, it is also important to think about when, where and by whom data will be collected.

Consider what assumptions need to be made

To complete the assumptions column of the log frame, the risks and the things that might go wrong during the programme, need to be considered. There are risks associated with every CBR programme: however, identifying them early can help ensure that there are no real surprises along the way. Once the risks have been identified, they can then be managed by changing the programme plan to reduce or eliminate them. The risks are then turned into positive statements (assumptions) and included in the log frame.

Prepare a monitoring and evaluation plan

All programmes should have monitoring and evaluation systems. It is essential that these systems are considered during the planning stage, as information needs to be collected as soon as implementation of the programme begins. The indicators and the sources of verification that were identified in the programme plan will provide the basic foundation for monitoring and evaluation systems (see Stage 3: Implementation and monitoring, and Stage 4: Evaluation).

Decide what resources are needed

Although the resources that are needed for a CBR programme may not be immediately available when the programme starts, it is important to think about the resources needed to implement the programme activities and how to go about obtaining them. Remember to refer back to the resource analysis carried out in Stage 1 to identify the resources that already exist (see Stage 1: Resource analysis). The following resources should be considered.

Human resources

The types of personnel needed to implement the programme, e.g. programme manager, CBR personnel, administration assistants and drivers.

Material resources

The types of facilities and equipment needed to implement the programme, e.g. office space, furniture, computers, mobile phones, vehicles, audiovisual equipment and rehabilitation equipment.

Financial resources

Cost can be a major limiting factor for new programmes, so it is important to think carefully about the amount of money that is needed. The best way to do this is to prepare a budget. It does not matter whether a CBR programme is using existing funds or funds from a donor/donors, it is always important to prepare a budget.

Prepare a budget

A budget describes the amount of money that the programme plans to raise and spend to implement the activities over a specified period of time. A budget is important for transparent financial management, planning (e.g. it gives an idea of what the programme is going to cost), fundraising (e.g. it provides information to tell donors what their money will be spent on), programme implementation and monitoring (e.g. comparing the real costs against the budgeted costs) and evaluation.

The budget must reflect the costs related to the resources outlined in the section “Decide what resources are needed” above. It is important to budget very carefully; if you do not have a large enough budget you may be unable to carry out some programme activities, but if you set the budget too high for some things, donors may be unwilling to fund the programme.

Stage 3. Implementation and monitoring

Introduction

The third stage, Implementation and monitoring, involves putting the plans from Stage 2 into action, and ensuring that all necessary activities are carried out as scheduled and are producing the required outcomes. During the implementation stage, it is important to continuously monitor the progress of the CBR programme. Monitoring provides information for managers so that they can make decisions and changes to short-term planning to ensure that outcomes are met and that, eventually, the goal and purpose are achieved. Monitoring systems should have been planned in Stage 2 and indicators and sources of verification defined. During Stage 3, these monitoring systems should be put in place, so that information can be collected, recorded, analysed, reported and used for management of the CBR programme.

Steps involved

Note that the following steps are not necessarily listed in the order in which they are carried out.

Develop detailed workplans

The first part of the implementation stage is to take the programme plan and, with the help of the team and other stakeholders, develop more detailed workplans to show:

  • what specific tasks are required to complete each planned activity
  • when each task will need to be under- taken, with start and finish dates
  • who is responsible for helping to complete each task.

It is helpful to summarize all the information in a workplan in a tabular format. This provides a clear visual outline or illustration. A common format used is a Gantt chart (3).

Mobilize and manage resources

Financial resources

Fundraising: It is essential to seek financial resources for the development of new programmes or to enable existing programmes to continue their work. Finance for CBR programmes may be mobilized from many different sources. Where possible, the emphasis should be on community-based funding, as this will contribute to the longer-term sustainability of programmes. Possible sources of funding in the community may include:

  • local government grants or subsidies;
  • local business donations and corporate sponsorships;
  • civil society organizations, e.g. Rotary Club, Lions Club;
  • service fees or user charges for people with disabilities who have the necessary means;
  • raffles, social events, competitions and other special events;
  • income-generating activities;
  • microfinance or community-based revolving funds.

If sufficient resources are not available locally, fundraising may be required at regional, national or international levels to develop and implement CBR programmes.

Financial management: It is important to establish a transparent system for managing finances. This will ensure that the programme is accountable to stakeholders, including funding bodies, community members and people with disabilities themselves. Financial management is a key role of the programme manager, but others may be involved, particularly when programmes are large and involve large amounts of money. Financial management involves:

  • having a mechanism to check that costs are related to the activities which have been outlined during the planning stage or have been agreed with the programme manager;
  • maintaining financial records adequately;
  • updating financial figures for ready reference;
  • putting in systems for appropriate checks and balances;
  • informing all stakeholders on a regular basis about the financial status of the programme.
Human resources

Recruitment: When recruiting CBR programme managers and personnel, it is better to select them from the local community, if possible, as this will ensure they have good knowledge of the local culture and language and better access to community members. CBR programmes should also be strongly committed to recruiting people with disabilities or family members of disabled people, because this shows a commitment to the principles of CBR (see Introduction: CBR today) and contributes to their empowerment. In all cases, people should be recruited on the basis of their knowledge, skills and ability to perform the job. Job descriptions should be prepared before the recruitment process. These usually outline the roles and responsibilities of the job and the experience needed.

Some CBR programmes may also consider recruiting volunteers, particularly where resources are limited. Volunteers are not paid for their work; instead, they usually receive incentives and resources to help them do their jobs. There may be many people in the community who are willing to work voluntarily for CBR programmes, e.g. people with disabilities, family members, students, and professional people. It is important to consider both the advantages and disadvantages of recruiting volunteers. For example, while volunteers usually have good local knowledge and are cost-effective, they often have limited time, and volunteer turnover is high.

Training: CBR programme managers and personnel require a wide range of knowledge and skills to enable them to carry out their roles and responsibilities (see also Stage 1: Stakeholder analysis). The recent development of the CBR matrix (see Introduction: CBR today) and the CBR guidelines will result in new training needs. It may be necessary for CBR programmes to update and strengthen existing training programmes or develop new training initiatives.

Throughout the world, a wide range of CBR training programmes are available for both programme managers and personnel. They are all different in terms of their content and duration, and offered by a variety of providers. For example, in some countries tertiary institutions offer diploma courses for CBR personnel, whereas in other countries training programmes may not be accredited and may only last for a few weeks or months.

Training for CBR workers aims to improve their capacity to deliver high-quality services to people with disabilities and their family members. Training may cover a wide range of areas, including: disability rights, community development and inclusive practices, communication, basic rehabilitation skills (e.g. identification, basic screening and assessment and basic therapy activities), and group processes (e.g. setting up self-help groups).

When developing training courses for CBR personnel, it is important to consider carefully what content is appropriate. Quite often, training courses are based on courses designed for rehabilitation professionals, such as physiotherapists or occupational therapists. As a result, these courses are often inappropriate and unrealistic, as they focus on the development of high-level clinical and technical skills instead of the skills needed for community development.

Training for CBR programme managers aims to build up their capacity for effective and efficient management of programme activities. It is important that programme managers are familiar with the four stages of the management cycle, which are crucial to the success of programmes. Managers also require an understanding of disability and the CBR strategy.

BOX 9Solomon Islands

Professional education for providing better care

In 2010, the Solomon Islands College of Higher Education will offer a Diploma in Community Based Rehabilitation, which is based on the CBR strategy. It aims to equip graduates with skills and knowledge to implement CBR strategies at a provincial level. It is a two-year course, which covers the following areas.

  • Therapy outreach skills – learning about types of disability and basic hands-on skills in physiotherapy, occupational therapy and speech therapy.
  • Community rehabilitation skills – skills to work with the community, including helping the community to understand disability and provide equal opportunities for people with a disability.
  • Community development skills – skills to initiate community projects and groups that promote disability in the community.
  • CBR practice in skills and fieldwork – practising all that was learnt on real people in the community.

Following completion of the course, it is expected that graduates would have the appropriate skills and knowledge to work in the CBR Unit (Ministry of Health and Medical Services), as fieldworkers in the provinces or as therapy assistants attached to hospitals. Outside the health sector, the education system and nongovernmental organizations have also been identified as potential areas of work.

Staff development, support and supervision: Staff development (e.g. ongoing training) is important to enable CBR programme managers and personnel to renew their existing skills and develop new skills as necessary. Often, resources that are available in local communities can be utilized for ongoing training, e.g. existing training courses, training materials from other organizations and experts in relevant areas.

Some CBR programmes may not be successful because they fail to provide enough support and supervision for their staff. CBR personnel are the backbone of CBR programmes, and managers therefore need to ensure that they are listened to and supported in their roles. Providing support and supervision involves establishing clear supervision and reporting lines, making sure personnel are aware of their roles and responsibilities, and undertaking regular performance reviews. It is important that programme managers watch for “burnout”, which may occur when CBR personnel take on too much work, too intensively and for too long.

BOX 10Papua New Guinea

Enhancing credibility and status of CBR personnel

In Papua New Guinea, after short training courses, CBR personnel are able to screen children for clubfeet and adults for cataracts, and refer them for the necessary medical interventions. These interventions are very effective for people with these impairments and their families, while also enhancing the credibility and status of the CBR personnel in their communities.

Carry out planned activities

The programme manager should be very familiar with the workplans and be able to make the necessary preparations to ensure that all the activities are carried out as planned. A detailed description of CBR activities will not be provided here, as these are included in each of the separate components (see booklets 26) and the supplementary booklets (see booklet 7). The activities generally fall under the following main areas.

Awareness-raising

Awareness-raising activities used in CBR are directed at key stakeholders to provide information and knowledge about disability and thus generate attitudinal and behaviour change. They are also used to generate support for the CBR strategy and programmes and to encourage stakeholder involvement and participation.

Coordination and networking

Coordination and networking activities are needed to build good relationships and partnerships with CBR stakeholders. They are important activities for sharing knowledge and resources, reducing duplication and mobilizing community effort.

Mainstreaming

Mainstreaming activities ensure that people with disabilities can fully participate and be supported to do so within each development sector, i.e. within the health, education, livelihood and social sectors. Mainstreaming activities are accompanied by specific measures, e.g. reasonable accommodation to ensure access to equal opportunities.

Service provision

Each CBR programme will provide a different range of services, depending on the parts of the CBR matrix they choose to focus on. Many of the activities associated with service provision are implemented by CBR personnel. Activities may range from identification of people with disabilities and referrals to mainstream/specialized services to the provision of basic rehabilitation and provision of simple assistive devices.

Advocacy

Historically CBR programmes have overlooked advocacy and focused instead on service provision for people with disabilities. There are many different types of advocacy activities which can be used to ensure that equal opportunities and rights for people with disabilities are achieved in the health, education, livelihood and social sectors as well as in other aspects of community life.

Capacity-building

Building the capacity of key stakeholders will ensure that they have adequate knowledge and skills to carry out their roles and responsibilities (see also Stage 1: Stakeholder analysis). Training is one way to build the capacity of key stakeholders, and is mentioned as a suggested activity throughout the guidelines. Not all stakeholders require the same type or level of training; training should be based on their expected roles and responsibilities and the needs that arise from these. Some stakeholders may only require short workshops, seminars or briefing sessions to sensitize them to disability issues and orientate them to the CBR strategy. Others may require formal training programmes.

CBR programmes need to identify existing training programmes in the community to conserve and maximize their resources. Possible training resources may include government agencies, mainstream development organizations and nongovernmental organizations specializing in disability. Training others on how to deliver CBR training is also important, to ensure that a pool of people with a good knowledge of CBR and the skills to teach it to others is always available at the local level.

Monitoring

What is monitoring?

Monitoring keeps track of programme activities. It involves the regular collection and analysis of information throughout the implementation stage. It is an internal function of the programme (i.e. carried out by CBR programme managers and personnel), helping the team to identify which activities are going well and which are not, so that the necessary changes can be made. If good monitoring systems are in place and are effective, it will also make evaluation of the programme much easier (see Stage 4: Evaluation).

Steps involved in monitoring

Setting indicators: Indicators should have been set during Stage 2: planning and design.

Deciding how to collect information: Decisions on how to collect monitoring information (sources of verification) should also have been made in Stage 2.

Collecting and recording information: Formal systems should be in place to collect and record information. It is important that these systems are as simple as possible and only collect the information that is needed. All staff should receive training on how to follow and use these systems, e.g. staff will need to be trained on how to use data collection forms correctly. Informal systems may also be useful, e.g. CBR personnel could be asked to keep detailed notes about their activities in a notebook or diary. It is important to ensure that there is a regular schedule for information collection. Schedules may be daily, weekly, monthly and/or quarterly, depending on the reporting needs of the programme.

Analysing information: Collecting and recording information is often much easier than analysing it. However, if CBR programme managers do not look closely at the information, they will not be able to observe the progress of the programme activities and identify any potential problems. After analysing the information, it may be necessary to carry out further investigations to find out what is really going on.

Reporting and sharing information: Reporting and sharing the results of monitoring with key stakeholders shows that the programme is transparent and accountable. A monitoring report should include information on: the activity or work area being reported on, work planned for the period and work completed, progress towards the programme outcomes, budgeted versus actual expenditure, achievements, constraints/problems and action taken or recommended, and lessons learned. Reporting requirements will vary depending on the management structures in place for CBR programmes. For example, at the local level, CBR personnel may need to report to the programme manager on a weekly basis, programme managers may need to report to higher levels on a monthly basis, and so on.

Managing information: A lot of information will be generated from a CBR programme, e.g. documents, reports, correspondence and accounts. An efficient fling system is one way to manage information, and will save a great deal of time and misunderstanding during monitoring. If confidential information is being collected, it is also important to ensure that it is stored in a secure place.

Stage 4. Evaluation

Introduction

The final stage of the management cycle, evaluation, involves an assessment of the current or completed CBR programme. It helps determine whether the outcomes outlined in the programme plan (see Stage 2: Planning and design) have been met and how the situation on which they were based (see Stage 1: Situation analysis) has changed. Evaluation can lead to a decision to continue, change or stop a programme, and can also provide important evidence that CBR is a good strategy for equalization of opportunities, poverty reduction and social inclusion of people with disabilities.

Some CBR programme managers may be worried about carrying out an evaluation because they are afraid of exposing their faults and weaknesses. It is important to understand that no programme goes entirely smoothly, and even very successful programmes have problems along the way. Successful CBR programmes must reflect on the problems they experience, learn from them and use their learning for future planning.

Many people think that evaluation is difficult, because manuals often provide very complex descriptions of the different approaches and methods. As a result, many CBR programme staff may think that they need to be experts to carry out evaluation. However, with the right level of planning and preparation, simple evaluation procedures can produce a great deal of useful information.

Evaluation

What is evaluation?

Evaluation simply means assessment. The relevance, efficiency, effectiveness, impact and sustainability of the programme are the core factors that should be considered in an evaluation. By carrying out an evaluation, CBR programmes can learn from their experiences and use the lessons learned to improve current activities and promote better planning by careful selection of alternatives for future action.

Who does the evaluation?

Evaluations can be carried out internally by staff involved in the CBR programme (self- evaluation) or carried out externally by an independent outside individual or agency (external evaluation). There are advantages and disadvantages of each approach, and therefore approaches to evaluation will vary from programme to programme. Ideally, an evaluation is carried out using a combination of the two approaches.

When does evaluation take place?

Evaluation is different to monitoring because it is not carried out continuously. Evaluation only takes place at specific points in the project cycle – an evaluation may be carried out midway through the implementation of the programme, immediately after its completion, or some time afterwards (e.g. a couple of years).

Steps involved in evaluation

The way in which an evaluation of a CBR programme is carried out will depend on what is being assessed, who has asked for it and who will carry it out. Generally, it comprises the following steps.

Focus the evaluation

The first step involves deciding what the focus of the evaluation would be, i.e. deciding why the evaluation is being carried out (purpose) and making a decision about the questions you want the evaluation to answer.

It is not possible for one evaluation to assess all aspects of the programme. Therefore it is important to think carefully about the purpose of the evaluation. The purpose may be to:

  • assess whether CBR personnel are able to carry out their roles and responsibilities competently, to decide whether they require further training;
  • assess which activities worked best, to determine which aspects of the programme should be continued or discontinued;
  • assess whether the programme is having the planned impact, to decide whether to replicate the strategy elsewhere;
  • assess whether resources have been well spent, outcomes achieved and procedures followed, to help with decisions about the future of the programme.

When the purpose of the evaluation has been confirmed, it is then possible to develop questions that the evaluation needs to answer. These questions are not usually simple enough to be answered with a “yes” or “no”. Many different questions can be asked, relating to the relevance, efficiency, effectiveness, impact and sustainability of the programme (see Table 4: Components of an evaluation).

Table 4. Components of an evaluation.

Table 4

Components of an evaluation.

Collect information

The second step involves making a decision about the best way to answer the evaluation questions, thinking about the following issues.

  • Who can provide the information – stakeholders are very good sources of information. Information can be gathered from people with disabilities and their families, other community programmes, local government authorities (e.g. national statistics offices), among others. CBR personnel and other professionals can also be good sources of information, as they usually keep records of the activities and interventions they carry out along with the outcomes.
  • How information can be collected – there are many different ways to collect information, each with its own advantages and disadvantages. Usually more than one method is used to collect information for an evaluation (see Table 5: Data collection methods).
  • When information should be collected – information can be collected at different stages. Collecting information before a programme starts provides baseline data (see Stage 1: Situation analysis). Baseline data are important when measuring the impact of the CBR programme – if the situation before the programme began is not known, it would be difficult to evaluate whether the programme has had any impact. Information can also be collected when the programme is under way (see Stage 3: Monitoring) or at the end of a programme.
Table 5. Data collection methods.

Table 5

Data collection methods.

Analyse the information and draw conclusions

After collecting the information, you will need to make sense of it. Analysing the information can identify patterns, trends or unexpected findings and determine whether the information answers the evaluation questions, and if so, to what extent. Different types of information are analysed in different ways. For example, quantitative data from questionnaires, tests or records are usually analysed using statistical methods and programmes. Qualitative data from interviews and focus group discussions are usually analysed by structuring and organizing them according to key categories and themes. After analysing the information, it would be possible to draw conclusions and make recommendations about the programme.

Share findings and take action

An evaluation is useless if no one acts on its conclusions and recommendations. Therefore it is important to report on and share findings. There are many different ways to do this: for example, a formal evaluation report could be written, the results of the evaluation can be presented at a meeting of community members, an article could be written for the local newspaper, a case-study could be written for a newsletter that is circulated to other agencies, an article could be written for a journal, or a paper could be presented at a conference. After an evaluation, it is also important to reflect and learn from the things that worked and the things that did not, and what you are doing right and what you are doing wrong. The results of the evaluation should influence decision-making about various aspects of the programmes: which should continue, which need to be changed, which should stop, which successful practices could be scaled up and which other areas and priorities in the community need to be addressed.

References

1.
CBR: A strategy for rehabilitation, equalization of opportunities, poverty reduction and social inclusion of people with disabilities. International Labour Organization, United Nations Educational, Scientific and Cultural Organization, and World Health Organization; 2004. [30 March 2010]. (Joint Position Paper 2004) www​.who.int/disabilities​/publications/cbr/en/index.html.
2.
Convention on the Rights of Persons with Disabilities. New York: United Nations; 2006. [30 March 2010]. http://www​.un.org/disabilities/ [PubMed: 29885750]
3.
Blackman R. Project cycle management. Teddington: Tearfund; 2003. [5 May 2010]. http://tilz​.tearfund​.org/Publications/ROOTS​/Project+cycle+management.htm.
4.
Australian Agency for International Development. AusGuideline: 3.3: The logical framework approach. Canberra: Commonwealth of Australia; 2005. [5 May 2010]. http://www​.ausaid.gov​.au/ausguide/pdf/ausguideline3.3.pdf.

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