Community Health Course Two PDF

COMMUNITY BASED REHABILITATION Course 44 OBJECTIVES At end of this unit the learner should be able to:-  Define the term health, community and community health  Describe the origin of community health  Differentiate between health and well-being  Describe the determinants of health ...

COMMUNITY BASED REHABILITATION Course 44 OBJECTIVES At end of this unit the learner should be able to:-  Define the term health, community and community health  Describe the origin of community health  Differentiate between health and well-being  Describe the determinants of health DEFINITIONS  Health – The word health is derived from “hal” which means hale, sound, whole.  Health is a state of complete physical, mental and social-well being and not merely the absence of disease and infirmity. (WHO, 1947)  Health is described in terms of six interacting and dynamic dimensions- physical, emotional, social, intellectual, spiritual and occupational. HEALTH AND WELLNESS  Health is a dynamic state in which the person is constantly adapting to changes in the internal and external environments. For example, a person may see himself/herself as healthy while experiencing a respiratory infection.  Wellness is a life – style aimed at achieving physical, emotional, intellectual, spiritual and environmental well being. The use of wellness measures can increase stamina, energy and self – esteem, and then enhance quality of life. COMMUNITY DEFINITION  Community – has been thought of as geographical area with specified boundaries.  Community is a group of people who have common characteristics; communities can be defined by location, race, ethnicity, age, occupation, interest in particular problems or outcomes, or common bonds. COMMUNITY CONT’D Communities are characterized by the following elements:-  Membership –a sense of identity and belonging  Common symbol systems – similar language, rituals and ceremonies.  Shared values and norms.  Mutual influence – community members have influence and are influenced by each other.  Shared needs and commitment to meeting them  Shared emotional connection- members share common history, experiences and mutual support. COMMUNITY HEALTH DEFINITION  Community health – refers to the health status of a defined group of people and the actions and conditions, both private and public to promote, protect and preserve their health.  Public health – refers to the health status of a defined group people and the government actions and conditions to promote, protect and preserve their health. DETERMINANTS OF HEALTH OBJECTIVES  At end of this unit the learner should be able to:-  Describe the determinants of health in the community  Understand the factors affecting the health of the community. DETERMINANTS OF HEALTH Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. Factors such as where we live, the state of our environment, genetics, our income and education level and our relationships with friends and family have considerable impacts on health. Factors such as access and use of health care services often have less impact. DETERMINANTS OF HEALTH CONT’D The determinants of health include:  The social and economic environment  The physical environment  The person’s individual characteristics and behaviors. 1.PHYSICAL Factors such as –  Geographical,  Environment  Community size and  Industrial development have an impact to our health GEOGRAPHY Community health problems can be influenced by its altitude, latitude and climate. Example – in tropical countries where humid temperatures and rain prevail throughout the year, parasitic and infectious diseases are a leading community health problem. Inadequate food production and malnutrition- due to poor soil. Adequate food- obesity and heart disease. ENVIRONMENT  Quality of our environment is directly related to the quality of our stewardship over it. COMMUNITY SIZE The larger the community, the greater its range of health problems and greater its number of health problems. Community size can impact both positively and negatively on community’s health. Ability of a community to effectively plan organize and utilize its resources can be determine whether its size can be used to good advantage. INDUSTRIAL DEVELOPMENT  Industrial development provide a community with added resources for community health programs, but it may bring environmental pollution and occupational illnesses.  It can have both negative and positive effects on the health status of a community. 2.SOCIAL AND CULTURAL FACTORS  It arise from the interaction of individuals or groups within the community.  For example- people in urban setup may experience higher rates of stress-related illnesses than those in rural areas. Likewise people in rural areas may not have same quality or selection of health care. SOCIAL AND CULTURAL  Cultural factors arise from the guidelines that individual inherit from a society. Culture teaches what to fear, what to respect, what to value and what to regard as relevant in our lives. Some factors that contribute to social and culture are discussed below.  Beliefs, Traditions and Prejudices- They can affect the health of the community  Beliefs about a specific health behavior such as exercise and smoking can influence policy makers on whether or not they will spend money on bike trails and no-smoking ordinances. 2.SOCIAL AND CULTURAL FACTORS CONT’D  Traditions – can influence the types of food and services in the community  Prejudices of one specific ethnic or racial group against another can result in acts of violence and crime. ECONOMY  Both national and local economy can affect the health of a community through reductions in health and social services.  Unemployed and underemployed face poverty and deteriorating health due to their economic status. POLITICS  Political will can improve or jeopardize the health of their community by the decisions they make. RELIGION  A number of religion have taken position on health care.  For example some religious communities limit the type of medical treatment their members may receive.  Religion can affect community’s health positively and negatively 3. COMMUNITY ORGANIZING  The way in which the community is able to organize its resources directly influences its ability to intervene and solve problems.  Community organizing is a process through which communities are helped to identify common problems or goals, mobilize resources and develop and implement strategies for reaching their goals collectively 4. INDIVIDUAL BEHAVIOUR  The behavior of the individual community members contributes to the health of the entire community.  For example if each occupant should wear a safety belt there could be a significant reduction in the number of facial injuries and death from car crashes. HEALTH MODELS  Clinical Model (Dunn, 1961)- In this model, health is interpreted as the absence of signs and symptoms of disease or injury; thus the opposite of health is disease.  Host –Agent – Environment Model (Leavell, 1965)- This model helps to identify the cause of an illness.  Health Belief Model (HBM) (Rosenstock, 1974, as Modified by Stone 1991)-There is a relationship between a person’s belief and actions. DELIVERY HEALTH CARE SYSTEM OBJECTIVES At end of this unit the learner should be able to:-  Define delivery health care system  Explain the levels of health care delivery system  Explain the classification of health care delivery system  Explain levels of prevention  Explain factors affecting health care delivery system  Describe models of health care DEFINITION  Is often used to describe the way in which health care is provided to the people.  Classification of health care delivery system is by perception of the client’s illnesses and level of specialization of the professionals. LEVELS OF HEALTH CARE DELIVERY  Primary care level -It is oriented towards the promotion and maintenance of health, the prevention of disease, the management of common episodic disease and the monitoring of stable or chronic conditions.  Secondary care level -It involves the provision of specialized medical services by physician or a hospital on a referral by the primary care provider.  Tertiary care level- It is a level of care that is specialized and highly technical in diagnosing and treating complicated or unusually health problems. CLASSIFICATION OF HEALTH CARE DELIVERY  Preventive: Is aimed at stopping the disease process before it starts or preventing further deterioration of a condition that already exists.  Curative: Is aimed at restoring the client's health.  Rehabilitative: Is aimed at lessening the pain and discomfort of illness and helping clients live with disease and disability. LEVELS OF PREVENTION  Primary prevention: refers to the prevention of an illness before it has a chance to occur.  Secondary prevention: includes the early detection of actual or potential health hazards.  Tertiary Prevention: is aimed at avoiding further deterioration of an already existing problem. SIX LIFE- CYCLE COHORTS AND SIX SERVICE DELIVERY LEVELS.  Pregnancy, delivery and  Level 6: Tertiary hospitals the newborn child (up to 2  Level 5: Secondary weeks of age) hospitals  Early childhood (2 weeks  Level 4: Primary hospitals to 5 years)  Level 3: Health Centers,  Late childhood (6 to 12 Maternities, Nursing years) Homes  Adolescence (13 to 24  Level 2: Dispensaries years)  Level 1: Community:  Adulthood (25 to 59 years) Villages/Households/Famil  Elderly (60 years and over) ies/Individual FACTORS AFFECTING HEALTH CARE DELIVERY  Health care as a right  Technological advances  Rising Consumerisms  Changing Health Services COMMUNITY STRATEGY COMMUNITY STRATEGY  The overall goal of the community strategy is to enhance community access to health care in order to improve productivity and thus reduce poverty, hunger and child and maternal deaths as well as improve education performance  This strategy document sets out the approach to be taken to ensure that Kenyan communities have the capacity and motivation to take up their essential role in health care delivery. Two categories of personnel promoting health at the community level. These are:  Community health workers (CHWs), who work on a volunteer basis  Community health extension workers (CHEWs), who are MOH employees. ROLE OF COMMUNITY HEALTH WORKER  Teaching the community how to improve health and prevent illness  Treating common ailments and minor injuries.  Referring cases to the nearest health facilities.  Promoting care seeking and compliance with treatment and advice  Visiting homes.  Promoting appropriate home care for the sick.  Participating in monthly community unit health dialogue and action day organized by CHEWs and CHCs. ROLE OF CHEW  Overseeing the selection of CHWs.  Organizing and facilitating CHW training.  Monitoring the management of the CHWs’ kit.  Supporting the CHWs in assigned tasks and coaching.  Compiling reports from CHWs and forwarding to level 2 and 3 management committees.  Receiving feedback from level 2 and 3facilities.  Following up and monitoring actions. PRIMARY HEALTH CARE (PHC) OBJECTIVES At end of this unit the learner should be able to:-  Define the term primary health care  Understand the historical background of PHC  Explain the elements of PHC  Explain the pillars of PHC  Explain the principles of PHC  Describe the challenges of PHC PRIMARY HEALTH CARE PHC is:  Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that community and the country can afford to maintain at every stage of their development in spirit of self-reliance and self determination(Alma-Ata, 1978) HISTORICAL BACKGROUND  PHC emerged from a realization of the failure of the dominant medical model to meet the major health needs of many countries and populations.  It attempts to move beyond the limitations imposed by a narrow bio-medical framework, including the idea of context into the picture of disease and health.  It emphasizes the notion that technical solutions and in particular on pharmaceuticals and clinical interventions will not be adequate in improving health without creation of healthy environments. HISTORICAL BACKGROUND  Put more emphasis on prevention of disease. This represents an acknowledgement of the need to manipulate the context of people’s lives either to foster health or curtail illness.  To promote conditions which foster health which is not merely the absence of disease but the total physical, psychological and social well-being of individuals and communities. HISTORICAL BACKGROUND  Is an expression of a global search for rational and humane health systems; since it calls for the human to be at the center of health systems thinking and action, as human, not just as recipient of medicine (Navarro 1986). Navarro says: improve the living condition of people and their health will improve.  The call for equity is a call for social change, for justice, rejection of situations where people are not allowed the basic means of dignified life ELEMENTS OF PHC  Education concerning prevailing health problems and the methods of preventing an controlling them  Promotion of food supply and proper nutrition  An adequate supply of safe water and basic sanitation  Maternal and child health care including FP  Immunization against major infectious diseases  Prevention and control local endemic diseases  Appropriate treatment of common diseases  Provision of essential drugs PILLARS OF PHC  Active Community Participation of populations in decision making about health moving towards a model of interaction between people and professionals which challenges the notion of the patient and community as passive recipients.  Appropriate technology- Is one which is scientifically sound, adapted to local needs, acceptable to those who apply it and to those on whom it is applied and which can be maintained by the people, as a part of self reliance and within the resources which can be afforded by the community and the nation. PILLARS OF PHC  Intra and Inter- sectoral Linkages: PHC involves in addition to the health sector all related sectors and aspects of national and community development in particular agriculture, animal husbandry, food, industry, education, housing, public works, communication and other sectors. PRINCIPLES OF PHC  Equitable distribution- Health services must be shared equally by all people irrespective of their ability to pay and all (rich or poor urban or rural) must have access to health services.  Inter-sectoral coordination -PHC involves in addition to the health sector all related sectors  Decentralization Away from the national or central level bringing decision making closer to the communities served PRINCIPLES OF PHC  Appropriate technology - The technology should be scientifically sound, adaptable to those who apply it and for those for whom it is used and can be maintained by the people themselves in keeping  Team approach -The team is a group of persons with different levels of knowledge, background abilities qualification and skills who share a common goal.  Community participation-There must be a continuing effort to secure meaningful involvement of the community in the planning, implementation and maintenance of health STRATEGIES OF PHC  Reducing excess mortality of poor marginalized populations  Reducing the leading risk factors to human health  Developing Sustainable Health Systems  Developing an enabling policy and institutional environment THE BASIC REQUIREMENTS FOR SOUND PHC (THE 8 A’S AND THE 3 C’S)  Appropriateness  Assessability  Availability  Accountability  Adequacy  Completeness  Accessibility  Comprehensiveness  Acceptability  Continuity  Affordability MILLENNIUM DEVELOPMENT GOALS INTRODUCTION  The Millennium Development Goals (MDGs) were a pledge to uphold the principles of human dignity, equality and equity, and free the world from extreme poverty.  The MDGs, with eight goals and a set of measurable time-bound targets, established a blueprint for tackling the most pressing development challenges of our time. MDGS 1. Eradicate extreme poverty and hunger a. Halve the proportion living on less than $1 a day b. Halve the proportion suffering from hunger 2. Achieve universal primary education a. Ensure universal primary education 3. Promote gender equality and empower women  a. Eliminate gender disparities in education. 4. Reduce child mortality a. Reduce infant and under-five mortality by 2/3 5. Improve maternal health a. Reduce maternal mortality by ¾ 6. Combat HIV/AIDS, malaria and other diseases a. Halt and begin to reverse the spread of HIV/AIDS b. Halt and begin to reverse the spread of malaria and other major diseases 7. Ensure environmental sustainability a. Integrate the principles of sustainable development and begin to reverse the loss of environmental resources b. Halve the proportion without access to safe drinking water c. Improve the lives of at least 100million slum dwellers (by 2020) 8. Develop a global partnership for development a. Develop further an open, rule based predictable, non-discriminatory trading and financial system b. Include the commitment to good governance, development and poverty reduction both nationally and internationally VISION 2030 OBJECTIVES At end of this unit the learner should be able to:-  Understand the pillars of vision 2030. VISION 2030  The Kenya vision 2030 is the country’s long-term development blueprint which aims to create a globally competitive and prosperous country providing a high quality of life for all citizens. It aspires to transform Kenya into a newly industrializing middle income country by 2030.  The vision 2030 is a long term national policy framework to be implemented through 5 year medium term plans.  The Vision is based on three “pillars” THREE PILLARS  Economic pillar aims at providing prosperity of all Kenyans through an economic development programme aimed at achieving an average gross Domestic Product (GDP) growth rate of 10% per annum the next 25 years.  Social pillar seeks to build a just and cohesive society equity in a clean and secure enviroment.  Political pillar aims at realising a democratic political system founded on issue based politics that respects the rule of law and protects the rights and freedoms of every individual in the kenyan society. PILLARS OF VISION 2030 o Economic pillar – To maintain a 10% economic growth rate annually o Social pillar – To build a just and cohesive society that enjoys equitable social development in a clean and secure environment o Political pillar – To strengthen rule of law and ensure good governance in the country. HEALTH EDUCATION OBJECTIVES At end of this unit the learner should be able to:-  Define the term health education  Explain the strategies of health education  Describe methods of approach used in health education. DEFINITION  Is a process of “empowering” individuals, families and communities; that is, it gives them the knowledge and insights to understand how their behavior affects their health and the incentive to promote the conditions that maintain good health.  The practice of instructing people and communities in the principles of hygiene and in ways of avoiding disease is a very ancient one.  An elementary study of the history of medicine reveals that since time immemorial it has been considered a necessity to instruct communities in health matters for their protection and survival. DEFINITION  Health Education is a process which informs, motivate and help people to adopt and maintain healthy practices and lifestyle, advocates environmental changes as needed to facilitate this goal and conducts professional training and research to the same end.(National Conference on Preventive Medicine, USA)  Health Education like general education is concerned with changes in knowledge, feelings and behavior of people. In its most usual forms, it concentrates on developing such health practices as are believed to bring about the best possible state of well-being. IMPORTANCE OF HEALTH EDUCATION  Health education improves the health status of individuals, families, communities, states, and the nation.  Health education enhances the quality of life for all people.  Health education reduces premature deaths.  By focusing on prevention, health education reduces the costs (both financial and human) TARGETS OF HEALTH EDUCATION  Individual  Groups  Health workers STRATEGIES FOR HEALTH EDUCATION  Analysis of the problem  Diagnosis of the problem  Planning the programme  Implementation of the programme  Evaluation of the programme ROLE OF HEALTH EDUCATOR  Assess individual and community needs  Plan Health Education Strategies, Interventions, and Programs  Implement Health Education Strategies, Interventions, and Programs  Conduct Evaluation and Research Related to Health Education  Administer Health Education Strategies, Interventions, and Programs  Serve as a Health Education Resource Person  Communicate and Advocate for Health and Health Education STRATEGIES FOR HEALTH EDUCATION  Analysis of the problem  Diagnosis of the problem  Planning the programme  Implementation of the programme  Evaluation of the programme METHODS OF APPROACHES IN HEALTH EDUCATION  Legal or regulatory approach  Administrative or service approach  Education approach LEGAL OR REGULATORY APPROACH  Makes use of the law to protect the health of the public Limitation  Applicable only at certain times or limited situations  They may not alter behaviour of the individual ADMINISTRATIVE OR SERVICE APPROACH  Intends to provide all the health facilities needed by the people.  Felt needs of people. EDUCATIONAL APPROACH Most effective Components  Motivation  Communication  Decision making  Results are slow but permanent and enduring  Sufficient time for an individual to bring about changes.  Learning new facts as well as unlearning wrong information as well ENVIRONMENTAL HEALTH OBJECTIVES At end of this unit the learner should be able to:-  Define what is environmental health  Describe factors that contribute to environment pollution.  Describe the components of environmental health DEFINITION OF ENVIRONMENT HEALTH  Environment health is defined as “ the discipline that focuses on the health interrelationships between people and their environment, promotes human health and well- being and fosters a safe and healthful environment.  Environment – is all that which is external conditions circumstances and influences surrounding and affecting the growth and development of an organism or community of organisms.  Environmental Hazards – may be biological, chemical, physical, psychological, sociological or site and location hazards. DEFINITION  Environmental Health comprises those aspects of human health, including quality of life, that are determined by physical, biological, social and psychosocial factors in the environment.  It also, refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the environment that can potentially affect adversely the health of present and future generations’ INTRODUCTION  Environmental is a component of the public health system and is committed to protecting the health of the public and enhancing quality of life by assessing, correcting, controlling and preventing those factors in the environment that can adversely affect human health.  Is a branch of public health that is concerned with all aspects of natural and built environment that may affect human health. Other terms referring to or concerning environmental health are environmental public health, and public health protection/ environmental health protection. INTRO CONT'  Environmental health and environmental protection are very much related.  Environmental health is focused on the natural and built environments for the benefit of human health, whereas environmental protection is concerned with protecting the natural environment for the benefit of human health and the ecosystems.  Environmental health addresses all human – health- related aspects of all the natural environment and the built environments. INTRO CONT'  Environmental health concerns include:  Air quality, including both ambient outdoor air and indoor air quality, which also comprises concerns about environmental tobacco smoke  Climate change and its effects on health.  Disaster preparedness and response.  Food safety, including agriculture, transportation, food processing.  The prevention of injury, disease and death that may result from interactions of people with their environment is the goal of environmental health program. CONTRIBUTORS TO THE “ENVIRONMENT”  Chemical −Air pollutants, toxic wastes, pesticides, VOCs  Biologic −Disease organisms present in food and water −Insect and animal allergens  Physical −Noise, ionizing and non-ionizing radiation  Socioeconomic −Access to safe and sufficient health care COMPONENTS OF ENVIRONMENTAL HEALTH  Environmental epidemiology - Associations between exposure to environmental agents and subsequent development of disease  Environmental toxicology−Causal mechanisms between exposure and subsequent development of disease  Environmental engineering−Factors that govern and reduce exposure  Preventive medicine−Factors that govern and reduce disease development  Law−Development of appropriate legislation to protect public health EPIDEMIOLOGY OBJECTIVES At end of this unit the learner should be able to:-  Define the term epidemiology.  Explain the objectives of epidemiology.  Describe the dynamics of disease transmission.  Describe the measures of morbidity  Describe the measures of mortality DEFINITION  The term epidemiology is derived from Greek words that can be translated into the phrase “the study of what, which is upon the people”.  Is the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems.”  The goal of epidemiology is to limit disease, injury and death in a community by intervening to prevent or limit outbreaks or epidemics of disease and injury. DEFINITION  Distribution – is concerned with the frequency and pattern of health events in a population.  Frequency – includes the number, rate and risk of disease in the population.  Pattern – refers to the occurrence of health – related events by time, place and personal characteristics.  Determinants – is concerned with the causes and other factors that influence the occurrence of health- related events.  Health – related states or events – chronic diseases, injuries, birth defects, maternal child health, occupational health, and environmental health. DEFINITION  Specified populations –The epidemiologist focuses on the exposure (action or source that caused the illness), the number of other persons who may have been similarly exposed, the potential for further spread in the community, and interventions to prevent additional cases or recurrences.  Application – epidemiology is more than “ the study of. It provides data for directing public health action. ASPECTS OF EPIDEMIOLOGY  Descriptive epidemiology- it provides the what, who, when and where of health-related events.  Descriptive data provide valuable information to enable health care providers and administrators to allocate resources efficiently and to plan effective prevention or education programs.  Analytic epidemiology-it provides the why and how of such events by comparing groups with different rates of disease occurrence and with differences in demographic characteristics, genetic or immunologic make-up, behaviors environmental exposures, and other so-called potential risk factors. OBJECTIVES OF EPIDEMIOLOGY  To identify the etiology or the cause of a disease and risk factors- that is, factors that increase a parson’s risk for a disease.  To determine the extent of disease found in the community.  To study the natural history and prognosis of disease.  To evaluate both existing and new preventive and therapeutic measures and modes of health care delivery  To provide the foundation for developing public policy and making regulatory decisions relating to environmental problems DYNAMICS OF DISEASE TRANSMISSION  Modes of transmission  Clinical and Subclinical Disease  Carrier status  Endemic, Epidemic and pandemic  Disease outbreaks  Herd immunity  Incubation period MODES OF TRANSMISSION  Disease can be transmitted directly or indirectly.  Disease can be transmitted person to person (direct transmission) by means of direct contact.  Indirect transmission can occur through a common vehicle such as a contaminated air or water supply, or by a vector such as mosquito. CLINICAL AND SUBCLINICAL DISEASE  Clinical disease is characterized by signs and symptoms.  Nonclinical (Inapparent) disease may include the following:  Preclinical Disease. Disease that is not yet clinically apparent, but is destined to progress to clinical disease.  subclinical – disease that is not clinically apparent and is not destined to become clinically apparent. This type of disease is often diagnosed by serologic (antibody) response or culture of the organism. CLINICAL AND SUBCLINICAL DISEA  Persistent (chronic) disease. A person fails to shake off the infection and it persists for years at times for life.  Latent disease. An infection with no active multiplication of the agent, as when viral nucleic acid is incorporated into the nucleus of a cell as a provirus. CARRIER STATUS  In this situation the individual harbours the organism but is not infected as measured by serologic studies (no evidence of an antibody response) or evidence of clinical illness.  This person may infect others although the infectivity is often lower than with other infections.  Carrier status may be of limited duration or may be chronic, lasting for months or years. ENDEMIC, EPIDEMIC AND PANDEMIC  Endemic is defined as the habitual presence of a disease within a given geographic area.  It may also refer to the usual occurrence of a given disease within such an area.  Epidemic is defined as the occurrence in a community or region of a group of illnesses of similar nature, clearly in excess of normal expectancy, and derived from a common or from a propagated source.  Pandemic refers to a worldwide epidemic. DISEASE OUTBREAKS  A disease outbreak is the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season.  An outbreak may occur in a restricted geographical area, or may extend over several countries. It may last for a few days or weeks, or for several years. HERD IMMUNITY  Herd immunity may be defined as the resistance of a group to an attack by a disease to which a large proportion of the members of the group are immune.  Once a certain proportion of people in the community are immune the likelihood is small that an infected person will encounter a susceptible person to whom he can transmit the infection; more of his encounters will be with people who are immune. INCUBATION PERIOD  Incubation period is defined as the interval from receipt of infection to the time of onset of clinical illness.  If you become infected today, the disease with which you are infected may not develop for a number of days or weeks.  During this time, the incubation period, you feel completely well and show no signs of the disease. MEASURING THE OCCURRENCE OF DISEASE – MORBIDITY  The occurrence of disease can be measured using rates or proportions.  Rates tell us how fast the disease is occurring in a population.  Proportions tell us what fraction of the population is affected.  Measures of morbidity  Incidence  Prevalence  Surveillance  Quality of life MEASURES OF MORBIDITY Prevalence  Measures of prevalence describe what proportion of the population has the disease in question at one specific point in time.  Prevalence is the total number of affected persons present in the population at a specific time divided by the number of persons in the population at that time.  Prevalence per 1000=No. of cases of a disease present in population at a specified time MEASURES OF MORBIDITY Incidence  Measures of incidence describe the frequency of occurrence of new cases during a time period.  Incidence is the number of new cases of a disease that occur during a specified period of time in a population at risk for developing the disease. MEASURES OF MORBIDITY Surveillance  Is a fundamental role of public health.  Is an ongoing systematic collection, analysis and interpretation of health data essential to the planning, implementation and evaluation of public health practice.  Is carried out to monitor changes of disease frequency or monitor changes in prevalence of risk factors.  Is also used to monitor for completeness of vaccination coverage and protection of a population MEASURES OF MORBIDITY Quality of life  Disease that may not be lethal may be associated with considerable suffering and disability.  It is also important to consider the impact of a disease as measured by its effect on a person’s quality of life.  It also establishes priorities for scarce health care resources. MEASURING THE OCCURRENCE OF DISEASE – MORTALITY  Mortality rates can serve as measures of disease severity and can help us to determine whether the treatment for a disease has become more effective over time.  Measures of Mortality  Mortality Rates  Case-Fatality Rates  Proportionate Mortality  Years of Potential Life Lost MEASURES OF MORTALITY  Mortality rate, or death rate, is a measure of the number of deaths (in general, or due to a specific cause) in a particular population, scaled to the size of that population, per unit of time.  The mortality rate is calculated by taking all the deaths that occurred during a particular time period and dividing that number by the total size of the population during the same time frame. The resulting decimal is then multiplied by 1,000 or 100,000 to give a whole number. MEASURES OF MORTALITY  Case fatality rate (CFR) —is the proportion of deaths within a designated population of "cases" (people with a medical condition), over the course of the disease.  The reported case fatality rate (CFR) is a measure of the severity of a disease and is defined as the proportion of reported cases of a specified disease or condition which are fatal within a specified time. MEASURES OF MORTALITY  Proportional mortality ratio (PMR) -- Number of deaths within a population due to a specific disease or cause divided by the total number of deaths in the population during a time period such as a year.  Years of potential life lost (YPLL) or potential years of life lost (PYLL), is an estimate of the average years a person would have lived if he or she had not died prematurely. It is, therefore, a measure of premature mortality. DISABILITY OBJECTIVES  Understand the evolution of disability.  Explain conceptual models of disability  Define the term disability  Explain the global trends of disability  Explain the relationship of disability and poverty  Understand the rights of people with disability EVOLUTION OF DISABILITY  Historically disability was largely understood in mythological or religious terms :-  People with disabilities were considered to be possessed by devils or spirits  It was often seen as a punishment for past wrongdoing.  Development of science and medicine in 19th and 20th centuries has help to create an understanding that disability has biological or medical basis CONCEPTUAL MODELS OF DISABILITY  Traditional model – this model viewed people with physical, sensory or mental impairment as people under spell of witchcraft, possessed by demons, or sinners being punished by God.  Medical model- have two perspectives  Impairment perspective – considers disability as an intrinsic problem of the person, directly caused by disease, trauma or other health condition which requires medical care.  Functional limitations perspective- the difficulties people with disabilities experience in getting around are considered as barriers that limit their chance in life. CONCEPTUAL MODELS OF DISABILITY  The functional limitation perspective expands the impairment perspective to include non medical criteria but still focuses on the inability of people with disabilities to adapt to society and measures people’s limitations against a standard of normality.  Social model – is longer seen as an individual problem but also consider the society’s failure to take into account people with disabilities.  It focuses on the strengths of the person (and not on her limitations as in the medical model) and values her potential. CONCEPTUAL MODELS OF DISABILITY  Social model is based on two perspective  Environmental perspective- sees disability as resulting from the physical and attitudinal barriers that affect the person’s participation and create the disabling situation.  The rights approach – considers that people with disabilities have the rights to enjoy health and well being and to participate fully in education, social, cultural, religious, economic and political activities as any other citizen within the community. DEFINITION OF DISABILITY  Convention on the Rights of Persons with Disabilities, states that disability is an evolving concept and “results from the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others”.  International Classification of Functioning, Disability and Health (ICF), states that disability is an “umbrella term for impairments, activity limitations or participation restrictions” which result from the interaction between the person with a health condition and environmental factors. GLOBAL TRENDS  Most common causes of disability include: chronic diseases, injuries, mental health problems, birth defects, malnutrition, HIV/AIDS and other communicable diseases  It is difficult to estimate the exact number of PWD throughout the world  The number is increasing due to population growth, increase in chronic health conditions, the aging of the population and medical advances that preserve and prolong life. POVERTY AND DISABILITY  Poverty as many aspects it is more than just lack of money or income.  Poverty erodes or nullifies economic and social rights such as the right to health, adequate housing, food and safe water and right to education.  Poverty is both a cause and consequence of disability  Addressing disability is concrete step to reducing the risk of poverty at the same time addressing poverty reduces disability in any country. HUMAN RIGHTS  Are internationally agreed standards which apply to all human being everybody is equally entitled to their human rights  These rights are affirmed in the declaration of human Rights adopted by all member states of United nations in 1948 CONVENTION ON THE RIGHTS OF PERSONS WITH DISABILITIES  December 2006 the UN General Assembly adopted the Convention on the Rights of Persons with Disabilities (CRPD).  It is build upon the UN Standard Rules on the Equalization of Opportunities for Persons with disabilities and the World Programme of Action Concerning Disabled Persons  Is to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities COMMUNITY BASED REHABILITATION OBJECTIVES At the end of the lesson the learner should be able to:-  Describe the history of CBR  Explain what the term CBR means  Explain the evolution of CBR matrix  Describe the components of CBR matrix  Explain the principles of CBR INTRODUCTION  Community-based rehabilitation (CBR) was initiated by the World Health Organization (WHO), following the Declaration of Alma-Ata in 1978.  It was promoted as a strategy to improve access to rehabilitation services for people with disabilities in low-income and middle-income countries, by making optimum use of local resources. DEFINITION  CBR is a strategy for rehabilitation, equalization of opportunities, poverty reduction and social inclusion of people with disabilities. CBR MATRIX  In light of the evolution of CBR into a broader multisectoral development strategy a matrix was developed in 2004 to provide a common framework for CBR programmes.  The matrix consists of five key components – the health, education, livelihood, social and empowerment.  Matrix has been designed to allow programmes to select options which best meet their local needs, priorities and resources. HEALTH  Health is a state of complete physical, mental and social well-being and not merely the presence of disease or infirmity.  Health is a valuable resource that enables people to lead individually, socially and economically productive lives, providing them with the freedom to work, learn and engage actively in family and community life. HEALTH COMPONENT  Goal – people with disabilities achieve their highest attainable standard of health.  The role of CBR – is to work closely with the health sector to ensure that the needs of people with disabilities and their family members are addressed in the areas of health promotion, prevention, medical care, rehabilitation and assistive devices.  Also need to work with individuals and their families to facilitate their access to health services and work with other sectors to ensure that all aspects of health are addressed. ELEMENTS OF HEALTH COMPONENT  Health promotion  Prevention  Medical care  Rehabilitation  Assistive devices ELEMENTS OF HEALTH PROMOTION  Health promotion aims to increase control over health and its determinants. The wide range of strategies and interventions available are directed at strengthening the skills of individuals and changing social, economic and environmental conditions to alleviate their impacts on health.  Prevention is very closely linked with health promotion. Prevention of health conditions (e.g. diseases, disorders, injuries) involves primary prevention (avoidance), secondary prevention (early detection and early treatment) and tertiary prevention (rehabilitation) measures. The focus of this element is mainly on primary prevention. ELEMENTS OF HEALTH PROMOTION  Medical care refers to the early identification, assessment and treatment of health conditions and their resulting impairments, with the aim of curing or limiting their impacts on individuals.  Rehabilitation is a set of measures which enables people with disabilities to achieve and maintain optimal functioning in their environments.  Assistive devices are devices that has been designed, made or adapted to assist a person to perform a particular task EDUCATION COMPONENTS  Education is about all people being able to learn what they need and want throughout their lives, according to their potential. It includes “learning to know, to do, to live together and to be” (1). Education takes place in the family, the community, schools and institutions, and in society as a whole.  Education is much broader than schooling. Schooling is seen as the context of a lifelong learning process. Education starts at birth in the home, and continues throughout adult life; it includes formal, informal, non-formal, home- based community and government initiatives. EDUCATION  Goal- People with disabilities access education and lifelong learning, leading to fulfillment of potential, a sense of dignity and self-worth, and effective participation in society.  The role of CBR- is to work with the education sector to help make education inclusive at all levels, and to facilitate access to education and lifelong learning for people with disabilities. ELEMENTS OF EDUCATION  Early childhood care and education  Primary education  Secondary education and higher learning  Non-formal education  Lifelong learning ELEMENTS OF EDUCATION  Early childhood care and education -This term refers to education from birth until the start of formal primary education. It takes place in formal, non-formal and informal settings, and focuses on child survival, development and learning – including health, nutrition and hygiene.  Primary education- This is the first stage of schooling, intended to be free and compulsory for all children. It is the focus of the Education for All initiative proposed by UNESCO (11), and the target of most educational funding. ELEMENTS OF EDUCATION  Secondary and higher education- This is formal education beyond the “compulsory” level. For young people with disabilities, further education can be a gateway to a productive and fulfilled life, yet they are often excluded.  Non-formal education- This includes a wide range of educational initiatives in the community: home-based learning, government schemes and community initiatives. It tends to be targeted at specific disadvantaged groups and has specific objectives. ELEMENTS OF EDUCATION  Lifelong learning- This includes all the learning that takes place throughout life, in particular those learning opportunities for adults not covered in the other elements.  It refers to the knowledge and skills needed for employment, adult literacy, and all types of learning that promotes personal development and participation in society.  In this element, the focus is on adults, rather than children. LIVELIHOOD COMPONENT  Livelihood is part of CBR because “It is essential to ensure that both youth and adults with disabilities have access to training and work opportunities at community level”  Work is an important life activity. It contributes to maintaining the individual, the family and the household by providing services and/or goods for the family, the community and society at large.  Most importantly work provides opportunities for social and economic participation, which enhances personal fulfilment and a sense of self- worth. LIVELIHOOD  Goal - People with disabilities gain a livelihood, have access to social protection measures and are able to earn enough income to lead dignified lives and contribute economically to their families and communities.  Role of CBR - is to facilitate access for people with disabilities and their families to acquiring skills, livelihood opportunities, enhanced participation in community life and self- fulfillment. ELEMENTS OF LIVELIHOOD  Skills development  Self-employment  Wage employment  Financial services  Social protection ELEMENTS OF LIVELIHOOD  Skills development - Skills are essential for work. There are four main types of skills: foundation skills, technical and professional skills, business management skills and core life skills. These skills can be acquired through traditional home- based activities and education, in mainstream vocational training centres and as an apprentice with members of the community.  Self-employment- provides the main opportunity for people with disabilities in low income countries to earn a livelihood. ELEMENTS OF LIVELIHOOD  Wage employment means any salaried or paid job under contract (written or not) to another person, organization or enterprise. It is more likely to be in the formal economy, but may also be in the informal economy.  Financial services - People with disabilities have the same needs for financial services as people without disabilities, both to start and to develop businesses and to manage their lives generally.  Microcredit refers specifically to loans and the credit needs of clients, while microfinance covers a broader range of financial services, e.g. savings, insurance, housing loans. ELEMENTS OF LIVELIHOOD  Social protection- measures are intended to provide a safety net to protect people against extreme poverty and loss or lack of income through illness, disability or old age. People with disabilities have an equal right to the social protection measures available to citizens generally.  Social protection measures include official provision by the government and large organizations and informal measures at the community level. SOCIAL  Being actively included in the social life of one’s family and community is important for personal development. The opportunity to participate in social activities has a strong impact on a person’s identity, self-esteem, quality of life, and ultimately his/her social status.  The social roles people hold are influenced by factors such as age, gender, culture and disability.  Social roles change throughout their lifespan, and many communities mark these transitions with important rituals and practices SOCIAL  Goal- People with disabilities have meaningful social roles and responsibilities in their families and communities, and are treated as equal members of society.  The role of CBR- Is to work with all relevant stakeholders to ensure the full participation of people with disabilities in the social life of their families and communities.  CBR programmes can provide support and assistance to PWDs to enable them to access social opportunities and positive social change. ELEMENTS OF SOCIAL  Personal assistance  Relationships, marriage and family  Culture and arts  Recreation. Leisure and sports  Justice ELEMENTS OF SOCIAL  Personal assistance- Some people with disabilities require personal assistance to enable them to participate in family and community life. In low-income countries where there are limited social services and benefits, families are often the main or only means of this support.  Relationships, marriage and family- Relationships are as important for people with disabilities as for everyone else. This element looks at the ways in which CBR programmes can support people with disabilities to enjoy a variety of social roles and responsibilities associated with relationships. ELEMENTS OF SOCIAL  Culture and arts-Participation in cultural and arts activities is important for personal growth and development. It helps to establish personal identity, and to provide a sense of belonging as well as opportunities for people with disabilities to contribute.  This element identifies and addresses barriers that exclude people with disabilities from participating in the cultural and artistic life of their families and communities.. ELEMENTS OF SOCIAL  Recreational, leisure and sporting activities are important for health and well-being and for strengthening the cohesion of the community.  This element looks at the benefits these activities can have for people with disabilities and provides practical suggestions about how CBR programmes can work with a range of stakeholders to increase opportunities for the inclusion and participation of people with disabilities.  The value of working directly with stakeholders to plan and develop programmes and activities that are appropriate and responsive to the local ELEMENTS OF SOCIAL  Justice- All community members may need to access justice at some point in time. At a local level it is important to be aware of existing laws that can be used to ensure people with disabilities are able to access their rights and entitlements as outlined in the Convention on the Rights of Persons with Disabilities.  This element focuses on how CBR programmes can support people with disabilities to claim their rights by raising their legal awareness and facilitating their access to a range of legal processes to challenge injustices. EMPOWERMENT  Focuses on the importance of empowering people with disabilities, their family members and communities to facilitate the mainstreaming of disability across each sector and to ensure that everybody is able to access their rights and entitlements.  The word empowerment has different meanings in different contexts. Simple descriptions of empowerment include: having a say and being listened to, self-power, own decision-making, having control, being free, independence, being capable of fighting for one’s rights, and being recognized and respected. EMPOWERMENT  Goal- People with disabilities and their family members make their own decisions and take responsibility for changing their lives and improving their communities.  The role of CBR- is to contribute to the empowerment process by promoting, supporting and facilitating the active involvement of people with disabilities and their families in issues that affect their lives. ELEMENTS OF EMPOWERMENT  Advocacy and communication  Community mobilization  Political participation  Self-help groups  Disabled peoples organizations ELEMENTS OF EMPOWERMENT  Advocacy and communication- This element is about self-advocacy, which means people with disabilities speaking out for themselves, and also communication, i.e. the way messages are sent and received, which is important for self- advocacy.  Community mobilization- Community participation is critical to the success of CBR programmes, and community mobilization is a strategy which aims to engage community members and empower them for change and action. ELEMENTS OF EMPOWERMENT  Political participation- Promoting the participation of people with disabilities in politics is an important approach to empowerment. Decision-making is central to politics, so political participation enables people affected by issues to be at the centre of decision-making and to influence change.  Self-help groups- are informal groups where people come together to pursue a range of activities and resolve common problems. CBR programmes need to focus their activities beyond the individual, on encouraging people with disabilities and their families to form, join and participate in self-help groups. PRINCIPLES OF CBR  Inclusion – It is the act or practice which ensures including people with disabilities in community life. It also means placing disability issues and people with disabilities in the mainstream of activities, rather than as an after thought.  Inclusion also means ‘convergence’ – that is, the involvement of people with disabilities in the campaigns, struggles and activities of other oppressed groups which are not centered exclusively on disability issues. PRINCIPLES OF CBR  Participation – Means the involvement of disabled people as active contributors to the CBR programmes from policy – making to implementation and evaluation for the simple reason that they know best what they need.  Participation also means people with disability being a critical resource within CBR programme – providing training, making decision. PRINCIPLES OF CBR  Sustainability – The benefits of the programme must be lasting. This means an approach to poverty alleviation where the socio-economic gains last beyond the short –term and benefit not just the present but future generations.  The CBR activity must be sustainable beyond the immediate life of the programme itself – able to continue beyond the initial intervention and thrive independently of the initiating agency. PRINCIPLES OF CBR  Empowerment – Means that local people – and specifically people with disabilities and their families make the programme decisions and control the resources. It means PWDs taking leadership roles within programmes. It means ensuring that CBR workers, service providers and facilitators are people with disabilities and all are adequately trained and supported.  It necessitates capacity building – that is the developing and using of the skills necessary to act with authority and responsibility, independent of the initiating agencies and CBR programme PRINCIPLES OF CBR  Self –Advocacy – Means the central and consistent involvement of people with disabilities defining for themselves the goals and processes for poverty alleviation.  Self- advocacy is collective notion not an individualistic one. It means self-determination. It means mobilizing, organizing, representing, creating space for interaction and demands. MANAGEMENT OF CBR PROGRAMMES OBJECTIVES CBR PROJECT AND PROGRAMMES  CBR projects are usually small in scale and may be focused on achieving very specific outcomes.  They are short – term with a set start-point and end –point.  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. MANAGEMENT STRUCTURE FOR CBR  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;  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 SUSTAINING CBR PROGRAMMES  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.  For sustainability which CBR programmes should consider  Effective leadership –  Partnerships  Community ownership  Using local resources  Considering cultural factors  Building capacity  Financial support  Political support 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 peoplewith disabilities who have unmet needs, it will contribute to a growing awarenessof disability issues in society and may also increase support for changes in policiesand resource allocation related to disability. Scaling- up requires (i) demonstration ofprogramme effectiveness; (ii) acceptance by people with disabilities and their familymembers; (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. THE MANAGEMENT CYCLE  Situation analysis  Planning and design  Implementation and monitoring  Evaluation SITUATION ANALYSIS  Collecting facts and figures  Stakeholders analysis  Problem analysis  Objectives analysis  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.  Facts and figures can be gathered about the environmental, social, economic, cultural and political situation at the national, regional and/or local level. STAKEHOLDERS 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 of the tools. 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. PROBLEM ANALYSIS  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.  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.  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).  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  Political structures.  It is often useful to map the location of these.  Prepare a monitoring and evaluation plan  Decide what resources are needed  Human resources  Material resources  Financial resources  Prepare a budget PLANNING AND DESIGN STAGE  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. PLANNING AND DESIGN  Plan together with key stakeholders  Set priorities  Prepare a programme plan  Determine the goal  State the purpose  Define the outcome  Determine the activities  Set the indicators  Determine sources of verification  Consider what assumptions need to be made 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. SET PRIORITIES  Many different needs have been identified during Stage 1 which could all potentially be addressed by a CBR programme.  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. SET PRIORITIES  Prioritization requires skill and an understanding of the realities – sometimes external facilitators can help prevent deviations from the programme goal. PREPARE 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); PREPARE PROGRAMME PLAN  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). DETERMINE 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. STATE THE PURPOSE  The purpose of the programme describes the change you want the programme to make towards achieving the goal. 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 key activities are listed in the log frame.  More detailed activities are considered later in the management cycle, e.g. when the workplans are developed. SET THE INDICATORS  Indicators are targets that show the progress towards achieving the outcomes of the CBR programme and are important for monitoring  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; SET THE INDICATORS  Extent to which the actual implementation of the programme matches the implementation plan;  Overall progress and development of programme implementation and barriers to these.  The 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); SET THE INDICATORS  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  Sources of verification is the information needed to measure each indicator.  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. ASSUMPTIONS  Assumptions are risks turned into positive statements and included in the log frame.  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.  Once the risks have been identified, they can then be managed by changing the programme plan to reduce or eliminate them. PREPARE MONITORING AND EVALUATION PLAN  All programmes should have monitoring and evaluation systems.  The indicators and the sources of verification that were identified in the programme plan will provide the basic foundation for monitoring and evaluation systems DECIDE WHAT RESOURCES ARE NEEDED  It is important to think about the resources needed to implement the programme activities and how to go about obtaining them.  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,  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. 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. PREPARE A BUDGET  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  Develop detailed work plans  Mobilize and manage resources  Financial resources  Fundraising  Financial management  Human resources  Recruitment  Training  Staff development, support and supervision  Carry out planned activities  Awareness- raising  Coordination and networking  Mainstreaming  Service provision  Advocacy  Capacity building MONITORING  Setting indicators  Deciding how to collect information  Analysing information  Reporting and sharing information  Managing information EVALUATION  Focus the evaluation  Collect information  Who can provide the information  How information can be collected  When information should be collected  Analyze the information and draw conclusions  Share findings and take action DATA COLLECTION METHODS COMPONENTS OF EVALUATION  Relevance  Efficiency  Effectiveness  Impact  Sustainablity COMMUNITY MOBILIZATION  At end of this unit the learner should be able to:- DEFINITIONS  Community Mobilization is the process of bringing together or empowering members of the community from various sectors to raise awareness on and demand for a particular development programme.  Community mobilization is defined as “a capacity-building process through which community individuals, groups, or organizations plan, carry out, and evaluate activities on a participatory and sustained basis to improve their health and other needs, either on their own initiative or stimulated by others. KEY STEPS IN COMMUNITY MOBILIZATION  Create awareness of the health issue.  Motivate the community through community preparation, organisational development, capacity developments and bringing allies together.  Share information and communication.  Support them, provide incentives and generate resources. REHABILITATION  Rehabilitation is a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment. Health condition refers to disease (acute or chronic), disorder, injury or trauma. A health condition may also include other circumstances such as pregnancy, ageing, stress, congenital anomaly, or genetic predisposition. Rehabilitation thus maximizes people’s ability to live, work and learn to their best potential. Evidence also suggests that rehabilitation can reduce the functional difficulties associated with ageing and improve quality of life ( REASON FOR RECOMMENDATIONS ON REHABILITATION  A World report on disability for Member States to “develop, implement, and monitor polices, regulatory mechanisms, and standards for rehabilitation services, as well as promoting access to those services”. The recommendations are also intended to support countries in implementing objective 2 of the WHO global disability action plan 2014–2021, “to strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation” (30, p. 3). The United Nations Convention on the Rights of Persons with Disabilities.  calls on Member States to take appropriate measures to organize, strengthen and extend rehabilitation services and programmes. To date, limited information has been available to countries on strengthening rehabilitation in the health system to respond to the growing population demand for services. The aims of these recommendations are to address this information gap and to provide system-level recommendations for improving rehabilitation service delivery OVERARCHING PRINCIPLES  The recommendations for rehabilitation service delivery and financing in this document are based on the following overarching principles of relevance and priority. These principles may be used in policy-making, planning and implementation of the recommendations, according to the national context.  Rehabilitation contributes to the provision of comprehensive person-centred care. Rehabilitation is an integral component of health services, which ensures that people can realize their full functional potential in the environments in which they live and work.  Rehabilitation services are relevant along the continuum of care. Rehabilitation includes interventions for the prevention of impairment and deterioration in the acute phase of care as well as for optimization and maintenance of functioning in the post-acute and long-term phases of care  Rehabilitation is part of universal health coverage; efforts should therefore be made to increase the quality, accessibility and affordability of services. Efforts to achieve universal health coverage should include actions and policies to improve the quality, accessibility and affordability of rehabilitation, thus acknowledging its importance as a health service  Policies and interventions are required to address the scope and intensity of needs for rehabilitation services in various population groups and geographical areas, so that high-quality rehabilitation services are accessible and affordable to everyone who needs them. People experience various barriers to accessing rehabilitation services. Therefore, specific requirements in the population and strategies to address them should be identified so that the health system can ensure equitable availability of services. BACKGROUND  While rehabilitation is delivered in the context of a health condition, usually in conjunction with other health services, it is currently not effectively integrated into the health system in many parts of the world. This has been attributed in part to how and by whom rehabilitation is administered. Responsibility for rehabilitation should be clearly designated for effective integration into the health system. This is becoming more important in view of the anticipated increase in the demand for rehabilitation services and the multiplicity of actors involved in providing rehabilitation . Although rehabilitation addresses the needs of people with any health condition or impairment, whether temporary or long-term, it is commonly associated with disability and is often administered in the same ministry (usually a ministry for social welfare). In some countries, rehabilitation governance is shared between the ministries of health and of social welfare. Determination of whether rehabilitation should be integrated into the health system or into the social welfare system includes issues of rehabilitation governance and the impact on how rehabilitation is integrated into services.  In many parts of the world, rehabilitation services are often provided only at selected levels of the health system. The reasons include underdevelopment of the rehabilitation sector and insufficient human resources and investment, which limit distribution of services among levels. Several long-standing misconceptions about rehabilitation have also determined at which level it is available. One pervasive misconception is that rehabilitation services are needed only by people with disabilities. BARRIERS TO IMPLEMENTATION OF THE REHABILITATION SERVICE DELIVERY AND FINANCING  1. Often, limited knowledge and understanding of rehabilitation by policy-makers In some settings, the concept of rehabilitation is novel and poorly understood by policy-makers and many others in the health and social sectors. Rehabilitation may be better understood in certain user groups, among people with certain health conditions or in certain settings, but not comprehensively. Policy dialogue with government leaders and decision- makers should include clear communication of what rehabilitation is, its role and its benefits for health, society and the economy. Some of the key messages to be relayed are as follows.  Rehabilitation is an essential health strategy, with prevention, promotion, treatment and palliation, and is necessary for the health of many people. Rehabilitation helps build human capital and supports people in returning to and participating effectively in education, work and family and community roles. Effective rehabilitation can speed recovery, prevent hospital readmission and support people in remaining independent for longer. The economic advantages that this generates create a strong case for investment 2. LIMITED FINANCES AVAILABLE TO INVEST IN REHABILITATION  The effect of limited financial resources on implementation of the recommendations for rehabilitation service delivery and financing will depend on the existing services and the budget, if any, already allocated for rehabilitation. Where rehabilitation services are poorly developed or inexistent, however, establishing the systems, workforce and infrastructure required to implement the recommendations calls for careful short-, medium- and long-term financial planning. Factors such as difficult geographical access, poverty and illiteracy can increase the financial investment required to ensure equitable service delivery.  When financial resource are limited, efficiency is paramount. Ensuring system capacity to plan, coordinate and carry strategies forward is critical in this regard; strong systems allow government and private resources to go further. Maximizing partnerships of organizations in service delivery and rehabilitation workforce training is one means of ensuring that financial resources are well used and distributed. 4. INSUFFICIENT NUMBER OF REHABILITATION PROFESSIONALS  A rehabilitation workforce is integral to service delivery, yet establishing a workforce adequate in number, skills and equitable distribution is a considerable challenge in many countries. Several mechanisms can be used in building a workforce for rehabilitation: strengthening training institutes for rehabilitation workers; government scholarships for rehabilitation personnel; increasing the number of rehabilitation posts; mandating the work setting after graduation (e.g. graduates are required to work in a rural setting for a prescribed period); providing incentives to retain skilled rehabilitation professionals; and recruiting internationally. 5. LACK OF OR INADEQUATE ORGANIZATIONAL AND ADMINISTRATIVE STRUCTURES FOR REHABILITATION  Most implementation activities are operated through an organization and administrative structure, which can strongly impact its effectiveness and efficiency. Often, these structures and systems will require strengthening concurrently with implementation, in accordance with the country situation. They can be strengthened by naming focal points for rehabilitation within the ministry of health, who can promote strong governance and accountability and ensure continuing commitment to national plans and strategies. 6. LACK OF INFORMATION ON THE SITUATION OF REHABILITATION IN THE COUNTRY  Implementation plans are best informed by a reliable assessment of the situation of rehabilitation in the country (or province). Comprehensive understanding of the health system and the rehabilitation capacity in a country, province or district is a critical first step in planning implementation. A national rehabilitation systems assessment tool is available from WHO1 , and technical assistance can be requested from the Secretariat if needed. Information can be drawn from numerous sources, including WHO statistics for the burden of disease, interviews with stakeholders, administrative records and rehabilitation training institutes and associations. ASSISTIVE DEVICES AND TECHNOLOGIES Assistive devices and technologies are those whose primary purpose is to maintain or improve an individual’s functioning and independence to facilitate participation and to enhance overall well- being. They can also help prevent impairments and secondary health conditions. Examples of assistive devices and technologies include wheelchairs, prostheses, hearings aids, visual aids, and specialized computer software and hardware that increase mobility, hearing, vision, or communication capacities. In many low-income and middle-income countries, only 5-15% of people who require assistive devices and technologies have access to them. COMMUNITY-BASED REHABILITATION (CBR)  Community-based rehabilitation (CBR) was initiated by WHO following the Declaration of Alma-Ata in 1978 in an effort to enhance the quality of life for people with disabilities and their families; meet their basic needs; and ensure their inclusion and participation. While initially a strategy to increase access to rehabilitation services in resource-constrained settings,  Community-based rehabilitation (CBR) was initiated by WHO following the Declaration of Alma-Ata in 1978 in an effort to enhance the quality of life for people with disabilities and their families; meet their basic needs; and ensure their inclusion and participation. While initially a strategy to increase access to rehabilitation services in resource-constrained settings, CBR is now a multisectoral approach working to improve the equalization of opportunities and social inclusion of people with disabilities while combating the perpetual cycle of poverty and disability.  CBR is now a multisectoral approach working to improve the equalization of opportunities and social inclusion of people with disabilities while combating the perpetual cycle of poverty and disability. CBR is implemented through the combined efforts of people with disabilities, their families and communities, and relevant government and non-government health, education, vocational, social and other services. DISABILITY AND REHABILITATION IN EMERGENCIES  Emergencies, particularly sudden-onset disasters and situations of protracted conflict, can result in a surge of people with critical injuries. In such contexts, local health and rehabilitation services may not be able to cope with their needs, and they may suffer from secondary complications of their injuries, due to a lack of access to medical management, medications,  and assistive devices. These injuries and complications may result in their experiencing long-term disability. People living with disability prior to the emergency are also disproportionately affected in such situations and are known to have particularly high rates of mortality in emergencies. DISABILITY  More than a billion people in the world today experience disability. These people generally have poorer health, lower education achievements, fewer economic opportunities and higher rates of poverty. This is largely due to the barriers they face in their everyday lives, rather than their disability. Disability is not only a public health issue, but also a human rights and development issue. WHO’s efforts to support Member States to address disability are guided by the overarching principles and approaches reflected in the WHO global disability action plan 2014-2021, the World report on disability, and the Convention on the Rights of Persons with Disabilities.