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219 Pages·2004·1.38 MB·English

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Since the advent of Community-based rehabilitation (CBR) in
1976, many developing countries have conducted CBR
projects. CBR has been presented as a relevant and cost- E Stakeholders’
effective way to provide rehabilitation services to people with m
disabilities. Twenty-five years later it was concluded that, Influences in
despite the growing amount of literature on the topic, the p
Graag nodig ik u uit
evidence base for CBR is still fragmented and therefore its o Community-Based U
w voor het bijwonen
effectiveness cannot be sufficiently established. In this thesis, a
van de openbare verdediging
theoretical model based on the competency levels of the different e Rehabilitation
stakeholders involved in CBR is presented. In addition, an r van mijn proefschrift: I
e
analysis of the stakeholders involved is carried out in order to Empowered
d
study the process of CBR. Finally, CBR projects in Southern T
Africa (i.e. Zimbabwe) have been analysed to determine the t to Differ
o
influence of these stakeholders on the CBR process.
D N
The stakeholders involved in CBR projects are highly
interdependent and rely on each other to achieve programme i
and individual objectives. However, the interests of these ff Op woensdag 31 maart 2004
stakeholders conflict on several issues. One of these issues is the e om 13.45 uur precies O
r
need for a specialised competency level versus a broad in de aula van de Vrije Universiteit,
competency level, and another is their orientation regarding De Boelelaan 1105 te Amsterdam.
D
the individual versus society. On the basis of these two issues,
this thesis concludes by providing four scenarios for the further
development of CBR. Harry Finkenflügel
I
Lodewijk Pincoffsweg 466, 3071 ASRotterdam
Harry Finkenflügel was involved in the Zimbabwe CBR pilot telefoon 010-4863652
e-mail: [email protected] G
projects and taught at the Rehabilitation Technicians Training
School (1988-1991). In the Netherlands, he has worked as a
physiotherapist, educational manager, and general manager
I
for organisations that serve people with severe learning PARANIMFEN:
disabilities. He is currently working at the ‘Institute for Health Frans Finkenflügel
N
Care Policy and Planning’ of the Erasmus Medical Centre in Dahliastraat 6, 7081 ECGendringen,
Rotterdam in the Netherlands. telefoon 0315-630827
e-mail: [email protected]
G
Rita Zijlstra
ISBN 90-77595-11-2 Lodewijk Pincoffsweg 466, 3071 ASRotterdam
Harry Finkenflügel telefoon 06-48351432
e-mail: [email protected]
Empowered to Differ
Stakeholders’ Influences in Community-Based Rehabilitation
Harry Finkenflügel
© Harry Finkenflügel, 2004, Rotterdam. [email protected]
ISBN 90-77595-11-2
VRIJE UNIVERSITEIT
Empowered to Differ
Stakeholders’ Influences in Community-Based Rehabilitation
ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad van doctor aan
de Vrije Universiteit Amsterdam,
op gezag van de rector magnificus
prof.dr. T. Sminia
in het openbaar te verdedigen
ten overstaan van de promotiecommissie
van de faculteit der Geneeskunde
op woensdag 31 maart 2004 om 13.45 uur
in de aula van de universiteit
De Boelelaan 1105
door:
Henricus Josephus Maria Finkenflügel
geboren te Gendringen
promotoren: prof.dr. I.N. Wolffers
prof.dr. G.J. Lankhorst
beoordelingscommissie: dr. D. Burck
prof.dr. C. Vlaskamp
prof.dr. W. van Mechelen
M. Miles, Ph.D
prof.dr. A. Vermeer
VI
Cover illustration:
Giovanni Vetere
Die Gesichter, die dem Betrachter wahrhaft “entgegenkommen”, nehmen
direkten Blickcontact mit ihm auf. Dieser Blickcontakt ist zentraler Inhalt
der Arbeiten einerseits, und macht es anderenseits fast unmöglich, sie einer
distanzierten Analyse zu unterwerfen. Die Einbildung fuktioniert so
unmittelbar, dass es oft recht schwierig oder auch befremdlicherscheint, mit
diesen Blicken, “einfach” umzugehen.
The faces that are coming towards the observer are taking up direct visual contact with him.
This visual contact is - on one hand - the central content of his works and on the other hand
makes it impossible to analyse them at a distance. The imagination is working immediately
making it often very hard or disconcerting to handle these looks “easily”.
(text in German: Christine Glenewinkel in: I Colori della vita. Die Farben des Lebens.
Giovanni Vetere wird 60, English translation by Monika Hoffman)
Editing contributions:
K. Elmer, M. Miles
This publication has been sponsored by:
Maurits van Kattendijke Stichting
Stichting Annafonds Leiden
Graphic design / lay out:
W.A.T.?! reclame, Rotterdam
VII
Preface
Fifteen years ago, in September 1988, I arrived in Zimbabwe to take up a position as a teacher
at the Rehabilitation Assistants Training School in Harare. In my first week Mrs. S.
Chidyausiku, head of the Rehabilitation Unit in the Ministry of Health, asked me to represent
the school in the committee set up to monitor the Community-based rehabilitation (CBR) pilot
projects in Zimbabwe.
CBR was a challenge in many ways. Zimbabwe had rapidly decentralised its health services and
adopted the Primary Health Care approach. Supported by donor organisations, the Ministry of
Health was determined to improve the care for people with disabilities along the same lines.
One of the challenges was to train the cadres for CBR. From 1981 ‘Rehabilitation Assistants’
have been trained in Zimbabwe and in 1988 the University of Zimbabwe started a
physiotherapy and occupational therapy training. At that time most therapists working for the
Ministry of Health were expatriates. Both expatriates and the people trained in Zimbabwe were
educated in the Western medical tradition and their skills and experience in counselling and
training people with disabilities, their families, and volunteers in disadvantaged communities
were limited. A second challenge was to beat the scepticism of many professional rehabilitation
workers. Their fear of ‘watering down’ services and expertise and offering ‘second-rate’ services
to people who were, in their view, entitled to ‘the best’ was difficult to address. Apart from the
WHO manual and the book “Disabled Village Children” we had no documentation and
evidence available to show that lay people and semi-skilled rehabilitation workers could provide
adequate assistance. The few CBR projects already running in Zimbabwe had too many
problems to convince the more reluctant rehabilitation workers. Most decisive in the process
was that there were indeed enough rehabilitation workers to take up the challenge and to start
projects. These projects were generally well prepared and problems were solved when they
arose. Although I personally was in favour of this naïve approach I was also worried about the
accountability of the efforts made and asked the Rehabilitation Technicians to collect specific
data on the projects, the volunteers, and the people with disabilities involved in the projects. I
also started reading on CBR as much as I could get my hands on. The early correspondence
with M. Miles, Brian O’Toole and Marigold Thorburn motivated me to get even more involved
in CBR.
In 1991 the eight pilot projects were well underway and my contract ended. I returned to The
Netherlands with a fascination for CBR. Dr. Adri Vermeer and prof. dr. Brian Hopkins of the
Vrije Universiteit motivated me to set up a curriculum and to get students involved in
rehabilitation in developing countries. Together with prof. dr. Ivan Wolffers I edited a book
“The handicapped community” and this was published in 1993. Since then, the idea of writing
a Ph.D. thesis stayed with me. In the ten years that it took me to write a consistent study on
CBR many events have sidetracked me from this thesis but the simple fact that this book is now
on your desk means that I’m really convinced that CBR is still an interesting approach.
VIII
IX
Glossary
CBR Community-Based Rehabilitation
CRW Community Rehabilitation Worker
CW Community Worker
IBR Institution-Based Rehabilitation
ILO International Labour Organisation
ILS Intermediate Local Supervisor
LS Local Supervisor
NGO Non-Governmental Organisation
PHC Primary Health Care
RA Rehabilitation Assistant
RCV Red Cross Volunteer
RT Rehabilitation Technician
SIDA Swedish International Development Authority
UN United Nations
UNDP United Nations Development Programme
UNESCO United Nations Educational, Scientific and Cultural Organization
UNICEF United Nations Children’s Fund
VCW Village Community Worker
VHW Village Health Worker
WHO World Health Organization
About the use of he, she, his, her, ...
Community-based rehabilitation has sometimes been referred to as Mother-Based
Rehabilitation to illustrate that it is usually the mothers, grandmothers, aunts and sisters that
care for people with disabilities. It is also observed that most of the volunteers are women. Men
are better represented in the professional cadres while the rehabilitation workers at district and
provincial level are mostly women. It is for these reasons that in this thesis ‘she’ and ‘her’ have
been consequently used. As such the probably more correct but unattractive ‘he/she’ and
‘his/her’ is avoided.