Alternative programming considerations
A review of Peace Corps' efforts in any field is bound to ask the question "What are the projects we should promote and try to replicate in other areas?" In this review of special education and rehabilitation projects, we were asked to discuss the relative merits of community-based versus institution-based programming. The question implies that there is a difference, that we can describe that difference, and that one is likely to be preferable over the other as a model. This paper reviews some issues regarding institution-based and community-based programming involving the disabled, speculates on future trends, and suggests some possible courses of action for Peace Corps.
Community-Based versus Institution-Based Programs
For purposes of discussion, an institution-based program for disabled persons may be described as one which utilizes a large central facility, has a predominantly professional staff, treats disabled persons as "patients" or "students", needs a substantial operating budget, and intensively treats a relatively small portion of the total population which might benefit from its services. By contrast, a community-based program would use a modest facility or building as a center, would be staffed primarily by community workers who receive "al the job" training, would deal with disabled persons more as "clients" or "colleagues", would have a small operating budget, and would provide more general services to a greater percentage of the community population. Of course, few programs fit neatly into one category or the other, but rather have elements of both.
Among the international development organizations, there is considerable disagreement about the relative effectiveness and appropriateness of institution-based versus community-based programming. At the simplest level, those who believe in institution-based programming tend to think that international technical assistance should be channeled through the existing institutional and organizational infrastructure of the host country. Those who promote community-based programming tend to think that assistance should be channeled directly to people in the communities where they live. This dichotomy implies that existing institutions may lack either the ability or the intention of actually meeting the extensive needs of the population that is often described as "the poorest of the poor". Community-based programming thus becomes a plea for alternatives to existing institutions and structures.
David Werner, among others, has voiced this plea in his volume, Health Care and Politics (1977):
Clearly, alternatives are needed: alternatives that restore dignity, responsibility, and power to the people on the bottom; alternatives that allow and encourage the poor to analyze the whole physical, social, and political reality of their situation and to organize so that they gain, through their own actions, greater control over their health and their lives.
The Community Rehabilitation Revolution: an historical perspective
The decade of the '70s saw an astonishing change in thinking and actions regarding international development efforts. E.F. Schumacher articulated that change most effectively in the popular volume, Small is Beautiful. The argument for more small-scale community-level development strategies and activities presented in this publication has created a world-wide revolution in the programming of international developmental assistance organizations.
The effects of that change in thinking are also evident among the relatively small group of international experts concerned with disability prevention and rehabilitation. Beginning in the mid-'70s, a number of prominent individuals as well as international organizations and agencies began to rethink their approach to development activities concerning disabled persons. In 1976, Duncan Guthrie, a development expert in England, convened a conference on "Disability and the Developing World". The report of that conference (now out of print) pointed the way to simplified models and low-cost approaches that take place at the community level. This report provided the same kind of conceptual base for those interested in disability that E. F. Schumacher's work did for the general international development community.
A second important event was the appearance of David Werner's book, Where There is No Doctor. This practical and enlightening handbook has demonstrated that the essential principles of primary health care at the village level can be rather simply but thoroughly described in one volume. Werner successfully demystified much of the professional jargon surrounding health care and provided a model for others to develop similar approaches in other areas.
Also in the mid-'70s, the prestigious and broadly-representative organization, Rehabilitation International, began to promote disability prevention and more simple approaches to special education and rehabilitation on a global level. In 1981, Rehabilitation International published the Charter for the 80s, a statement of consensus about international priorities for action during the decade 1980-1990. The Charter was developed based on the most extensive international consultation ever undertaken in the fields of disability prevention and rehabilitation. Thousands of people throughout the world discussed and debated the issues at national, regional, and international meetings during the three year period from 1978-1980. The Charter recommends targets for action at the community, national, and international level to serve as a guideline and stimulus for all nations. The section on community targets is included below in its entirety.
Targets at the Community Level
Shifting of the focus of rehabilitation efforts to the community level. This includes extension of community level rehabilitation services, in both urban and rural locales and preferably within existing community services.
Strengthening all measures to foster community integration of people with disabilities including elimination of all barriers to their use of public facilities and services.
Establishment of a system within each community for early identification of children and adults with disabilities.
Providing rehabilitation services taking into account the economic and social situation and cultural background of the person with a disability and his or her family.
Assuring the participation of people with disabilities and their families in decision making about their lives and the rehabilitation assistance that they receive.
Improving and increasing dissemination of information to people with disabilities and their families concerning the realization of their rights within society and the services available to them.
Providing rehabilitation services to all in need of them without discrimination on the basis of age, sex, financial capability, religious or ethnic background, or type and cause of impairment.
Expanding training of community level personnel to identify people with disabilities, assist them and their families, and, when necessary, refer them to appropriate service programs. All generic training programs for community workers, including teachers, social workers, health services personnel, administrators, clergy, family counselors, and civic planners, should incorporate basic training about the nature of disability and the rehabilitation process.
Adopting of measures by trade unions and employers to facilitate employment of members of the community with disabilities. Employers of large numbers of workers, particularly agencies of government, should be encouraged to take the lead.
Adopting of measures by trade unions and employers to prevent accidents at work and to reduce injuries to workers.
Other organizations such as AHRTAG in England, L'Arch in France, the Canadian Institute on Mental Retardation, and a variety of U.S.-based organizations such as Helen Keller International, Goodwill Industries, Partners of the Americas, and others, began to develop specific projects and programs dealing with low-cost approaches to disability prevention and rehabilitation that are relevant to developing countries.
Despite the remarkable shift in thinking and programming toward community-based approaches by some, it is not universally accepted. Clearly, the planners and policy-makers of national govern meets must be persuaded of the wisdom and appropriateness of such new methods. Also, community rehabilitation approaches may be perceived as somewhat hat threatening by the leaders of existing institutional programs for the disabled. In many countries, some of the most highly trained and most respected professionals in rehabilitation and special education are not yet convinced that simplified community approaches will be effective. Just as Schumacher's notions of intermediate technology were criticized in some quarters as being "mediocre technology", simplified rehabilitation and special education approaches will certainly be criticized as being unprofessional or second-rate by some persons. New economic and cost-effectiveness data compiled by Rehabilitation International and the World Health Organization may do more to spur on the development of community-based programs than any other kind of argument
The World Health Organization, for example, in its manual, Training the Disabled in the Community, analyzes the gap between the needs of disabled persons and the services available in developing countries. Using a realistic example of a developing country, the authors report that at any given time only 1.1 percent of persons needing rehabilitation services were actually receiving them. An attempt to meet the remaining needs through institutional means would cost approximately US $34 per capita per year - an amount that would be beyond the capability of developing countries. By contrast, the authors compute that providing full coverage through community-based programs would cost only US $1.78 per capita per year. Furthermore, they also estimate that it would take 124 years to implement full coverage through institution-based programs, but only 11 years to reach full coverage by community-based care.
In the developed countries of North America and Western Europe, the soaring expense of institutional care is already shaking the foundations of traditional professional service delivery models. And if WHO's figures are valid, national planners and policy makers worldwide may be expected to give community-based rehabilitation approaches additional attention in the coming years.
The Peace Corps: its changing role in the international spectrum
The Peace Corps has had extensive experience in both institution-based and community-based programs. The majority of placements have traditionally been in institutional settings, as it is the rehabilitation hospitals, schools for retarded children, or national centers that most frequently request Peace Corps assistance. Volunteers have performed admirably and effectively in many such institution-based programs and often appear to have encouraged the institutions to expand their work to broader segments of the population.
Nevertheless, the basic structure and functions of such institutions led a Peace Corps Health Need Area Team to report in 1978 that:
Often, the clients are institutionally-based and the condition is chronic. While addressing a major need and involving worthwhile jobs, the work is curative by definition and is often isolated from other development efforts. Improved institutional rehabilitation may have little effect in the long run if communities are not prepared to accept the rehabilitated person or if the cause of the handicap is unchecked and the population needing services continues to increase.
The authors view this comment as a valid criticism of institution-based programming in rehabilitation. Indeed, it is essentially the same argument used to criticize institutions in the United States. The dilemma for the Peace Corps is that the existing institutions are often the only resource in most countries well enough organized to request Peace Corps assistance. A second problem is that virtually all institution directors regard themselves as heading community-based organizations responding to the needs of the people of their community. They quickly argue that their lack of outreach or extensive education or preventive programs is caused by a lack of financial and personnel resources. If only the Peace Corps will supply them with a physical therapist, an occupational therapist, a rehabilitation nurse, and a social worker, the community will be better served. It is difficult for the Peace Corps staff member who walks through the waiting room of such an institution to refute the obvious compelling human need represented the ret
During the past few years, the Peace Corps has recognized the need for a more systematic programming approach in special education and rehabilitation as opposed to "gap filling" in institutions and schools. This juncture in Peace Corps programming offers a particularly opportune time to explore the benefits of closer collaboration with other international organizations concerned with the needs of the disabled. Most of these organizations have highly developed conceptual schemes for implementing community-based rehabilitation programs but very few personnel to implement their plans. The Peace Corps, on the other hand, has a large number of people working with the disabled in communities throughout the developing world but lacks the long range planning and technical resources these other organizations can provide.
Increased collaboration between Peace Corps and other international rehabilitation organizations would thus seem to offer many mutual benefits as well as new promise for disabled people in the developing world.
Model Programming in Disability Prevention, Special Education, and Community-Based Rehabilitation
As a general practice, the authors believe that the Peace Corps should engage in three primary areas of programming to address problems of disability, with a fourth special disability project area for innovative new approaches. These are:
1) Disability Prevention (can be institution-based or community-based);
The four areas have common principles that programmers ought generally to follow to make projects appropriate for continued Peace Corps support:
• Disability-related projects should build new capacities among host country citizens.
• Volunteers should not have primary assignments providing direct health services or direct classroom teaching, except when counterpart training is clearly evident.
• All Peace Corps Volunteers and staff should be trained to ask the question "what long-term impact, if any, will this project have on disabled people or on the effort to prevent disabilities?"
• Volunteers should not work in institutions that provide primarily residential services.
• The planning of special education and rehabilitation projects should systematically involve disabled persons and their families.
• Peace Corps should promote mutual self-help activities among disabled people at the community level.
Disability Prevention Model Projects:
The Peace Corps engages in a number of activities that may be described as having the effect of preventing disability. In most countries, disability prevention projects will likely be planned with public health officials and might include such projects as maternal and child health, nutrition education, environmental sanitation, and other general health and education programs which work to expand the access of the general population to known and effective practices. All public health activities have the intention of preventing disability, but a specific disability prevention project is a more precisely focused public health activity.
The advantages of a disability prevention project for the host country and the Peace Corps are plentiful. Such projects require little institutional infrastructure and few specialized facilities. The project staff can have varied educational backgrounds and can be intensively trained in prevention techniques in a short period of time Prevention projects reach a large segment of a given population and can be shown to be quite cost effective. For Peace Corps purposes, volunteers can be used in ways that build new capacities in host country personnel and also to expand the amount and the types of human services available. Counterpart training is easier to arrange since less-specialized prerequisite skills are required. Primary health care projects, community education programs, and parent education courses are among the most effective ways of using a volunteer's skills to reach a large number of people.
While disability prevention projects are likely an excellent area for expanded programming in the Peace Corps, there may be initial difficulties in establishing such projects. Substantial cooperation with public health officials will be required for Peace Corps staff to plan prevention projects. However, the public health sector of many developing countries often receives only a small share of the total health budget and acute care facilities such as "mode!'' hospitals frequently receive a disproportionately large share of the available resources. Consequently, it may take a long time to get even a small amount of money allocated to a new project. Peace Corps programmers may find it useful to stay in touch with health planners and watch for programming opportunities when a new public health or community education program is beginning. It will certainly be easier to include a disability prevention component in the planning of a new program than to start and fund a separate project from scratch.
There are also opportunities for the Peace Corps to join in disability prevention efforts already begun by other organizations. The World Health Organization, for example, has begun an extensive blindness prevention campaign involving, in particular, many African nations. Helen Keller International is also very involved in developing new strategies for blindness prevention in rural areas. In Venezuela, an extensive mental retardation prevention program is now underway and Costa Rica is developing new hearing conservation programs.
An excellent concept paper on disability prevention written by Tonya
Madison, a former Peace Corps staff member in Kenya, is excerpted below:
The common theme of Peace Corps, meeting basic human needs, represents a combination of disciplines functioning in various areas to improve the quality of family life. The improvement of the quality of family life is synonymous with the prevention of disease and malnutrition and consequently their resulting handicaps.
Disability prevention is not, and should not be considered a specialized area for which separate services are required. It is a neglected area of intervention, and must be given greater attention within the general framework of existing resources.
Ideally, a prevention program would be based on a complete survey of the etiologies and incidences of disabilities. This type of study is not available, and is difficult to produce. A prevention program need not wait for such a survey. Known facts can be utilized to create a program.
The fact is known that the incidence of mental retardation, for example, can be reduced by as much as 50% The crucial period for prevention is from the time of conception to early infancy, when the developing nervous system is sensitive to a complex of variables, including infectious disease, toxic substances and malnutrition.
The potential exists to incorporate principles of prevention into the developing health care system. Methods effective in preventing disabilities are part of the many efforts aimed at improving the quality of life that are being carried on within multiple agencies throughout the country. Existing programs aimed at improving family life will subsequently decrease the occurrence of disabilities. For example:
Maternal Child Health/Family Planning Clinics: By prenatal care and availability of means for child-spacing;
Family Life Training Centers: by the improvement of nutritional status by food supplements and education; and,
Rural Training Centers: by early identification of children at risk in the field.
These represent examples of practices which will decrease the incidence of disability. In Kenya, these programs have indicated an interest in utilizing Peace Corps Volunteers in various programs of health planning and personnel training. They require experienced health educators and training personnel in various ways with the common objective of producing healthy babies.
Health education is an important aspect of prevention. Knowledge is the means by which people can control their own destinies. Education provides the awareness as to what means are available to produce healthy children and environments conducive to growth.
Health education needs to focus on the affected adult population, especially women of child-bearing age. Women, the people with the most direct contact with children (especially in rural areas), do not benefit from as high a level of formal education. Therefore, the person with the greatest responsibility for the child's development is least likely to be aware of what alternatives are available. The following are ideas of what health education would include:
1. The relevance of immunizations;
2. The need for immediate medical care in the case of high fever;
3. Nutritional information;
4. The harmful effect of toys such as lead batteries; and
5. The importance of hygiene as related to decreasing the possibility of infections.
The aim to reduce the occurrence of disabilities is a complex issue. The implementation of prevention programs within the existing structures is a necessary step to the alleviation of disabilities. The application of known practices can serve as a basis for initial steps to initiate prevention programs.
In summary, disability prevention projects for selected Peace Corps countries appear to be a most appropriate target area for future Peace Corps programming. There is an excellent fit between the goals of the Peace Corps, the human needs of most developing countries, and the capabilities of Peace Corps Volunteers. However, disability prevention projects represent relatively uncharted territory in international technical assistance as well as national planning efforts. The authors believe that, in order to be successful, disability prevention projects will need high levels of initial planning between Peace Corps staff and host country personnel. These planning efforts may be facilitated and enhanced by involving a third component such as consultants from other international technical assistance programs with technical expertise in the development of disability prevention projects.
Special Education Model Projects:
The Peace Corps has an extensive and impressive history in the special education field in the past decade. Many hundreds of volunteers have worked in special education schools and community facilities in helping meet the educational needs of handicapped children. In some places, such as the Seychelles, Peace Corps Volunteers have helped initiate some of the first special education efforts in a given area. In other places like Costa Rica, volunteers have helped expand the knowledge and service base of the existing special education infrastructure. In both cases, the contributions have been substantial and appropriate for the Peace Corps.
Special education assignments are generally more institution-based than community-based in the sense that the education of handicapped children, even in the very poorest countries, usually takes place in a school or clinic setting. Frequently, a large number of different kinds of handicapped children are lumped together in one group, and less frequently, the handicapped children are included along with non-handicapped children in the educational program of a given community. Special education schools may be either public or private, and may even operate as profit-making facilities in some of the large capital cities of developing countries.
The most successful special education projects usually have several volunteers with a wide range of skills assigned to a particular geographical area. In their assignments, the volunteers will usually engage in some amount of actual classroom teaching, will serve as resource teachers on an occasional basis to other classes, will arrange in-service training programs for all teachers in the system, and will be active in involving the parents in the education of the handicapped child. These volunteers are often very helpful in bringing other resources to bear from international organizations or local civic groups to help the school or system in which they work. In their off-hours, many help develop recreational activities for handicapped children, lead discussion groups with family members of handicapped children, and visit the homes of the students with whom they work. These volunteers often become valued members of the community and leave behind both their substantial skills and considerable good will when their term of service is completed.
The authors believe that special education assignments represent the most appropriate kinds of institution-based programs for Peace Corps programming relating to disability. The nature of special education schools or classes typically places them closer to the community than other kinds of institutions, particularly rehabilitation hospitals or residential institutions for handicapped populations.
Peace Corps programmers have had considerable success in planning capacity-building projects with host country personnel in the special education field. As special education is still in the very early stages of development in most Peace Corps countries, there should be continued opportunity for creative special education programming in the foreseeable future in almost every country.
Community Rehabilitation Model Projects:
As briefly mentioned earlier, community rehabilitation may be differentiated from institutional rehabilitation by a variety of factors:
• Community rehabilitation tends to involve numerous, non-specialized public facilities and home settings for much activity.
• Community rehabilitation tends to involve more general services involving a larger number of people.
• Community rehabilitation tends to integrate disabled people and treat them more like fellow citizens with special needs.
• Community rehabilitation tends to be relatively low in cost and takes advantage of the unschooled talents and abilities of people.
There is such compelling logic for more community rehabilitation programs in developing countries that it is often difficult to understand why so little has been done in this area. One explanation is that it is hard to make community rehabilitation projects last. Without a large building, without a permanent professional staff, and without a prominent board of directors, it is easy for a community rehabilitation project to disappear when key people depart or problems occur.
Useful models for community rehabilitation efforts are just beginning to appear in published form. One interesting conceptual model for the early childhood education of handicapped children has been developed by David Fisk of the High/Scope Educational Research Foundation . He has developed an "Ecological Intervention Model" to serve as a future guide for the education of children with disabilities in less-developed countries. He contrasts this model with the more typical Welfare Program Model and the Showcase Program Model. In this model, the home and neighborhood becomes the service setting and parents and paraprofessionals are the primary providers of services. More preventive programs are emphasized and the clientele is not rigidly defined. Services are viewed as a right rather than a charity or a privilege. (See chart on final page of this section.) While this conceptual model refers primarily to early childhood education of the handicapped, it also has utility for other community-based models for helping the disabled at the community level.
This model offers potential for a much-needed conceptual grasp for Peace Corps programming. Yet it does not deal with the problem of Peace Corps Volunteers being temporary members of the community. This is less of an issue in an institutional setting because staff members routinely change and are not necessarily expected to be members of the community. Implanting and nurturing outside elements, while encouraging selfreliance and mutual community assistance, is a delicate and time consuming task. David Werner, for example, worked for fifteen years in a remote area of Mexico to carefully bring in new knowledge and skills to improve primary health care.
It is apparent that community rehabilitation efforts, whether introduced by Peace Corps or other international organizations, must acknowledge the fundamental contradiction of having foreign citizens come into a community to develop self-help activities. This contradiction is causing considerable reflection and questioning among international technical assistance organizations.
Because of this apparent contradiction, the authors of this report believe that Peace Corps programmers should look for already-existing community-initiated projects in which a community rehabilitation component might be added as a new community resource. As an experiment in training, it would be useful to develop a short-term, pre-service training program using the new World Health Organization's manual entitled Training the Disabled in the Community.*
With a combination of a new rationale for community rehabilitation programming, new tools in the form of resource materials, and creative efforts by Peace Corps programmers to identify a series of careful placements in community development programs, the Peace Corps can become a much stronger force in the global effort to help disabled people become full participants in the life of their communities.
Special Disability Projects:
The Peace Corps has occasionally undertaken special disability-related projects of an innovative, experimental nature. For example, a Special Olympics
* In the view of the authors of this report, the WHO manuals will likely prove to be the single most useful set of printed resources for implementing practical community action in special education/rehabilitation in the decade of the '80s. These manuals are expected to be published in final form in 1982 and are only available in an experimental version at the time of this writing. project in Colombia utilized ten volunteers who attempted to set up a nationwide Special Olympics program for mentally handicapped youth. The Philippines Deaf Education project trained a number of skilled deaf volunteers to develop educational programs for deaf children and youth. These projects are described more fully in the Selected Country Reviews section of this report.
Such projects usually require additional technical training for volunteers and are not always replicable in other countries. Nevertheless, innovative program efforts should be encouraged to explore new strategies for improving the impact and effectiveness of Peace Corps' work.
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