Community-Based Rehabilitation Program Design and Implementation in Central America
Michael Lundquist, Executive Director, Polus Center
Since 1997, the Polus Center for Social & Economic Development, Inc., has been supporting orthotic and prosthetic (O&P) services in Central America. In 1999, Polus expanded its effort and, in collaboration with local citizens of Leon, Nicaragua, opened Walking Unidos, an outreach O&P workshop. Since the success of Walking Unidos, the Polus Center has helped develop two other O&P programs: Vida Nueva in Choluteca, Honduras, and the other in Managua, Nicaragua, a venture made possible with the support of the International Committee of the Red Cross (ICRC). In addition, the Polus Center developed several other disability-related programs, including the Disability Leadership Center, an access project entitled "A City for Everyone" and the Ben Linder Café, an economic development project. These programs are based in Leon, Nicaragua, and were developed in response to needs identified through extensive planning processes, which included many individuals with disabilities and various disability organizations. All programs were implemented and are administered by local citizens. None of these programs relies on expatriate staff.
For those who are interested in developing effective community-based rehabilitation (CBR) services in Central America, there are several important considerations to address prior to program implementation. After making certain that a replication of service organizations involved in program design does not already exist, one should answer the following questions:
After several initial fact-finding visits to Central America, the Polus Center considerably broadened its understanding of O&P services and the day-to-day life experiences of people who suffered limb loss. Over the course of several years, Polus Center staff and volunteers conducted hundreds of in-depth face-to-face interviews with Central Americans with disabilities. This information, obtained directly from landmine survivors, trauma victims, and victims of diabetes, polio and other diseases, all of which resulted in amputations or physical deformity, became the foundation upon which the Polus Center took direction and proved the guiding force in the design of program services that are coherent with the people's needs.
Exporting Rehabilitation Service Models From Developed Nations
Many non-governmental organizations (NGOs), including the Polus Center, are based in developed countries and began by designing and implementing human service programs to suit the needs of their particular country. For example, since 1979, the Polus Center has been providing support for people with both physical and mental disabilities in Massachusetts, USA. In North America and developed countries elsewhere in the world, human service programs are numerous. A wide variety of O&P services—mental health counseling, education and employment training, legal advocacy, physical therapy, and more—is available to those in need. Services and information about organizations offering particular programs are readily available to most citizens.
Both the abundance and professionalization of rehabilitation programs have influenced many NGOs' approach to design and delivery of human service programs. The goal of specialization and the mantra "do one thing well" is ingrained in our organizational culture. In the best-selling management book In Search of Excellence, we are reminded to "stick to the knitting," and management gurus continually encourage organizations to stay singularly focused. However, when implemented in developing countries, this approach has significant limitations because the scarcity of services and of available resources is much greater than that of developed nations. There are simply too many pressing needs and not enough effective services for people. This reality is further exacerbated for people with disabilities who are often oppressed and ostracized and have been without any formal services at all.
This single phenomenon of exporting service models to developed countries has very important implications with regard to the overall effectiveness of rehabilitation services and to certain fundamental organizational development principles. Despite the apparent differences in available resources and differing cultural attitudes, many NGOs tend to export rehabilitation service models from developed countries to developing countries. In most cases, this is counterproductive to the social and economic integration of people with disabilities.
For example, even in developed countries, some traditional human services such as sheltered workshop and other types of vocational programs and congregate living (as represented by large institutions and groups homes for the disabled) often gather together people with disabilities, thereby diminishing the likelihood of obtaining social and economic integration (i.e., obtaining competitive employment or having a meaningful role within the community). In developed countries, these service models have failed to help people with disabilities obtain real employment for competitive wages. Similarly, congregating and segregating people with disabilities in a variety of rehabilitation programs and special education programs continues to reinforce negative stereotypes and fails to promote inclusion. By exporting them to other countries, the inherent weaknesses within these service models and the impact of these shortfalls are often aggravated in countries that do not have the resources to buffer or protect their most vulnerable people. Yet, despite their shortcomings, we continue exporting these service models to locations where they are even less likely to be successful.
Throughout Central America, and especially within poorer countries such as Nicaragua and Honduras, there are enormous gaps in rehabilitation services. Due to poverty and overarching social issues, NGOs must operate within the context of myriad challenges and address multiple problems simultaneously. This reality brings with it significant implications with respect to rehabilitation program design. In short, seldom does a singular service remedy the multiple problems faced by the individual. In these countries, starvation, sickness, lack of potable water, post-traumatic stress from war or stepping on a landmine, and unemployment are rampant. Simple solutions, such as a quality artificial limb, will do little to make life better in and of themselves. Therefore, to truly help people with disabilities in Central America, it can be useful and often is imperative to employ a holistic approach to rehabilitation services. And given the reality that there is a dearth of both rehabilitation programs and highly specialized services to address all the problems that people with disabilities face, it becomes necessary for organizations to address several areas of need, oftentimes simultaneously.
A Commitment to People
To seriously address the problems that people with disabilities in Central America face over an extended period of time (far longer than any grant cycle or fleeting political interest), a commitment to the people must be developed. The main challenge of a holistic approach to CBR is that it requires a long-term commitment to people with disabilities that supersedes any obligations to government programs or projects, as well as any reliance on grant cycles. This challenge must be met by NGOs. It is simply impractical, often impossible and occasionally immoral to walk away from programs because of unrealistic expectations that all projects can become self-sufficient within an allocated period of time that coincides with a grant cycle. In Central America and many developing countries throughout the world, this is an unfair, unrealistic expectation given the larger challenges they face.
Rehabilitation services, particularly those in the field of prosthetics, require a long-term commitment. Frequent adjustments due to natural physiological body changes mean that adults need new prosthetic limbs every couple of years. Due to the changes caused by rapid growth, children need new prostheses even more frequently. Additionally, prosthetic components break or become worn due to excessive use and therefore need regular replacement. For people requiring prostheses, the need is perpetual. Consequently, effective service models and delivery services must react accordingly if they are to be a permanent solution rather than a temporary fix.
Because human service programs exist in a complex system of competing interests, it is important to find ways to safeguard the commitment to the real needs of the service recipients. Individual and collective interests—such as containing health costs, wage and benefit considerations, contracting agreements, and innumerable other pressures and issues—influence service delivery. Therefore, to best address the needs of the people while considering the social situation at large, NGOs should develop an organizational culture that values the notion of prudence and develops both internal and external safeguards to secure program integrity and effectiveness. Organizational prudence indicates an acknowledgement of fallibility and suggests the need for program safeguards that are independent of each other and can function in a variety of important administrative and program areas. One example of such safeguards is employing local people, at least some of whom have a disability, within all levels of the organization. These systems are especially important for those organizations that wish to make a long-term commitment to people with disabilities in a manner that ensures the service remains coherent with people's service needs.
The Polus Center uses two "model coherency" planning process to identify its most pressing needs. Model coherency is a unique planning process that is extremely useful in both the initial planning stage and the future evaluation of human service programs. The process of coherent program development and planning begins by interviewing service recipients or potential service beneficiaries in order to gather information. Through extensive team interviews, important information beyond the immediate direct service need is ascertained. A person's social and economic status, ability to access other community activities and services, and personal relationships can influence future program design.
The pertinent information gathered through the interviewing process is then used to help design the ideal program. While it is understood that many constraints, such as limited financial and human resources and a countless number of competing interests, will prevent achieving the ideal, it is important to begin by describing a program service that would be ideal. In addition to providing valuable information relevant to program design, face-to-face interviews give agency personnel and those interested in program services the opportunity to identify and empathize with people who need service. This experience can help service designers/evaluators to understand the impact of particular life experiences of people who need services. In addition to gathering information, this process helps to identify local leadership and mobilize communities around disability issues, such as access, discrimination, and other public policy issues.With need clearly defined, it is then possible to propose a model for service delivery that ultimately reaches the right people with the most helpful service and in the most appropriate manner. Having clearly-defined services is crucial for the development of an organizational mission, guiding principles and an overall human service program that is truly responsive to people's needs.
Holistic Approach to CBR Services
In Nicaragua and Honduras, the Polus Center has used the above process to design and implement not only O&P services, but other needed services, such as vocational training, leadership development, and disability access. All of these programs have been designed carefully to address specific needs that were identified by many Nicaraguan citizens with disabilities, their advocates and various disability organizations.
Rehabilitation programs in Central America must be designed in the context of where and for whom services are most needed. This requires a creativity and flexibility in program design that can meet the most pressing needs of people with a wide array of disabilities and life problems. Exporting program models is not only ineffective, but fails to encourage innovation and local capacity building. People with disabilities must be the driving force behind program design and they should be involved at every level of program implementation. It is also imperative that programs are broad enough in scope to address multiple needs and are able to change in accordance with how particular needs change over time. Finally, organizations, donors and those who are committed to international rehabilitation must find ways to ensure program sustainability that is not tied to grant cycles and other barriers to long-term commitment.
*Photos and graphs c/o author.