Community-based rehabilitation (CBR)

Community-Based Rehabilitation (CBR) is defined (ILO/UNESCO/WHO Joint Position Paper, 2004) as a strategy within general community development for the rehabilitation, poverty reduction, equalisation of opportunities and social inclusion of all people with disabilities.

CBR is implemented through the combined efforts of people with disabilities themselves, their families, organisations and communities, and the relevant governmental and non-governmental health, education, vocational, social and other services. It is not simply “physiotherapy delivered at home” — it is a multisectoral development strategy.

Evolution: CBR began after Alma-Ata (1978) to extend basic rehabilitation to people who could never reach an institution. It has since evolved into a comprehensive, multisectoral approach now recognised as the core strategy for Community-Based Inclusive Development (CBID) — a shift from delivering services to the disabled to making the community itself inclusive.

Policy anchors: the Helsinki International Consultation (2003), the ILO/UNESCO/WHO Joint Position Paper (2004), World Health Assembly resolution WHA58.23 (2005) urging Member States to promote and strengthen CBR, and the WHO CBR Guidelines (2010) developed with over 180 individuals from nearly 300 organisations, mostly in LMICs. CBR is now implemented in over 90 countries, and the guidelines position CBR as a means of implementing the UNCRPD (Article 26 — Habilitation and Rehabilitation).

The WHO CBR Guidelines comprise 7 booklets — an Introduction with a Management chapter, one booklet per matrix component, and a Supplementary booklet covering HIV/AIDS, mental health, leprosy and disasters — areas historically neglected by CBR programmes.

Core principles: inclusion, participation, sustainability, self-advocacy, empowerment, non-discrimination, use of local resources and appropriate technology, community ownership, intersectoral collaboration, and referral linkage to secondary and tertiary services.

Three-tier structure: the person with disability and family at the centre → the community and CBR worker → linkage upward to district and referral services. The programme fails if the referral link is missing.

The rehabilitation setting should be a menu, not a single option — stand-alone rehabilitation hospitals, designated rehabilitation units, general wards, nursing and residential homes, day hospitals, community day centres, outpatient rehabilitation centres, and the patient’s own home. Ideally a range of options should be available to meet the needs of individual patients at a given time.

Intermediate care is intensive, short-term, community- or home-based rehabilitation that aims to prevent hospitalisation, facilitate early discharge from hospital, and/or maximise independent living. It is the geriatric bridge between hospital and home.

Community long-term care programmes that support CBR (Kane): home care (home nursing and homemaking), adult day care, adult foster care, assisted living, geriatric assessment, hospice, telephone reassurance, caregiver support, congregate housing, home repairs, congregate and home-delivered meals, respite care, and emergency alarms.

Home-based assessment and the home visit. A hospital-to-home assessment programme shortens hospital stay, allows evaluation of the home itself and how the patient actually functions within it, and can be targeted at those who will derive maximal benefit. Preventive home visitation aims at primary prevention (immunisation, exercise), secondary prevention (detecting untreated problems) and tertiary prevention (improving medication use) — but its benefits have not been definitively confirmed, so it cannot be recommended as routine practice.

Case management is the glue. In most cases a strategy for long-term follow-up and often formal case management should be developed to ensure that needs and services are appropriately matched and followed through. Discharge from hospital is a transition in rehabilitation, not its conclusion, and some follow-up is essential.

Integrated models: PACE (Program of All-Inclusive Care of the Elderly) uses pooled capitated Medicare and Medicaid funding to deliver integrated health and social services to older people who are nursing-home eligible but still living in the community — the best example of creative integration, though expensive and targeting a narrow group. Hospital-in-the-Home (Australia) delivers hospital-level care at home with quality at least equivalent to traditional hospital care in cost, satisfaction and medical outcomes.

Technology extends CBR’s reach. Remote sensors, wireless data transfer, GPS, robotics and mobile computer systems facilitate early transfer from hospital-based to home-based rehabilitation, with cost savings, fewer hospital-acquired infections, and return to a familiar environment. The same technology then maintains independence, reduces caregiver burden and prevents institutionalisation.

CBR team: the CBR worker / community rehabilitation worker (in India an ASHA, ANM or Multipurpose Worker), family caregivers, physiotherapist, occupational therapist, speech therapist, community nurse, social worker, primary care physician with geriatric linkage, Panchayati Raj and self-help groups, and Disabled People’s Organisations. Even in low-resourced settings, health workers can be trained to detect declines in physical and mental capacity and deliver effective interventions — the premise of the WHO ICOPE package, deliberately based in community and primary care to maximise accessibility, with Step 5 devoted to enlisting the community and supporting caregivers.

Institutional care is almost absent in low- and middle-income countries — only 0.1% of older people live in institutions in Iran, 0.6% in Botswana and about 1% in Brazil and Mexico, compared with 7.5% in Switzerland. This very lack of infrastructure opens the way to create alternative community-based long-term care systems.

Informal family care is the cornerstone. In dementia, informal care accounts for 58% of all costs in low-income and 65% in middle-income countries, versus 40% in high-income countries, while direct social care costs are only 4% in LMICs versus 42% in high-income countries. Most family care in developing countries is provided by women, and this supply is shrinking with female labour-force participation, migration and smaller families.

Advantages of CBR: low cost, wide coverage, culturally appropriate, uses local resources, keeps the person in their own environment and roles, reduces institutionalisation, empowers families, and addresses participation restriction, which hospital services never reach. Limitations: variable quality and supervision, dependence on committed community workers, weak referral pathways, poor evidence base for programme-level effectiveness, funding insecurity, risk of shifting the burden onto already-overloaded women in the family, and unsuitability for severely disabled or unsupported patients.

The scale of the need has been formally quantified A landmark study jointly developed by WHO and the Institute for Health Metrics and Evaluation established that one-third of the world’s population — about 2.41 billion people — live with a health condition that would benefit from rehabilitation, and that this need has risen 63% since 1990 (from 1.48 billion). The study establishes rehabilitation as a key strategy for universal health coverage in the 21st century and challenges the view that rehabilitation is an optional service needed only by a minority. The main drivers are ageing, rising non-communicable disease, and the consequences of injury, and more than half of those needing rehabilitation in LMICs do not receive it.

WHA76.6 (May 2023) — the first-ever WHA resolution on rehabilitation It calls for expanding and integrating rehabilitation into health systems as part of universal health coverage, with emphasis on rehabilitation in primary care and in emergency preparedness and response, and highlights the critical shortage of rehabilitation workforce. It was the first resolution to directly address rehabilitation in 75 years of the World Health Assembly, found global need largely unmet — in many countries fewer than half receive the care they require — and commits Member States to expand financing, integrate rehabilitation into national health systems, minimise the prohibitive costs of assistive technologies such as hearing aids, glasses, wheelchairs and prosthetics, and promote research.

World Rehabilitation Alliance and the Package of Interventions for Rehabilitation Following the 3rd Global Rehabilitation 2030 meeting (July 2023), WHO launched the World Rehabilitation Alliance (WRA), conducting evidence-based advocacy through five workstreams: (1) rehabilitation workforce, (2) rehabilitation in primary care, (3) rehabilitation in health policy and systems research, (4) rehabilitation in emergencies, (5) external relations. WHO’s Package of Interventions for Rehabilitation (PIR) helps ministries of health integrate rehabilitation into health systems, with particular focus on LMICs. PAHO has issued a Basic package of interventions for rehabilitation: a toolkit for primary care professionals (March 2025).

CBR is now framed as CBID; the evidence base is broadening but still thin CBR is described as a community development strategy promoting inclusion, participation and empowerment of persons with disabilities by addressing both physical and sociological barriers, now recognised as a core strategy for community-based inclusive development (CBID), with components not implemented sequentially but as a flexible “pick-and-mix” framework linking community resources with existing government services. A 2024 systematic review of the grey literature (International Journal of Mental Health Systems) examined CBR for people with psychosocial disabilities in LMICs — reflecting the continuing reliance on non-peer-reviewed programme evidence. Alongside this, the 2024 BMC Medicine meta-analysis showed geriatric rehabilitation in inpatient and day-hospital settings reduced mortality, care-home admission and functional impairment, and the BGS 2024 report argues rehabilitation should be a component of every service for older people.

India — the operational structures to name in an exam District Disability Rehabilitation Centres (DDRCs) were initially planned for 325 districts, but with effect from 9 December 2020 all districts were approved for DDRCs, funded under the Deendayal Disabled Rehabilitation Scheme (DDRS) from 2020–21. Services include survey and identification of persons with disabilities through a camp approach, awareness generation, assessment/provision/fitment/repair of assistive devices, support to ADIP/ALIMCO camps, vocational identification and training, and referral services. Each DDRC provides therapeutic services — physiotherapy, occupational therapy and speech therapy — and facilitates disability certificates, bus passes and concessions. Each is run by a District Management Team headed by the District Magistrate/Collector. Other Indian structures: NPHCE (19 Regional Geriatric Centres, 2 National Centres for Ageing), Ayushman Arogya Mandir / Health and Wellness Centres as the primary-care delivery point, ASHA/ANM as the CBR workforce, Rashtriya Vayoshri Yojana and ADIP/ ALIMCO for assistive devices, Composite Regional Centres (CRCs), and AB-PMJAY extended to all aged ≥70 years (2024). Key legal gap: the Rights of Persons with Disabilities Act, 2016 governs disability services, but age-related functional decline does not automatically confer “disability” status, so many frail elders fall outside the DDRC pathway — an argument for explicitly linking NPHCE and DDRC services.

CBR = a strategy within general community development for rehabilitation, poverty reduction, equalisation of opportunities and social inclusion (ILO/UNESCO/WHO, 2004).

CBR Matrix = 5 components × 5 elements = 25: Health, Education, Livelihood, Social, Empowerment.

Health component elements: promotion, prevention, medical care, rehabilitation, assistive devices.

Empowerment elements: advocacy and communication, community mobilisation, political participation, self-help groups, Disabled People’s Organisations.

WHO CBR Guidelines (2010) = 7 booklets; supplementary booklet covers HIV/AIDS, mental health, leprosy and disasters.

WHA58.23 (2005) urged Member States to strengthen CBR; CBR runs in over 90 countries.

CBR is the operational vehicle for UNCRPD Article 26.

CBR complements, never replaces, hospital rehabilitation.

Intermediate care = short-term intensive community/home rehabilitation to prevent admission, enable early discharge and maximise independence.

Day care may make the critical difference in keeping an impaired elder at home — often through carer respite alone.

Senior centre = well elderly; day care = functionally limited; day hospital = rehabilitation-focused ambulatory hospital care.

Institutional care is ~0.1–1% in LMICs versus 7.5% in Switzerland.

Informal care = 58–65% of dementia costs in LMICs versus 40% in high-income countries.

2.4 billion people need rehabilitation; over half in LMICs do not receive it.

India: DDRCs are now approved in every district.