Community-Based Rehabilitation (CBR)
Evaluation Framework
Manjula Marella
Co-authors: Ecosse Lamoureux and Jill Keeffe
Centre for Eye Research Australia
University of Melbourne
Community-based rehabilitation (CBR)
 The World Report on Disability identifies CBR
as an important component of health systems
 Rehabilitation within one’s own community
using local resources
 The World Health Organization (WHO)
guidelines promote a comprehensive system
addressing Health, Education, Livelihood,
Social participation and Empowerment of
people with disabilities
Effectiveness of CBR services
 Evaluations published on CBR programs lack
evidence-based research
 Published evaluations are mainly descriptions of
services
 Different methodologies and indicators used for
evaluations
 Common indicators and a systematic framework
for evaluation that are valid for different settings
of CBR are essential
Evaluation framework
 To address the gap in the literature related to
effectiveness of CBR programs, the Centre for
Eye Research Australia (CERA)-CBR Framework
(CCF) has been developed
 The CCF includes indicators to
comprehensively evaluate CBR programs
CERA – CBR Framework (CCF)
Delivery
Components Service
System
Key Areas
Program
Management
Networking
Outcomes
Availability of
Services
Program
Planning
Linkages
Intended
outcomes
Utilisation of
Services
Human
Resources
Referral
System
Functional
independence
Quality of
Services
Infrastructure
Advocacy
Psycho-social
Coverage
Support from
families
Education
Sustainability
Support from
community
Economic
Independence
Empowerment
Changes in
Community
Manjula Marella, CERA November 2010
Satisfaction
with services
Key area
Themes/Questions
Indicators
Eligibility to enrol
Enrolments
Client demographics
Average number of clients
enrolled per year
Waiting time
Waiting list
Utilisation of services
Number of clients on waiting list
Dropouts
Number of clients who
discontinue annually
Socio-demographic profile of
dropouts
Gender ratio of dropouts
Reasons for dropouts
Developing questionnaires
 Questions for each indicator
 Data collection methods and
sources
 Key informant questionnaires
– CBR staff
– Clients and Family members
– Government (Health and Social
Welfare)
– Eye care practitioners
– Disabled People Organisations (DPOs)
– Non-government organisations (NGOs)
Face validity of the CCF
 Reviewed by an expert panel (n=7)
– CBR
– Evaluation methods
 To assess the appropriateness of the content and
structure of the CCF
 The CCF was modified based on the feedback from
the panel
 Modified version of the CCF included 230 indicators
Field-validation of the CCF
 Fiji Society for the Blind (FSB)
 Cambodian Development Mission for Disability
(CDMD)
Field-validation of the CCF
Fiji
Cambodia
Total
Population
Location of
services
Number of CBR
workers
Types of
services
944,720
14,494,293
4 areas of Viti Levu Island
4 provinces (29 districts) in the south
4
20
 Functional rehabilitation
 Referrals to hospitals, social
welfare department and special
education.
 Inclusive education program is
only for high school students
 Functional, vocational and social
rehabilitation
 Empowerment
 Referrals to hospitals and inclusive
education
Sample size
38
148
Analysis





Collated responses from various stakeholders
NVivo 8
Qualitative analysis
Strengths and limitations of the CBR programs
Usefulness of indicators
– Applicable (relevant to the context of services)
– Measurable (feasible to obtain data)
 Triangulation – information obtained from
different sources and compared
1. Service delivery system
Fiji
Cambodia
Strengths
• Medical model of
• Social model of
rehabilitation:
rehabilitation addressing all
components in the WHO
- functional skills training and
CBR matrix: health,
- referrals to school for the
education, social, livelihood
blind
and empowerment
• Regular follow-up and
monitoring systems
Limitations
• Lack of systematic follow-ups • Unable to manage children
and internal monitoring
<5 years
protocols
2. Program planning
Fiji
Cambodia
Strengths
• Saving costs associated with • Involvement of external
office space and transport by
stakeholders to plan
working in collaboration with
activities
Social Welfare and Eye
departments
Limitations
• Activities do not match with
the goals of the program
• Poor financial sustainability
• Poor financial
sustainability
3. Networking
Fiji
Cambodia
Strengths
• Collaboration with Social
Welfare and Eye
departments for resources
• Involving families in
rehabilitation of the clients
• Good compliance with
referral services
• Involving families in
rehabilitation of the clients
• Advocating for inclusion of
PWDs
Limitations
• Poor collaboration with DPO
and government
• Lack of community
involvement in CBR program
• Accessibility to referral
services
• Poor collaboration with DPO
and government
• Lack of community
involvement in CBR program
• Negative attitudes of staff at
referral centres
4. Outcomes
Fiji
Cambodia
Strengths
• Improvement in daily living
skills
• Changes in community
attitudes
• Inclusion of clients in
community as a result of selfhelp groups and income
generation
• High client satisfaction
- 35 (81%) clients and 52 (88%)
family members interviewed
felt their needs were met
Limitations
• Client satisfaction
- 4 (36%) clients and 7
(50%) families interviewed
felt their needs were met
• Lack of systems to evaluate
outcomes of services
• Lack of systems to evaluate
outcomes of services
Usefulness of the CCF
Overall 230 indicators in the framework
Fiji
Cambodia
Both
Applicable
201 (87%)
219 (95%)
197 (85%)
Measurable
167 (83%)
178 (81%)
156 (79%)
Discussion
 The CCF is comprehensive and useful to evaluate
the effectiveness of CBR programs
 First study to compare two models of CBR
 Comprehensive model of CBR is feasible and
more effectively meets the needs of the clients
 Recommendations provided based on the
findings using the CCF helped the organisations
to plan new services and strategies
– Training of staff
– Plans for financial sustainability
Application of the CCF
 144 (63%) indicators were derived from the
literature where they were not proposed for
any specific disability
 The majority (197, 85%) indicators were
applicable to two different settings
 The framework is likely to be applicable to
different programs irrespective of model and
type of disability
Limitations and recommendations for
future research
 The component ‘outcomes’ needs further
validation
 Only two case-studies in this study
 Does not include economic analysis
 Application in other settings including
developed countries
Summary
 The CCF has been developed to evaluate the
effectiveness of vision-related CBR programs
 Field-tested in two different CBR settings in Fiji
and Cambodia
 Practical and useful to investigate the
strengths and limitations of the two CBR
programs
Acknowledgements
 Supervisors: A/Prof Ecosse Lamoureux and
Prof Jill Keeffe
 Fiji Society Blind and Cambodian Development
Mission for Disability
 Vision Cooperative Research Centre (CRC)
 University of Melbourne
Thank you