Hesperian Health Guides
Chapter 45: Starting Village-Based Rehabilitation Activities
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Top-Down or Bottom-Up?
Around the world today there are many examples of what have sometimes been called “community-based rehabilitation programs.” Some of these are imposed upon the communities they serve. They may work well or not so well. We call them “top-down.” Others arise from within the community. We call them “bottom-up.”
Top-down: Chain of command
Top-down programs or activities are mostly planned, started, organized, and controlled from outside the community: by government, by an international organization, or by distant “experts.” And the local leaders are usually persons in positions of authority, influence, or power.
Bottom-up: Equality in decision-making
Bottom-up programs or activities are those that are largely started, planned, organized, and controlled locally by members of the community. Much of the leadership and direction comes from those who need and benefit most from the program’s activities. In brief, the program is small, local, and user-organized.
Community participation is important to both top-down and bottom-up programs. But it means something different to each:
In top-down programs, people are asked to participate only in ways that have already been decided from above. For example, a decision might be made by a team of foreign specialists that certain persons in each community be selected as “local supervisors.” The local supervisors are taught several pre-decided “packages” of cookbook-like information. Each supervisor then instructs a given number of “local trainers” (family members of the disabled) how they must train each particular person with disabilities. Thus community participation, from the viewpoint of the experts, means “getting people to do what we decide is good for them.”
In bottom-up programs, community participation means something else. The program develops within a village or neighborhood, according to the needs and wishes of its members. It may take an outsider with some knowledge in rehabilitation and skill in organizing people to help get things started. But it is the people themselves, especially people with disabilities and their families, who make the decisions about their own program. They can learn from other programs and from the experts. But they do not simply copy or follow others. They pick and choose from whatever advice and information they can get in order to plan activities that fit the needs and possibilities of their particular village, and their particular children.
There are advantages and disadvantages to both types of program. For a central government, a standardized, top-down approach is easier to introduce, administer, and evaluate in many communities at the same time. But in primary health care, it has become clear that these programs frequently fail or have serious weaknesses, mainly because they do not have enough popular leadership, understanding, and personal commitment. These are especially important for rehabilitation. Every child with disabilities is different and has her unique combination of needs. An imaginative, problem-solving approach is essential. If decisions and plans come pre-packaged from above, rehabilitation measures often do limited good and sometimes even harm.
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| In the village of Ajoya, Mexico, over 60 families participated in building a cement walkway from the rehabilitation center to the main street. |
When a program is organized from within the community, there is a greater sense of equality, and of arriving at decisions together. People do not just follow instructions. They consider suggestions. They want to know why. This greatly increases the chances that exercises, aids, and activities will really fit the individual needs of the child. It also makes rehabilitation more interesting, meaningful, and valuable for all concerned. It helps both parents and children become more independent.
This approach to rehabilitation has the advantage of flexibility and adaptability that comes from being organized and controlled locally. Planning is a continuous learning process that responds to the changing needs, difficulties, and possibilities within the community. Especially when people with disabilities and family members play a leading role, participants at every level are likely to develop a spirit of respect, friendliness, and equality that keeps a program human and worthwhile.
Above all, a program organized by those it serves decentralizes and redistributes power: people who have been powerless begin to find strength through unity. You can never be sure where things may lead, how far people may go in terms of taking charge of their own lives or in demanding their rights.
On the following pages we look at community rehabilitation activities and programs organized from within the communities they serve. This is where our own experience lies. For a different approach with more of the planning from above, we suggest you see the World Health Organization’s Training In the Community for People with Disabilities along with the supplementary materials.