The Convention has been deemed revolutionary, a long-awaited victory for the world’s largest minority (Convention on the Rights of Persons with Disabilities 2009). And, to whoever might wonder why the Convention represents such a watershed moment, the United Nations’ data on disability provide clear answers. Currently, people with disabilities constitute over 10% of the world’s population, a number that steadily increases along with population growth, average life expectancy and the range of medical resources to prolong or protect life (World Health Organization 2009a). Most of them, over 80%, reside in the southern hemisphere, and 20% of the ‘bottom billion’, the poorest people on Earth, live with a disability. People with disabilities are chronically and vastly under-represented in all social systems, including education and employment (Werner, 1998 and Wiman et al., 2002), and United Nations Children’s Fund (UNICEF) studies also indicate that 30% of street children struggle with a disability (Convention on the Rights of Persons with Disabilities 2009).

Since only 45 countries have so far embedded legislation aimed at protecting the rights of people with disabilities in their legal framework (Turmusani et al 2002), these rights have remained largely ignored (Thibeault, 2008 and Boyce and Lysack, 1997). People with disabilities are routinely perceived as second-class citizens incapable of making their own decisions and are often treated as wards of the state. Recognition of their rights was and is still a precarious affair, but it gained considerable momentum in the early 1970s with the advent of primary healthcare (PHC) (Périquet 1984). This new concept called for true community consultation, participation and education in healthcare and it appealed greatly to people with disabilities. Quickly percolating through their ranks, it gave rise shortly thereafter to a budding movement by and for people with disabilities called community-based rehabilitation (CBR) (Boyce and Lysack, 1997 and Willig-Levy, 2009). Through a series of grassroots initiatives mostly taking place in the southern hemisphere, CBR gradually established itself, but with numerous glitches along the way. Perceptions softened slowly, with government agencies still leaning towards patronizing attitudes and top-down decisions imposed without consultation with people with disabilities. The first major breakthrough occurred in 1978, at the Alma Ata conference on primary healthcare, held under the aegis of the World Health Organization (WHO). In Alma Ata, health was defined as a prerequisite to socially and economically productive lives. Burden of disease and disability, and its associated costs, were then identified as major obstacles on the road to economic self-sufficiency for the southern hemisphere. It was imperative to resolve the issue for the economy to run smoothly and, to do so, two main strategies were proposed. The first was called Disability Prevention through Impairment Reduction. This strategy implied that all social sectors needed to be mobilized in order either to prevent disability or to adapt to existing disabilities. The onus of full social participation shifted from the individual to society, and the confining of people with disabilities to institutions or lives of stigma and ostracism was no longer seen as acceptable. The second strategy, Rehabilitation Delivery, entailed the design of community-based services with an appropriate system of supervision and referral. Together, these two initial strategies articulated CBR core values and gave a more definite shape to the emerging movement. CBR was officially born (Périquet 1984).

Over time, the two initial strategies of Disability Prevention through Impairment Reduction and Rehabilitation Delivery expanded into more complex conceptual horizons. New notions and paradigms were integrated, fleshing out the original philosophical nucleus. These notions or paradigms were not specific to the context of disability, but were inserted into the growing CBR framework for their relevance to any vulnerable population. Among them, the following have exercised the greatest influence on CBR’s evolution.

In the 1960s and 1970s, the concept of empowerment nearly became a household name, thanks to the Independent Living Movement that spread through the USA and beyond (Willig-Levy 2009), bringing independence for people with disabilities into the realm of the possible. It was defined as ‘the multi-dimensional social process that helps people gain control over their own lives … and that fosters power in people for use in their own lives, their communities and in their society, by acting on issues they define as important’ (Page & Czuba 2009, p.1).

Empowerment meant that people with disabilities could and should be involved in all decisions concerning them. This was especially contentious at the time since, in CBR, the word disability applies just as much to the psychological as to the physical, and ostracism of those with mental disabilities was even more prevalent then than it is today.

The concept of enablement was coined shortly thereafter and could be described as the operational application of empowerment. While empowerment aims to ascertain the legitimacy of making choices, enablement provides the means to actualize decisions. Going beyond the notion of power, it encompasses ‘the adequate power, means, opportunity, or authority (to do something), to make (something) possible’ (Reverso 2009, p.1). When implemented correctly, enablement should translate into full participation, facilitation and self-advocacy (Helander 1999).

As means and opportunities are closely linked to resources, which are often quite scarce in the southern hemisphere, new ways of addressing the challenges faced by people with disabilities had to be explored. These included the creative provision of low-cost services and, because professionals are too costly to offer and monitor services continually on site, the responsibility of day-to-day service delivery was passed on to local communities. Two principles were then added: a commitment to low-cost services and a clear recognition of the local communities’ responsibility for their CBR programmes (Gautron 1999).

Finally, in the early 1990s, the Disability Action Group, a unit within the United Nations Development Programme (PNUD), embedded CBR within the WHO structure and anchored its foundations in five guiding principles: equality, social justice, solidarity, integration and dignity for all persons with disabilities (ILO et al 2004). This is why, in many ways, CBR is considered more of a social movement than a rehabilitation approach. And, as with any social movement, its main purpose is to change mentalities.

The 2004 joint task force presented CBR as:

Despite apparent clarity, significant debate has occurred over the structure of CBR. Initially meant as a purely bottom-up rather than top-down approach (Werner, 1988, Werner, 1998 and Peat, 1997), it did not deliver on its promises of yielding purely grassroots rehabilitation systems. The original vision revolved around communities that would spontaneously initiate the request for rehabilitation services and involved six major groups that would join forces to provide a continuum of care (Helander 1999); people with disabilities, at the centre of the process, would define their needs and be assisted by volunteer family trainers, local CBR agents and local stakeholders, who together constitute the local CBR committee. In turn, whenever needed, this local CBR committee would call upon personnel in referral facilities and national specialists to tackle issues too complex for local means. However, this ideal scenario remained elusive; people with disabilities frequently lacked the necessary awareness and self-confidence to launch the projects, and the impetus for the creation of CBR programmes came mostly from the outside. ‘Hybrid’ CBR programmes have thus emerged that bring together a wide range of players wielding varying degrees of influence (Finkenflügel et al., 2008 and Kuipers et al., 2003).

Currently, there are over 10 different configurations that would still qualify as CBR programmes (Finkenflügel et al 2008). Their common, defining CBR features lie in keeping the needs and quality of life of people with disabilities as the main focus, remaining rooted in the local community and promoting equal opportunities. Since the 2004 joint paper, efforts have been made to introduce within the general CBR agenda the issues of human rights, poverty, inclusive communities accessible for all, and a more active role for organizations of people with disabilities.

Although some CBR programmes have taken hold in the developed nations, most occur in the southern hemisphere in poor urban or rural settings. In the northern hemisphere, except for the Canadian Arctic (Thibeault & Forget 1997), CBR programmes have been developed by relatively affluent subgroups such as farmers with disabilities or ethnic minorities wishing to ensure delivery of community rehabilitation services in their mother tongue (Peat 1997). Although these are still the exception, several analysts and healthcare providers advocate the use of CBR in wealthier economies as well (Peat, 1997, Hirsch, 2009 and Lindsay et al., 2008).

CBR usually unfolds according to a 15-step process but, given the diversity of CBR formats (Finkenflügel et al 2008), these steps only reflect general guidelines and not cast-in-stone directions. Moreover, the steps do not necessarily always follow this sequence in a linear fashion.