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1. Introduction
The global report on disability shows that more than one billion people worldwide have some form of disability [1]. Meanwhile, estimates of government resources in Iran indicate a disability rate of about %4 in the Iranian population [2]. Rehabilitation is defined as the process of using the combination and coordination of medical professional, social, and psychological measures to enable individuals to achieve the possible highest level of positive health and, thus, achieve social integration [3]. Following the slogan Health for All in the Alma-Ata declaration at the International Conference on Primary Health Care in 1978, the World Health Organization (WHO) identified community-based rehabilitation (CBR) in 1981 as a strategy for rehabilitation, equalization of opportunities, poverty reduction, and social inclusion of people with disabilities (PWDs) [4]. CBR has been specifically designed for low- and middle-income countries where 80% of PWDs live and are significantly deprived due to the general lack of government support [5]. Therefore, CBR includes various strategies in collaboration with different sectors to empower PWD, their families, and community members to meet basic needs and facilitate their access to health, education, and job opportunities [3, 6]. People who live in rural areas and are far from care centers need more healthcare services due to long distances and poverty [7]. CBR faces challenges, such as a lack of understanding of professionals and staff, which reduced awareness of physical, environmental, financial, and personal experiments [8, 9, 10]. There are also more challenges, such as poverty, lack of access, ineffective referral system, and insufficient budget in the long-term implementation of the program [11, 12, 13]. Therefore, CBR is an approach to address issues related to disability and limited access to rehabilitation, especially in developing countries [14, 15]. In Iran, there are also many challenges, including difficult access, financial problems, and the cost of providing rehabilitation services to PWD [16, 17]. CBR has a long-term positive effect on PWD and is of particular importance for growth and development in disadvantaged communities [18]. CBR program in Iran seeks to gain community support, meet the needs of all PWD and strengthen their role in the program. Despite vital problems, such as poverty, deprivation, the distance of villages from urban areas, and budget constraints, the CBR program has been able to provide 93% coverage in Iran and provide individuals with disability in rural areas and a limited number of disadvantaged cities of 31 provinces with significant access to the services of Welfare Organization and other sectors in charge of governmental organizations [19]. Despite the significant benefits and effects of the CBR program in improving the quality of life of PWD and the government’s commitment to expanding the program in rural and urban areas, its implementation in the country has faced severe problems. Due to the complexity and abstraction of the phenomenon and the lack of knowledge and the studies with a qualitative approach in Iran in this area and its dependence on the context in different societies, this study aimed to create a better understanding of the CBR program based on the experiences of various stakeholders of CBR services and identify the challenges of implementing these services to improve the quality of service delivery, and ultimately, empower PWD. Identifying and anticipating these challenges is essential to implement the CBR program more effectively.

2. Materials and Methods
Study design and participants
This qualitative research used conventional content analysis. In this method, the concepts were extracted directly from the data through interviews and after coding that can be identified through a systematic classification and explicit themes or patterns in the text [20]. 25 Participants were selected from different job positions of the national, provincial, and city headquarters throughout Iran using a purposive sampling with work experience of more than five years from the staff at different levels, managers, experts, and non-governmental organizations working in the CBR project. 

Data collection
The semi-structured face-to-face interview was used to collect data. Each interview began with an open-ended question: What is your experience of the challenges of implementing the CBR program at different levels, including local, city, provincial, and national? Continued with follow-up or explorative questions based on the participant’s response: Can you explain which one? Give an example. Explain more. The interviews continued until data saturation, i.e., until no new data were extracted after observing the data by the research team. 

Data analysis
Conventional content analysis was used to analyze the data described by Graneheim and Lundman [21]. The content of each recorded interview was transcribed verbatim and read line by line several times until a general understanding of the text was obtained. Then semantic units were condensed, and their open coding was performed, and then a code was assigned to the main concepts in the semantic unit summary. By comparing similar codes, a list of subcategories was obtained. Based on the subcategories’ similarity and relationship, the categories were classified.

Trustworthiness
The four-dimension criteria (credibility, dependability, confirmability, and transferability) proposed by Guba and Lincoln [22] were used to evaluate the extracted data rigor. To confirm the credibility of the data, the technique of long-term engagement with data (12 months) was used [23]. The strategy of checking the interview with the participant was used to meet the data dependability [24]. For meeting the transferability of data, the conditions for using the findings in other social contexts were provided by in-depth and analytical and clear descriptions of the background and characteristics of the participants, study context, and challenges and limitations [22]. To achieve confirmability, all stages of the research, especially data analysis, were recorded in detail so that another researcher can easily follow this work based on the available documents related to the interviews, analyses, and other stages of the research.

3. Results
25 participants were selected from the staff of the Welfare Organization at different levels, including 14 experts, six managers, three middle facilitators, and two NGOs 0.052 of the participants were male and 0.048 were female. Participants had 5 to 23 years of experience in the implementation of CBR for PWD. All participants had education from bachelor’s and doctoral degrees.
The participants of this study were 25 people whose demographic characteristics are shown in Table 1. 

The results were displayed in Table 2 in the form of eight main categories and 39 subcategories as challenges in implementing of CBR program in Iran. 


Neglecting the local conditions and role of provinces
One of the most critical factors in implementing the CBR program in Iran is the cultural and local context and lifestyle of people in different parts of the country. Lack of freedom of action for the provinces in implementation based on the existing potential in their areas and their non-participation in planning was another problem. The approved annual budget of the program did not meet the needs of PWD in the provinces, and the provinces had to provide unrealistic statistics and performance to the country’s headquarters to receive more funding. This category included four subcategories. In this regard, a participant stated: “A significant challenge is the program’s localization, but it is ignored. I mean the principle of CBR is that its rules and regulations should come from the local community and be transferred to higher levels, but in some cases, it is not observed.”
Another participant said: “Experts in the provinces are not allowed to comment on the entire program. Credit and business policies are not known at all, and they do not tell us how to plan!”

Poor policymaking and planning
Adopting policies and strategies without the involvement of work partners, lower-level stakeholders in planning and making decisions based on personal opinions and higher-level authorities created problems in proper planning and policymaking, which was the most critical problem of implementing a CBR program. 
Other problems in this area were the obsolescence of the program instructions, the existence of different methods and instructions, and the lack of a comprehensive guideline for implementing the program. Overall, this category had ten subcategories. Regarding the expansion of the program without capacity building, one participant stated: “One of the major problems is the uncontrolled expansion of the CBR, without having the sufficient human and financial capacity to implement the program; the implementation has been outsourced to the non-governmental sector, which requires a high capacity of institutions and NGOs; however, no capacity building has taken place.” Regarding parallel working, one participant said: “The problem in the field of rehabilitation is the parallel work of many activities. This parallel working does not allow the CBR program to provide effective services.”

Deviation from the primary goals
One of the critical reported challenges was getting away from the main goals of the program, which included five subcategories. It is essential for authorities to fund the program, and no attempt has been made to change the current situation and return the program to the main path, which is inclusive community-based development. None of the CBR program components are performed. Employment of PWD as the only goal emphasized by managers has not been achieved due to the lack of necessary planning for sustainable employment and lack of legal resources and support, and the components of health and rehabilitation have been neglected. A participant stated in this regard: “The person with a disability and his/her family should solve their problems in health and treatment. This issue is highly neglected; their employment and livelihood are suitable, but later they may have bedsores. They do not have the skills to drive a wheelchair; their family does not know either. Other problems mentioned by the participants were the frequent changes of managers at the city, province, and headquarters levels and their lack of knowledge of the program, unwillingness to get acquainted with the principles of the program, and, thus, their lack of cooperation in the program.”

Lack of a comprehensive evaluation system
Another critical challenge based on the participants’ experiences is the lack of a comprehensive monitoring and evaluation system that had four subcategories. For many rehabilitation activities, some systems have been defined for monitoring and control, and the CBR program is one of the few programs that the information of the covered people, the services they receive, assessments, the self-help groups active in the program, the performance of non-governmental institutions, the number of created sustainable jobs, and the number of meetings of the Rehabilitation Council are not recorded in a specific information system; all the information is recorded in a traditional way (written). One of the participants stated: “Is it possible to get enough information only based on provincial statistics and without presence and supervision in the province? There is no system for monitoring and evaluating the program. Provinces report as they wish and receive more budgets.” “If an expert does not do his/her job properly, there is no indicator to evaluate his/her real performance”, said another participant.

Inefficient resource management
Another main category related to the challenges of the CBR program was inefficient resource management, which had five subcategories. Among the problems raised by the participants in this field are the very low per capita allocation to provide services to each person and the reluctance of managers to increase the per capita budget. The annual budget forecast does not consider the growing population covered by the program. In addition to the many problems in the budget provision, their allocation to the provinces is not timely, which confuses the provinces at the end of the year to spend the funds. In this regard, one of the participants said: “The per capita income of each disabled person is so low that if a walker is purchased for him/her, his/her per capita will run out by the end of the year. If you give a disabled person an employment allowance, you should ignore the annual per capita of 40 people with a disability to give one person an employment allowance.” 
Other problems related to resources are the lack of manpower at various levels, which has caused severe problems in implementing, teaching, monitoring, and supervising the program. One of the participants stated: “Colleagues assigned for country issues, who are two people, cannot perform supervision and management in the whole country at the same time. In the city, we have one CBR expert for 50 villages. Village monitoring needs facilities and credit; how can one supervise implementing the CBR program in 50 villages?”

Weakness in the facilitation approach
The use of local facilitators instead of using those working in health centers, while the necessary infrastructure and capacities were not provided and work partners had no cooperation, created challenges in the CBR program classified into four subcategories. Low necessary capabilities in local facilitators in terms of educational level, basic knowledge, how to communicate and interact with PWD and their families, and how to attract the participation of the local community and work partners were among the factors that led to negative attitudes towards them and their non-acceptance among work partners. One of the participants indicated this problem: “Choosing a facilitation approach was a necessity at that time; it was supposed to be a strategy parallel to the work of business partners, not just an approach alone. The reason that facilitators are not recognized by the village head assistants and health workers is that the facilitators were supposed to go to the heart of the local community and ask the health workers to participate in the program, but this did not happen; they did not play their essential roles as the facilitator, because they had no related skills.” 
The selection of local facilitators from the rural community is often based on their unemployment and expectation of income generation, and their interests and motivation are not considered during the survey. Most of them leave the program due to the difficulty of traveling to multiple villages, low wages, and lack of insurance support, and the institutions are forced to recruit and train new personnel, which imposes additional training costs on institutions. One of the participants said: “Due to the lack of cooperation of health workers, the organization was forced to use facilitators. Each city has selected a facilitator, but in selecting them, their interest and tendency have not been considered.”

Inadequate communication
Due to the gradual evolution of CBR towards a multi-sectoral development approach, the necessary infrastructure for the realization of this approach is to establish communication and interaction between the systems involved in the program. Participants’ experiences of communication challenges at various levels led to the extraction of two subcategories. The weakness of the program’s policymakers in taking actions, such as attracting the cooperation of work partners, concluding a memorandum of understanding, holding joint meetings, and informing the senior managers of the organizations related to the program were the problems reported by the participants in this field. One of the participants stated: “If we had done better in promoting health, the support of the ministry of health from the program, which is the only work we have in common with them, would have been better attracted.” The lack of proper communication, even between the deputies within the Welfare Organization, has led to several problems, including parallel work and the gradual weakening of the program. Failure to hold international congresses, lack of communication with the CBR managers of other countries, and lack of coordination and communication with the WHO’s rehabilitation director to monitor and supervise the program’s implementation had a significant negative impact on the quality of program implementation in Iran. In this regard, one of the participants said: “In 2010, we were a matrix analyst and sent our action plan to the WHO, but now we have nothing to do with the world. They didn’t see us in 2020, and we had no connection with them. We do not know the news about the program in other countries or what they are doing for the 2020 version.”

Inefficiency of NGOs
NGOs in the form of institutions and associations for disabled cases can play an essential role in demanding, empowering, and social participation of PWD; however, according to the participants, these organizations in the cities did not have enough potential to implement the program; they did not do the necessary capacity building, and their activities caused problems in the program. This category was reported in three subcategories. Even though one of the strategic policies of the CBR program is networking at various levels, the failed network connection of NGOs in the cities with active provincial and national associations has faced this networking with problems. Capable and high-potential NGOs generally operate independently and are reluctant to participate in the implementation of the program. On the other hand, newly established NGOs that entered the program showed poor performance. One of the participants stated about the problems of these NGOs: “the CBR program has been outsourced to the non-governmental sector but dependent on government funding. If this funding is cut off and the facilitator does not receive the money, the activity will be stopped.” 

4. Discussion
The current article was conducted due to the importance of CBR services for PWDs. The study results showed that various factors are challenges in implementing a CBR program in Iran. The main categories extracted according to the experiences of participants included (1) neglecting the local conditions and role of provinces, (2) poor policymaking and planning, (3) deviation from the main goals, (4) lack of a comprehensive evaluation system, (5) inefficient resource management, (6) weakness in facilitation, (7) ineffective communication, and (8) inefficiency of NGOs. In previous studies, the concepts of limiting the participation of provinces in planning, forcing provinces to provide unrealistic data, and ignoring the performance differences of provinces related to the first category have not been mentioned as obstacles for implementing a CBR program. What should be considered in planning and policymaking is to pay attention to the potential of the provinces in terms of resources, culture, beliefs, customs, and lifestyle of the people, and geographical conditions and social context of the region, which are different in different provinces. The non-involvement of the provinces in the decision-making and planning affected the results of the CBR program implementation. Unreal data also led to a waste of resources. The results related to the second category indicated that policymakers expanded the program without capacity building, which led to other problems, including the adoption of incorrect policies regarding self-help groups that led to the non-continuation of activities of these groups. According to the findings, many countries, such as Ethiopia, Tanzania, and Mauritania, have adopted the CBR as a national strategy for more than ten years but have no national plan because external resources are mainly used to start CBR programs in these countries. In countries, such as Gabon, Congo, and Mauritania, national CBR programs began with the support of international NGOs but were stopped due to cutting off funding [25]. These results showed that the stewardship of the program implementation in these countries is unclear, and the government is not responsible for its implementation, which is similar to the result of our study under the subcategory of unknown stewardship related to the second category. Evidence has shown multiple stewardship in rehabilitation [26, 27]. 
Other subcategories, including individual opinion-based policy-making, expansion of the program without capacity building, lack of policies to support self-help groups, assignment without considering the capacity of the non-governmental sector, inflexible financial rules, parallel work of other activities with the program, lack of a comprehensive guideline for the program, and insufficient attention to legal capacity at country level have not been mentioned in other studies. Another key concept regarded in this study was a deviation from the main goals of the program. Mendis and Gurung stated that PWDs have more problems in the dimensions of daily living activities, self-care, and ability to change posture, bowel and bladder problems, and need more attention in the CBR program [28]. These findings are like the subcategories identified in our study: insufficient attention to the program’s components and neglecting the empowerment of the disabled. Tjandrakusuma mentioned that it was not possible to do business after training without investing in raw materials. Due to prejudices and negative attitudes, sustainable employment for the disabled was difficult, and apprenticeships were much more helpful and efficient than those provided in vocational training centers [29]. This is consistent with our findings regarding the subcategory of insufficient support for sustainable employment of the disabled. The results of Cayetano and Elkins regarding the lack of knowledge and understanding of CBR by experts agree with our findings regarding the subcategory of managers’ unawareness of the program’s goals [18]. Based on the participants’ experiences in our study, the CBR program had not been a priority for senior managers in recent years. The livelihood component was the only part considered by planners for implementation, and other components, such as health, which is a prerequisite for empowerment and social participation of PWD, have received less attention. Another reported challenge was the lack of a comprehensive evaluation system. Zhao et al. stated that there is no single method and evaluation system as the best way to run the CBR program; hence, it is impossible to set evaluation policies for the CBR program worldwide, but a general framework for the evaluation can be determined [30]. Evidence pointed to the lack of a comprehensive information system in the field of rehabilitation in Iran [26], which is consistent with the subcategory lack of information system for the program in our study related to category four. In collaboration with the International Disability and Development Consortium, the WHO developed indicators to measure CBR changes in the lives of PWDs in local communities to distinguish them from those without disabilities. This comparability provides valuable information for CBR program managers and can be used to guide decision-makers, seek support, and improve accountability. This does not mean that the work on CBR indicators is over. These indicators measure CBR differences based on an evidence-based process [31]. 
The present study also suggested the need for indicators for the CBR program evaluation. In the study by Wirz et al., regarding the evaluations performed on CBR, it was stated that there is a tendency to describe the used methods instead of the program’s effectiveness, and there is a challenge of not having solid indicators to measure these methods [32]. Our results also showed no continuous and codified evaluation system for the program; evaluation indicators were poor and non-standard, and institutions were not ranked based on performance. Moreover, the program did not have an online database of the covered people, which affected the planning, budgeting, monitoring, and evaluation. Inefficient management of resources (financial and human resources) was another major challenge in our study. Given the growing and diverse needs of the target community and the need to expand the number and scope of services, especially in deprived areas of the country, increasing funding resources and timely allocation of budget is essential. The inconsistency of resources with the program’s scope has led to challenges that have diverted the program from its original path. Previous studies have pointed to the lack of funding as a problem for long-term implementation [11, 13, 33]. WHO reported the wide gap between the services needed by PWDs and the available facilities and resources was mentioned. Therefore, developing countries will be in a tight spot regarding rehabilitation manpower [34]. In the annual report of the Department of Empowerment of Persons with Disabilities at the Iranian Welfare Organization in 2018, low funding resources and lack of budget allocation in a foreseeable period have also been mentioned [19]. 
In a study in Norway, the need for change in the workforce and the challenge of human resources in this program were also mentioned [35]. In the previous studies, unbalanced human resources structure, multiple human resources duties, and inefficient allocation and funds have not been mentioned as a challenge to CBR implementation. Extraction of these subcategories in the present study shows the need for senior managers to defend, communicate, allocate, and use the budget correctly and on time, and change the human resources structure in the country to a strong staff team to train, supervise and monitor the program, and determine the human resources tasks wisely to increase a sense of commitment and accountability. Another extracted concept as a challenge for CBR implementation was weakness in the facilitation approach. The poor skills of the facilitators led to a negative attitude towards them. Moreover, the educational system for them suffered from many problems, such as lack of up-to-date educational resources, lack of access to experienced teachers, repetitive and useless educational content, old and traditional teaching methods, and lack of credits. Furthermore, due to receiving low wages once every few months and a lack of insurance support, they were less motivated to perform their duties. Lukersmith also pointed to the lack of commitment and responsibility among staff in the CBR program [35]. Another study also indicated the shortcomings of the rehabilitation education system in Iran [27]. The highest dissatisfaction among CBR workers was related to low salaries [36]. In the present study, the low salary was also one of the leading causes of facilitators’ lack of motivation. A study performed at the University of Cincinnati, Ohio, USA, reported the lack of profitability and low cost-effectiveness as weaknesses in the CBR program [37]. In Iran, about 30% of the program’s total credits are spent on the facilitator’s wages; in some provinces, the amount of wage credits has exceeded the determined amount in recent years [19]. In terms of the low-cost effectiveness and efficiency of the use of facilitators as human program resources, their results are consistent with our findings. 
According to the findings, there are several reasons for the lack of access to facilities in the facilitator’s networks. What is being done with the facilitation approach is entirely different from the fundamental nature of facilitation, whose main task is to teach, encourage, and persuade PWD to participate and integrate socially and use the resources and facilities of society to empower PWDs. The wrong attitude towards the facilitation approach reported in the present study is specific to the culture of the Iranian society in using this approach and can be found in other countries [38]. One of the other main concerns of the participants in the implementation of CBR was poor communication. O’Toole also stated that due to the lack of cooperation between different organizations, meeting the needs of PWD is not a priority [39]. The annual report of the Department of Empowerment of PWDs indicated the lack of inter-sectoral cooperation in other organizations [19]. The present study also reported the weakness in attracting the cooperation of work partners due to problems related to inter-and intra-organizational communications. In previous studies, poor inter-sectoral cooperation has been mentioned more, while poor intra-organizational and international communications have received less attention. Because the CBR program is a community-based program with a multi-sectoral approach, due to international communication and non-participation in international congresses, up-to-date information has not been received. Inside the country, there was very little interaction between the partners related to the program, and no action had been taken to conclude a memorandum of understanding with the partners.
Finally, the inefficiency of NGOs was another challenge reported in this study. In previous studies, including the WHO report, insufficient cooperation and coordination between departments at different levels, lack of optimism in communities to participate in the program, and violation of financial obligations by partner organizations have been reported as the CBR program implementation risks [40]. Also, failure in recognizing disability organizations as an essential resource in the CBR program was reported as a challenge of program implementation [41]. Previous studies have not addressed NGOs’ high reliance on government funding and insufficient strengthening of NGO networking as challenges in implementing the program. The participants’ experiences in this study showed that NGOs and disability associations were not able to implement the program without government funding, which can be due to the presence of financially weak organizations and associations in the program as partners. Furthermore, networking had not been done at the provincial and national levels, increasing the demand for organizations and individuals with disabilities.

5. Conclusion
Given the challenges reported in implementing the CBR program in Iran, it is necessary to take the necessary measures to address these challenges. Our findings showed a clear pathway for all the main actors to change their vision and consider CBR as a key approach to rehabilitation services to reform their rehabilitation system. Profound changes should be made in the implementation of the CBR program. The service delivery process is improved to promote intra- and inter-sectoral cooperation and pay more attention to effective issues, such as working partners and the local community’s participation and credits. Some practical measures in changing the implementation of the program are paying particular attention to informing the community, proper education to all members involved in the program, especially PWD, their families, and local facilitators, and changing the attitudes and awareness of the managers of all organizations related to the program. Efforts to socially integrate PWDs and normalize their living conditions, like healthy people in society are necessary.

Limitations
One of the limitations of this study was the lack of interviews with other stakeholders, including PWDs and their families because we tried to explore the challenges of implementation of CBR, which can be considered in future studies.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1398.128).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 


Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors appreciate the thoughtful comments and ‎suggestions provided by the reviewers of this manuscript. ‎Also, we thank all the participants for their time and consideration.


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