HEALTH FACILITIES FOR ALL HEALTH FACILITIES FOR ALL Making health facilities disability-inclusive: actions against barriers WPR/2017/DNH/005 © World Health Organization 2017 All rights reserved. All photographs © World Health Organization HEALTH FACILITIES FOR ALL Making health facilities disability-inclusive: actions against barriers Objectives Situation, challenges, trends and barriers Action to remove barriers Suggestions for accomplishing the dimensions of change Additional information 3 4 8 10 12 CONTENTS Health Facilities for All Making health facilities disability-inclusive: actions against barriers Objectives: (1) To raise awareness of disability-inclusive health. (2) To educate the health sector (and allied ministries) on barriers encountered by people with disabilities in accessing health care. (3) To suggest actions that can be taken to remove barriers. Dimensions of change: (1) treatment of people with disabilities with respect and dignity; (2) accessibility of health facilities and services; (3) affordability of health care; (4) people-centred and integrated health care and referral pathways, case management, and self-help groups; and (5) participation of people with disabilities in governance and decision-making. HEALTH FACILITIES FOR ALL4 Situation, challenges, trends and barriers According to the WHO Global Disability Action Plan 2014– 2021: Better health for all people with disability, evidence shows that people with disabilities, throughout the life- course, have unequal access to health-care services, have greater unmet health-care needs and experience poorer levels of health compared with the general population. As a result, people with disabilities have poorer health outcomes than the general population. This means that people with disabilities frequently experience preventable diseases and report high incidences of risk behaviour such as obesity, smoking and physical inactivity. It means not being able to go to school or to earn a living. It means a parent or spouse who could potentially be contributing income to the family is sometimes taken away from this to provide support and care. It means potential catastrophic health expenditures that can drive individuals and their families into poverty. However, many avoidable and unjust health inequities reported among people with disabilities are not necessarily a direct result of having a disability but rather are linked to difficulty accessing community services and programmes. For further information on avoidable and unjust health inequities see ”Key Findings: Persons with Disabilities as an Unrecognized Health Disparity Population” (http://www.cdc.gov/ncbddd/disabilityandhealth/features/ unrecognizedpopulation.html) or “Persons with Disabilities as an Unrecognized Health Disparity Population” (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4355692/). HEALTH FACILITIES FOR ALL 5 Population differences between people with and without disabilities on health indicators of health-care access, health behaviours and health status, United States of America Health behaviours Health status Adults who smoke (100 cigarettes in lifetime and currently smoke) Health indicator 28.8 People with disabilities (%) 18.0 People without disabilities (%) In the past year, needed to see doctor but did not because of cost 27.0 12.1 Behaviour Risk Factor Surveillance System 2010 Adults who engage in no leisure-time physical activity 54.2 32.2 National Health Interview Survey 2008 Children and adolescents considered obese (aged 2–17 years) 21.1 15.2 National Health and Nutrition Examination Survey 1999–2010 National Health Interview Survey 2010 Adults who are obese 44.6 34.2 National Health and Nutrition Examination Survey 2009–2010 Annual no. of new cases of diagnosed diabetes (per 1000 persons) 19.1 6.8 National Health Interview Survey 2008–2010 Adults with cardiovascular disease National Health Interview Survey 2009–2011 18–44 years 12.4 3.4 45–64 years 27.7 9.7 Data source Source: Krahn GL, Walker DK, Correa-De-Araujo R (2015). Persons with disabilities as an unrecognized health disparity population. Am J Public Health. 105(Suppl 2):S198–S206. doi.org/10.t2105/AJPH.2014.302182. Health-care access HEALTH FACILITIES FOR ALL6 Failure to address health-care needs of people with disabilities is to deny people the right to participate in society. It is a deprivation of their dignity and a violation of their rights. Continued exclusion is unacceptable. Health-care facilities can make improvements so people with disabilities can have better health and consequently participate fully and effectively in society. More than 270 million people (15% of the population) in the Western Pacific Region experience disability. Disability includes impairments, activity limitations and participation restrictions that result from the interaction between an individual with a health condition and that individual’s contextual factors. “Persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which, in interaction with barriers, may hinder their full and effective participation in society on an equal basis with others” (United Nations Convention on the Rights of Persons with Disabilities, http://www.un.org/disabilities/convention/conventionfull.shtml). Ageing populations, rising prevalence of chronic diseases such as diabetes, hypertension and mental illness, and the upward trend in injuries due to road accidents, natural disasters and conflict are strongly influencing disability prevalence. The health status of people with disabilities is affected not only by their primary conditions but also by unhealthy behaviours and lifestyle choices, and other coexisting or resulting diseases or conditions. All people with disabilities have the same general health-care needs as everyone else, and therefore need access to mainstream health-care services. Some people with disabilities due to their health conditions require extensive or specialist health care, but other people with disabilities do not have such needs. Health systems frequently fail to respond adequately to both the general and specific health-care needs of people with disabilities. Health care for people with disabilities is often expensive. Assistive products and adaptive equipment are often costly and difficult to obtain and maintain. Wheelchairs, suitable to different conditions, are costly. Hearing aids, magnifiers and spectacles that could transform lives are often unobtainable, especially in rural and remote areas. Health system response to the situation is constrained by insufficient and misaligned health financing, lack of community empowerment and engagement, suboptimal health workforce (volume, distribution and competencies), and inappropriate service delivery models. Health service delivery is also affected by sociopolitical changes such as rising costs of health care, innovations in technology, increased citizen advocacy and continued globalization. HEALTH FACILITIES FOR ALL 7 People with disabilities encounter a range of barriers when they attempt to access health care. Physical barriers Inadequate skills and knowledge of health workers Limited availability of services Prohibitive costs Affordability of health services and transportation are two main reasons people with disabilities do not receive needed health care in low-income countries. Data show that 32–33% of nondisabled people are unable to afford health care compared to 51–53% of people with disabilities. Uneven access to buildings (e.g. hospitals, health centres), inaccessible medical equipment, poor signage, narrow doorways, internal steps, inadequate bathroom facilities, and inaccessible parking areas are examples of physical barriers to health-care facilities. For example, women with mobility difficulties are often unable to access breast and cervical cancer screening because examination tables are not height-adjustable and mammography equipment only accommodates women who are able to stand. People with disabilities are more than twice as likely to report finding health-care provider skills inadequate to meet their needs, four times more likely to report being treated badly and nearly three times more likely to report being denied care. Misconceptions among health workers about the health of people with disabilities lead to assumptions that they do not require access to health promotion and disease prevention services and programmes. Some people with disabilities encounter lack of respect or negative attitudes and behaviour towards them. They also experience informational barriers and communication difficulties; and receive inadequate information about their right to access health-care services. The lack of appropriate services for people with disabilities is a significant barrier to health care. Source: WHO 2016. Disability and health: factsheet. Geneva (http://www.who.int/mediacentre/factsheets/fs352/en). HEALTH FACILITIES FOR ALL8 Action to remove barriers Governments can improve health outcomes for people with disabilities by improving access to quality and affordable health-care services that make the best use of available resources. As several factors interact to inhibit access to health care, reforms in all the interacting components of the health-care system are required. Policy and legislation Financing Service delivery Human resources Data and research Assess existing policies and services, identify priorities to reduce health inequalities and plan improvements for access and inclusion. Make changes to comply with the UN Convention on the Rights of Persons with Disabilities. Establish health-care standards related to care of persons with disabilities with enforcement mechanisms. Where private health insurance dominates health-care financing, ensure that people with disabilities are covered and consider measures to make the premiums affordable. Ensure that people with disabilities benefit equally from public health-care programmes. Use financial incentives to encourage health-care providers to make services accessible and provide comprehensive assessments, treatment and follow-up. Consider options for reducing or removing out-of-pocket payments for people with disabilities who do not have other means of financing health-care services. Provide a broad range of modifications and adjustments (reasonable accommodation) to facilitate access to health-care services. For example, change the physical layout of clinics to provide access for people with mobility difficulties or communicate health information in accessible formats such as Braille. Empower people with disabilities to maximize their health by providing information, training and peer support. Promote community-based rehabilitation (CBR) to facilitate access for people with disabilities to existing services. Identify groups that require alternative service delivery models, for example targeted services or care coordination to improve access to health care. Integrate disability education into undergraduate and continuing education for all health-care professionals. Train community workers so that they can play a role in preventive health-care services. Provide evidence-based guidelines for assessment and treatment. Include people with disabilities in health-care surveillance. Conduct more research on the needs, barriers and health outcomes for people with disabilities. HEALTH FACILITIES FOR ALL 9 With the goal of “better health outcomes for people with disabilities” in mind, WHO proposes five steps (dimensions of change) to work towards disability-inclusive health facilities. People with disabilities are treated with respect and dignity. Dimensions of change Actions for change (some examples)Goal Health facilities and service delivery are accessible (physical and communication) to people with disabilities. Health care is available and affordable for people with disabilities. People with disabilities and disabled people’s organizations have an opportunity for participation in decision-making regarding health. Achieve people-centred and integrated health service delivery ✓ Promote disability inclusion through policy reform. ✓ Develop human resource capacity to deliver disability- inclusive care. ✓ Improve skills of the health workforce. ✓ Adopt reasonable accommodation including additional time to carry out adapted procedures. ✓ Increase awareness of people with disabilities on health-care services and financing options. ✓ Reach out to people with disabilities who cannot go to health facilities. ✓ Provide people with disabilities with the education and support they need to make decisions and participate in their own care. ✓ Partner with disabled people’s organizations. ✓ Ensure continuous referral pathways. Better health outcomes for people with disabilities HEALTH FACILITIES FOR ALL10 Suggestions for accomplishing the dimensions of change The following are suggestions for accomplishing the steps/dimensions of change. People with disabilities are treated with respect and dignity. Many people with disabilities are discouraged to seek health care because they were treated badly in the health-care system, were denied health care or experienced inadequate health-care provider skills and facilities. Health-care practitioners can: u Partner with local disabled people’s organizations (DPOs) that can help facilitate disability-awareness sessions for the entire staff of the health facility and recommend ways to make its system more disability-inclusive. u Provide health-care staff with continuing education about disability such as communicating in appropriate formats, finding information about how to access disability resources, coordinating care, making reasonable accommodations for people with disabilities, addressing health needs (including sexual and reproductive needs), and assisting people with disabilities in using the health facilities (including completing forms and educating about health). u Have an organizational or facility-level disability anti-discrimination policy. Health facilities and service delivery are accessible (physical and communication) to people with disabilities. Women and men with disabilities can face physical barriers in accessing health care. Some people with disabilities regularly cite communication difficulties between themselves and service providers as an area of concern. Health-care practitioners can: u Make structural modifications to facilities to make them accessible for all people with disabilities. u Use equipment with universal design features. u Communicate information in appropriate formats. u Link with translation services. u Use information and communication technologies. HEALTH FACILITIES FOR ALL 11 Achieve people-centred and integrated health service delivery. People with disabilities are frequent users of the health-care system. Many seek more collaborative relationships in managing primary, secondary and co-morbid health conditions. Health practitioners can: u Support primary health-care workers to work with specialists who may be located elsewhere. u Explore the options for use of information and communication technologies for improving services, health-care capacity and information access to persons with disabilities. u Identify groups who require alternative service delivery models, for example targeted services and care coordination to improve access to health care. u Coordinate care by identifying a care coordinator and compiling a directory of referral services. People with disabilities and disabled people’s organizations have an opportunity for participation and decision-making regarding health. Health practitioners can: u Educate and support people with disabilities to manage their health. u Provide time-limited, self-management courses involving peer support to enable people with disabilities to better manage their health. u Involve family members and caregivers in service delivery where appropriate. Family members and caregivers can support the health-seeking behaviours of people with disabilities. Health care is available and affordable for people with disabilities. More than half of people with disabilities cannot afford health care. Affordability was the primary reason people with disabilities, across gender and age groups, did not receive needed health care in low-income countries. Health ministries can: u Raise sufficient resources for health by increasing the efficiency of revenue collection, reprioritize government spending and development assistance, and promote efficiency and eliminate waste. u Remove financial risk and barriers to access like providing affordable health insurance and general payments to improve access. u Target people with disabilities who have the greatest health-care needs. HEALTH FACILITIES FOR ALL12 Additional information World Health Organization http://www.wpro.who.int/disability_rehabilitation/en/ http://www.who.int/disabilities/actionplan/en/ http://www.who.int/disabilities/publications/care/en/ CBM http://www.cbm.org/Publications-252011.php Development for All https://www.did4all.com.au/ResourceTheme.aspx?a4f44d2b-7700-452d-80bd- 4a833388b1b0 Nossal Institute for Global Health, University of Melbourne http://mspgh.unimelb.edu.au/research-groups/nossal-institute-for-global-health/ inclusive-health-and-development Department of Foreign Affairs and Trade, Australia http://dfat.gov.au/about-us/publications/Pages/accessibility-design-guide-universal- design-principles-for-australia-s-aid-program.aspx
For more information, please contact us: Disabilities and Rehabilitation Division of NCD and Health through the Life-Course World Health Organization Regional Office for the Western Pacific P.O. Box 2932 1000 Manila wprodar@who.int Telephone: +63 2 528 8001 Fax: +63 2 521 1036 or 526 0279
u “Disability” is an umbrella term that includes impairments, activity limitations and participation restrictions that result from the interaction between an individual with a health condition and that person’s contextual factors (such as the environment in which they live). u The United Nations Convention on the Rights of Persons with Disabilities (CRPD) recognizes that disability is a complex and evolving concept, and that people with disabilities include those whose participation in society – in education, health and employment – is limited because of the interaction between their long-term impairment and certain barriers in society (e.g. environmental or attitudinal). u WHO considers disability to be an issue of human rights, public health and development. What is disability? DISABILITY AND HEALTH DISABILITY AND HEALTH © WHO DISABILITY AND HEALTH Health trends affecting disability prevalence Addressing barriers to health services u Disability prevalence is influenced by several factors: ageing populations, rising prevalence of chronic diseases associated with disability (e.g. diabetes, hypertension and mental illness), and increasing trends in injuries due to road accidents, natural disasters and conflicts. u In general, older persons are disproportionately represented among populations of people with disability. For example, China’s 2006 data indicate that adults aged 60 years and older constituted 53.2% of people with disabilities, as compared with 10.9% of the total population. In Vanuatu, the prevalence was also more than 50% for those aged 60 years and older (ESCAP, 2016). u In Samoa, illness, especially noncommunicable diseases, was the most reported cause of disability in a survey conducted in 2004 (Pan Pacific & Southeast Asia Women's Association, Inclusion International & National Council of Women, as cited in Baker 2013). u Formal acknowledgement in national health-care policies that people with disability experience health inequalities is an essential step towards reducing health disparities. u Making existing health-care systems inclusive at all levels and making public health programmes (including health promotion) accessible to persons with disabilities throughout the life course will reduce health disparities. u Reform of health policy and legislation is needed to improve governance and increase levels of awareness, knowledge and data in health and related ministries so that they improve access to services. u Barriers to financing and affordability of health services need to be addressed by including basic social security guarantees that ensure universal access to essential health care and income security. u Community-based rehabilitation (CBR) is an important strategy for ensuring and improving coordination of and access to health services, particularly in rural and remote areas. u Good-quality data and research on disability are essential for providing the basis for policy and programmes and for efficient allocation of resources. They are also important for deepening understanding of disability issues and successful ways to remove barriers and for ensuring that persons with disabilities can participate in and contribute to society on an equal basis. Disability in the Western Pacific Region u More than 270 million people in the Western Pacific Region, roughly 15% of the total population, experience some form of disability. u About 46% of people with disabilities in the Western Pacific Region are 60 years or older, while 79% live in low-income or lower-middle-income countries. Overall, people who are otherwise vulnerable, such as poor people, women and older people, experience a higher prevalence of disability (ESCAP, 2016). u Prevalence of disability in the Western Pacific Region varies widely from 1% in the Lao People’s Democratic Republic to 18.5% in Australia. The average disability prevalence for Asia and the Pacific is 4.96% compared to the global estimated disability prevalence rate of 15% (ESCAP, 2016). © WHO DISABILITY AND HEALTH Poorer health outcomes and greater unmet health-care needs u While there is a link between disability and health, disability need not preclude good health. u People with disabilities have the same general health-care needs as everyone else and require access to mainstream health services. u Across the Western Pacific Region, people with disabilities experience poorer health outcomes than the general population (WHO & World Bank, 2011). u People with disabilities report a higher incidence of obesity, smoking and physical inactivity. u People with disabilities have a higher risk of injury from road traffic crashes, burns or falls. Children with disability are 3–4 times more likely to experience violence (Jones et al., 2012). u Many health disparities reported among people with disabilities are not necessarily a direct result of having a disability but rather are linked to difficulty accessing community services and programmes. Depression is a common secondary condition among people with disabilities (WHO & World Bank, 2011). u While some people with disabilities due to their health conditions require extensive or specialist health-care needs, others do not have such needs. u Health systems frequently fail to respond adequately to both the general and specific health-care needs of people with disabilities. u People with disabilities face a wide range of attitudinal, physical and systematic barriers when they attempt to access health care. u Health-care providers often lack adequate knowledge and skills and hold misconceptions about the health of people with disabilities, leading to assumptions that people with disabilities do not require access to health promotion or disease prevention services and programmes. This can include information about sexual and reproductive health. u People with disabilities also experience information and communication barriers. They receive inadequate information about their right to access health-care services. u Physical barriers exist in the form of inaccessible architectural design of health facilities, medical equipment not adapted to different physical conditions, and inaccessible transport systems going to health-care facilities. u Health care for people with disabilities is often expensive. Basic assistive devices such as wheelchairs that are suitable for different conditions are costly. Other assistive products and adaptive equipment can be costly and difficult to obtain and maintain. Hearing aids, magnifiers and spectacles that could transform lives are often unobtainable, especially in rural and remote areas. Not all countries provide exemptions, waivers or reductions for people with disabilities for their health-care costs. WHO response u Adopting the Global Disability Action Plan 2014–2021 The WHO Global Disability Action Plan 2014–2021: Better health for all people with disability (GDAP) calls on Member States to remove barriers and improve access to health services and programmes. To realize this objective, people with disabilities through their representative organizations should be fully consulted and actively involved in all stages of formulating and implementing policies, laws and services that relate to them. u Supporting progress towards the achievement of the objectives of GDAP WHO provides guidance, training and technical support to Member States, upon request, for improving access and removing barriers to health care for people with disabilities. Monitoring and reporting to the governing bodies on progress in implementing GDAP are recommended at the midway point (2017) and during its final year (2021). © WHO DISABILITY AND HEALTH Proposed actions for Member States National and local governments play a significant role in the implementation of the WHO Global Disability Action Plan 2014–2021: Better health for all people with disability such as: u Take the lead towards attaining disability- inclusive health care by developing and/or reforming health and disability laws, policies, budgets, strategies and plans to help to ensure better access for and inclusion of people with disabilities. u Ensure the participation of people with disabilities and their representative organizations in health policy-making and quality assurance processes. u Remove barriers to financing and affordability through options and measures to ensure that people with disabilities can afford and receive the health care they need without extreme out-of- pocket and catastrophic expenditures. u Adopt national accessibility standards (in line with universal design principles) and ensure compliance with them within mainstream health settings. u Make appropriate accommodations and modifications to overcome barriers to accessing mainstream health services, including: structural modifications to facilities, equipment with universal design features, adjustments to appointment systems, alternative models of service delivery, and communication of information in formats such as sign language, Braille, large print, Easy Read and pictorial information. u Support education and training by promoting and encouraging the integration of disability into relevant undergraduate curricula and continuing education for service providers. Disability-inclusive health-care initiatives in the Western Pacific Region Health systems can be more disability-inclusive when people with disabilities or their representative organizations participate in planning for health-care services. This is being done in 10 countries in the Western Pacific Region. A disability focal office or designated person in the country’s Ministry of Health may also help improve access to health- care services and health facilities for people with disabilities. This has been done in 9 out of 13 countries in the Western Pacific Region. Making health promotion disability-inclusive In Solomon Islands, the Bethesda Disability Training and Support Centre has developed health promotion programmes on topics such as nutrition, hygiene and sanitation education for all students enrolled at the centre. Elsewhere in Solomon Islands, televised nutrition education programmes use sign language. Reducing financials barriers to health-care access In Viet Nam, the 2010 Law on Persons with Disabilities provides for improved access to services such as health, education and employment and for better physical accessibility of infrastructures, transportation, and information technology. Registered persons with disabilities are also automatically enrolled in social health insurance schemes of the government. In the Philippines, people with disabilities can avail themselves of medicines and health-care services at reduced cost using government- issued cards. Mainstreaming disability in national government health action plans Malaysia’s Disability Action Plan demonstrates the country’s shift from a charity-based to rights-based approach to disability. It seeks to provide equal opportunities for health care for people with disabilities and to empower individuals, families and communities for self-care and development of support services. References Baker S (2013). Samoa Disability Program final design document. Canberra: Australian Department of Foreign Affairs and Trade (http://dfat.gov. au/about-us/publications/Documents/samoa-disability-program-design-document.pdf, accessed 21 July 2017). Economic and Social Commission for Asia and the Pacific (ESCAP) (2016). Disability at a glance 2015: strengthening employment prospects for persons with disabilities in Asia and the Pacific. Bangkok: United Nations. WHO, World Bank (2011). World report on disability 2011. Geneva: WHO. Jones L, Bellis MA, Wood S, Hughes K, McCoy E, Eckley L, et al. (2012). Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. The Lancet. 380(9845):899-907.
u Rehabilitation is a set of measures that assists people who experience a health condition or impairment to achieve and maintain optimal functioning in and interaction with their environment. u Rehabilitation can target improvements in functioning such as walking, eating and drinking, and in modifying the environment such as installing handrails and ramps. u Regional and global data on the need for rehabilitation services, the type and quality of measures provided, and estimates of unmet need do not yet exist. u The need for rehabilitation services is projected to increase with the rise of noncommunicable diseases and ageing populations. u The process of rehabilitation involves identifying what a person needs to function in their environment, setting goals, planning and implementing appropriate measures, and evaluating the effects of these measures. u Rehabilitation is a collaborative effort involving the person, family, health professionals, and specialists in education, employment, social welfare and other fields. u Rehabilitation measures are provided along a continuum of care, ranging from hospital care to rehabilitation in the community. Rehabilitation REHABILITATION AND ASSISTIVE PRODUCTS REHABILITATION AND ASSISTIVE PRODUCTS © WHO REHABILITATION AND ASSISTIVE PRODUCTS u Rehabilitation is broadly divided into three categories: 1) Rehabilitation medicine – concerns diagnosis and improvement of health conditions, reducing impairments, and preventing or treating complications. Medical specialists such as psychiatrists, paediatricians, geriatricians, ophthalmologists, neurosurgeons and orthopaedic surgeons can be involved in rehabilitation medicine. 2) Therapy – involves restoring and compensating for loss of function; preventing or slowing deterioration in functioning, for example training in activities of daily living, exercise and compensatory strategies; modifying the environment; and providing resources and assistive technology. Therapists and rehabilitation workers include occupational therapists, orthotists, physiotherapists, prosthetists, psychologists, rehabilitation and technical assistants, social workers, and speech and language therapists. 3) Assistive products – include health technologies that maintain or improve people’s functioning and well-being, such as a wheelchair, hearing aid and prosthetics. The impact of assistive products extends beyond health to socioeconomic benefits by enabling a more productive labour force, for example. u In low-resource settings, rehabilitation may involve non-specialist workers such as community-based rehabilitation (CBR) workers, friends and community groups. u Rehabilitation can improve health outcomes, especially if started early; reduce costs by shortening hospital stays; reduce the impact of barriers for persons with disabilities; and improve quality of life. u Rehabilitation need not be expensive. u An assistive product is any item, piece of equipment or product, whether it is acquired commercially, modified or customized, that is used to increase, maintain or improve the functional capabilities of individuals with disabilities. u Common examples of assistive products include crutches, prostheses, orthoses, wheelchairs, hearing aids, magnifiers and white canes, communication boards, speech synthesizers and day calendars with pictures. u Assistive products must be appropriate to the user and the user's environment. For example, users living in rural areas with rugged terrains may need wheelchairs with more traction than users living in urban areas with paved roads. u Assistive products can be powerful tools to increase independence, improve participation and reduce the need for personal care support services. Assistive products Rehabilitation in the Western Pacific Region u Half of the countries in the Region have a national rehabilitation strategy or plan. u All but one country in the Region have a unit or person responsible for rehabilitation either within a health or social affairs ministry. u In high- and middle-income countries, the government is the primary financial source for rehabilitation. In some countries, such as Cambodia and the Federated States of Micronesia, nongovernmental organizations contribute significantly to the financial support of rehabilitation services. u The most common rehabilitation service is physiotherapy, which is available in all high- and middle-income countries and in 90% of lower- middle-income countries. u Major rehabilitation centres are usually located in urban areas; in rural areas, even basic therapeutic services are often not available. Travelling to secondary or tertiary rehabilitation services can be costly and time-consuming, and public transport is often not adapted for people with mobility difficulties. u Women may experience additional difficulties in travelling to health-care services. © WHO REHABILITATION AND ASSISTIVE PRODUCTS Barriers to rehabilitation services u Lack of policies and plans u High cost of services and nonexistent or inadequate funding mechanisms u Insufficient numbers of appropriately trained professionals u Absence of facilities and equipment u Ineffective service models u Lack of integration and decentralization of services (e.g. rehabilitation service provision within primary and secondary health-care services) u Major rehabilitation services located in urban areas, with basic services unavailable for rural populations u Transportation to rehabilitation services that is costly, time-consuming and inaccessible, especially for women u Insufficient involvement of persons with disabilities in the provision of rehabilitation services Potential rehabilitation needs based on prevalence data Global data on the need for rehabilitation services, the type and quality of measures provided, and estimates of unmet need do not exist. However, prevalence data on health conditions associated with disability can provide information to assess rehabilitation needs. u Globally, 18.6% of people who are 18 years or older report moderate or extreme difficulty related to moving around. An estimated 1000 million people experience disability worldwide. Of this number, many would benefit from assistive products, but only 1 in 10 people have access to assistive technologies (World Report on Disability 2011). u In developing countries, 0.5% of the population need orthotic or prosthetic services (ISPO and WHO); 1% of the population require wheelchairs; and 20% of people with disability require hearing aids. World Report on Disability 2011 Addressing barriers in service delivery in the Western Pacific Region Mid-level training can address gaps in the rehabilitation workforce. u Mid-level training programmes established in low- and middle-income countries such as China and Viet Nam have responded to the lack of professional resources. u Mid-level training is less expensive than professional training, and although insufficient by itself, it may be an option for extending services in the absence of full professional training. u Mid-level workers, therapists and technicians can be trained as multipurpose rehabilitation workers with basic training in a range of disciplines (occupational therapy, physical therapy, speech therapy, for example) or as profession-specific assistants who provide rehabilitation services under supervision. u Rehabilitation training times have been shortened after conflicts when the number of people with impairments increased sharply – for example, in Cambodia after its internal conflict. u Prosthetics and orthotics courses meet the WHO/ International Society for Prosthetics and Orthotics (ISPO) standards in several developing countries including Cambodia and Viet Nam. Investments in rehabilitation are beneficial. u Investments in rehabilitation and provision of assistive products are beneficial because they develop human capacity and can be instrumental in enabling people with limitations in functioning to remain in or return to their home or community, live independently, and participate in education, the labour market and civic life. u These investments can reduce the need for formal support services as well as reduce the time and physical burden for caregivers. © WHO REHABILITATION AND ASSISTIVE PRODUCTS Role of Member States in rehabilitation WHO response Adopting the WHO Global Disability Action Plan 2014–2021: Better health for all people with disability (GDAP) GDAP is a comprehensive WHO action plan based on evidence in the World Report on Disability, and in line with the Convention on the Rights of Persons with Disabilities (CRPD). It also aligns with the outcome document of the high- level meeting of the United Nations General Assembly on the realization of the Millennium Development Goals and other internationally agreed development goals for people with disabilities. The vision of GDAP is a world in which all persons with disabilities and their families live in dignity, with equal rights and opportunities, and are able to achieve their full potential. The overall goal is to contribute to achieving optimal health, functioning, well-being and human rights for all persons with disabilities. The action plan has three objectives: 1) to remove barriers and improve access to health services and programmes; 2) to strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation; and 3) to strengthen collection of relevant and internationally comparable data on disability and support research on disability and related services. In line with Article 4 of the CRPD, persons with disabilities through their representative organizations should be fully consulted and actively involved in all stages of formulating and implementing policies, laws and services that relate to them. WHO provides guidance, training and technical support to Member States, upon request, to improve access and remove barriers to rehabilitation services. Monitoring and reporting to the governing bodies on progress in implementing the action plan are recommended at the midway point (2017) and during the plan's final year (2021). © WHO u Provide leadership and governance for developing and strengthening policies, strategies and plans on habilitation, rehabilitation, assistive products, support and assistance services, community-based rehabilitation and related strategies. u Provide adequate financial resources to ensure the provision of appropriate habilitation services, which aim to help those who acquire disabilities congenitally or early in life to develop maximal functioning, as well as rehabilitation services and assistive technologies. u Develop and maintain a sustainable workforce for rehabilitation and habilitation as part of a broader health strategy. u Expand and strengthen rehabilitation and habilitation services ensuring integration, across the continuum of care, into primary (including community), secondary and tertiary levels of the health-care system, and equitable access, including timely early intervention services for children with disabilities. u Make available appropriate assistive products that are safe, of good quality and affordable. u Promote access to a range of services that support independent living and full inclusion in the community. u Engage, support and build the capacity of persons with disabilities and their family members and/or informal caregivers in order to support independent living and full inclusion in the community.
u CBR is a community development strategy that aims to enhance the quality of life for people with disabilities and their families, and ensure their inclusion and participation in the community. u CBR was initially launched by WHO as a strategy to increase access to rehabilitation services at the community level for people with disabilities, but it has evolved into a much broader and multisectoral approach to community-based inclusive development. u CBR aims to achieve rehabilitation, equalization of opportunities and social inclusion by involving people with disabilities in community development processes. It presents an opportunity to operationalize the United Nations Convention on the Rights of Persons with Disabilities (CRPD). u CBR is implemented through the combined efforts of people with disabilities, their families, disabled people’s organizations (DPOs), other community stakeholders including nongovernmental organizations (NGOs), and relevant governmental bodies, particularly those responsible for health, education, vocational and social services. u CBR uses a grass-roots approach to guide development priorities. u CBR mobilizes local capacity and resources and uses community strengths and structures, and often fills community service gaps. What is community-based rehabilitation (CBR)? COMMUNITY-BASED REHABILITATION COMMUNITY-BASED REHABILITATION © WHO COMMUNITY-BASED REHABILITATION Why implement CBR? Benefits to people with disabilities and their families u Addresses impairment, improves functioning and independence, and promotes participation of all people on an equal basis. u Empowers people with disabilities to make informed decisions, attain their goals and understand their individual rights. u Enhances the quality of life of people with disabilities and their caregivers by addressing gaps in basic needs. Benefits to the community u Builds awareness of the diversity within the community, including diversity in functioning of people with disabilities, older persons and children. u Fosters more positive attitudes towards people with disabilities, and develops a greater understanding of disability, rights and the importance of equity so that no one is left behind when community development activities occur. u Focuses on local service systems, local resources and local practical solutions to real barriers that exist for people with disabilities and their caregivers with respect to access to services and participation in society. u Promotes inclusion of all people, particularly those with disabilities, in local decision-making, governance and resource allocation. WHO published and field-tested its first CBR manual to support training in the community for people with disabilities (Helander, 2007). A joint position paper released by the International Labour Organization (ILO), the United Nations Educational, Scientific and Cultural Organization (UNESCO) and WHO promoted CBR as a strategy within general community development for the rehabilitation, equalization of opportunities, poverty reduction and social inclusion of people with disabilities (ILO, UNESCO & WHO, 2004). This approach was adopted across various agencies and sectors, moving the emphasis from rehabilitation more broadly to general inclusive development. In 2005, a World Health Assembly resolution (WHA58.23) on disability prevention and rehabilitation urged Member States “to promote and strengthen community-based rehabilitation programmes...”. In 2009, the CBR Asia-Pacific Network was established, and WHO transitioned from being the primary driver in CBR to facilitating cooperation among CBR practitioners. 1980s 2000s WHO initially viewed rehabilitation as a complex specialty requiring extensive and costly resources at the national level – with teams of professionals providing services in medical institutions (Helander, 2007). In 1974, WHO began to shift its focus to increasing access to rehabilitation services at the community level. The utilization of sufficiently trained local human resources and the development of referral systems improved the participation of people with disabilities in social and economic activities (Helander, 2007). In the late 1970s, rehabilitation was viewed as a component of primary health care, with the Declaration of Alma-Ata on Primary Health Care introducing another shift, with the entry point of rehabilitation being at the community level and not necessarily through medical institutions (Helander, 2007). 1970s (from rehabilitation services to inclusive community-based development) Evolution of CBR © WHO In 2010, WHO published the CBR guidelines to provide guidance on how to develop and strengthen CBR programmes in line with the CBR joint position paper and the CRPD (WHO, 2010). The aim now is to build inclusive communities and strengthen support for people with disabilities and their communities, in particular across the five CBR sectors (heath, education, livelihood, social and empowerment) that are outlined in the CBR Matrix (http://www.who.int/disabilities/cbr/cbr_ matrix_11.10.pdf). 2010s COMMUNITY-BASED REHABILITATION CBR in the Western Pacific Region Countries in the Region have varied experiences and successes in implementing CBR. More comprehensive CBR programmes Initially, CBR programmes in the Region focused on access to health care and education for people with disabilities. Most of them now include livelihood, social and empowerment efforts. Increased government support At least 12 countries in the Region have a national CBR policy, strategy or action plan, with six more countries in the process of drafting such a framework. Most programmes in the Region are funded by governments, making efforts more sustainable. Increasingly the lead disability ministry or government office plays the key role (not the ministry of health). Improved support, collaboration and mutual understanding among stakeholders Local governments are increasingly funding CBR programmes and personnel. NGOs continue to support CBR and play a complementary role to governments. Disability-focused international NGOs have been shifting from leading programmes to supporting local CBR efforts, while international development NGOs are now funding CBR. Most importantly, DPOs are taking more active roles and participating in planning, implementation, management, monitoring and evaluation of CBR programmes. The CBR Asia- Pacific Network was established following the first Asia-Pacific CBR Congress in February 2009 in Bangkok, Thailand. Its aim was to promote and strengthen CBR across the Region and globally and to mobilize and support resources and information exchange. The first Pacific CBR Forum was held in Fiji to develop the Pacific Community-Based Rehabilitation Action Plan 2012–2014. The second Pacific CBR Forum in 2015 endorsed the Pacific Regional Framework for Community-Based Rehabilitation 2016–2021. © WHOChallenges to CBR implementation u Most CBR programmes are located in urban areas, but more people with disabilities live in rural areas. Sustaining capacity development and service delivery to communities for CBR personnel remains under-resourced. u Many countries have yet to develop disability policies and legal frameworks to legitimize CBR programmes. Sometimes further legal and administrative orders are required to support CBR at the local level. u While CBR is gaining support from governments, more active engagement of local governments is essential in developing, implementing and sustaining CBR programmes. u Better coordination among governments, NGOs and DPOs is needed for efficiency and more effective mobilization of resources. u Social exclusion and stigma persist. Raising awareness regarding rights and needs of people with disabilities is still a priority. u Government health insurance is not universally available across the Region to cover the cost of CBR. Out-of-pocket expenses can be significant for many people with disabilities. WHO response Under the WHO Global Disability Action Plan 2014– 2021: Better health for all people with disability, WHO provides technical guidance for countries and areas in the Western Pacific Region that want to develop or strengthen CBR programmes. Health ministries, other relevant governmental bodies and development stakeholders receive technical assistance to develop the capacity of training providers, advance standards for training and create platforms for exchange among practitioners. WHO also supports countries in integrating rehabilitation and habilitation services into the health system with a focus on decentralization of services at the community level. COMMUNITY-BASED REHABILITATION Examples of CBR moving forward in the Region CBR in Solomon Islands The Ministry of Health and Medical Services provides strong leadership and coordination support for the national CBR programme in Solomon Islands. A cadre of CBR workers has been trained on disability rights, empowerment of people with disabilities as well as practical advice and techniques to support people and their families. The CBR workers are located near communities and have access to transport. As a result, the national CBR programme has reached people with disabilities in their homes; provided home-based therapy and family education; carried out home improvement for physical accessibility; joined other health departments in campaigns; promoted disability in media; assessed and provided mobility aids such as wheelchairs, crutches, and supportive seating for children with cerebral palsy and developmental delay; and undertaken community awareness-raising activities. Integration of CBR in Mongolia It took Mongolia many years to integrate CBR into their health system and to reach the rural areas. Along with a cascading system of training from medical to paramedical personnel on CBR, ad hoc committees were set up at the provincial level, composed not only of medical staff, but also of a DPO or local grass- roots association representative. This mechanism has progressively raised awareness among associations about the rights and capacities of persons with disabilities. The DPO network and its members received appropriate training on advocacy as part of an empowerment process to promote the rights of people with disabilities. They succeeded in stimulating a more disability-inclusive social, cultural and political climate. The Mongolian Government signed the CRPD in 2009, and the Parliament revised at least seven national laws to be more disability-inclusive. The CBR programme has also resulted in the mapping of people with disabilities in each community and the organization of local CBR committees. What can governments do? u Invest in CBR. Use CBR as a strategy to complement and strengthen existing rehabilitation and disability- related community service provision, particularly in countries where few services are available. u Promote sustainable funding. Use local resources and gradually reduce external funding. u Develop strong linkages between services and stakeholders. Establish mechanisms for effective coordination between different service providers, DPOs, communities and families through referral networks and service directories. u Leave no one behind. CBR provides an opportunity for local interventions to be undertaken with community resources. Oftentimes, individuals and families who have been excluded from participating in development processes due to disability are revealed. © WHO References Helander E (2007). The origins of community-based rehabilitation. Asia Pacific Disability Rehabilitation Journal. 18(2):3-32. WHO (2010). Community-based rehabilitation: CBR guidelines. Malta. ILO, UNESCO, WHO (2004). CBR: a strategy for rehabilitation, equalization of opportunities, poverty reduction and social inclusion of people with disabilities: joint position paper. Geneva: WHO.