World Report on Disability
World Report on Disability

In June 2011, the World Bank and World Health Organization (WHO) released the first World Report on Disability. Noting that one billion people in the world have some sort of disability, this comprehensive report sheds light on the myriad of challenges facing disabled persons and the potential solutions.

About fifteen percent of adults worldwide have moderate disability, while two to three percent has a severe disability. About five percent of children worldwide (93 million) have a moderate disability, while .7 percent (13 million) has a severe disability. Females have a higher prevalence of disability than males. The prevalence of disabilities around the world will be increasing in the future because of global aging trends.

Numerous globalization factors are highlighted in the report including technology, trade, media, education, development, migration, health, human rights, and international law. This analysis will review the report’s findings in light of these global factors.

Defining Disability

This report examines disability as a medical and social issue. Disability encompasses impairments, activity limitations, and participation restrictions. The International Classification of Functioning, Disability and Health (ICF) defines disability as a dynamic interaction between health conditions and contextual factors, both personal and environmental. Environmental factors include knowledge and attitudes, technology, natural or built environment, services, systems, policies, and support.

International Law and Human Rights

The United Nations Convention on the Rights of Persons with Disabilities (CRPD), passed in 2006, is the main international policy document addressing the rights of disabled persons. Framing disability as a human rights issue, the CRPD makes general human rights law applicable to persons with disabilities and clarifies existing international law concerning disabilities. Countries that ratify the CRPD must adopt appropriate legislation, modify or repeal laws that discriminate against disabled persons, include disability in relevant policies and programs, and take all measures to prevent any discrimination against persons with disabilities. Reasonable accommodations are required.

Despite the CRPD, there is still a major lack of national disability laws. A 2005 global survey found that of the 114 countries participating: 48 countries did not adopt rehabilitation policies and 57 countries did not pass rehabilitation legislation. As for accessibility standard, 54 percent had no standards for outside environments, 43 percent had no standards for public building, and 44 percent had no standards for schools and health facilities. About 65 percent had not started educational programs for this population, and 58 percent had not allocated funds for disability programs. Reasons included lack of strategic planning, lack of resources and health infrastructure, and lack of a coordinating agency.

Non-compliance is also a problem, even among developed countries such as Australia, Brazil, Denmark, India, and the United States. Voluntary efforts are not enough to ensure compliance, mandatory minimum standards are needed. Full compliance with accessibility standards costs only one percent of the total costs for new construction, however, making older buildings more accessible costs more. The report states that it is better to continually expand the scope of accessibility rather than try to make everything fully accessible at once.

Development and Migration

Disability is considered a development issue because of its relationship to poverty. Poverty may increase the risk of disability. The rates of disability are higher in developing countries. For example, the prevalence rate of disabilities for those 60 years old and above was 43.4 percent in low income countries and 29.5 percent in high income countries.

People with disabilities incur additional expenses to achieve a standard of living similar to those without disabilities. These expenses include health care services, assistive devices, costlier transportation options, and special diets, among other. For example, the extra cost of disability is about 11 – 69 percent of income in the United Kingdom and 29- 37 percent in Australia. Countries spend an average 1.2 percent of GDP on disability programs covering six percent of the working population in 2007. Countries incur productivity loss as well stemming from underinvestment in human capital linked to lack of employment or underemployment.

Developing countries often have limited resources to handle the range of disability problems. For example, about .5 percent of people living in developing countries need prostheses or orthotics and an estimated 30 million people in developing countries need 180,000 rehabilitation professionals. There are only six rehabilitation doctors in sub-Saharan Africa, all practicing in South Africa. There are also few women rehabilitation doctors and in some countries, such as Afghanistan, women are only allowed to be treated by female therapists.

Another challenge for developing countries is the retention of health care workers, including rehabilitation specialists, as many choose to move to developed countries to earn higher incomes. There has been a recent emigration wave of physical therapists from Brazil, Egypt, India, Nigeria, and the Philippines.

Health

The CRPD guarantees equal access to health promotion, although the primary prevention of health conditions does not fall under its scope. People with disabilities have poorer health than the general population. They have increased prevalence of obesity and are at greater risk of violence, i.e. sexual abuse.

Access to mental health services is often limited. A recent multi-country survey found that 35-50 percent of people with serious mental disorders living in developed countries and 76-85 percent of people with serious mental disorders living in developing countries did not receive mental health services in the year before the study was conducted.

Affordability was the main reason why people with disabilities did not receive health care in low income countries. Affordability and lack of employment are interrelated since employers often provide private health care plans. Lack of insurance plans also contributes to disabled persons having to bear the full cost of assistive technologies. Few governments worldwide allocate funding for prosthetic and assistive devices and for repairs of these devices.

Physical barriers to health care service delivery include inaccessible architectural designs of the health care facilities and lack of access to medical equipment and transportation. Communications barriers can often exist as well. For example, providers may be uncomfortable talking to people with severe mental illnesses. Providers often spend more time with people with disabilities and are not usually compensated for the extra time. Disabled persons have unmet needs across the medical spectrum in promotion, prevention, and treatment.

Conditional cash transfers have been found to increase the use of preventative health services for the poor in Latin America. Bangladesh, Brazil, India, and South Africa all have cash transfer programs for household with disabled persons. Tax credits to small health practices can also offset patient accommodations. Training of health care providers is crucial as well.

Community-based rehabilitation (CBR) is a key strategy for addressing disability, especially in developing countries. CBR programs are active in 90 countries worldwide. CBR programs are shifting from medical-focused programs to programs that encompass rehabilitation, equalization of opportunities, poverty reduction, and social inclusion of people with disabilities. CBR is also being used for the delivery of mental health services as there is a trend of deinstitutionalization of psychiatric hospital. While deinstitutionalization has improved the quality of life of many disabled persons, the programs often cost more.

Education

Historically, children and adults with disabilities have been excluded from mainstream education institutions and were educated in targeted institutions, a practice that did not reach the majority of disabled and was not cost-effective. In general, children with disabilities are less likely to be enrolled in or stay in school; this trend is even more pronounced in poor countries.

The CRPD recognizes the right of children with disabilities to be educated in the general education system. Schools in Europe and in much of the developed world are moving toward an inclusive model. Developing countries are just starting to take this approach. Flexibility is needed as mainstreaming is not always the best approach and sometimes segregated classes work better, especially for certain types of disabilities.

There are many barriers to reaching educational attainment Only 10 of 28 countries participating in the Education for All Fast Track Initiative had specific policy commitments for children with disabilities. Funding is problematic since it costs more to educate a disabled child and enough funds are not usually set aside for this purpose. Physical barriers at schools and lack of training in sign language are problems as well. Negative attitudes by students are another obstacle.

Overcoming these barriers require a national policy that addresses the inclusion of children with disabilities in education, supported by a legal framework, institutions, and resources. When possible, students should be mainstreamed, schools should be flexible in their curriculum and assessments, classroom specialists should be provided, and education and rehabilitation services should be linked.

While most developed countries have university rehabilitation programs, most developing countries cannot afford to establish them. Low and middle income countries, such as China, Lebanon, and Thailand have established mid-level training programs instead. India has established a regional training center servicing Bangladesh, Nepal, and Sri Lanka as well.

Labor and Employment

In both developed and developing countries, persons with disabilities have lower employment rates than those without disabilities. The CRPD recognizes the right of disabilities person to work on an equal basis with others. Many disabled persons work part-time or are in the informal sector. Their wages tend to be less than non-disabled persons.

Transportation is one of the major barriers. The full travel chain from home to office needs to be accessible, including public transportation. Universal design is increasingly being adopted in bus and rail systems in developed countries, including lifts and ramps for all vehicles and visual and tactile warning systems at the edge of platforms, amongst other features.

Some countries overprotect disabled persons, particularly in Eastern Europe, resulting in less employment, as they mandated to have shorter workdays, longer paid leave, higher severance pay, etc. Many countries have anti-discrimination laws and legislation, and some (Brazil and Ghana) address it in their constitution. Reasonable accommodation is required in some countries (U.S.) and voluntary in others (Denmark). Israel has affirmative action laws for people with disabilities. Other countries, such as Turkey, have a quota system. Switzerland offers sheltered work for disabled persons and has one of the highest rates of employment for disabled persons, although many countries prefer to try to mainstream employment options.

Social protections for disabled persons provide an important safety net, but also deter people when the jobs they seek offer lower wages than the long-term disability benefits. Six percent of the working age population in OECD countries receives disability benefits. It is an increasing burden for many countries, for example it accounts for 4-5 percent of the GDP in Netherlands, Norway, and Sweden. Limiting the duration of the benefits and disconnecting wage support from the compensation for the extra cost of disability are two ways to prevent social protections from becoming an employment distinctive.

Technology, Media and Culture

Technology and media plays an important role in helping people with disabilities to function in society. While the ICTS and the media can provide valuable information on health care and other services, televisions, phones, and the Internet are often not accessible. Captioning, audio descriptions and sign language interpretation are not universally offered on television programs, especially on those rebroadcast over the Internet. According to a survey by the World Federation of the Deaf, only 21 of 93 countries offer captioning of current affairs programs. The proportion with sign language was even lower.

Legislation, even in developed countries, is spotty due to the blurring of sectors. In Asia and the Pacific only eight countries out of thirty-six had accessibility standards for ICTs. The 1996 U.S. telecommunications act covered telephony, but not the Internet. Disabled persons are also protected via consumer protections laws and non-discrimination legislations that cover ICTs. Legal challenges have led to improvements, but are often costly and time-consuming.

As noted in the health section, access to assistive technologies is often limited due to high cost and limited insurance options. Economies of scale, centralized large-scale purchasing or consortium buying, and local manufacturing can help reduce costs. Some countries, such as Nepal, have lowered taxes for imported devices or have none at all (Vietnam). Price for parts is problematic as well. Botswana is examining rechargeable batteries using solar power since access to batteries impacts the use of many devices, such as hearing aids.

ICTS are being used in tele-rehabilitation for data collection, tele-psychiatry services, cardiac rehabilitation, speech and language therapy, and training and support of health care workers, among other services.

Moving Forward: General Recommendations

The World Report on Disability offers nine overarching recommendations to improve the lives of disabled persons.

  1. Enable access to all mainstream policies, systems and services: persons with disabilities should have access to the same services (health, education, social, etc) as the general public.
  2. Invest in specific programs and services for people with disabilities: while mainstreaming is the ideal, sometimes support services, such as rehabilitation and training are needed to achieve parity.
  3. Adopt a national disability strategy and plan of action: a national disabled strategy will provide a long-term vision for the country and provide a mechanism for coordination and monitoring of the efforts.
  4. Involve people with disabilities.
  5. Improve human resource capacity to ensuring non-discrimination and participation.
  6. Provide adequate funding and improve affordability: consider the financial sustainability of the national action plan and programs
  7. Increase public awareness and understanding of disability
  8. Improve disability data collection
  9. Strengthen and support research on disability

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