The International Classification of Functioning, Disability and Health (ICF) defines disability as an umbrella term for impairments, activity limitations and participation restrictions. Disability is the interaction between individuals with a health condition (e.g. cerebral palsy, Down syndrome and depression) and personal and environmental factors (e.g. negative attitudes, inaccessible transportation and public buildings, and limited social supports).
Over a billion people are estimated to live with some form of disability. This corresponds to about 15% of the world's population. Between 110 million (2.2%) and 190 million (3.8%) people 15 years and older have significant difficulties in functioning. Furthermore, the rates of disability are increasing in part due to ageing populations and an increase in chronic health conditions.
Disability is extremely diverse. While some health conditions associated with disability result in poor health and extensive health care needs, others do not. However all people with disability have the same general health care needs as everyone else, and therefore need access to mainstream health care services. Article 25 of the UN Convention on the Rights of Persons with Disabilities (CRPD) reinforces the right of persons with disability to attain the highest standard of health care, without discrimination.
Unmet needs for health care
People with disability report seeking more health care than people without disability and have greater unmet needs. For example, a recent survey of people with serious mental disorders, showed that between 35% and 50% of people in developed countries, and between 76% and 85% in developing countries, received no treatment in the year prior to the study.
Health promotion and prevention activities seldom target people with disability. For example women with disability receive less screening for breast and cervical cancer than women without disability. People with intellectual impairments and diabetes are less likely to have their weight checked. Adolescents and adults with disability are more likely to be excluded from sex education programmes.
How are the lives of people with disability affected?
People with disability are particularly vulnerable to deficiencies in health care services. Depending on the group and setting, persons with disability may experience greater vulnerability to secondary conditions, co-morbid conditions, age-related conditions, engaging in health risk behaviours and higher rates of premature death.
Secondary conditions
Secondary conditions occur in addition to (and are related to) a primary health condition, and are both predictable and therefore preventable. Examples include pressure ulcers, urinary tract infections, osteoporosis and pain.
Co-morbid conditions
Co-morbid conditions occur in addition to (and are unrelated to) a primary health condition associated with disability. For example the prevalence of diabetes in people with schizophrenia is around 15% compared to a rate of 2-3% for the general population.
Age-related conditions
The ageing process for some groups of people with disability begins earlier than usual. For example some people with developmental disability show signs of premature ageing in their 40s and 50s.
Engaging in health risk behaviours
Some studies have indicated that people with disability have higher rates of risky behaviours such as smoking, poor diet and physical inactivity.
Higher rates of premature death
Mortality rates for people with disability vary depending on the health condition. However an investigation in the United Kingdom found that people with mental health disorders and intellectual impairments had a lower life expectancy.
Barriers to health care
People with disability encounter a range of barriers when they attempt to access health care including the following.
Prohibitive costs
Affordability of health services and transportation are two main reasons why people with disability do not receive needed health care in low-income countries - 32-33% of people without disability are unable to afford health care compared to 51-53% of people with disability.
Limited availability of services
The lack of appropriate services for people with disability is a significant barrier to health care. For example, research in Uttar Pradesh and Tamil Nadu states of India found that after the cost, the lack of services in the area was the second most significant barrier to using health facilities.
Physical barriers
Uneven access to buildings (hospitals, health centres), inaccessible medical equipment, poor signage, narrow doorways, internal steps, inadequate bathroom facilities, and inaccessible parking areas create 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.
Inadequate skills and knowledge of health workers
People with disability were 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.
Addressing barriers to health care
Governments can improve health outcomes for people with disability by improving access to quality, affordable health care services, which 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
Assess existing policies and services, identify priorities to reduce health inequalities and plan improvements for access and inclusion. Make changes to comply with the CRPD. Establish health care standards related to care of persons with disability with enforcement mechanisms.
Financing
Where private health insurance dominates health care financing, ensure that people with disability are covered and consider measures to make the premiums affordable. Ensure that people with disability 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-ups. Consider options for reducing or removing out-of-pocket payments for people with disability who do not have other means of financing health care services.
Service delivery
Provide a broad range of modifications and adjustments (reasonable accommodation) to facilitate access to health care services. For example changing the physical layout of clinics to provide access for people with mobility difficulties or communicating health information in accessible formats such as Braille. Empower people with disability to maximize their health by providing information, training, and peer support. Promote community-based rehabilitation (CBR) to facilitate access for people with disability to existing services. Identify groups that require alternative service delivery models, for example, targeted services or care coordination to improve access to health care.
Human resources
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.
Data and research
Include people with disability in health care surveillance. Conduct more research on the needs, barriers, and health outcomes for people with disability.
WHO response
In order to improve access to health services for people with disability, WHO:
- guides and supports Member States to increase awareness of disability issues, and promotes the inclusion of disability as a component in national health policies and programmes;
- facilitates data collection and dissemination of disability-related data and information;
- develops normative tools, including guidelines to strengthen health care;
- builds capacity among health policy-makers and service providers;
- promotes scaling up of CBR;
- promotes strategies to ensure that people with disability are knowledgeable about their own health conditions, and that health-care personnel support and protect the rights and dignity of persons with disability.