Persons with disabilities have greater health needs and challenges in accessing health care. In poor countries this is aggravated by constraints in health care and by poverty. In order to achieve equity in health, it is necessary to address the additional challenges faced by persons with disabilities.
Persons with disabilities are among the poorest and most disadvantaged in any population, with the worst health and poverty outcomes, and the lowest access to health and social services (1). Defining equity as ‘the absence of avoidable or remediable differences among groups of people’ (2), implies that equity in health cannot be achieved without addressing the needs of persons with disabilities (3, 4). It is therefore necessary to act on the challenges persons with disabilities face in accessing health care, particularly in poor societies, as an essential part of addressing equity in the global health agenda. This article discusses the interaction between disability, poverty and equity in health, and a new agenda for practice and research.
Lately, addressing the needs of persons with disabilities and other vulnerable and disadvantaged groups has been emphasised as a prerequisite to eradicating poverty (5). The 2030 Sustainable Development Agenda (6), reflected in the Sustainable Development Goals (SDGs) (7), states that addressing the needs of and barriers faced by disadvantaged groups is a prerequisite for an inclusive and equitable society, further reflected in the pledge to ‘leave no one behind’.
Disability is a contested concept. The dominant understanding today is based on the International Classification of Functioning, Disability and Health (ICF) (8), which understands disability as linked to health and functioning and as being created in the interaction between an individual and society. The classification provides a framework for understanding and describing disability and the disablement process, and comprises the components of bodily functions and structure, health, contextual factors, activity and participation. The model presented in the International Classification of Functioning, Disability and Health represents an amalgamation of a medical model linking disability primarily to the body, and a social model depicting context as the primary source of disability. Disability is seen as the outcome of the interaction among the components in the model and may be operationalised as limitations to activity and/or restrictions in social participation. Taking this as its framework, the World Health Organization (WHO) has estimated that more than 1 billion people globally have disabilities (1), of which 80 % live in poor countries.
The International Classification of Functioning, Disability and Health provides a tool for understanding and analysing disability as strongly influenced by a range of social and environmental determinants. The determinants interacting to create disability need to be addressed to reduce or eradicate barriers to equity in health (9). Individuals with disabilities face a number of environmental and social challenges that not only impact directly on their health, but also on their access to health services. This may for instance be an inappropriate wheelchair that leads to further and more serious health problems, or it could be the absence of access to mobility devices, reducing a person's ability to move from the home to the health facility. Another example could be maltreatment at home, for instance skewed distribution of food and family resources and denial of education and other forms of participation. A third example may be health workers with discriminatory practices denying access to persons with disabilities.
Disability is associated with a diverse range of primary health conditions, higher risk of developing secondary conditions, and higher risk of comorbid conditions (1). Additionally, persons with disabilities have higher rates of health risk behaviour, are more exposed to violence and have higher risk of premature death. Bearing in mind that persons with disabilities have more health needs than the non-disabled, it follows that they need more attention from health services than the general population to reduce the consequences of ill health. Distributing health services according to needs is referred to as vertical equity as opposed to horizontal equity where everybody gets the same (health services) (10).
Access to health services has been suggested as comprising five dimensions that may be useful for analysing barriers to health care for vulnerable groups. Firstly, availability concerns whether services are within reachable distance from where people live. Secondly, accessibility has to do with the structure of entrances and buildings. Thirdly, accommodation is about the services adapting to the needs of their clients. Fourthly, affordability is about the individual cost for someone to obtain services. Finally, acceptability is about services given in a way that is ethically sound and does not infringe on the integrity of the patients (11). If any of these dimensions are compromised, access is reduced. The dimensions may be used to disaggregate the concept of access and to compare between groups.
The article refers to results from a study funded by the Norwegian Federation of Organisations of Disabled People and the Atlas Alliance. This article is part of the series ‘Global Health in the Era of Agenda 2030’, a collaboration between Norad, the Centre for Global Health at the University of Oslo and the Journal of the Norwegian Medical Association. Articles are published in English only. The views and opinions expressed in the articles are those of the authors only.