1. World Health Organization
DISABLING BARRIERS – BREAK TO INCLUDE
WORLD REPORT ON DISABILITY

2. World Health Organization
Background
World Health Organization
World Health Assembly
Resolution (May 2005) on "Disability, including prevention, management and rehabilitation", requests WHO to produce a World Report.
Developed and published in partnership with the World Bank.
Convention on the Rights of Persons with Disabilities (CRDP)
UN treaty came into force in May 2008.
Reinforces our understanding of disability as a human rights and as a development issue.
International Classification of Functioning, Disability and Health (ICF)
Emphasizes the role of the environment in enabling or disabling people with health conditions.
Adopted as the conceptual framework for the report.
How did the World Report on Disability come about? Like everything that WHO does, it began with a resolution from the World Health Assembly, the governing body of the Organization. Subsequently, the World Report on Disability was developed jointly with the World Bank, as disability is broader than health, rehabilitation and community living.
The wider context was the CRPD, the major international treaty which reinforces our understanding of disability as a human rights and as a development issue.
This treaty has now been signed by XX countries and ratified by ZZ countries
[As of July 15, 149 signatories and 103 ratifications but check latest figures at
The CRPD understands disability to arise from the relationship between a person with an impairment and the wider environment. This interactional approach is consistent with the WHO ICF classification, which emphasises the role of the environment in either enabling or disabling people with health conditions. The CRPD has been described as the "moral compass of the report", while the ICF provides the conceptual framework.

3. Aims of the World Report on Disability
World Health Organization
To provide governments and civil society with a comprehensive analysis of the importance of disability and the responses provided, based on best available evidence.
To recommend national and international action to improve the lives of persons with disabilities.
To support implementation of the Convention on the Rights of Persons with Disabilities.
The World Report on Disability fills a major gap, by providing evidence on the global disability situation. It answers questions such as "how many disabled people are there?" "What is the extent of need and unmet need?" "What are the barriers to participation?" and "What works to overcome those barriers".
The World Report also helps by showing what works, and highlighting what can be done, in line with the CRPD, to improve the lives of persons with disabilities, for example better policy, more accessible services, better knowledge, and training for professionals from health and other fields so they understand the human rights approach to disability.
The World Report therefore provides evidence which underpins many Articles of the CRPD, and will assist member states in the implementation of the CRPD.

4. How was the World report developed?
World Health Organization
Involvement of a large number of stakeholders:
advisory and editorial committee;
over 380 contributors;
over 70 low, middle and high income countries represented.
Extensive review process:
regional consultations, peer review.
People with disabilities central to the process
We know that disability is complex and multi-dimensional. If we are to address disability disadvantage, we need to work together. That is why it was so important to involve a wide range of people in developing the report.
Over 380 people from 70 different countries contributed to the report, including academics, policy-makers, professionals, disability rights advocates and people from the NGO community. The report has been through an extensive consultation process in all WHO regions and rigorous peer review.
A particular feature is the involvement of people with disabilities themselves. People with disabilities have been on the advisory committee, the editorial committee as contributors and peer reviewers. Personal testimonies from people with disability open each chapter, some of which can be found at greater length on the website for the report.

5. What does the World Report tell us?
World Health Organization
Higher estimates of prevalence
1 billion people (15%), of whom million adults have very significant difficulties in functioning.
Growing numbers
Due partly to ageing populations, increase in chronic diseases, injuries from road traffic crashes, disasters etc.
Inequalities
Disproportionately affects vulnerable populations: women, poorer people, older people.
Not all people with disabilities are equally disadvantaged.
So, turning to the evidence in the World Report. First, it tells us something about people with disabilities as a group. Since the 1970s, WHO has been saying that 10% of the population are disabled. Now, through analysis of the World Health Survey (WHS), the Global Burden of Disease (GBD) Survey, and national surveys, we can see that a more accurate estimate is 15% or one billion people.
Secondly, the World Report tells us about trends: there are increasing numbers of PWD, because we are living longer (and older people have a higher risk of disability) and because chronic diseases such as arthritis, diabetes and heart diseases are on the rise.
Finally, disability is very diverse and affects people unequally. Poor people, women and older people are more likely to experience disability. And while disability correlates with disadvantage not all people with disabilities are equally disadvantaged. School enrolments differ among impairments. Those most excluded form the labour market are people with intellectual impairments and people with mental health conditions.

6. Disabling barriers: widespread evidence
World Health Organization
Inadequate policies and standards
Negative attitudes
Lack of provision of services
Problems with service delivery
Inadequate funding
Lack of accessibility
Lack of consultation and involvement
Lack of data and evidence
As we mentioned, both the CRPD and the ICF highlight the role that the environment can play in facilitating or restricting participation. The World Report provides strong evidence of some of the most common barriers faced by people with disabilities.
The environment can be modified. As such much of the disadvantage experienced by people with disabilities is preventable. We can do something about these problems!
To the right of the slide, you can see three of the women in WHO You Tube videos. From Lebanon, Mia told us about the discrimination she had faced in education. From United Republic of Tanzania, Faustina explained how assistive devices such as wheelchairs are vital to empowerment. In United Kingdom, Rachael told us about the obstacles she had had to overcome in order to train and work as a nurse.

7. Outcomes of disabling barriers
World Health Organization
Poorer health than the general population
Lower educational achievements
Less economic participation
Higher rates of poverty
Increased dependency and reduced participation
It is the way that society treats people with disabilities
which matters most
What are the outcomes of these barriers?
Poorer health than the general population.
Lower educational achievements: Children with disabilities are less likely to start school than their non disabled peers and more likely to drop out. Even in countries where most non disabled children go to school – disabled with disabilities do not go to school. For example:
- in Bolivia about 98% of non disabled children go to school, but less than 40% of disabled children go to school;
- In Indonesia over 80% of non disabled children go to school, but less than 25% of children with disabilities go to school.
Less economic participation: disabled people are less likely to be employed, and generally earn less when employed. A recent OECD study found that the inactivity rate for people with disability (49%) was 2.5 times higher than among persons without disability (20%).
As a result, people with disabilities have higher rates of poverty - including food insecurity, poor housing, lack of access to safe water and inadequate access to health care as well as fewer assets. People with disabilities often face extra costs for example for healthcare and assistance.
PWD also experience increased dependency and restricted participation: for example as a result of institutionalisation, lack of access to transport and environments, and this results in isolation.
The important thing is to realise that it is not so much the health condition which causes problems for people with disabilities – it is the way that society treats people with a health condition which matters most.

8. World Health Organization
Content overview
World Health Organization
Understanding disability
Disability – a global picture
General healthcare
Rehabilitation
Assistance and support
Enabling environments
Education
Work and employment
The way forward
This slide shows the cover of the World Report which is one of the pictures taken from a poster series breaking barriers.
There are nine chapters that include disability concepts, data, general healthcare, rehabilitation, assistance and support, environments (buildings, transport and information and communication) as well as education and employment. The World report does not cover the whole of the CRPD, but it does cover key areas necessary for inclusion in society.
Each chapter has a similar structure, looking at need and unmet need, then barriers, and then ways of overcoming barriers. There are specific recommendations at the end of each chapter, as well as the general recommendations at the end of the report.

9. Data: issues, challenges and solutions
World Health Organization
Disability is complex and can be difficult to measure. Lack of consistency of definitions and methodologies across the globe.
Use tools which reflect complexity of disability, e.g. disability as a spectrum, role of environment, measure functioning rather than "impairment head counts".
Adopt the ICF.
Improve national statistics.
Improve comparability of data.
Develop appropriate tools and fill the research gaps.
Disability is complex and can be difficult to measure. Different approaches and definitions have been adopted around the world, which do not always cover all aspects of disability and make comparison difficult.
There is enormous scope for enhancing the availability and quality of data on disability.
Disability is on a spectrum, and the environment always plays an important role. Disability can also be a temporary state. These characteristics of disability need to be reflected in data collection tools so that a more true representation of disability is achieved. Impairment data is not a proxy for disability data.
Data gathered needs to be relevant at the national level and comparable at the global level – both of which can be achieved by basing design on international standards, like the International Classification of Functioning, Disability and Health (ICF). Using the ICF allows for consistency in how disability is measured and ensures that results from different studies can be compared. Using the ICF means that data is collected on ALL the components of disability: impairments, activity limitations and participation restrictions, related health conditions, and environmental factors.
Improving national statistics can be achieved, particularly by moving away from measuring only impairment towards taking a ‘difficulties in functioning’ approach. It is useful if the country’s Census incorporates the UN Washington Group’s questions, and if disability questions are added into existing sample surveys ( Where resources exist to carry out comprehensive disability surveys this can greatly add to the detail and level of understanding of the situation of people with disabilities, and to the information about subgroups, such as children, women and older people.
Improving the comparability of data will be promoted by these national improvements, by refining the methods we use to generate prevalence estimates, and by collaborating on comparable definitions and methods for data collection.
Further work is needed to gain a better understanding of environments and their influences, of the relationships between health conditions and disability, and to understand the lived experience of people with disabilities.
Better information will support better policy making, will enable us to monitor progress in terms of the CRPD and will, hopefully, lead to improvements in the lives of people with disability.

10. General health care
People with disabilities have ordinary health needs and therefore require access to mainstream health care.

11. Health Care: issues and challenges
World Health Organization
Danger of overlooking general healthcare needs: "diagnostic overshadowing".
Narrower margin of health: e.g. secondary conditions and co-morbidities.
Possible risky behaviours: e.g. smoking, poor diet, physical activity.
Greater vulnerability to violence, often higher rate of unintentional injuries.
Barriers to healthcare:
2 x likely healthcare provider skills or equipment inadequate;
3 x more likely to be denied care;
4x more likely to be treated badly.
Inaccessible information or facilities or lack of transport.
Financial barriers are crucial: 50% or higher risk catastrophic health expenditure.
People with disabilities have ordinary health needs. Some people with disabilities may also be particularly vulnerable to secondary conditions – such as pressure sores or bladder infections for people with spinal cord injury or MS – or to co-morbidities such as diabetes for people with schizophrenia. They may also engage in risky behaviours and be vulnerable to violence and unintentional injuries.
The emphasis of the health chapter is on barriers which people with disabilities experience in accessing mainstream healthcare.
People with disabilities experience barriers in accessing healthcare. For example, World Health Survey analysis revealed that people with disabilities were:
more than twice as likely to find healthcare provider skills or equipment inadequate to meet their needs,
nearly three times more likely to be denied care and
four times more likely to be treated badly
Cost, distance and transport are the main barriers to accessing healthcare.
In low-income countries more than half of people with disabilities are unable to afford healthcare, compared with one third of nondisabled people. People with disabilities spend more of their total household expenditure on out of pocket heath-care costs (15%) than non disabled people (11%). As a result they are more vulnerable to catastrophic health expenditure. From the WHS, nearly 30% of PWDs spend more than 40% of their income on health, compared to 20% for non disabled people. Low income countries showed even higher rates.
Health insurance should be an option BUT people with disabilities across the world experience difficulties when accessing government or private healthcare systems, for example, social insurance- commonly linked to payroll contributions - are also often in accessible because PWD have lower employment rates.

12. Health Care: solutions
World Health Organization
Reform policy and legislation.
Financing: health insurance, targeted funding, income support, reducing fees, incentives to providers, conditional cash transfers.
Service delivery: reasonable accommodations including accessible information, targeted interventions, coordination.
Human resources: education and training.
CBR: to promote access to healthcare.
Research: include PWD; produce disaggregated data.
To overcome barriers, it is necessary to:
- reform policy and legislation
- establish standards for healthcare (in high income countries, disability access and quality standards can be built into contracts with providers).
- address affordability problems (through health insurance, targeted funding, income support or reducing out of pocket expenditure);
- improve physical access to premises, transport and equipment;
- train healthcare workers particularly around a human rights-based approach to disability, and challenge negative attitudes. People with disabilities and their representative organizations can be providers of training.
In LMIC, CBR can play a role in promoting access to healthcare. In all settings, empowering PWD to look after their own health through information, training and peer support is a good strategy.
To fill the gaps in data and research, PWD need to be included in research and disaggregated data on service use is required.

13. Rehabilitation
Rehabilitation assists individuals with disability to achieve and maintain optimal functioning in interaction with their environment by reducing the impact of a broad range of health conditions.

14. Rehabilitation: issues and challenges
World Health Organization
Rehabilitation is a good investment because it builds human capacity and promotes participation.
Global data is limited on met and unmet needs, but country surveys reveal large gaps in the provision of rehabilitation and assistive devices.
Limited access results in deterioration in health, activity limitations and participation restrictions, increased dependency, and reduced quality of life.
Few rehabilitation personnel: limited capacity, particularly in Africa.
Systemic problems: rehabilitation overly centralized, lack of effective referral.
Need for more investment in rehabilitation services.
Rehabilitation assists individuals with disability to achieve and maintain optimal functioning in interaction with their environment by reducing the impact of a broad range of health conditions. Yet rehabilitation is a neglected area of healthcare, and of disability policy generally.
(supporting information for Bullet 2) For example, a 2005 global survey of the implementation of the nonbinding, UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities in 114 countries found that:
- 42% countries had not adopted rehabilitation policies.
- 50% did not pass legislation on rehabilitation.
- 40% did not establish rehabilitation programmes.
Evidence from studies conducted in Malawi, Mozambique, Namibia, Zambia, and Zimbabwe reveal large gaps in the provision of medical rehabilitation: % of people who needed the services did not receive them; and % of people who needed assistive devices did not receive them. Inequalities between men and women, between rural and urban dwellers and based on socioeconomic status were also found. Just in the area of hearing aid provision, hearing aid producers and distributors estimate that hearing aid production currently meets less than 10% of global need, and less than 3% of the hearing aid needs in developing countries are met annually. A recent global survey (2006‑2008) of vision services in 195 countries found that waiting times in urban areas averaged less than one month, while waiting times in rural areas ranged from six months to a year.
(….Bullet 4) There are insufficient rehabilitation personnel with appropriate capacity. For example the 30 million people who need prostheses, orthotics and related services in Africa, Asia, and Latin America require an estimated rehabilitation professionals. However, in 2005 there were only 24 prosthetic and orthotic schools in developing countries, graduating just 400 trainees annually.
(….Bullet 5) Services also tend to be centralized (that is, concentrated in urban areas) leaving the rural poor with little or no access to rehabilitation. Referral systems are generally inadequate with services operating in a fragmented and poorly coordinated manner.
(….Bullet 6) At the policy and legislation level, there is a lack of responsibility taken by Governments, inadequate strategic planning, and implementation. There is limited government spending and selective coverage.

15. Rehabilitation: solutions
World Health Organization
Policy, legislation and regulatory mechanisms.
Financing: address cost and coverage through international cooperation, partnerships, targeted funding.
Human resources: increase capacity and supply of personnel through education and training, mechanisms for recruiting and retaining. Mid-level workers as first step.
Service delivery: integration into health system, coordination, community-based, early intervention.
Assistive technology: appropriate for user needs, good follow-up, local manufacturing, reducing taxes.
Research and evidence-based practice.
Policy responses should emphasize early intervention, the benefits of rehabilitation to promote functioning in people with a broad range of health conditions, and the provision of services as close as possible to where people live. Creating or implementing national plans on rehabilitation, and establishing infrastructure and capacity to implement the plan are critical to improving access to rehabilitation.
Funding mechanisms to address barriers related to financing of rehabilitation require careful evaluation for their applicability and cost-effectiveness. Mechanisms may include: reallocation or redistribution of resources; support through international cooperation; public-private partnerships for service provision; making essential rehabilitation services available free of charge for poor people with disabilities who cannot afford to pay; and promoting equitable access to rehabilitation through health insurance.
Increasing human resources for rehabilitation and productivity will require training capacity to be built in accord with national rehabilitation plans; the identification of incentives and mechanisms for retaining personnel especially in rural and remote areas; and the training of non-specialist health professionals (doctors, nurses, primary care workers, CBR workers) on disability and rehabilitation relevant to their roles and responsibilities.
Established rehabilitation services should focus on improving efficiency and effectiveness, by expanding coverage and improving quality and affordability. Client centred and multidisciplinary approaches should be encouraged. In less-resourced settings the focus should be on accelerating the supply of services through community-based rehabilitation (CBR), complemented by referrals to secondary services. In all cases service users must be included in decision making – rehab is always voluntary. Increase the use and affordability of technology and assistive devices. Access to assistive technologies can be improved by pursuing economies of scale, manufacturing and assembling products locally, and reducing import taxes.
Expanding research programmes, including improving information and access to good-practice guidelines is essential.

16. Assistance and Support
Assistance and Support refers to non-therapeutic forms of help which enable people to live independently and participate in society.

17. World Health Organization
Issues and challenges
World Health Organization
Access to assistance and support are often prerequisites for participation.
Institutional solutions are generally favoured.
Formal service provision is limited in low and middle-income countries.
Even in high income countries, between 20%-40% do not have needs met.
Unmet needs for assistance lead to social isolation, dependency on others, lack of choice and control, risk of abuse.
Unmet needs can also have adverse consequences for informal caregivers.
Assistance and Support refers to non-therapeutic forms of help which enable people to live independently and participate in society. For example, personal assistants, sign language interpreters and other forms of assistance and support can help people with disabilities to go to school, to get jobs, and to live in the community.
Where provision does exist, historically it has been in residential institutions. These segregate people with disabilities from society, restrict choices, and increase vulnerability to abuse.
Where community services exist, they may not be responsive to the needs of people with disabilities or their families. Private services may be unavailable or unaffordable. NGO's may be the only service providers but may not be regulated to ensure quality of provision. There is extensive evidence of unmet need, even in high income countries 20%-40% do not have needs met.
There is also a problem with supply and quality of support staff in many countries. Other barriers include lack of coordination, negative attitudes, and vulnerability of service users.
Without effective assistance and support, not only are people with disabilities isolated and excluded, their families and friends also have to provide informal support, thus excluding them also from labour market or schooling.

18. World Health Organization
Solutions
World Health Organization
Deinstitutionalization: transition planning, allocate sufficient funding, ensure adequate human resources.
Improve policies and practices: commissioning frameworks, assessment processes, improving coordination, and monitoring standards.
Improve affordability: reallocating money, creating tax incentives, contracting, devolving budgets.
Expand community services: developing a mixed economy of care, in particular support independent living schemes, develop respite care and other support for families, create training schemes for interpreters.
Build capacity of support providers and service users, increase user involvement/ control.
How can we solve these problems? Particularly in high and middle income countries, the report recommends approaches such as transition away from institutions, commissioning of services in the community, independent living units so that people with disabilities have maximum choice and independence, and provision of information and respite care to support families.
Governments should develop mechanisms for assessing need, contracting out care, and ensuring high quality.
More investment in support services is needed, particularly in middle income countries. Reallocation of funding from institutions to community living can help meet financial needs.
A range of solutions are needed as disabled people are different and their needs and desires vary. A "mixed economy of care" should be looked at, that is, provision of services by not-for-profit, for-profit as well as by the state. Training schemes are needed to ensure supply of support staff, sign language interpreters, advocates etc. In low income settings, Community Based Rehabilitation (CBR) can help empower people with disabilities and their families. In all settings, it is important to prevent and monitor abuse, to which people with disabilities are particularly vulnerable.
Wherever possible, people with disabilities should be in control, with professionals "on tap but not on top". Even when paid support is unrealistic, changing relationships between those who provide and those who receive support, to ensure choice and control, is possible and desirable. DPOs have a role to support people with disabilities to become independent, and investment in DPOs is important.

19. Enabling Environments
Accessibility describes the degree to which an environment, service, or product allows access by as many people as possible, in particular people with disabilities.

20. World Health Organization
Issues and challenges
World Health Organization
Environments (physical, social, attitudinal) can be enabling or disabling.
Access to public accommodations and transport is essential for participation in healthcare, education, employment.
But low level of compliance with access laws, need for appropriate standards and enforcement.
People with disabilities are often also excluded from media and communications, e.g. the "digital divide" in ICT.
Negative attitudes can produce barriers even after physical barriers are removed.
Environments (physical, social, attitudinal) can be enabling or disabling.
Unless people with disabilities can access buildings, transport and information, they cannot access healthcare or participate in schools, work or society. The key barriers which are reported include:
Low level of compliance with laws on accessibility. Reports from countries with laws on accessibility, even those dating from 20 to 40 years ago, confirm a low level of compliance
Limited awareness about the existence of standards.
- Inappropriate standards across different contexts.
- Limited understanding of universal design features.
- Incompatible technology.
- Prohibitive costs act as disincentives.
An example of communication barriers are the trouble which Deaf people often have accessing sign language interpretation: a survey of 93 countries found that 31 countries had no interpreting service, while 30 countries had 20 or fewer qualified interpreters
In the contemporary world, being able to use cell phones, and internet are increasingly vital. But often websites or devices are inaccessible, or the rapid pace of technological development means that new communication products are not compatible with existing assistive devices.
Inaccessible environments and information make people excluded or dependent on others for assistance. But even an accessible environment can be rendered inaccessible when non-disabled people have negative attitudes towards people with disabilities – think of a bus driver who cannot be bothered to help a wheelchair user with a ramp or elevator.

21. World Health Organization
Solutions
World Health Organization
Adopt appropriate laws and standards.
Improve compliance: raise awareness of laws and standards, monitor compliance and enforce implementation.
Apply universal design principles in design and development, for example bus rapid transport schemes which promote access for all.
Promote information and awareness, for example through training for architects, designers, engineers and other professionals and awareness campaigns for general public.
Ensure user participation in design, access audit, development, monitoring.
Across domains, key requirements for addressing accessibility and reducing negative attitudes are appropriate laws, access standards; cooperation between the public and private sector; a lead agency responsible for implementation; training in accessibility; universal design for planners, architects, and designers; user participation; and public education.
Experience shows that mandatory minimum standards, enforced through legislation, are required to remove barriers in buildings. A systematic evidence-based approach to standards is needed. Accessibility audits by disability organizations can encourage compliance. For developing countries a strategic plan with priorities and increasingly ambitious goals can make the most of limited resources. The 1% extra cost of access compliance in new buildings is cheaper than adapting existing buildings.
Improved ICT accessibility can be achieved by bringing together market regulation and antidiscrimination approaches, along with relevant perspectives on consumer protection and public procurement. Countries with strong legislation and follow-up mechanisms tend to achieve higher levels of ICT access, but regulation needs to keep pace with technological innovation.
In transport the goal of continuity of accessibility throughout the travel chain can be achieved by introducing accessibility features into regular maintenance and improvement projects, and developing low-cost universal design improvements that result in demonstrable benefits to a wide range of passengers. Accessible bus rapid transit systems are increasingly being adopted in developing countries.

22. Education
Despite the importance of education, children with disabilities may be excluded from school.
Inclusive Education is based on the right of all learners to a quality education that meets basic learning needs and enriches lives. Focusing particularly on vulnerable and marginalized groups, it seeks to develop the full potential of every individual.

23. World Health Organization
Issues and challenges
World Health Organization
Education is vital if children with disabilities are going to participate in society and get employment opportunities.
Children with disabilities are less likely to start school than peers. Enrolment rates differ across impairment groups.
At system level, problems of leadership, policy, resourcing.
At school level, problems of negative attitudes, lack of teacher training, inaccessible facilities, inappropriate pedagogy and assessment.
Inclusion of children in mainstream schools is desirable, but evidence on impact of setting on education outcomes is not conclusive.
Despite the importance of education, children with disabilities are excluded from schooling.
Data from Malawi, Namibia, Zambia, and Zimbabwe show that children with disabilities aged 5 years or older were 2 – 3 times more likely never to have attended school than non disabled children. The gap between the percentage of disabled children and the percentage of nondisabled children attending primary school ranges from 10% in India to 60% in Indonesia. Even in countries with high primary school enrolment rates, many children with disabilities do not attend school (see slide on outcomes).
Enrolment rates also differ among impairment groups, with children with physical impairment generally faring better than those with intellectual or sensory impairments. For example in Burkina Faso in 2006 only 10% of deaf 7-to-12 year olds were in school, whereas 40% of children with physical impairment attended, only slightly lower than the attendance rate of non-disabled children.
The costs of exclusion are enormous. In Bangladesh alone the cost of disability due to forgone income from a lack of schooling and employment, both of people with disabilities and their caregivers, is estimated at US$ 1.2 billion annually, or 1.7% of gross domestic product.
The barriers preventing inclusion in education are:
At the level of the system
- Divided ministerial responsibility. For example, education for disabled children is responsibility for MoSW not MoE.
- Lack of legislation, policy, targets and plans.
At the level of the school
- Inaccessible curricula and pedagogy.
- Inadequate resources.
- Inadequate training and support for teachers.
- Physical and attitudinal barriers.
The report recommends inclusive schooling, because it supports CRPD principles and is cost-effective. When children with disabilities attend mainstream schools, this can reduce stigma and negative attitudes around disability as it promotes interaction between disabled children and their non-disabled peers. But there is no definitive evidence on outcomes.

24. World Health Organization
Solutions
World Health Organization
Inclusive education system: adopt legislation, policy and national plans
Learner centred approaches: review curricula, teaching methods, assessment systems
Provide additional supports: special education teachers, classroom assistants, therapy
Build teacher capacity: professional development, support, supervision
Remove physical barriers and overcome negative attitudes
Research: collect qualitative and quantitative data
The success of inclusive systems of education depends largely on a country’s commitment to adopt appropriate legislation, provide clear policy direction, develop a national plan of action, establish infrastructure and capacity for implementation, and benefit from long-term funding.
Education systems need to adopt more learner-centred approaches with changes in curricula, teaching methods and materials, and assessment and examination systems. Many countries have adopted individual education plans as a tool to support the inclusion of children with disabilities in educational settings.
Some children will require access to additional support services including specialist education teachers, classroom assistants, and therapy services.
Appropriate training of mainstream teachers can improve teacher confidence and skills in educating children with disabilities. The principles of inclusion should be built into teacher training programmes and accompanied by other initiatives that provide teachers with opportunities to share expertise and experiences about inclusive education.
Many of the physical barriers that children with disabilities face in education can be easily overcome, with simple measures such as changing the layout of classrooms.
Finally, systematic collection of qualitative and quantitative data, which can be used longitudinally, is required for countries to map their progress and compare relative developments across countries .

25. Employment
Disability need not be synonymous with an inability to work.
Reasonable accommodations may be necessarily to enable a person with a disability to perform a job on a equal basis with all others.

26. World Health Organization
Issues and challenges
World Health Organization
People with disabilities have lower economic participation.
Employment rates are variable depending on type of disability.
Wage gap between men and women with and without disabilities is significant.
Exclusion from the labour market is a major reason for poverty.
Physical barriers and lack of transport make it harder to find and keep work.
Negative attitudes, misconceptions about productivity and discrimination limit opportunities.
Overall, people with disabilities are more likely to be unemployed and generally earn less even when employed.
(supporting information for Bullets 1 and 2) Global data from the World Health Survey show that employment rates are lower for disabled men (53%) and disabled women (20%) than for nondisabled men (65%) and women (30%). A recent OECD study (25) showed that in 27 OECD countries working-age persons with disabilities experienced significant labour market disadvantage and worse labour market outcomes than working-age persons without disabilities. On average, their employment rate, at 44%, was slightly over half that for persons without disability (75%). People with intellectual disabilities and people experiencing disability associated with mental health conditions have reduce economic opportunities.
The Barriers which people with disabilities report in employment include:
Lack of access: for example, limited education and training opportunities, and physical/ information barriers in the workplace, or in travel to work.
Misconceptions about disability: for example, that PWD are less productive, or low expectations of PWD, or thinking that accommodations would be too complex and costly.
Discrimination: particularly for people with mental health conditions or intellectual impairments.

27. World Health Organization
Solutions
World Health Organization
Laws and regulations: anti-discrimination laws, affirmative action, quotas.
Tailored interventions: incentives to employers, supported employment, employment agencies, disability management.
Promote access to vocational rehabilitation and training.
Develop skills and access to microfinance.
Social protection schemes, avoiding disincentive to productive work.
Challenge misconceptions about disability through awareness raising and work with employers.
Antidiscrimination laws provide a starting point for promoting the inclusion of people with disabilities in employment. Where employers are required by law to make reasonable accommodations – such as making recruitment procedures accessible, adapting the working environment, modifying working times, and providing assistive technologies – these can reduce employment discrimination, increase access to the workplace, and change perceptions about the ability of people with disabilities to be productive workers. A range of financial measures, such as tax incentives and funding for reasonable accommodations, can be considered to reduce additional costs.
In addition to mainstream vocational training, community-based vocational rehabilitation, peer training, mentoring, and early intervention show promise in improving disabled people’s skills. Community-based rehabilitation can improve skills and attitudes, support on-the-job training, and provide guidance to employers. User-controlled disability employment services have promoted training and employment in a number of countries.
For people who develop a disability when employed, disability management programmes – case management, education of supervisors, workplace accommodation, early return to work with appropriate supports – have improved the rates of return to work. For some people with disabilities, including those with significant difficulties in functioning, supported employment programmes can facilitate skill development and employment. These programmes may include employment coaching, specialized job training, individually tailored supervision, transportation, and assistive technology.
Where the informal economy predominates, it is important to promote self-employment for people with disabilities and facilitate access to microcredit through better outreach, accessible information and customized credit conditions.
Mainstream social protection programmes should include people with disabilities, while supporting their return to work. Policy options include separating the income support element from the one to compensate for the extra costs incurred by people with disabilities such as the cost of travel to work and of equipment, using time-limited benefits and making sure it pays to work.
The misconceptions about disability need to be constantly challenged by working with employers and the public.

28. Cross cutting recommendations
World Health Organization
Enable access to all mainstream policies, systems and services.
Invest in specific programmes and services for persons with disabilities.
Adopt a national disability strategy and plan of action.
Involve people with disabilities.
Improve human resource capacity.
Provide adequate funding and improve affordability.
Increase public awareness and understanding of disability.
Improve disability data collection.
Strengthen and support research on disability.
The report concludes with 9 cross cutting recommendations. Implementing them requires involving different sectors – health, education, social protection, labour, transport, housing – and different actors – governments, civil society organizations (including disabled persons organizations), professionals, the private sector, disabled individuals and their families, the general public, the private sector, and media. It is essential that countries tailor their actions to their specific contexts. Where countries are limited by resource constraints, some of the priority actions, particularly those requiring technical assistance and capacity building, can be included within the framework of international cooperation.
First recommendation is on mainstreaming: this is the process by which governments and other stakeholders address the barriers that exclude persons with disabilities from participating equally with others in any activity and service intended for the general public, such as education, health, employment, and social services. To achieve it, changes to laws, policies, institutions, and environments may be indicated. Mainstreaming not only fulfils the human rights of persons with disabilities, it also can be more cost-effective
Second, in addition to mainstream services, some people with disabilities may require access to specific measures, such as rehabilitation, support services, or training.
Third, a national disability strategy sets out a consolidated and comprehensive long-term vision for improving the well-being of persons with disabilities and should cover both mainstream policy and programme areas and specific services for persons with disabilities. The development, implementation, and monitoring of a national strategy should bring together the full range of sectors and stakeholders.
Fourth, people with disabilities often have unique insights about their disability and their situation. In formulating and implementing policies, laws, and services, people with disabilities should be consulted and actively involved. Disabled people’s organizations may need capacity building and support to empower people with disabilities and advocate for their needs.
Fifth, relates to training of healthcare workers, architects and other professionals, but also to ensuring availability of rehabilitation staff, sign language interpreters and support staff.
Sixth, adequate and sustainable funding of publicly provided services is needed to ensure that they reach all targeted beneficiaries and that good quality services are provided.
Seven, mutual respect and understanding contribute to an inclusive society. Therefore it is vital to improve public understanding of disability, confront negative perceptions, and represent disability fairly.
Eight and nine emphasise the gaps in our knowledge about disability, the need for disaggregated data, the need for evidence on outcomes of interventions so we know what works. More researchers, including more researchers with disabilities, should be trained to conduct these studies.

29. World Health Organization
Ways forward
World Health Organization
National
plan
of action
Law and policy
World
Report on
Disability
National policy
dialogues
National
and
Regional
programs
Services
Capacity Building
Awareness
Research
This slide shows how the World Report on Disability will contribute to generating country level action.
National launches or policy dialogues in countries will be the basis for developing or revising national plans of action with concrete actions and resource allocation to improve access to services, build capacity and raise awareness. These will develop country and regional programmes which can then be scaled up.
WHO and the World Bank anticipate that the report through international policy dialogue will also help generate increased political will and raise awareness. It will also set the agenda for technical support activities.
The large number of partners – WHO, DPOs, NGOs, professionals, development actors, academics - involved in the development of this report are also committed to supporting its implementation.
Technical support
International policy dialogue

30. World Health Organization
Summary
World Health Organization
1 billion people
Increasing numbers
Barriers can be overcome
World Report shows us how
It's time to scale up

31. World Report on Disability: Our most accessible document
World Health Organization
Braille
DIASY (audio files)
Easy Read version
Accessible PDF
As well as being available in several other languages, the World Report on Disability is available in Braille, DAISY audio, accessible PDF and Easyread for people wanting a simplified version with pictures.

32. World Report on Disability
World Health Organization
Alana Officer -
Tom Shakespeare -
Aleksandra Posarac -