Framework and strategy for disability and rehabilitation in south africa 2015/16 – 2020/2021

1.INTRODUCTION

This Policy Framework and Strategy for Disability and Rehabilitation services in South Africa outlines comprehensive and integrated disability and rehabilitation services within the broader health and developmental context to facilitate improved access at all levels of health care.

With improved treatment people live longer, and with this a higher number of people experience chronic conditions/illness and disability. This places a larger burden on household and fiscal finances, facilities and human resources in the country.
Some programmes within the health sector can prevent the onset of impairment, however many interventions required for the prevention of disability lie outside its mandate, within the broader society, with other government departments and are part of the social determinants of health. The emphasis in this document is on health interventions with rehabilitation cutting across the promotive, preventive, curative, rehabilitative and palliative continuum of care. Rehabilitation services make the vital, practical link between medical treatment and the translation of a person’s restored capacity into a productive and health-promoting social and economic life. Rehabilitation should start as early as possible, be as decentralised as possible, and requires a defined referral pathway, extending from community to tertiary and specialised rehabilitation levels. Referral pathways for persons with disabilities and those at risk must be in place to create access to appropriate care by the best qualified service providers, in the right place and at the right time. It is critical that referral pathways are aligned to departmental policy on referrals, clinical guidelines and protocols.

2.CONTEXT

The prevalence of disability in South Africa is contentious in part because stakeholders are not agreed on a definition of disability. Present definitions are applied in terms of different legislation and contexts, and focus primarily on impairment without necessarily addressing the contexts in which barriers limit participation. A major limitation in determining true levels of disability in South Africa is that disability prevalence surveys are usually based on reported disability, often by a proxy informant, which may overestimate or underestimate the prevalence.

According to a Statistics South Africa Report based on Census 2011 data², the national disability prevalence rate is 7.5% in South Africa. Disability is more prevalent among females than males (8.3% and 6.5% respectively). It must be noted however that this prevalence rate excludes children under the age of 5 and people with psychosocial and certain neurological disabilities.
The prevalence of a specific type of disability shows that 11% of people 5 years and older had seeing difficulties, 4.2% had cognitive difficulties remembering/concentrating), 3.6% had hearing difficulties, and around 2% had communication, self-care and walking difficulties.
Provinces with the highest reported disability were Free State and Northern Cape (both 11.0%). Reported disability figures for the remaining provinces, in descending order, are North West (10.0%), Eastern Cape (9.6%), KwaZulu-Natal (8.4%), Mpumalanga (7.0%), Limpopo (6.9%), Western Cape (5.4%) and Gauteng (5.3%).
The overall prevalence of childhood disability has been studied among smaller target populations in South Africa over the past 30 years, but recent data is scant.³ Moreover estimates of child disability prevalence are not directly comparable as studies use different definitions of disability and methods of data collection.
With regards to older persons, according to StatsSA⁴, South Africa’s population over 60 years is 7.8% and the proportion of people with disabilities in the 60 to 69 year age group is 14.5%, rising to 34.7% in the over-70 year group.⁵ Population ageing is associated with impaired functioning and mobility limitations, i.e. impaired vision, glaucoma, diabetic retinopathy, hearing loss, and impaired mobility due to strokes, falls, bone and joint conditions.^{6 -7} The prevalence of Alzheimer’s and Parkinson’s disease and dementia in the South African population is not known.⁸
Decreased childhood mortality in South Africa has had the unintended and unfortunate consequence of increased childhood disability, as is evidenced by the number of children presenting with developmental delays and cerebral palsy^a. Chhagan and Kauchali⁹ advocate for combining improved child survival with optimal development into a single outcome measure of “disability-free survival”.
The role of disability in entrenching and exacerbating the cycle of ill-health and poverty is often inadequately understood in health service planning.
Figure 1 illustrates the cycle in which poverty increases the risk of ill-health, while simultaneously restricting access to appropriate and affordable healthcare. Poor health outcomes frequently include residual functional impairments, which result in loss of productive capacity, increased care and cost burdens on households, and create additional barriers to healthcare access.
Figure : Cycle of poverty, ill-health and disability
Multiple health risks

Ill-health

POVERTY

Poor access to HEALTH CARE

More complex and enduring health needs, increasing barriers to health care access

Lost participation in work and education

Household burden of care

Health care access costs

Poor health outcomes: residual impairments lead to DISABILITY

Source: Sherry K.2015. Cycle of poverty, ill-health and disability (unpublished).
In South Africa, poor people, and particularly those living in rural areas, frequently have the least access to quality healthcare, including rehabilitation services. Poor health outcomes have a regressive effect, both increasing the incidence and complexity of healthcare needs in the affected person, and creating additional barriers to accessing healthcare, such as an inability to use public transport or a need for personal assistance when seeking healthcare.
As increasing numbers of people from high-risk groups (e.g. high-risk babies and people with HIV) survive due to medical and social interventions, the number of people with disabilities increases. Ironically, a saved life does not automatically become a productive or healthy life in the long term.
Many risk factors and common conditions may lead to disability. These include health related risk factors (pre-natal, perinatal and postnatal risk factors, various communicable and non-communicable diseases, ototoxic drugs), environmental risk factors (Food insecurity and under-nutrition, Iron-deficiency anaemia (IDA), Micronutrient deficiencies (e.g. vitamin A deficiency (VAD), poverty, violence, injury, motor vehicle crashes, neglect, child abuse and child sexual abuse).
Challenges experienced in implementing rehabilitation services in South Africa are related to a variety of factors. These include:

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  A medical model resulting in poor access to a comprehensive disability and rehabilitation service especially to persons in rural and disadvantaged areas.
  
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  The implementation of disability and rehabilitation services as a vertical programme with little or no scope for integration with priority health programmes, such as Non-Communicable Diseases, Maternal Child and Women’s Health (MCWH), HIV and AIDS.
  
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  Inadequate follow-up due to a lack of clarity on referral pathways as well as poor availability of services. This problem is aggravated by the fact that there inadequate rehabilitation units in district hospitals and only two specialised rehabilitation centres in the country. There is also poor communication and coordination between service levels.
  
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  Inaccessible and unaffordable transport. Families of people with disabilities incur significant costs for public transport and car hire in order to access health care. Studies have been conducted in the Eastern Cape¹⁰ and Mpumalanga¹¹ relating to “out-of-pocket” expenditure when accessing health care.
  
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  Poor inter-sectoral collaboration.
  
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  Inaccessibility of health services with regard to facility infra-structure^a, signage and information in an appropriate medium including sign language and Braille. In addition, therapy is often not done in the client’s first language.
  
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  Inadequate provision of appropriate assistive devices/technology and accessories. Assistive devices ranging from walking aids to Augmentative and Alternative Communication devices should be available to clients based on their needs. Some devices such as the white cane have traditionally been issued only by the NGO sector.
  
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  The lack of awareness, knowledge and training among healthcare providers regarding the challenges, needs and rights of in poor care and disempowerment. Negative attitudes towards children and adults with disability obstruct their participation in health and rehabilitation services. Rehabilitation professionals are often not “culture-sensitive” and do not respect the value systems and beliefs of their clients, which may delay early identification and intervention.¹²
  
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  The paucity of appropriate rehabilitation indicators in the national and provincial data sets impairs the quality and type of service, as there is no proof of effective service delivery which could be used to motivate for resources. There is little research linked to the outcomes of rehabilitation services at secondary, tertiary and specialised levels, and none at PHC level.
  
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  The ideal core rehabilitation team usually does not exist. This should comprise of a physiotherapist, occupational therapist, speech therapist, audiologist, medical orthotist and prosthetist, and related mid-level health workers. (Please see Appendix A for a Description of the Core Team and their respective roles.) The support team should include a social worker, dietician, orientation and mobility instructor, podiatrist, optometrist and psychologist. There is a lack of inequitable distribution and high vacancy rate of service providers at the different levels of care especially rehabilitation staff at primary level (see Table 1 below). In particular, junior rehabilitation professionals are often unsupported and not trained to work with complex cases.
  

Table : Vacancy rates per province (2015)

Prov-ince	Occupational Therapist		Physiotherapist		Speech-Language Therapist and Audiologist
	Posts filled	Vacancy rate	Posts filled	Vacancy rate	Posts filled	Vacancy rate
EC	75	54%	111	45%	40	42%
FS	69	30%	68	36%	12	63%
GP	271	16%	230	14%	149	9%
KZN	236	9%	327	9%	154	14%
LP	193	3%	58	5%	67	14%
MP	96	54%	75	63%	49	68%
NC	63	28%	59	34%	33	21%
NW	70	13%	85	14%	26	16%
WC	140	5%	143	3%	66	3%
SA	1 213	22%	1 256	23%	596	27%

Source: Department of Health. Occupational Categories; February 2015.
Additionally person with disabilities have specific health needs which require special attention. These include:-

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  reproductive health services,
  
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  oral health,
  
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  spinal care,
  
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  medication and consumables,
  
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  adequate sun protection,
  
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  bladder and bowel management including incontinence products,
  
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  prevention, management and control of communicable and non-communicable diseases
  
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  surgical interventions.
  

Ideally both health and rehabilitation services should be accessible at single points of care.

The above challenges as well as the specific health care needs of persons with disabilities illustrate the need for a comprehensive strategy for the provision of disability and rehabilitation services across the life course at all levels of the health system, extending from the community to specialised centres.