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Khasnabis C, Heinicke Motsch K, Achu K, et al., editors. Community-Based Rehabilitation: CBR Guidelines. Geneva: World Health Organization; 2010.
Social protection measures are intended to provide a safety net to protect people against poverty and loss or lack of income through illness, disability or old age.
In high-income countries, a majority of people have social protection in the form of social welfare or a pension, whether from the State or a private scheme or both. The majority also have access to health care, which is funded by taxes or insurance premiums. In these countries, if people cannot work they are prevented from falling into poverty by unemployment benefits, disability allowances and other forms of assistance. For people who become disabled as a result of an accident at work, or illness, social protection measures may include compensation, income maintenance and the cost of care. People with disabilities may receive various forms of financial assistance, such as mobility allowances or incapacity benefits. In these countries, social protection measures are designed to guarantee access to goods and services that are essential for a life with dignity.
The situation in low-income countries varies greatly depending on the strength of the economy and government resources, but in general very few people have social protection. Those who have wage employment in the formal economy may have pensions and other forms of social protection, but the great majority often struggle for survival in the informal economy where there is no formal protection against loss of income in old age, or through illness or disability. Public health care may be inadequate and private health care unaffordable for poor people. People with disabilities may be unable to afford the most basic aids and appliances that would enable them to live more dignified lives.
Most people, both disabled and nondisabled, in low-income countries therefore rely on informal systems of social protection based on the family and local community. For people with disabilities who cannot work much owing to the severity of their impairments, social security is the only option.
The Convention on the Rights of Persons with Disabilities (3) requires States to recognize the right of persons with disabilities to social protection and to the enjoyment of that right without discrimination on the basis of disability (Article 28). It spells out what is required to enable people with disabilities to enjoy this right including: access to food, clothing, clean water, affordable services, devices and other assistance for disability-related needs, social protection and poverty reduction programmes, adequate training, counseling, financial assistance and respite care, public housing programmes, and retirement benefits and programmes.
Opha is a wheelchair user in Bulawayo, Zimbabwe. She sells fruit and vegetables in the market and is a member of four different savings groups:
a women's group formed by a local disability nongovernmental organization; a church group; a small savings group; a residents' association.In each of these groups she is involved in some kind of savings.
In the women's group, she contributes to a kind of insurance savings, a “burial club”. When she dies, her dependent niece will get a lump sum which can be used for funeral costs or other things.
In her church, she belongs to a savings group focused on saving for household items.The third group is a ROSCA (see Financial services) of five friends; she uses the periodic lump sum to buy more fruit wholesale, enabling her to increase her turnover.
The residents' association to which she belongs ensures that rents and utility bills are fair and pools its resources to improve the building where she rents a flat.
Despite earning little from selling fruit and vegetables, Opha demonstrates that a low income does not necessarily lead to personal poverty. Her thrift and participation in savings groups enables her to manage her life and support her niece through school. In the absence of any Government safety net, such local, community-based support mechanisms are essential for millions of people with disabilities in low-income countries.
Opha says: “I fear God. I do not use money recklessly. I have an eye for detail. I make friends with my customers. If I am regarded as successful, it is because of these thing”.
People with disabilities who are out of work, who cannot work, or whose resources from occupational activities are not sufficient to maintain their livelihood enjoy a minimum standard of living through social protection measures.
The role of CBR is to facilitate the access of people with disabilities to mainstream or specific social benefits and promote the provision of social protection measures.
People with disabilities have the same access to social security measures against loss of income through old age, sickness or disability as other citizens.
People with disabilities who are out of work, earn too little for a decent living, or are unable to work or have access to available social protection measures.
Existing social services providers are sensitized and aware of the specific difficulties faced by people with disabilities and adapt their service provision accordingly.
Social security providers develop partnerships with people with disabilities, through their representative organizations and service providers, to adapt practices to their specific needs.
Social protection schemes aim at ensuring that individuals covered by such schemes enjoy a minimum standard of living. Social protection schemes can be broadly divided into official (government and large organizations) and informal (arrangements made in the community).
Whether a country offers any form of official social protection to people with disabilities depends chiefly on its economy and government resources. Official social assistance programmes may be aimed at poor and vulnerable people in general through poverty alleviation or reduction schemes, or specifically at people with disabilities.
Examples of measures in place under such schemes, which are often run by governments or large organizations, are food support, low-cost housing assistance, conditional cash transfer schemes and public works programmes which hire poor people on a food-for-work or cash-for-work basis. Such schemes exist in many low-income countries and may or may not specifically include people with disabilities.
The Indian “People with Disabilities Act” commits state governments to a reservation of not less than 3% of people with disabilities in all poverty alleviation schemes. However, the inclusion of people with disabilities in such schemes is generally very low. In 2005, India passed the National Rural Employment Guarantee Scheme Act (NREGS) which entitles every rural household to 100 days of guaranteed employment at the legal minimum wage or else an allowance if work is not provided within 15 days of registration. This law, through its guarantee of wage employment, seeks to safeguard the “right to work” enshrined in the Constitution, which itself is seen as pivotal for the realization of the “right to food”.
However, the Act contains no reference to the 3% reservation for people with disabilities committed to under the People with Disabilities Act. Studies have found that in implementing NREGS there is heavy discrimination on the grounds of caste, gender and disability (6).
Social assistance measures are basic relief given to those who cannot earn a living in the open market and include unemployment assistance, disability benefits and pensions. As with social security measures, social assistance is provided in high-income countries, but rarely in low-income countries. Similarly, the extra costs of being disabled (the costs of carers, transport, adaptations to accommodation, etc.) may be met under social assistance measures in high-income countries, but seldom in low-income countries.
Some very poor countries give no direct assistance to people with disabilities. Others make cash transfers to certain categories of people with disabilities, but at a purely symbolic level. On the other hand, countries with a stronger formal economy and regular tax base may provide enough for a family to survive on. The challenges of operating such schemes in low-income countries include the following.
Disability statistics for low-income countries are often unreliable, but most governments which give such assistance use a figure of 1 % or less - well below the actual number of persons with disabilities.
The amount of benefit may be less than the cost of travelling to receive it.Many poor people with disabilities living in remote rural areas do not know about these schemes, or may have no access to the benefits offered.
In Yemen, the Social Welfare Fund, under the Ministry of Social Affairs and Labour, is a cash transfer mechanism for vulnerable groups in society, including households headed by women, people with disabilities and orphans. This is theoretically available to anyone in these categories who applies for monthly payments. However, very few know about the possibility and individual payments are limited. Delivery points are urban and costly to access for people in rural areas.
For the few with jobs in the formal economy, worker compensation schemes may be available for employees who acquire a disability as a result of an accident at work or a work-related illness. These are often funded through compulsory social insurance.
In some countries, contributions to social security are made through national provident funds - compulsory savings schemes for employees yielding a range of benefits to cover health, disability, old age and other risks. As with social insurance schemes, people are covered only if they are in formal employment.
Since few people with disabilities in low-income countries have formal jobs and since the direct welfare schemes that exist are largely symbolic or inadequate, they rely on informal solutions to survive the crises of loss of work, illness, disability and old age. These are:
individual or family support; community support groups or associations; self-help groups; microinsurance schemes.For most people in low-income countries, the family is still the primary means of support throughout life. The family tends to work as an economic unit to a far greater extent than that in high-income countries. However, because making an economic contribution is so important, people with disabilities may experience discrimination in their families if they cannot make such a contribution. CBR programmes, because they work with families, need to help both the person with disabilities and his/her family to understand how best a contribution can be made.
Charitable groups, religious and community-based organizations may give either occasional or systematic help to vulnerable people, including people with disabilities. They may assist with the purchase of wheelchairs and other aids and appliances, and are potential allies and useful resources for CBR programmes.
Self-help groups set up to save money and provide other types of mutual support are an effective form of social protection available to people with disabilities in poor communities. The most common is the ROSCA (see Financial services).
Other types of savings groups have more limited aims. A number of women might form a group to save for household items, or to re-roof their homes, or to establish a funeral fund. Such groups usually are entirely in control of their own resources.
An advantage of such self-help groups is that all the money generated comes from their members, not from outside. Self-help groups are a powerful tool for developing self-reliance and social capital. CBR programmes in India, especially, use group formation as their main strategy to reach people with disabilities and help them escape from poverty. In other countries, self-help groups are less developed and CBR programmes can play a lead role in helping to establish them.
In the absence of official social security schemes, many communities in low-income countries have organized microinsurance schemes to cater to their need for security and access to social services and to manage risks. These voluntary schemes are organized by trade unions, municipalities, private insurance companies, microfinance institutions, health service providers, nongovernmental organizations, community-based organizations and mutual health organizations. Households pay a small premium for limited coverage in the event of losses, illnesses, accidents and disability. They may operate as individual insurance schemes, but are frequently group schemes, in which the risks are pooled - group members in need are supported by those who do not need to draw on the insurance at that time. Members often participate in decision-making and influence the operations of their scheme. Such schemes are sometimes promoted by governments, which may contribute to the fund, exempt the schemes from tax, or introduce enabling legislation.
The Association d'Entraide des Femmes (ASSEF) is a microfinance cooperative in Benin to provide services to low-income women in the deprived areas of the capital and its surrounding areas. Its health microinsurance has benefits for patients which can be accessed at contracted health-care providers, with a copayment required for all services.
Whatever form of social protection is considered, there is an ongoing debate about who to protect and how. Who is disabled and who should be eligible to receive special social assistance? What is the difference between rights and charity in this context? Is social protection compatible with the ideal of nondependency?
CBR programmes have a responsibility to engage with the issue and influence outcomes; along with disabled people's organizations they need to act as catalysts, informants, advocates and guides. If they do not, people with disabilities risk being left out of social protection schemes designed to combat extreme poverty.
In the following suggested activities, CBR programmes should work in partnership with people with disabilities and their representative organizations.
Social protection is an integral element of a comprehensive approach to disability. CBR programmes need to work in partnership with disabled people's organizations to ensure that all people with disabilities are covered by existing social protection measures, whether these are provided through a social security system, a social assistance programme or an informal scheme. To do this effectively, CBR programmes need to:
be fully informed of provisions under the law, such as workers' rights and any entitlements that people with disabilities may claim, such as assistance with transport, schooling, training, aids and appliances;
make sure that all the people with disabilities they work with are aware of these entitlements and how to obtain them;
compile an information database on all social security and assistance schemes available both nationally and locally and make sure people with disabilities have access to this information; this database should include criteria for selection, how to apply and what kind of benefits are available;
facilitate disabled people's organizations and parents' organizations to establish contacts and partnerships with mainstream social security and assistance services to ensure that they understand and adapt their practices to the specific needs of people with disabilities;
join disability activists and advocates in lobbying for disability entitlements where they do not exist.
CBR programmes need to be aware of programmes and services which are in place to ensure that families are adequately provided with food and water and work to ensure that the specific requirements of persons with different types of disabilities are adequately taken into account. This may be done in partnership with disabled people's organizations. Toilets are a big problem in many parts of the developing world, where many people do not have a toilet in their home and need to use the natural environment instead. It is difficult for people with disabilities, especiallly women with disabilities, to do this. CBR programmes need to work with local authorities to facilitate toilet facilities along with water connections.
The cost of renting suitable accommodation can be higher for people with disabilities than for others, (because, for example, they may need a ground floor flat), adding to the daily living costs of people whose income is already limited. Discrimination in housing provision is often encountered by people with disabilities. CBR programmes need to be aware of this problem and act as advocates with the relevant authorities to ensure equality of opportunity and treatment for people with disabilities and their families.
Accessible accommodation may also become a problem when individuals with disabilities leave home to attend training, seek employment or start a small business in another location. People with disabilities may not be able to use the available accommodation because it is inaccessible. CBR programmes need to familiarize themselves with the accessibility requirements of individuals with disabilities and work closely with relevant public sector and private agencies to facilitate the finding of suitable housing. Where public housing is being planned, steps should be taken to ensure that the housing is fully accessible, affordable and developed in a way that will contribute to the full participation of people with disabilities in their communities.
People with disabilities need access to health-care services on an equal basis with people who are not disabled. Some people with disabilities will need health care specific to their health condition/impairment (e.g. drugs for epilepsy).They may also need assistive devices (see Health component).
CBR programmes need to learn where health-care services and assistive devices are available in the local area and pass on this information to people with disabilities and their families. In some cases, the CBR programme will directly arrange or facilitate the provision of suitable care or assistive devices. Where such devices are available from the government or nongovernmental organizations, this information needs to be made widely known to persons with disabilities.
A CBR programme in rural Peru found that most mothers of children with disabilities were not taking the children to the health centre for check-ups or when they were sick. The programme helped the mothers to enrol their children with disabilities in the free national health programme for children. The CBR programme formed a bridge between the health service providers and the disabled children's families.
Some people with disabilities may require personal assistance with daily care and support. Personal assistance can be provided in communities by volunteers, often family members trained in these roles. Where disabled people's organizations and nongovernmental organizations do not provide personal assistance training, CBR personnel have a central role to play in organizing such training. Fundamental to the provision of personal assistance is the recognition that the person with a disability should be able to choose his/her assistant (see Social component: Personal assistance).
In some countries, governments provide allowances to cover the disability-related costs of people with disabilities that are additional to their everyday costs of living. These additional costs may be related to transport, accessible housing, assistive devices or adaptations to everyday articles and equipment. They also include the cost of loss of earnings by volunteer carers, who are mainly women. These costs must be met if people with disabilities are to participate fully in family and community life, but they are particularly difficult to meet when people with disabilities and their families are already living in poverty.
Where such provisions are in place, the CBR programme needs to know about these, make the information available to people with disabilities and support them in taking advantage of them. Having access to this type of support may make the difference between exclusion and inclusion, and thus between partial and full participation in the community and society.
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