Framework and Strategy for Disability and Rehabilitation in South Africa 2015/16 2020/2021

FRAMEWORK AND STRATEGY FOR DISABILITYAND REHABILITATION SERVICES
IN SOUTH AFRICA
2015 - 2020

TABLE OF CONTENT

FOREWORD BY THE MINISTER

MESSAGE OF SUPPORT FROM THE DEPUTY MINISTER

ACKNOWLEDGMENTS BY THE DIRECTOR-GENERAL

1.INTRODUCTION

2.CONTEXT

3.LEGISLATIVE AND POLICY FRAMEWORK

4.POLICY FRAMEWORK AND STRATEGY ON DISABILITY AND REHABILITATION

4.1.Vision

4.2.Mission

4.3.Values

4.4.Goals

5.APPROACH

5.1Home/Community Setting

5.2School Setting

5.3Primary Health Care Facilities (clinics, community health centres)

5.4Hospital Based Services

STRATEGIC PLAN 2015 - 2020

REFERENCES

LIST OF APPENDICES

Appendix A: Core professional rehabilitation service providers and description of Roles

Appendix B: GLOSSARY (abbreviations used in this glossary are defined in the list of abbreviations and acronyms

LIST OF FIGURES:

Figure 1: Cycle of poverty, ill-health and disability

Figure 2: The CBR Matrix reflecting five core components and their key elements

LIST OF TABLES

Table 1: Vacancy rates per province (2015)

FOREWORD BY THE MINISTER

The transformation of the South African health system towards universal coverage is a critical step in overcoming the deep inequities in our society. People with disabilityare recognised as a previously disadvantaged group, and the health system has a crucial role to play in reducing the number of people who sustain impairments, improving their access to healthcare, and supporting all to live long and healthy lives.

Rehabilitation is recognised as an important component in the continuum of care and is essential if quality of life is to be achieved. A transforming health service, including the Primary HealthCare Re-engineering, makes this the perfect moment to reconfigure rehabilitation as an integral part of health services across all programmes, within a system that provides services as close as possible to where people live and work.

Disability is known to have far-reaching effects on the health and socio-economic status of households and communities, and people with disability continue to be disproportionately represented among the extremely poor. As South Africa works towards reducing inequality and eliminating absolute poverty[1], rehabilitation has a crucial role to play in translating health gains made by mainstream clinical services into people’s capacity to live socially and economically productive lives, thus interrupting the vicious cycle of poverty and ill-health.

This Framework and Strategy for Disability and Rehabilitation Services in South Africa 2015 was compiled in consultation with people with disabilities, the Task Team on Disability, professional rehabilitation service providers, academics, and other key stakeholders in the field. It offers a blueprint for how rehabilitation services within Primary Health Care Re-engineering reflects commitment to an increasingly equitable and inclusive society, which will ensure “a long and healthy life for all South Africans”.

DR PA MOTSOALEDI, MP

MINISTER OF HEALTH

MESSAGE OF SUPPORT FROM THE DEPUTY MINISTER

This document signals the Department's commitment to addressing issues of people with disability. While much of the prevention of disability rests in the social determinants of health, there is much required from the health sector in terms of prevention as well as rehabilitation and access to health services.

The Framework and Strategy on Disability and Rehabilitation envisages disability and rehabilitation services at all levels of care; from home to tertiary services. The role that individuals with disabilities and their families play is recognized and valued as the inherent knowledge that those with disabilities have forms part of the intervention plans. The framework reinforces the dictim “nothing about us without us”.

South Africa embraces the human rights culture as espoused in the UN Convention on the Rights of Persons with Disabilities. In line with this we commit to a package of services that we will make available to all affected by disability. All reasonable measures will be taken so that services are made available at the closest point to where people live. We also commit ourselves to provide services in the shortest possible time. Article 26 of the UN Convention on the Rights of Persons with Disabilities enjoins us to organize, strengthen and extend comprehensive habilitation and rehabilitation services and programmes, and through this document we intend to achieve these ideals.

DR J PHAAHLA

DEPUTY MINISTER OF HEALTH

ACKNOWLEDGMENTS BY THE DIRECTOR-GENERAL

Given government’s commitment to equity and non-discrimination, including people with disabilities, the Honourable Minister of Health, Dr Aaron Motsoaledi appointed a Task Team to develop a Framework and Strategy for Disability and Rehabilitation in 2013. ThisTeam represented a wide range of stakeholders, including but not limited to Disabled People's Organizations, universities, professional organizations, provincial representatives, private sector and other government departments. On behalf of the Department I would like to express my gratitude to all the members of the Task Team for the dedication they put into doing this work - especially as this work had to be fitted into already busy schedules.

I also want to thank other contributors to this document, among them Dr Pamela McClaren from Disability Action Research Team and Fiorenza Monticelli from the Health Systems Trust for managing the final inputs from consulted contributors. Iam confident that this document will put the Department on the right course to improve our servicesto persons with disabilities. We will endeavour to implement this framework and strategy to ensure that services for persons with disabilities are available at all the levels of health care.

MS MP MOTSOSO

DIRECTOR-GENERAL: HEALTH

1.INTRODUCTION

This Policy Framework and Strategy for Disability and Rehabilitation services in South Africa outlinescomprehensive 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 treatmentpeople live longer, and with this a higher number of people experience chronic conditions/illness and disability. This places a larger burden onhousehold 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 disabilitiesand 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 agreedon 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 data[2], 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 people5 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 usedifferent definitions of disability and methods of data collection.

With regards to older persons, according to StatsSA[4],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 andParkinson’sdisease 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[1]. Chhagan and Kauchali[9] 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 1illustrates 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 A: Cycle of poverty, ill-health and 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 toa variety of factors. These include:

• A medical model resulting in poor access to a comprehensive disability and rehabilitation service especially to persons in rural and disadvantaged areas.
• 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.
• 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.
• Inaccessible and unaffordabletransport. 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 Cape[10]and Mpumalanga[11]relating to “out-of-pocket” expenditure when accessing health care.
• Poor inter-sectoral collaboration.
• Inaccessibility of health serviceswith regard tofacilityinfra-structure[2], 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.
• 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.
• 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]
• 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.
• 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 1: Vacancy rates per province (2015)

Source: Department of Health. Occupational Categories; February 2015.

Additionally person with disabilities have specific health needs which require special attention. These include:-

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

3.LEGISLATIVE AND POLICY FRAMEWORK

The following key legislative and policy instruments guide the content of this Framework and Strategy.

1. Key International Instruments
2. The Convention on the Rights of the Child (CRC)provides for children with disabilities to enjoy all the same rights as other children, including the right to health.
3. The UN Convention on the Rights of Persons with disability(CRPD) was signed and ratified by the South African government in 2007 and its provisions reflect the obligations of the State. The CRPD is an international human rights treaty aimed at protecting the rights and dignity of people with disabilities. Central principlesinclude respect, non-discrimination, full and effective participation andinclusion in society, equality of opportunity and accessibility. The ratification of the CRPD requires the State to review a range of national policies and legislation across sectors to ensure compliance.

The CRPD contains specific provisions for health,habilitation and rehabilitation, but equally applicable are articles relating to personal mobility, living independently and being included in the community, as well as many cross-cutting articles.

1. National Instruments
2. The Constitution of South Africa Act (108 of 1996)provides that everyone is equal before the law and has equal protection and benefit of the law. It prohibits discrimination on a number of grounds, including disability.
3. National Development Plan envisages a country which by 2030 has eliminated poverty and has reduced inequality. The NDP 2030 acknowledges that many persons with disability are not able to develop to their full potential due to a range of barriers, resulting in their often being viewed as unproductive and a burden and proposes changes to redress this
4. Promotion of Equality and Prevention of Unfair Discrimination Act (4 of 2000)gives effect to section 9 of the Constitution, to prevent and prohibit unfair discrimination and harassment; to promote equality and eliminate unfair discrimination; and to prevent and prohibit hate speech. It mandates the removal of barriers and taking positive steps to ensure that PwD are able to enjoy full and equal participation and access to opportunities.
5. National Health Act (61 of 2003) provides for the provision of quality health services to the population of South Africa. The Act also provides for the establishment of the National Health Council, which is a structure responsible for making health policy in the country. It further gives the Minister of Health the authority to make regulations on any health matter, including regulations on rehabilitation and assistive devices.
6. Mental Health Care Act (17 of 2002)provides a framework for the provision of mental healthcare services in South Africa. Among other things it enables the establishment of observation services for 72 hours in non-mental health facilities. It further provides a framework for the designation of mental health facilities and establishment of mental health review boards.
7. Other sector instruments such as Road Accident Fund Act (56 of 1996), Social Assistance Act (13 of 2004), Road Accident Fund Amendment Act (19of 2005) and Children’s Act (38 of 2005) promote and protect the rights of persons with disability within different sectors.

4.POLICY FRAMEWORK AND STRATEGY ON DISABILITY AND REHABILITATION

4.1.Vision

Accessible, affordable, appropriate and quality disability and rehabilitation servicesthroughout the life course.