Perspective Chapter: Disability-Inclusive Sustainable Services – The Role of Social Workers

Abstract

Over the years, social workers have played diverse roles in engaging individuals, groups, families, communities, and organisations in their quest to promote overall well-being. However, persons with disabilities (PWDs) continue to face several challenges. The COVID-19 pandemic adds a layer to their vulnerabilities. While several interventions have been put in place to address the needs of persons with disabilities in developed countries, their counterparts in low-income countries, such as Ghana, continue to face marginalisation and exclusion. Using user-perspective and co-production approaches, we analyse existing services for Ghanaians with disabilities and the relevance and usefulness of these services. We also attempt unpack the complexities of both service providers and recipients. We conclude with strategies to help social workers develop interventions to promote sustainable disability-inclusive services.

1. Introduction

The World Health Organisation estimates that more than a billion people live with some form of disability globally, representing about 15% of the world’s population. The majority of PWDs live in developing countries. In Africa, it is estimated that about 10% of the population live with disabilities with the majority living in poorer regions of the continent [1]. In Ghana, getting up-to-date statistics on PWDs is a challenge as a result of the lack of well-coordinated data on the actual number of PWDs living in the country. The 2021 Population and Housing Census General Report estimates that about 2,098,138 (representing 8%) of the country’s population of 30,832,019 live with some form of disabilities. It is worth mentioning that this figure represents the population of 5 years and older. This suggests that the actual prevalence rate of disability in the country could be more if data were collected on PWDs below this age. The Census data could also be underreported because PWDs are one of the hard-to-reach populations, exacerbated by prejudices and discrimination against PWDs [2].

The 2012 Human Rights Watch report states that over 5 million people in Ghana live with disabilities, a remarkable difference from the Census data. The estimate of the Human Rights Watch report collaborates with the World Health Organization’s projection that disability affects 15–20% of every country’s population. Five million Ghanaians with disabilities is a huge number that cannot be ignored in any developmental discourse.

Ghanaians with disabilities continue to encounter challenges, including socio-cultural, physical, information and transportation inaccessibility, which impede their inclusion and full-effective participation in mainstream society [3, 4]. These challenges impede socio-economic and political participation as well as the overall well-being of PWDs. For example, there is evidence that the challenges PWDs encounter impact their educational attainment [5], social participation, including sexual reproductive rights and marriage [6, 7], freedom to participate in political and civic life [8, 9], labour market inclusion [10, 11, 12] and access to healthcare [13, 14, 15]. The COVID-19 pandemic could increase the vulnerabilities of PWDs [16].

But what services exist to address their needs? How relevant and useful are existing services? What challenges do both service providers and service recipients experience? What strategies can social workers adopt to provide sustainable disability-inclusive services? This paper attempts to answer these questions.

2. Background to social work practice in Ghana

Social work practice in Ghana started as a welfare practice during the pre-colonial era. The family system, typically the extended family, was seen as the epitome of providing welfare services for members in need [17]. The era saw a mutual interdependence of family system, where individuals within the family (i.e., grandparents, parents, uncles, aunties, and cousins) assisted in solving individuals, families, and societal problems [17]. Post-colonial developments such as modernization and technology development saw the need for professional social work interventions, necessitating the need for professionally trained social workers in Ghana [18]. Efforts to realize this necessity was met with the establishment of the School of Social Work in 1946 at Osu, Accra, to train social workers in certificate courses and the graduates mostly work with the social welfare departments across the country. Subsequently, the University of Ghana and currently a few other universities offer diplomas, bachelors, master’s in social work. It is noteworthy that the University of Ghana is the only institution that offers PhD degree in social work.

2.1 Roles of social workers in areas of disability

Social workers perform different roles to promote disability rights in Ghana. Social work practitioners in Ghana mostly work with the department of social welfare, providing case management and other services for the vulnerable populations, including persons with disabilities. Others work in institutions such as the Domestic Violence and Victims Support Unit, Ministry of Gender, Children and Social Protection, Metropolitan, Municipal and District Assemblies (MMDAs). Yet others work as special education coordinators and teachers in schools.

Also, social work educators engage in teaching and training more social workers. Over the years, social work education in Ghana has focused on training and equipping students with knowledge and skills to tackle social problems, including disability, that require professional interventions [18]. Social work educators work in collaboration with social service providers regarding field practicum. Students do their field practicum with department of social welfare, civil society organizations (CSOs) and non-governmental organizations (NGOs) in the area of disability. Through these strategies, social work students acquire hands-on experience as well as network with these organisations [19]. Social work researchers also engage in disability research to heighten public awareness of disability issues intended at reducing discrimination and stigmatization against persons with disabilities as well as their needs.

3. Methodology

This paper reviewed existing services and regulations for and regarding persons with disabilities in Ghana. The authors used policy documents and guidelines for service provision as well as literature documenting the regulations and services. The authors also factored in their own experiences working in the field of social work. For example, the lead author, has several years’ social work practice experience, working with persons with disabilities and women. The other two authors also have some social work practice experience with persons with disabilities and other vulnerable population such as children and persons with mental illness. The authors’ work experiences were brought to bear on the paper.

4. Organisation of services for persons with disabilities

Persons with disabilities need both mainstream and specific services to promote their well-being [20]. The Persons with Disability Act (Act, 715) is the legal framework that promotes the rights of PWDs, providing the blueprint to respond to their challenges. Act 715 provides for the basic rights of PWDs, including the right to education, health care, employment, transportation, housing, medical rehabilitation services, access services, buildings and sporting events, festivals, and cultural activities. Section 41 of the Act establishes the National Council for Persons with Disabilities to advise the government on disability centered policies and programmes as well as to oversee the implementation of same.

Ghana has put in place programmes and services to promote the rights of the vulnerable including PWDs. These include Livelihood Empowerment Against Poverty (LEAP), District Assembly Common Fund (DACF), Community Based Rehabilitation programmes, specialized schools, and training centres [21] to promote PWDs inclusion in society.

4.1 Livelihood empowerment against poverty (LEAP)

The Livelihood Empowerment Against Poverty (LEAP) programme is a social protection programme that started in 2008. LEAP seeks to promote access to services and to increase consumption among the extremely poor and vulnerable populations with the ultimate goal of reducing poverty [22, 23]. The beneficiaries receive cash transfers bi-monthly ranging from GHS 64.00 for an eligible person, GHS 72.00 for households with two eligible members, GHS 88.00 for households with three eligible persons, and GHS 106.00 for households with four or more eligible persons per payment cycle. Payments are made via E-zwich inter-bank payment platform.

Enrollment in this programme is subjected to means-testing and demonstrated eligibility [24, 25, 26]. The LEAP outlines eligibility as:

“The programme covers extremely poor and vulnerable households, including orphans and vulnerable children, persons with a severe disability with no productive capacity and elderly persons 65 years and above” [27].

But the question is, who is a person with a severe disability with no productive capacity? Which PWDs fall under this category? Not all those who require this service. What happens to those who are unemployed, given that most persons with disabilities in Ghana are more likely to be unemployed and/or work in menial, seasons, and marginal jobs? [10, 11, 12].

Also, LEAP is said to be one of the successful social protection schemes that aim at eradicating household poverty [26, 28]. For example, de Groot [29] in his review of Ghana’s LEAP programme reported that the LEAP programme had a strong impact on fighting household poverty, particularly on certain subgroups such as PWDs. Also, the UNICEF report on the impact of the LEAP on its target population, indicates that as of December 2017, LEAP was reaching more than 213,000 poor families, including PWDs in all 216 districts of Ghana. LEAP has improved school enrollment, access to health, consumption and wellbeing among LEAP recipients. However, how many PWDs have received these services thus far? We do not know because only aggregated data is reported, which makes it difficult to know how many PWDs benefit from such programmes. Also, it would be difficult to conclude that meagre LEAP benefits could improve the well-being of PWDs who must also cater for disability-related expenses, noted to be very expensive [30].

4.2 National health insurance scheme

The National Health Insurance Scheme (NHIS) was established from the National Health Insurance in 2003 under Act 650. Act 852 replaced Act 650 in 2012 to strengthen the management and effective administration of the NHIS. The principal aim of the NHIS is to guarantee access to healthcare for all Ghanaian residents. Persons exempted from paying premium include “pregnant women, indigents, categories of differently-abled persons determined by the Minister responsible for Social Welfare, persons with mental disorder, Social Security and National Insurance Trust (SSNIT) contributors and SSNIT pensioners, persons above 70 years of age (older adults) and other categories prescribed by the Minister” ([31], p. 20). Everyone that qualifies for LEAP enrolls on NHIS. For persons with disabilities to enroll free to the scheme, they must qualify as “indigent.” Regulation 58 (Section 1) of the legislative instrument (LI 1809) that operationalises the NHIS defines an indigent as a persons who is (a) is unemployed and has no visible source of income; (b) does not have a fixed place of residence according to standards determined by the scheme; (c) does not live with a person who is employed and who has a fixed place of residence; and (d) does not have any identifiable consistent support from another person.

The term indigent as stated in the NHIS policy is also vague thus, given frontline workers liberty to use their discretion to enroll who they believe is indigent. For example, what does it mean not to have a fixed place of residence because in Ghana many people live in their family houses or with family members? And how can PWDs who are more likely to be poor afford to pay the premium of GH

72-approximately US$11.64?

4.3 District Assembly Common Fund (DACF)

The District Assembly Common Fund (DCAF) for Persons with Disabilities is the only intervention that specifically targets PWDs. The DCAF seeks to minimise poverty among PWDs in the informal sector [32]. The government of Ghana in 2005 gave a directive instructing all district assemblies to allocate up to 5% of their shares of the District Assembly Common Fund for PWDs. In 2007, the government in its quest to support development of PWDs, added a ring-fencing clause to the guidelines for the utilisation of the District Assembly Common Fund. Part I, guideline #6 of the DACF states that, “two percent (2%) shall be utilized to support initiatives by the physically challenged in the district.” The government increased the required DCAF percentage to 3% in 2018. An effort hailed by everyone, especially persons with disabilities, their families and their organisation.

Ghana’s initial report to the United Nations Convention on the Rights of Persons with Disabilities (CRPD) in 2018, indicates that approximately GH

85.5 million Ghana cedis was disbursed to MMDAs to support persons with disabilities between 2013 and 2017 [26]. This is commendable. But the multimillion question is, how many persons with disabilities enjoyed this support and how does the DCAF for persons with disabilities meaningfully impact their lives? There is evidence that not every person with a disability who needed the DCAF support benefits, and the amount of money that beneficiaries received is inadequate and does not guarantee meaningful and sustainable impact on their lives [33]. Attitidinal and environmental barriers were identified as hindrances to accessing DCAF for PWDs.

4.4 Community based rehabilitation (CBR) programme

The CBR programme was introduced to improve the quality of life of PWDs. CBR aims at integration and equalisation of opportunities for PWDs in the community by establishing community-based programmes and rehabilitation services. CBR emphasis on community involvement, PWD should live in their own communities and get the resources required for full participation in the community [34, 35]. The programme was initially funded by the Norwegian Association of the Disabled (NAD) and the Swedish Handicap Organization from 1992 to 1999. After 1999, the United Nations Development Programme (UNDP) expanded the projected national coverage of CBR from 1999 to 2002 [36]. The CBR programme provides home-based rehabilitation services delivered by family members of PWDs, with the support of trained volunteer local supervisors. After the funding of the programme from its external donors ceased, each community was required to mobilize local community resources to support and sustain the activities of CBR programme, which has become a challenge for the continuation of CBR in Ghana.

4.5 Educational/training institutions

There are educational institutions that provide specialized services to PWDs to promote successful integration and inclusion in mainstream society. There are two specialized schools for persons with visual impairment, ten basic schools and a secondary school for persons with hearing impairment and three assessment centres [37]. For people with mental disabilities, there are seven regional mobile centres for children with learning difficulties and other development problems and nine schools for persons with mental disabilities. Boarding schools for persons with mental disabilities in Echoing Hills and the Autism Awareness Care and Training Centre provides training for autistic children. There are 38 National Vocational Training (rehabilitation) centres across the country that serves the populace but only 10 focuses mainly PWDs.

It is noteworthy that, although these institutions do not require payment of school fees, there is anecdotal evidence that students provide most of the necessities including, toiletries, school uniforms and some food items. The assessment centres also require payment for services provided. Social workers can play diverse roles to ensure that persons with disabilities receive better services.

4.6 Social work leadership in the field of disability

Social workers can undertake different leadership roles, especially at messo and macro levels, to promote disability rights in Ghana. At the messo-level, social workers could take up leadership roles in rehabilitation teams in hospitals and community-based rehabilitation team-where they exist, community planning teams, boards of nongovernment organisations and civil society organisations working for and with persons with disabilities. At the messo level, social workers could occupy leadership positions in departments where decision making happen. Disabilities issues cut across several sectors of the society, including education, transport, healthcare, social welfare, and employment. Social workers could advice on disability inclusion and advocate for services for persons with disabilities.

At the macro level, Ghanaian social workers could engage policy decision-making, lobbying and advocacy [38]. They could lobby for effective and efficient implementation of existing policies, advocate for policies and programmes that could promote disability rights and/or for the representation of persons with disabilities in decision-making, especially on interventions and issues relating to them. Currently, there is little representation of person with disabilities on boards/committees making decisions about their lives [39].

5. Challenges of service providers and recipients

Individuals with various forms of disabilities require a range of services to address their diverse needs. Services provided to PWDs must be continuous, effectively and efficiently coordinated and transition from one stage to the other. They should range from early intervention to educational services, healthcare and rehabilitation, vocational training and access to employment, housing, support services, leisure, and mobility-related services [15, 20, 40, 41, 42, 43, 44]. Although the 1992 Constitution of the Republic of Ghana, Persons with Disability Act, 2006, National Disability Policy, 2000, and other frameworks lay foundation for services provision to address the needs of PWDs, the experiences of service-providers and service-users is characterised by challenges. There is no coordinated and systematic service provision for PWDs in Ghana to holistically address the numerous challenges that they encounter daily in a sustainable manner.

We will use the framework of the 5 A’s of access to service proposed by Blanchet [20] to discuss these challenges. The 5 A’s are Availability, Accessibility, Affordability, Acceptability and Accountability [42, 45, 46].

Regarding the Availability of services, as discussed previously, fewer interventions exist to address the needs of PWDs. Most of the available services are mainstream interventions which lump PWDs with other vulnerable populations, therefore, making it difficult to include eligible PWDs and/or inadequately address their needs. For example, unemployed PWDs are not included in the eligibility lead criteria. How then do they provide for themselves, given that the support that they also receive from family and friends is minimal? [11]. Regarding education, there are not many schools to cater for the number of children with disabilities in Ghana. For example, one secondary school for persons with hearing impairment that admits 250 students yearly is inadequate to cater for the needs of children with hearing impairment across the country [37]. Similarly, two secondary schools for persons with visual impairment across the country is agreeably inadequate to ensure inclusion for vulnerable children with visual impairment. These schools are still relevant given the challenges facing inclusive education in Ghana.

Secondly, it is also evident that PWDs have difficulty accessing existing services due to attitudinal and environmental barriers [47, 48, 49, 50]. Altitudinal barriers which hinder efforts for the inclusion of PWDs are rooted in Ghanaian socio-cultural beliefs, traditions, and practices, which marginalize PWDs [11, 51, 52]. Environmental barriers including, physical, transportation, information and inaccessible healthcare also persist and impede the inclusion and full-effective participation of PWDs in mainstream activities [4, 53]. Another form of accessibility challenge relates to excessive bureaucratic process, including lengthy paperwork, which most times require physical presence to determine eligibility. This situation, coupled with environmental barriers, could compound the situation of PWDs.

Thirdly, we discuss affordability. There is virtually no government programme/incentive to address the assistive devices needs of PWDs in Ghana. These devices are costly [54, 55], as well as disability-related services, such as the cost of personal assistants and accessible transportation [30]. Further, due to the challenges in government inclusive educational institutions, parents of children with disabilities enroll their children in private schools, which could be more expensive. However, currently, there is no government incentive/scholarships targeting the education of PWDs

Monitoring and evaluation of social services in Ghana is slow, and that could impact accountability. A study of the DCAF for PWDs by Ephraim et al. reported calls by the beneficiaries to increase monitoring to prevent misuse of the fund.

Service providers also encounter challenges while delivering services. Professional social work practice in Ghana is still a developing field of practice [18] and hence faces several challenges [56, 57]. Baffoe and Dako-Gyeke [18] argue that social work practice is mostly characterised with western welfare regimes [58], contrary to the Ghanaian traditional way of solving problems, which is mostly through family support and networks. Thus, social work values, principles and methods are not fully understood, and integrated into Ghanaian values and the role of social workers left vaguely to the discretion of institutions [57].

Further, government service providers, who are mostly social workers, face several challenges in the line of duty. Ghanaian social workers have several responsibilities but have inadequate resources and logistics to effectively perform their duties. Inadequate logistics could be a challenge to the provision of adequate and quality services to PWDs. Also, the lack of incentives/motivation, including opportunities for career progression could also impact service provision [59].

Despite the challenges of advancing disability rights including inadequate professional social workers at the department of social welfare agencies and financial difficulties [19] social workers continually strive to harmonize efforts and interventions aimed at providing assistance to persons with disabilities that goes beyond the capacity of families and communities [18].

6. Conclusion and recommendations

Persons with disabilities in Ghana fall behind their counterparts in other countries regarding existing services. Fewer services that are not well-coordinated exist, which are also not accessible. Access to services is key to inclusion for PWDs. Given that formal and information support for PWDs is limited, could propel them into poverty. The World Disability report asserts the association of disability and poverty. Disability-inclusive sustainable services are imperative to break the cyclical challenges that characterize the experiences of PWDs in Ghana and promote their overall well-being [50]. The following recommendations could be necessary for sustainable services for PWDs in Ghana. As evident in the paper, attitudinal barriers impede access to the few available services for PWDs. This was also reported in Ghana’s initial report to the United States Convention on the Rights of Persons with Disabilities (CRPD). The report emphasized attitudinal barriers as issues impeding access to social protection, independent living, and full integration of persons with disabilities in the Ghanaian society [26, 60]. The need for social workers to increase awareness about the capabilities of PWDs at all levels (micro, mezzo and macro) is imperative.

We also recommend the involvement of PWDs in decision making at all levels, from planning through to implementation, monitoring, and evaluation. Policy makers and implementors, as well as services providers should all make conscious efforts to include PWDs at all levels of decision-making to ensure that all interventions support their rights and interests to enhance their total inclusion. They are expert knowers of their issues, and they can best proffer solutions to the challenges they encounter.

Further, since there are various forms of disabilities, each type of disability may have unique needs and, hence require unique services to address the needs. Also, some PWDs are more marginalised than others. For example, the intersection of gender and disability or ageism and disability could complicate the experiences of the individuals who falls within these intersections, women with disabilities and older adults with disabilities. We, therefore, suggest that social workers should use the lens of intersectionality of vulnerabilities to understand the unique needs of individuals who fall within several vulnerable groups and how their needs could be addressed.