Authors:

Jacques Alastuey, Morwena Kerdraon

Centre de Réadaptation Professionnelle et Fonctionnelle, France

Jan Ekberg, Erkki Kemppainen

National Research and Development Centre for Welfare and Health, Finland

Jane Peters, Pat Healy, Steve Cooper

Royal National Institute for the Blind

Great Britain

TIDE Rue de la Loi 200

Egidio Ballabio Office: BU29 3/7

Ramon Puig de la Bellacasa B-1049 Brussels

The Swedish Handicap Institute P.O. Box 510

Gunnar Fagerberg S-162 15 Vällingby

Ulla Göranson

Centre de Réadaptation Professionnelle et B.P 34

Fonctionnelle F-77 792 Nemours Cedex

Royal National Institute for the Blind 224, Great Portland Street

John Gill London W1N 6AA

National Research and Development Centre P.O. Box 220

for Welfare and Health SF-00531 Helsinki

Technical Research Centre of Finland (VTT) P.O Box 316

Medical Engineering Laboratory SF-3301 Tampere

Center for Medical Technology Assessment S-581 83 Linköping

University of Linköping Sweden

Jan Persson

D.1.1: Census of legislation affecting the rehabilitation technology market

D.2.1: Existing socio-economic models

D.1.2: Assessment of impact of legislation on rehabilitation technology

D.2.2: Assessment and refinement of socio-economic models

D.1.3 (final report): Proposals for future action on legislation and regulation impacting

rehabilitation technology

D.2.3 (final report): Proposals for future actions on socio-economic models for studies of

rehabilitation technology

Legal Notice

All rights reserved. No part of this report may be reproduced, stored in a retrieval system, or transmitted, in any. form or by any means, without written permission from the Commission of the European Communities

Introduction 7

Legal and administrative framework 7

Legislation related to rehabilitation technology 8

Future trends 13

References 18

Introduction 20

Legal and administrative framework 20

Legislation related to rehabilitation technology 21

Future trends 24

References 25

Legal and administrative framework 26

Legislation related to rehabilitation technology 27

Future trends 34

References 36

Introduction 39

Legal and administrative framework 39

Legislation related to rehabilitation technology 40

Future trends 45

References 48

Legal and administrative framework 52

Legislation related to rehabilitation technology 52

Future trends 57

References 59

Introduction 61

Legal and administrative framework 61

Legislation related to rehabilitation technology 62

Future trends 65

References 68

Legal and administrative framework 69

Legislation related to rehabilitation technology 69

Future trends 73

References 74

Introduction 75

Legal and administrative framework 75

Legislation related to rehabilitation technology 76

Future trends 79

References 81

Legal and administrative framework 82

Legislation related to rehabilitation technology 83

Future trends 89

References 90

Legal and administrative framework 92

Legislation related to rehabilitation technology 93

Future trends 99

References 101

Introduction 103

Legal and administrative framework 103

Legislation related to rehabilitation technology 105

Future trends 109

References 111

The following report examines the national legislation existing in eleven European countries - eight European Community Member States and three European Free Trade Association (EFTA) countries - and identifies the legislative measures which do, directly or indirectly, affect the rehabilitation technology market.This report was completed in August 1993 and thus does not take account of more recent legislation.

The report does not set out to provide a comprehensive picture of all existing legislation, regulations, guidelines or voluntary codes of practice in each country. It does, however, focus on the principal laws and regulations within certain areas of activity, such as working life, where they exist and highlights the areas where there is no statutory provision of technical aids. Neither does the report analyse the effectiveness of the legislation in each country as this will be the subject of the second report.

The individual country reports, written by Royal National Institute for the Blind (UK), National Research and Development Centre for Welfare and Health (Finland) and Centre de Réadaptation Professionnelle et Fonctionnelle de Nanteau sur Lunain (France), necessarily differ in style and the level of content in specific subject areas. This reflects the considerable differences which exist in the national policies both towards general legislation for the disabled and the elderly and more specifically towards the provision of technical aids. Despite these differences, the authors of the reports have all carried out their research and written their reports within a common framework and have taken into account the need to cover specific areas of relevance to enable some form of comparison of legal provision to be made. All the reports therefore cover the following areas :

For ease of reference each report also contains a technical annex listing the major pieces of relevant legislation mentioned in the texts.

The information contained in the reports has been collected from a variety of published sources and from information provided specifically for the project by Government officials, research establishments, Non-Governmental Organisations and other bodies in the countries concerned. Wherever applicable the source has been identified in the Annexes to each report and direct quotes have been attributed.

The availability of rehabilitation technology to elderly and disabled people is dependent upon a number of different factors. The cost of the rehabilitation aids and the level of public financing for them, access to professional information about the various types of product on offer, and the efficiency of the service delivery mechanism are three examples of practical issues which affect the rehabilitation technology market. The impact of legislation on the supply of and the demand for technical aids cannot be underestimated. It directly underpins many aspects of the service delivery systems in operation in Europe and it also has less tangible indirect effects on the market.

In terms of general policy towards people with disabilities and elderly people, there appears to be a trend in many countries, including the UK, Netherlands and Finland, for the development of services which will allow people to stay in the community and in their own homes rather than in institutions. This trend, if it sustained, could have an important and positive impact on the demand for technical aids. The overall budgetary restraints also have a significant impact on the provision of technical aids. In several countries, the bodies responsible for providing technical aids are now facing financial pressures, as a result of rising costs of services, increasing numbers of elderly people and changes in the allocation of central government subsidies.

The reports illustrate quite clearly, and as one would expect, that there are considerable differences in the policies adopted towards legislation for the elderly and the disabled in the countries studied and yet there are also a number of common themes.

In terms of specific legislation affecting rehabilitation technology, the reports identify three broad models : firstly, the "global" model such as exists in Denmark where one Act, the Social Assistance Act 1974, provides the legal basis for income support and the provision of virtually all kinds of technical aids and equipment for disabled and elderly people; secondly, the "disability/elderly specific" model where specific legislation exists for particular areas for these groups ; an example would be the 1979 Swedish Act governing the Adaptation of Public Transport Services for Disabled People; thirdly, the "inclusive" model where provisions or clauses have been contained within general pieces of legislation such as building regulations which stipulate requirements with regard to the disabled or elderly. In practice most countries have both of these types of legislation with the exception of Ireland which has no specific legislation addressing the needs of these groups (except the Mental Treatment Acts 1945-61 which are of no relevance to the supply or demand of technical aids).

The philosophies behind the legislative approaches taken are also worth noting. The Nordic countries have developed their legislation on the principles of equality, integration and social responsibility for all groups in society. In countries such as the UK and Belgium, a feeling of collective responsibility for those injured in the wars of the twentieth century prompted the establishment of financial support and employment promotion measures for war victims and thus was an important catalyst for the development of legislation. These measures have subsequently been extended to cover all disabled people.

Another conclusion which can be drawn from the reports is that there is often a distinction between the legislative basis for the provision of medical devices and that for technical aids which assist integration of the disabled in working and vocational life as well as for daily living. In many countries such as Italy, it is health legislation which provides for the supply of medical aids whereas social assistance legislation or other specialized legislation determines the provision of other technical aids.

Finally, the reports illustrate the complexity of the systems governing the supply and demand for technical aids. They also highlight the range of organisations, from national government to voluntary bodies, involved in implementing the legislation and administering these complex systems.

It is planned to present this report to the HEART Consumer Board whose comments would enable the country reports to be as accurate as possible.

The second report, which will focus on the effectiveness of certain pieces of legislation identified in this report, will be prefaced by a short summary of the findings of this first report on a country by country basis.

Consequently, there are now three different levels of decision-making and legislation in Belgium. The definition of the general rules concerning health policy, allowances for people with disabilities or Social Security payments are still a national responsibility; however, their concrete application has in general been transferred to the Communities.

For instance, social security remains a national responsibility - i.e. elderly people's pensions, annual holidays, family allowances, health insurance, unemployment allowances, insurance against industrial injuries and occupational diseases. The financial rules of policies in favour of people with disabilities are decided nationally, but specific actions have in general been transferred to the Communities ; however, matters related to employment policy are a regional responsibility. The National Fund for Social Rehabilitation of the Disabled has been dissolved and replaced by three Community Funds.

Even though Belgium is a signatory to a number of international conventions which include provisions for disabled people, the Belgian Constitution, unlike the constitutions of other countries, contains no single article guaranteeing basic social rights, let alone the rights of the disabled. Social legislation took a long time before including specific provisions for disabled people. The only exception was war victims.

The idea of the responsibility of the Nation towards those who had suffered an injury while serving their country appeared after the First World War. The legislator created two institutions aimed at assisting the war victims : the National Order of War Orphans (O.N.O.G., 1919) and the National Order of War Invalids (O.N.I.G., 1919). Twenty years later, the National Order of War Veterans (O.N.A.C., 1938) was created. In the late 1940s, the competence of those three institutions was extended to the victims of World War II, then of the de-colonisation war in the Belgian Congo. In 1982, the three institutions were unified ; the National Institute for War Invalids (I.N.I.G.) currently has 417.581 members whose health and pharmaceutical expenses are totally covered (even for illness not directly caused by the war).

Belgian legislation concerning any other categories of disabled people was not really organised in a coherent fashion until the 1960s. At that time, certain allowances were granted to pensioners, people suffering from long-term illness, victims of industrial injuries or occupational diseases, the unemployed and some children. Yet, the existing legislation needed to be completed and developed, and the various existing initiatives had to be co-ordinated by some kind of public service. Therefore, the National Fund for Social Rehabilitation of the Disabled (F.N.R.S.H.), a public institution dependent on the Ministry of Employment, was created in 1958 ; its mission was to establish any measure which would enable people with disabilities to readapt to the social and economic community around them. Subsequently, two Acts were promulgated in order to ensure the improvement of facilities for the disabled : the Social Rehabilitation Act of 16 April 1963 and the Allowances for the Disabled Act of 27 June 1969 (simplified and revised by the Act of 27 February 1987). A system of compulsory insurance against illness and disability was set up in 1963, organised by the National Insurance Institute for Sickness and Invalidity (I.N.A.M.I.). The idea of responsibility of the employer towards his employees was codified in the early 1970s.

The allocation of technical aids to people with disabilities in Belgium is currently financed or subsidised by different institutions, depending on the origin of the disability and the purpose of the technical aid. The five systems mentioned hereafter grant benefits directly for the acquisition of technical aids upon medical prescription and the advice of their physician. Each institution functions with its own underlining principle. There are three principles which appeared successively, corresponding to a historical evolution : responsibility, insurance and solidarity.

Responsibility:

Towards those who served the Nation :

the National Institute of War Invalids (I.N.I.G.) grants technical aids to the military and civilians who have been declared victims of war (the two World Wars and the decolonisation war in the former Belgian Congo are taken into consideration). The Institute has its own functioning rules and grants very wide protection to the beneficiaries.

Towards the employees from the employer :

the insurance companies finance technical aids for the victims of industrial injuries.

Insurance:

The National Insurance Institute of Sickness and Invalidity (I.N.A.M.I.) intervenes on the basis of a national convention signed between the orthopaedists and the insurance companies. A ruling determines the deadline for renewing prostheses, orthoses and other technical aids. Those aids are included as part of the medical care of the patient.

The insurance companies pay for technical aids needed as a result of traffic accidents and other accidents implying the responsibility of a third person.

Solidarity:

At each Community level, the three Funds, respectively for the French - speaking, Flemish and German Communities, have inherited of all the former responsibilities of the F.N.R.S.H. or Fonds National de Reclassement Social des Handicapés, including registration procedures and benefits granted to people with disabilities, as well as subsidies granted to institutions working with them. The only exception concerns individual benefits for functional re-adaptation which now forms part of the I.N.A.M.I.'s responsibilities. The general rule concerning reimbursements given by those funds is that the technical aid must be used in the framework of vocational rehabilitation (vocational is understood widely to include housework).

Belgian legislation related to special education institutes compulsory education for disabled children from the age of three to the age of 21. Adapted education is paid for and subsidized by the State and is designed to give an education to children who are physically or mentally incapable of going to a normal school.

The State may help towards the expenses of home teaching and the transport of pupils. Increased family allowance for disabled children can also be claimed.

Employment of people with disabilities is an important element influencing the market of technologies. The main and obvious reason is that an employed disabled person has an income that may allow him/her to buy technical aids. Some employers contribute to the acquisition of technical aids when it is necessary for the adaptation of the working environment. As for the Community Fund, its primary criterion for financial intervention is the need for the aid for professional rehabilitation.

Public sector:

Belgian legislation provides for a prescribed number of posts in public administrations to be reserved for people with disabilities. If the physical and mental condition of the disabled person allows him/her to work as a civil servant and if there is no danger for him/her or anyone else to do so, there should be no obstacle in the recruitment of such a person. If a candidate is rejected, the explicit reasons must be given to the Community Fund where he/she is enrolled; the Fund can give its opinion on the decision to the administrative health service.

In addition, one post out of 55 is reserved for people with disabilities in the provinces, communes, associations and public centres of social aid.

Private sector:

There is in theory an obligation for private companies of at least 20 persons to employ a number of people with disabilities. However, the implementation law was never adopted. As a result, there is no legal obligation in Belgium for private companies to employ people with disabilities. Yet, there are some incentives that are meant to reduce some of the financial costs to a company as a consequence of employing disabled people.

For example:

The development of the market for rehabilitation technologies is directly influenced by the income of the potential clients. This income is itself very dependent on the allowance system, which is determined on a national basis. The allowances intervene on the basis of two systems : the principle of social security and the notion of social solidarity.

Any employed person pays social security contributions in order to be insured against any risk of illness or disability. At the same time, during the working period of their life, people pay contributions for their future pension which is a form of old age insurance.

Invalidity allowance :

People who have worked before becoming disabled can benefit from the invalidity allowance. The definition of a disabled person for the invalidity allowance is as follows: any worker who has ceased all professional activities and whose lesions and functional disorders have been recognised as reducing his earning capacity to at least one third of what a person of similar occupation and education could earn by his professional activity.

The invalidity allowance is given until the age of retirement (65 years old) by the I.N.A.M.I. Its amount is indexed and adapted to reflect the cost of living. The invalidity allowance and the insertion allowance (infra) can both be payable at the same time.

The amount of the pension depends on the number of working years and the salary received.

Social solidarity:

The notion of solidarity corresponds to the desire to avoid the exclusion and isolation of parts of the population. Its basis is to ensure a minimum revenue for everyone; it extends to the granting of additional financial assistance and of a number of non financial advantages.

Allowances for non-retired adult disabled people :

Those allowances belong to the system of social assistance (or solidarity) and no longer of social security. They are tax-free and indexed. The system of allowances for people with disabilities has been modified by the Law of 27 February 1987. Since 1988, there are two allowances:

* Substitution of income allowance : this is granted to disabled people over 21 years old who have never worked, and for whom it has been established that their physical or psychological condition has reduced their earning capacity to at least one third of what an able-bodied person can earn.

* Insertion allowance : this is granted to disabled people of at least 21 years old whose lack of autonomy has been established, and consequently, who have to bear additional costs in order to integrate into social life.

Allowances for older disabled people (more than 65 years old):

* Allowance for elderly people (Law of 27 February 1987 and framework-law of 12 December 1988): this is given to people over 65 years old whose disability appeared after the age of 65, and for whom a lack of autonomy or a reduced autonomy has been established.

This allowance is additional to the guaranteed income for older people and to the pension.

* Substitution of income allowance and insertion allowances: disabled people whose handicap appeared before the age of 65 and who received those two allowances continue to receive them after the age of 65 years.

In parallel, there are a series of advantages that may improve the financial situation of people with disabilities. The following list is not exhaustive but mentions the most important measures:

Transport

The Royal Decree of 9 May 1977 on accessibility to public buildings applies in particular to airports, to the Belgian train stations and to city transport buildings. Generally speaking, standards on accessibility to public transports are established by Decree, but their application is left to local initiative.

Studies have been made by various working groups constituted by the S.N.C.B. and urban transportation companies in association with the National Fund, the technical aids department of the Belgian Red Cross (C.E.P.I.A.T.H.) and the Ministry of Communications in order to examine the problems of access to the platforms and coaches of public transport.

Some positive initiatives have been taken. However, they remain limited in scope and general progress is slow. Many obstacles to easy access to tramways and buses persist : for instance, the height of the step is too big, the doors are too narrow and there is no way of fixing the wheelchair in a stable and secure position. Concerning the underground train system, the situation is not better ; trains are accessible, but the underground stations themselves remain too often completely inaccessible to wheelchairs.

An interest-free loan can be granted by the Community Funds for the adaptation of a private car under very strict conditions when the I.N.I.G., the I.N.A.M.I. and the credit institutions have refused to intervene. The adaptation must be justified by the type of disability of the user ; the Fund will intervene only if the car is needed for the exercise of a professional activity and if it is used exclusively for the transportation of the disabled person. These conditions are obviously very restrictive.

We are interested here in any measure or incentive allowing people with disabilities to live in a normal environment and remain as independent as possible. These measures can concern the technical adaptation of houses and apartments to the particular disability, general accessibility of buildings to disabled and older people as well as the development of services such as the delivering of meals.

The housing policy in Belgium has been transferred to the Regions : Brussels, Walloon region and Flanders. The former National Institute for Housing had established a series of standards concerning the construction and transformation of housing for disabled people using a wheelchair. Those standards are used by the architects as well as by the Community Funds that finance the additional cost of constructing adapted accommodation.

The Funds also intervene in the adaptation cost of existing buildings. The financial aid is granted to disabled owners, and sometimes, to the tenants with sufficient guarantees concerning the length of occupation of the housing.

There are several rules in Belgium concerning access of people with disabilities to public buildings. Those rules vary from one region to another, and sometimes even from one city to another.

Unfortunately, it seems that the various standards enacted are rarely respected. Too many public buildings remain inaccessible to people with disabilities.

In Belgium, a technical aid may be reimbursed by the Community Funds when it is needed for a professional rehabilitation purpose. In order for a technical aid to be reimbursed by the I.N.A.M.I., it has to enter the official classification of health allowances. This classification does not list the official products but it details the characteristics that the products need to have in order to be accepted. A basic price for each product is established by the body of director-physicians based on the information given by the producers. Only technical aids that are part of medical care are taken into consideration. Therefore, an alarm system will not be financed by the I.N.A.M.I., whereas a wheelchair may be. The classification was established by Royal Decree in 1984 and has been regularly revised since then.

A producer who wants a new product to be accepted must send a full description of its purpose, characteristics and price to the I.N.A.M.I. If they correspond to an existing category, the product may be recognised ; otherwise, the producer can ask that a new category be created, but this can be done only by Royal Decree, therefore almost impossible and in any case a very lengthy process.

The example of wheelchairs

There is a great variety of wheelchairs. The I.N.A.M.I. refers to the following types of wheelchair : attendant propelled, self-propelled and electric/electronic. It also lists a whole series of additional accessories. Precise quality standards are given as well as guarantee requirements. In 1989, the I.N.A.M.I. spent B.F. 307.986.565 - ECU 7.652.999 for wheelchairs, the majority to be used by pensioners (B.F. 139.984.164 - ECU 3.478.394).

When the acquisition of a wheelchair is necessary for professional rehabilitation, the Community Fund can finance it. (For instance, in 1991, the French-speaking Community Fund intervened in 231 cases).

Competition among producers and importers of wheelchairs is very strong. All the details of the product, including general adaptation, quality and materials used, as well as design of the product are factors that influence the consumer's choice. On the other hand, due to the low purchasing power of those consumers, the amount of State Funding towards the total price of the product is an important element in the decision to buy a wheelchair. The public funding covers partial reimbursement of the cost of wheelchairs, usually based on fixed amounts. In addition, a reduced VAT rate of 6% is applicable to wheelchairs which reduces overall cost.

A major portion of the distribution of technical aids in Belgium is carried out by specialised firms : importers, producers, retailers and orthopaedists. There is no distribution of such products in supermarkets. This is not surprising when one considers that financial contributions by the I.N.A.M.I. are granted only for products bought from approved professionals.

There are also strict rules concerning the advertising of technical aids. Any advertising for products which relate to medical care and thus are included in the classification of the I.N.A.M.I. is forbidden. Non medical products may be freely advertised.

The example of alarm systems

Alarm systems are a relatively recent product that have greatly developed in the last five years. An alarm system allows disabled and/or elderly people to call a third person when they need help (the main reason being a fall). All systems are equipped with a cordless transmitter that sends a signal from any point in the house. Alarm systems allow:

Elderly people are the main users of these products.

The cost of alarm-systems is not reimbursed. However, some Communes contribute towards the price of alarms, in particular for underprivileged users.

Competition among firms offering an alarm system is quite strong in Belgium. When the product appeared (around 1987), there was no Belgian producer, which explains the large number of foreign products used by Belgian firms. In the region of Brussels alone, there are 6 or 7 alarm companies. Advertising is authorised ; however, some of the firms offering an alarm service cannot advertise because of their status. This is the case of the Centrale de Soins à Domicile, a non-profit making organisation which is financed by the I.N.A.M.I. and which offers other services including medical care by nurses.

With the new responsibilities of the linguistic Communities and the institutional reforms, it is still difficult to assess the current situation and to forecast future developments. New Community Funds are in a position to extend their activities and responsibilities to new areas. This may however give rise to differences in treatment between Commun-ities.

Law of 16 April 1963 relative to social rehabilitation of people with disabilities

Law of 10 April 1971 on industrial injuries

Decree of 19 June 1990 on the creation of an office in the German-speaking community on behalf of people with disabilities and covering special social assistance

Decree of 27 June 1990 on the creation of a Flemish Fund for the social integration of people with disabilities

Decree of 3 July 1991 related to the integration into society and employment of people with disabilities

Royal Decree of 1 December 1964 on the checking of required physical aptitudes of candidates to given jobs in public administrations

Royal Decree of 11 August 1972 encouraging employment of people with disabilities in public administrations

Royal Decree of 5 January 1976 in application of the Law of 16 April 1963 and of the Royal Decree of 11 August 1972

Royal Decree of 23 December 1977 establishing the number of people with disabilities who should be employed by administrations including provinces, communes and associations of communes

Royal Decree of 6 March 1978 establishing the number of people with disabilities who should be employed by public centres of social assistance

Royal Decree of 23 May 1984 encouraging employment of people with disabilities in Post and

Telecommunication Administration (modified by a Royal Decree of 16 February 1990)

Order of 13 September 1990 of the Walloon Regional Executive Administration stipulating the number of reserved jobs in their services

Law of 17 July 1975 on accessibility

Royal Decree of 9 May 1977 on accessibility standards to public buildings

Ministerial Decree of 5 December 1990 modifying the Ministerial Decree of 27 September 1977 stipulating the list and value of benefits granted to people with disabilities for functional rehabilitation and equipment with assistive devices

Buchkremer, N. (1991). Etude de rentabilité du contrôle de l'environnement pour personnes handicapées. Namur : Facultés Universitaires Notre-Dame de la Paix.

Centre d'Etudes, de Promotion et d'Information sur les Aides Techniques pour les personnes Handicapées (1992). Les alarmes individuelles et les systèmes de télévigilance. Bruxelles : Croix Rouge de Belgique.

Centre d'Etudes, de Promotion et d'Information sur les Aides Techniques pour les personnes Handicapées (1987). Les aides techniques en Belgique : enjeux et besoins. Bruxelles : Croix Rouge de Belgique.

Comité pour la Réadaptation et le Réemploi des invalides (1990). Législation relative à la réadaptation des personnes handicapées dans seize Etats membres du Conseil de l'Europe. 4ème Ed. Strasbourg : Conseil de l'Europe.

Fondation Roi Baudoin. Les personnes à mobilité réduite dans la ville.

Fonds communautaire pour l'intégration sociale et professionnelle des personnes handicapées (1992). Rapport Annuel 1991. Tomes 1 et 2. Bruxelles : F.C.I.S.P.P.H.

Fonds communautaire pour l'intégration sociale et professionnelle des personnes handicapées (1992). L'intégration sociale et professionnelle des personnes handicapées en Communauté française. Bruxelles : F.C.I.S.P.P.H.

Groupe d'Action pour une Meilleure Accessibilité aux Handicapés. Accessibilité aux personnes handicapées des bâtiments ouverts au public. Réglementation belge selon les régions. Liège : GAMAH.

HELIOS (1993). Base de données Handynet. Commission des Communautés Européennes.

Institut National d'Assurance Maladie Invalidité (1989). Rapport général. 4ème Partie. Service des soins de santé. Partie statistique. Bruxelles : I.N.A.M.I.

Institut National d'Assurance Maladie Invalidité (1991). Historique et évolution de la législation relative aux organismes publics ayant pour mission d'accorder une assistance tant matérielle que morale aux invalides de guerre, anciens combattants et victimes de guerre. Information. Ed. Spéciale. Bruxelles : I.N.A.M.I.

Institut National d'Assurance Maladie Invalidité (1992).Votre Institut National ... pour qui ? pour quoi ? Information. No 16. Bruxelles : I.N.A.M.I.

Onkelinx, L. (1993). Guide de la personne handicapée. Bruxelles : Ministère de la Prévoyance Sociale.

Recognition of the needs of people with disabilities in Denmark is part of a long Nordic tradition that the State should provide what cannot reasonably be expected to be provided by the individual. This has led to one of the most advanced systems of support for people with disabilities in Denmark.

The system is based on the acceptance of responsibility for meeting the need, irrespective of how it arose or what contribution the individual may have made through taxation or insurance. The private sector and voluntary organisations play minor roles in provision of services. However voluntary bodies are important in providing support to people with disabilities in particular by campaigning for equal treatment.

The overall aim of policy is to enable disabled and elderly people to remain in their own homes if they wish, despite their disabilities, and to promote the integration of people with disabilities into all areas of society.

Although provision of equipment is exceptionally good in Denmark, precise information about its impact on the lives of people with disabilities is difficult to establish. This is because people with disabilities themselves resist being classified or registered in any way. Statistics are, therefore, at best estimates.

Section 75, Subsection 2 of the Danish Constitution states that people unable to support themselves or their dependants are entitled, where no other persons are responsible for their or their dependants' maintenance, to receive public assistance provided they comply with their legal obligations.

Voluntary provision for people with disabilities ended in 1933 when the Special Care Act placed total responsibility for the financial support, education, training and treatment of people with disabilities on the State. Specific laws on the deaf followed in 1950; on the blind in 1956 and for people with learning difficulties in 1959.

Local government reform in 1970 created new local and regional units - 275 municipalities and 14 counties - to whom responsibility for provision was devolved under the Social Assistance Act, 1974. The Act is comprehensive, providing the legal basis for income support and all kinds of technical aid and equipment for disabled and elderly people, for children and for other groups. The Ministry for Social Welfare issues circulars on the implementation of specific sections of the Act.

At the same time that responsibility for provision of services and aids to people with disabilities was decentralised, the Central Council for the Disabled was established to bring together representatives from disability organisations, central and local government, to monitor social conditions of people with disabilities. The Council's membership includes representatives from relevant ministries: housing, regional planning, traffic, education and training, and employment. Similar responsibilities are exercised by consumer councils run by county authorities.

Denmark maintains its broad policies on disability in its external relations by including consideration for people with disabilities in public and private development projects in developing countries.

Section 58 of the Social Assistance Act lays the basis for the provision of technical aids both in the home and at work.

The section says : "For persons with disability or impairment caused by permanent illness or age, financial support may be granted for technical aids which:

- are necessary for the person in question to carry on a profession;

- can make every day home life easier."

The Act itself does not mention specific types of equipment, but describes situations in which it should be provided. Some equipment, such as telephones and glasses, is mentioned in a Ministerial Order to local authorities. The Order says:

"Technical aids should help people with disabilities lead a more normal and independent life. Thus technical aids should compensate for, or more or less remedy, an impairment."

"It is demanded that the technical aid remedies the permanent consequences of the impairment considerably and thereby makes daily life considerably easier. Otherwise the aid must be necessary for the applicant to carry on a profession."

"A technical aid grant must enable the applicant to live as normal and independent as possible and make the applicant as independent as possible of every day help from others."

Until recently, a list of the equipment which could be granted was maintained, but the list was discontinued because of the difficulties of keeping it up to date when new products are constantly introduced. There is, therefore, a very broad range of equipment that can be provided.

Each of the 14 counties maintains a technical aids centre, staffed by occupational therapists and technicians who can make, adapt or convert standard equipment to meet the requirements of the individual disabled person. These centres have weekly sessions open to members of the public who can see what technical aids are available and receive advice and information on their use. The centres also organise regular seminars and courses for social and health workers to keep them up to date with what equipment is available. The counties also partly fund the Danish Centre of Technical Aids for Rehabilitation and Education, a national information resource whose tasks include developing, testing and evaluating technical aids.

The individual's need is assessed by an occupational therapist or social worker employed by the local authority. The therapist or social worker visits the disabled person at home to advise on what technical aid or other help should be provided. If necessary, the disabled person and the occupational therapist will visit the local technical aids centre together to find the necessary equipment. This process may involve several visits.

Local authorities interpret "needs" in various ways and may decide that support arrangements, such as the provision of hot meals, are a better solution to the individual's needs than the provision of a technical aid.

Technical aids are provided free of charge except for items, such as a walking stick, which cost less than a set amount in 1993 of 200 Danish Krone (ECU 26). However if someone needs several items which together exceed the limit, they are provided free.

A wide range of wheelchairs, including those of modern design that are more acceptable to young people, is available to people who need them. People with disabilities have a right to choose what technical aids they will use, including an electric wheelchair if necessary.

Responsibility is shared between municipalities and counties when the disabled person is aged under the 67 retirement age in Denmark, but municipalities alone meet the costs of aids for retired people. Local authorities also pay for most repairs to technical aids, except that users meet the costs where they are caused by wear and tear.

There are also specialized institutions all over Denmark testing and adjusting aids for people with hearing and visual disabilities.

The Primary Education Act provides that all children in Denmark, regardless of any physical or mental disability, are entitled to education in primary schools and to special education if they have special needs. Public schools are required to accept children with disabilities and cannot refuse a child on the grounds of lack of equipment.

The Social Assistance Act provides that educational equipment for people with disabilities should be made available at every age, including for babies and toddlers in nursery schools and classes. Schools and other educational institutions must provide the technical aids needed by children or students with disabilities to enable them to study. This includes computers, adapted chairs and hearing aids. Most disabled children are educated in ordinary schools, and some go on to special training after completing their normal school education.

The Rehabilitation Act 1960 provided for technical aids and working tools to be made available to people with disabilities and led to 12 rehabilitation centres being established. It has been superseded by the Social Assistance Act, Section 43 of which provides for advice, financial and technical support to be given to people with disabilities in connection with vocational training. Disabled adults undergoing a training course have free transport.

Section 91 of the Social Assistance Act places a duty on county authorities to offer sheltered employment or other employment measures to people who are unable to find and maintain employment in the open labour market because of a physical or mental disability. This has led to both sheltered workshops and rehabilitation institutions being established, some run directly by public authorities and others by private firms with state subsidies. Workplace adaptations can also be provided under this Act. In theory, the technical and other supports needed will be made available to enable a paraplegic to train as, for example, a car mechanic.

Denmark has considered introducing a quota scheme, i.e. an obligation for employers to hire disabled persons as a given proportion of their staff. It finally rejected it on the grounds that other measures are already in place to ensure that people with disabilities are treated fairly in the labour market. People with disabilities have priority for certain jobs in both the public and private sectors, with more than half the costs financed by the public employment service.

Since 1991, personal assistance for people with disabilities in employment has been made a permanent feature of their support. Companies which employ people with disabilities can get financial support to pay a personal assistant to the disabled person for up to 20 hours a week. Similar support is available to self-employed people with disabilities. The personal assistant helps with practical tasks which the disabled person cannot carry out.

People with disabilities have the same access to income support from the State as other citizens, with supplements to compensate for the extra costs of their disability. Under Section 37 of the Social Assistance Act, flat rate benefits are paid to people who can no longer support themselves or their families because of changed circumstances. The Social Pension Act provides people unable or with limited capacity to work with a guaranteed basic income. Special legislation governs pensions for people disabled as a result of industrial injuries.

Parents of children with disabilities are entitled to financial support for the extra costs associated with the disability, including special toys and clothes, under Section 48, paragraph 1, of the Act. Paragraph 3 of the same section provides similar benefits for seriously disabled adults living at home.

Denmark has a national health service which provides free medical care to all at the point of use and does not rely upon the principle of reimbursement for medical treatment. There are charges for prescribed drugs and medication, but these are subsidised by the State and the elderly can get a medical card to pay for expensive medicines. Where people are temporarily disabled through illness or accident, hospitals have a duty to loan the necessary technical aids.

Public policy in recent years has been directed towards helping more people to live in the community, rather than in institutions. This includes helping the elderly to remain in their own homes as long as possible and moving people with learning difficulties from large hospitals to smaller collective housing units, integrated with the local community. Rehabilitation technology is often needed to fulfil this aim, and can be provided under the Social Assistance Act.

Alarm systems for elderly people are provided under paragraph 58 of the Act and form part of the care system under which local authorities provide assistance in the home by day and night if necessary. Alarm systems can be connected to rescue services. Elderly people may carry an alarm with them, provided by their local authority as part of their responsibility to provide aids to daily living.

Residential institutions must supply the technical aids and equipment needed by elderly and people with disabilities living there.

Section 58 of the Social Assistance Act provides for help to be made available with transport for people with disabilities. This help includes adaptations to cars and grants towards the purchase price of cars. Disabled drivers can also receive interest free loans to buy invalid vehicles, which must be driven for six years when they are replaced and a new loan becomes available. Disabled drivers are also entitled to free parking.

The Public Transport Act 1992 introduced new obligations on counties to help people with disabilities travel. Sections L36 and L37 provide that every city must make transport available for people with disabilities to enable them to get about for leisure as well as work purposes. County authorities are obliged to plan with disability organisations to ensure the provision of specialised transport for severely disabled people, including adapted buses and taxi systems.

House adaptations are carried out under the Social Assistance Act. The relevant Section states : "Persons with disabilities or impairment caused by permanent illness or age, can be granted necessary housing modification help in order to make it a better place to live for the person in question."

Several counties have established special technology and communication centres in the last few years. The centres offer inter-disciplinary testing, direction and teaching in connection with communication aids and other technological equipment.

Denmark has introduced anti-discrimination legislation on grounds of race, religion and gender but not disability. This is partly because of the difficulties perceived over defining "disability" when the people affected do not wish to be labelled and partly because it is assumed that people with disabilities are equal before the law.

There have been difficulties in recent years because of financial restraints on local authorities and some have responded by not providing equipment that used to be available. One example is adjustable easy chairs which used to be freely available to people with limited mobility, but are increasingly being refused on the grounds that most households will buy easy chairs anyway. There appears to be less difficulty, however, over the provision of much more expensive equipment such as home computers adapted for severely disabled people for whom it is the only means of communication. These aids can also be provided free of charge in accordance with the Social Assistance Act.

The Danish system is based on high taxation and the more difficult financial climate of recent years has led to the emergence of a degree of resentment about this. It has not, however, led to serious proposals to limit rights for people with disabilities. However, fears that this may happen has led to the establishment in 1993 of the Centre for Equal Status for the Handicapped. This body, believed to be the first of its kind in Europe, will be a watchdog organisation with powers to bring cases of discrimination to a Parliamentary Ombudsman. It will operate in close co-operation with the Central Council for the Disabled and with government departments (Denmark Review (March 1993). According to Need. The Danish Centre for Technical Aids).

Special Care Act 1933. Placed responsibility for financial support, education and training of people with disabilities on the State.

Rehabilitation Act 1960. Provided for technical aids and working tools to be made available to people with disabilities (superseded by Social Assistance Act 1974).

Social Assistance Act 1974. Provided legal basis for income support and all kinds of technical aids and equipment for people with disabilities.

Public Transport Act 1992. Introduced new obligations on counties to help people with disabilities to travel.

Primary Education Act. Basis for rights of all children to education and to special education if appropriate.

Commission of the European Communities (1993). Second Report on the application of the Community Charter of the Fundamental Social Rights of Workers. Social Europe, Supplement 1/93. Luxembourg : Commission of the European Communities.

Employment Observatory MISEP (1992). Policies 39. Commission of the European Communities.

Kampmann Hansen, E. (1993). Supply and Financing of Technical Aids for the Disabled in Denmark. Paper published by the Danish Centre for Technical Aids, Rehabilitation and Education.

Munday, B. (Editor) (1992). Social Services in the Member States of the European Community. Canterbury : European Institute of Social Services, University of Kent.

European Handbook on Social Services.

WHO (1990). Is the law fair to the disabled? European Series No 29. Copenhagen : WHO Regional Publications.

The leading principles of the Finnish policy concerning people with disabilities are equality, full participation and the right to an independent life. These principles are stated explicitly both in legislation and in the National Plan for Social Welfare and Health 1993-1996. The integration of people with disabilities into society is the general aim of Finnish social policy. It is hoped to achieve this aim by following strategies to organize the services and economic support for people with disabilities and their families. The principal form of services for people with disabilities is the same as for the rest of the population; special services for people with disabilities are always secondary and used only when the general services are not applicable.

The Finnish constitution does not, as yet, mention people with disabilities, but it ensures that all Finnish citizens have equal rights and obligations. The basic laws on health and social services, education and employment should satisfy most of the needs of people with disabilities. In the more difficult cases, the specific legislation serving the smaller group of people with disabilities is applied.

The Ministries which are responsible for administration policies related to rehabilitation are: the Ministry of Education, the Ministry of Labour and the Ministry of Social Affairs and Health.

For regional administration, Finland is divided into 12 provinces which are responsible for paying out the State subsidies to the municipalities.

Local government is separated from state administration. For this purpose Finland is divided into 455 (1 January 1993) municipalities which exercise extensive self-government. The municipalities are locally responsible for schools, health and medical care, social welfare etc. The municipalities also have the right to levy local taxes. They also produce and supply the bulk of services.

For specific purposes municipalities combine to form Joint Municipal Boards. Large Joint Municipal Boards, like the country's 21 central hospital districts, handle most of the specialist medicine, while 213 of the health centres, in charge of primary health care, are run by small Joint Municipal Boards of two or more municipalities. (Seppäläinen 1989.) The municipalities or Joint Municipal Boards produce and deliver the services through welfare offices, local health centres and hospitals or through district central hospitals or university central hospitals.

The Social Insurance Institution and its district offices operate under the National Pension Scheme and the National Sickness Insurance Scheme. The Insurance Rehabilitation Agency operates under the Employment Accident Insurance, Motor Liability Insurance and Earnings Related Employment Pension Schemes. (Seppäläinen 1989.) In addition to the public health care system there is also a supply of health services given by private practitioners.

A National Committee of Disabled Persons was set up in 1985. It has an equal re-presentation of people with disabilities and government officials. The National Committee of Rehabilitation Affairs coordinates rehabilitation and other services for people with disabilities. At the moment local councils for the disabled have been established to work with the municipal governments of nearly half of the municipalities. Their function has been to bring forward the views of people with disabilities about the accessibility of public buildings, streets and other facilities. These councils have also reviewed local services from the point of view of the needs of the disabled.

Much of the implementation of services for people with disabilities is arranged by non-governmental organisations for the disabled. In Finnish society the position of organisations for people with disabilities has always been very strong. Most of them are so-called patient organisations in which all the members are disabled. Many of these organisations arrange rehabilitation services for the groups they represent. This activity has increased the influence of the organisations within the field of social and health services as equal partners with health professionals. In addition there are numerous commercial enterprises such as spas giving physiotherapy as well as hundreds of private professional physiotherapists. The Slot Machine Association which organises lotteries in Finland and obtains income from slot machines, grants sums of money annually to various organisations within the social and health sector.

The assistance and interpretation required by the students with disabilities in comprehensive and vocational schools are provided by the education authorities. The integrated school system guarantees that all children during compulsory school age will have the opportunity to receive education comparable to that given in comprehensive schools. For the tuition of children who, owing to their deficiencies, cannot be taught in the nine or eleven years of basic school, there are special schools. Nine of the schools for children with severe hearing, sight or locomotor deficiencies are owned and financed by the State. Seven schools for children with severe locomotor deficiencies are operated by municipalities with State support. Education for almost all mentally retarded children is arranged as special instruction. The only exceptions are profoundly retarded children, who receive instruction on the basis of the Act on the Special Care for the Mentally Disabled. This group will also be integrated into the comprehensive school system in future years. (Seppäläinen 1989.)

Working life and vocational rehabilitation

Responsibility for the employment of people with disabilities is divided between the Ministry of Social Affairs and Health and the Ministry of Labour. The manpower services are administered by the Ministry of Labour. The country is divided into 13 labour Districts. Each District has several Manpower Offices and the total number of such offices is 180. All the offices serve people with disabilities. The services are free of charge to the client. There are one or more staff members in each Manpower Office who have special expertise in the provision of services to people with disabilities and co-operation with other client services. (Seppäläinen 1989.)

Among the special services to disabled job-seekers at Manpower Offices, the most important area of activity - besides individual services - is supportive measures for job placement. The labour administration has special services for people with disabilities, such as medical examinations and rehabilitation evaluations, employment preparation at work, evaluation clinics, trial periods of work and training, financial support for reorganizing work conditions and subsidized employment. The labour administration pays the rehabilitant a daily allowance and reimburses travel costs. (Seppäläinen 1992.)

Financial support for reorganizing working conditions is paid to the employer of the disabled person. It means reimbursement of the costs of adaptation of machinery and working environment to make them suitable for the disabled person. It can also be used to cover the extra costs arising from the help given by a fellow worker to the disabled person at work. Special employment support is paid by the labour administration to the employer for employing a disabled person or keeping him employed. The support is useful when there is need for more thorough than normal instructions for the work and to compensate for the period of time before the employee's performance is normal. The support may be paid for a period of up to two years. (Seppäläinen 1989.)

The purpose of wage subsidies is to enable all employers to employ people with disabilities. Under this scheme the employer is compensated for extra costs that may arise from the reduced working capacity of the disabled worker. The goal of the subsidy is to promote permanent employment. (Seppäläinen 1989.)

There are at present 15 work evaluation clinics which do diagnostic work for rehabilitation and planning for suitable and individual programmes. Most of the clinics have been established by private organisations of various groups of people with disabilities. Some of the clinics work in close co-operation with central hospitals and Manpower Offices. Clients are referred to the clinics by the different systems of rehabilitation service delivery. The individual costs of evaluation are normally paid by the referring system. There are assessment centres and sheltered workshops, even though most of the clients and workers come to these services through local employment offices. Sheltered work is provided for the disabled, including the mentally retarded and persons suffering from mental health problems, in sheltered work centres. These centres provide work for 3500. They operate on the principle that the persons they employ are motivated to work and have the ability to do so but could not meet the productivity demands of the open labour market. Work at these centres is governed by the general employment legislation with the exception of the wage clauses. The wages are on average about 75% of those paid on the open labour market. (Seppäläinen 1989; WHO 1990)

The general system of vocational guidance provides services also for the disabled. However, the clients often get in touch with health or social services who then refer them to a rehabilitation service. This in turn advises the client to turn to the vocational guidance office in order to get help in evaluation of his own capacities and aptitudes in planning the proper rehabilitation programme. In addition to the local and regional vocational guidance offices, there are three specialized guidance offices under the Ministry of Labour functioning in conjunction with the following institutions:

According to the Act on Vocational Institutions, vocational training of people with disabilities is integrated according to the integration and normalization principles and the need for special schools for the disabled is diminishing. There are 16 special vocational schools for the disabled altogether which can accommodate about 1500 students. One of the special schools serves the visually impaired, two schools serve students with hearing disabilities and three schools are for students with mental disabilities. Eight of the schools are maintained by the State. Other vocational schools for the disabled are maintained by private organisations which receive subsidies from the State covering investment and running costs. (Seppäläinen 1989).

In the vocational schools for the disabled, training basically follows the same lines as in general vocational schools. There are, however, more possibilities for individualized curricula, smaller classes, rehabilitation services etc. Some questions have been raised about whether the range of occupation in vocational schools for the disabled has kept up with the changes in industrial structure. As examples of modern trades there are courses in dataprocessing for the blind and courses in industrial electronics. The trend in training is towards fewer manual trades and more to service occupations. (Seppäläinen 1989.)

Vocational training courses are under the administration of the Ministry of Labour and the National Board of Education. There is one training centre which specialises in training of the disabled. (Seppäläinen 1989.)

Another form of vocational training is training-on-the-job. This method of vocational rehabilitation has gained increasing importance during recent years. Arrangements for this kind of training are usually made by manpower offices or by other bodies, such as the Social Insurance Institution or the Insurance Rehabilitation Agency. Some work evaluation clinics also organize training-on-the-job as part of their assessment programme which often continues as a training programme. (Seppäläinen 1989.)

Early vocational rehabilitation is not sufficiently developed, however, since the legislation concerning occupational health care requires the employer only to inform the disabled worker of the possibility of rehabilitation, not to arrange it. Much vocational rehabilitation is arranged by the Social Insurance Institution or the Insurance Companies' Rehabilitation Centre.

General

Citizen welfare is promoted by income security based on social insurance, and by social and health services. Preventive social and health policies also play a major role. The means available include pricing and fiscal policies, legislation on the environment, counselling, health education, and participation of relevant bodies in planning and decisions at both national and local level. Health inspections, screenings and occupational health care also play a major role in prevention. (Social security 1991.)

Most income security is in the form of statutory insurance, comprising sickness, accident, pension and unemployment insurance. Social insurance in Finland is divided between minimum security for all, and earnings-related security. Those who do not get enough income from their pay or social insurance receive a last resort living allowance from their local authorities. Those with no income from work get the minimum allowance. (Social security 1991.)

The industrial accidents insurance covers accidents at work, occupational diseases, and accidents while commuting to or from work. Survivors' pensions and funeral benefits are paid in the event of fatal accidents. (Social security 1991.)

According to unemployment security legislation, union unemployment funds pay their members earnings-related benefits. Payments continue for 500 days. After that, the unemployed are entitled to a flat-rate daily allowance out of public funds. The flat-rate allowance is also paid to non-members of union funds. It is not subject to a time limit. (Social security 1991.)

Former employees and self-employed persons receive earnings-related and flat-rate pensions. The pensions include old-age, disability and unemployment pensions. Survivors' pensions are paid under both the earnings-related and the flat-rate systems. All pensioners who are disabled or over 65 get respective basic flat-rate pensions. An increment is available, but it is reduced for persons receiving other pensions. There is also a discretionary housing allowance. Pensions are taxable income. The public sector, Church of Finland, and seamen have their own pension systems, which are similar in broad outlines to the private-sector scheme for employees. (Social security 1991.)

All insurance, including private insurance, is supervised by the Ministry of Social Affairs and Health. Flat-rate pensions, sickness insurance, parents' allowances and flat-rate unemployment security are handled by the Social Insurance Institution, which is directly subordinate to Parliament. Earnings-related pensions are in the hands of insurance companies and foundations. They are coordinated by the Central Pension Security Institution. Accident insurance is managed by insurance companies. Earnings-related unemployment security is run by trade union funds. (Social security 1991.)

Health care and medical rehabilitation are mainly financed by funds collected by municipal and state taxation. There are certain service fees, but services for people with disabilities are free of charge. The aim of the health care system is, however, to make the services accessible to everyone regard-less of their economic situation.

Since 1 January 1984 the welfare of people with disabilities has been financed by the municipal sector. It was previously totally state financed. The planning and budgeting of services for the disabled were extended throughout the sector of health and social services.

In a new Act on the Cooperation Concerning Customer Service in Rehabilitation there are stated obligations on the authorities working in the fields of social and health care, education and labour to cooperate at local, provincial and national level. According to § 17 subsection 3 of the Social Welfare Act social welfare authorities channel, if needed, customers, who need a form of rehabilitation which is not the responsibility of the social welfare authorities, to health care, to labour or to other organisations working in the field of rehabilitation.

An extensive revision of the rehabilitation legislation entered into force on 1 October 1991. The new Acts and Decrees meant specification in the system of supplying assistive devices, particularly concerning cooperation between different organisations providing rehabilitation services. The new provisions stipulated statutory cooperation between authorities and different rehabilitation organisations, specified the responsibilities of the Social Insurance Institution (SII) in funding the costs incurred in procuring expensive technologically sophisticated equipment needed in connection with people with disabilities' work and studies. Furthermore, the primary indemnity liability of insurance institutions was considerably extended to include new categories of assistive devices. However, the demarcation line between health care authorities and the SII concerning liability to fund assistive devices procurement is still in need of some clarification. (Eräkanto 1992.)

The Act on the Cooperation Concerning Customer Service in Rehabilitation and the related Acts and Decrees carry provisions on duties concerning rehabilitation and cooperation between authorities and some institutions and corporations, on social assistance during the rehabilitation period, and on rehabilitation services based on employment accident insurance and motor liability insurance. This Act on Rehabilitation Cooperation creates an administrative framework for cooperation between different branches of administration, and gives guarantees that each rehabilitation patient will receive the services they need, and that the rehabilitation will be arranged in a systematic way emphasizing the individual contribution of each patient in the process (Government proposal 1990). According to the Public Health Act § 14.3. the municipalities are charged with the task of organizing health rehabilitation whenever this duty has not been assigned to the SII by other provisions. Health rehabilitation activities include, in addition to rehabilitative treatments, counselling, examinations to determine needs and prospects of rehabilitation, supply of assistive devices, adaptation training and guidance and related activities. However, according to the same Act 14 § 4. this does not apply to supplies of assistive devices when the need for this equipment is based on an injury or an occupational disease as defined by provisions in the Accident Insurance Act, Accident Insurance of Farming Enterprises Act, Military Injuries Act, Motor Liability Insurance Act, or in any of the corresponding previous Acts which have since been repealed.

The aim of increasing the efficiency of rehabilitation systems was to enable citizens to participate in working life and to cope with other situations in their lives, taking into account their respective ages and capacities, longer and more fully than previously. The legal reform sought to increase citizens' prospects of leading active lives, to diminish their need to retire on early disability pensions or on any other type of long-term social security benefits. It also aimed to harness the abilities of people with disabilities by improving rehabilitation services. (Government proposal 1990).

With the aim of clarifying the division of labour between different servicing systems and of improving the position of patients undergoing rehabilitation, provisions covering statutory rehabilitative activities and cooperation between different organisations were included in main Acts covering fields of welfare and health care, labour administration and insurance systems. The revised provisions of accident insurance and motor liability insurance stipulating indemnity liability for funding the rehabilitation and the income security during the rehabilitation period are extending the range of rehabilitative activities covered by indemnity liability. Thus these provisions reflect the developments and achievements in the field of rehabilitation better than the previous ones (Government proposal 259/1990). There is a new Act in both these fields: the Accident Insurance Act 1991 and the Motor Insurance Act 1991.

Provisions for income security during rehabilitation are included in the Rehabilitation Allowances Act and the Rehabilitation Allowances Decree. The income security of a patient during the rehabilitation period is guaranteed by a rehabilitation allowance, payable to patients of working age, i.e. 16 to 64 years of age. The conditions for payment of the allowance are that the rehabilitation has the purpose of enabling the patients to stay in the labour market, return to labour market or enter into labour market and, furthermore, that working during the rehabilitation period is not possible. The rehabilitation allowance amount would normally be equal to that of the patient's daily sickness insurance allowance. A patient entitled to a pension or unemployment allowance would receive this benefit plus 10%.

Division of responsibilities in the field of rehabilitation activities was specified by assigning the Social Insurance Institution the duty of organising occupational rehabilitation, as well as rehabilitation aimed at maintaining the ability of people with severe disabilities. Provisions stipulating the SII duties of organising rehabilitative activities are contained in the Rehabilitation by the Social Insurance Institution Act and the respective Decree.

The guidelines for the tasks of the Insurance Rehabilitation Agency - that was established in 1964 - are:

- To carry out vocational rehabilitation as a part of insurance compensation stipulated in the legislation.

- To assist the insurance and employment pension companies and institutions in the preparation, implementation and standardisation of the rehabilitation programmes.

The Agency also administers Patient and Drug Insurances. The main emphasis of the activities of the Agency is on vocational rehabilitation even if medical and social rehabilitation also receive attention. The clients of the Agency are normally referred by the insurance companies and institutions. (Seppäläinen 1989.)

In Finland adaptation training was developed by several organisations of people with disabilities at the beginning of the 1960s. The provisions for adaptation training are now appended to both the health care and social welfare legislation and social insurance legislation. The aim of adaptation training is, by a reorientation process, to support disabled persons and their families in their social integration, to support them to accept the realities of the disability and to enable the disabled persons to make full use of their capacity to integrate into society. Adaptation training is given on specially organized courses. This service is mainly arranged by organisations of people with disabilities in co-operation with social welfare and health authorities and with social insurance systems. (Seppäläinen 1989.) Also the Slot Machine Association grants remarkable amounts of money to assist the financing of the adaptation training.

Health care

The health care system is divided between primary and specialist care. Primary care is given in local health centres or by private practitioners. If the patient needs special treatment he is referred to a general specialist hospital or to a university central hospital. Central hospitals have a special rehabilitation unit.

Since 1 January 1984 medical rehabilitation has become an integral part of medical care through local health centres and hospitals, according to the primary health care legislation and the Specialised Hospitals Act and the Decree on Medical Rehabilitation. Medical rehabilitation may include:

The most extensive responsibility for rehabilitation technology lies nowadays in health care.

Social Assistance

In Finland the trend has in recent years been more towards the provision of services for the disabled within the framework of services in general. The primary document governing social welfare is the Social Welfare Act, which places obligations on the municipalities. The services covered by the Social Welfare Act include:

- social work,

- support to subsistence (living allowance),

- institutional care,

- family care and fostering,

- housing and homehelp services,

- counselling,

- information services, and

- home care for old and disabled.

The purpose of the Services and Assistance for the Disabled Act, the Services and Assistance for the Disabled Decree and other new legislation is to improve the conditions of a disabled person so that he may live and act as a member of society on an equal basis with others, and to improve the potential of people with disabilities for independent action and for influencing the planning and implementation of the services provided by society, especially by improving the conditions of the most severely disabled. Under this legislation the municipality must provide such services either itself, as a member of a Joint Municipal Board or by purchasing services from a private supplier, another local authority, Joint Municipal Board or the State. The Services and Assistance for the Disabled Act applies to all persons who, because of their disability or illness, have long-term difficulties in managing the normal functions of everyday life.

The obligation of the municipal welfare is, however, secondary if the disabled person is entitled to the corresponding services by some other delivery system.

Under the Services and Assistance for the Disabled Act the severely disabled have a special right to

- Finance for alterations to their home and the purchase of special equipment and appliances to eliminate or alleviate specific housing problems (as of 1 January 1988).

The new legislation partially entered into force at the beginning of 1988, and will be fully in force in 1994. A municipality can, at its discretion, also refund the costs of adaptation training, a personal assistant, special clothing and special food to persons other than the severely disabled. It may also supply or refund half the cost of devices, machines and equipment required by a disabled person in his or her everyday life. Such aids may be necessary for getting about (a car, an invalid moped) managing at home (various domestic appliances) or for recreation activities ( a ski, sled, a special saddle).

Services to disabled war veterans are provided by special legislation. Many services are also provided by non-governmental organisations.

According to the Act on the Special Care for the Mentally Handicapped and the Decree on the Special Care for the Mentally Handicapped the municipalities are responsible for the care of mentally retarded with support from the State. Municipalities have established Joint Municipal Boards which have at their disposal resources from medical, psychological and social diagnoses and research, to health care, training and education, sheltered work, housing and living arrangements, technical aids, individual and family counselling, genetic prevention and special institutional care. The care for mentally retarded could now be called open-care-centred instead of the traditional institutional-centred care. It is also based on normalization and integration prin-ciples as much as possible. This means, among other things, emphasis on local, municipal services by the general service systems (health and social care, housing) intended for all members of the municipality. The care for mentally retarded has always been carried out with the assistance of private organisations. (Seppäläinen 1989.)

The Building Decree § 85a demands that public facilities be built so that they are accessible to people with disabilities. The local councils for the disabled are efficient in monitoring developments in this respect.

According to the Services and Assistance for the Disabled Act all public services have to be organized in such a way that they are also suitable for people with disabilities. This must be accomplished when planning buildings, traffic arrangements and when supplying services. The local councils for the disabled have an important role in this respect.

In traffic legislation, there are among others, provisions which allow people with disabilities to park their vehicles in such places where it would otherwise be prohibited. People with disabilities can also be refunded taxes (wholly or partly) that they have paid for their cars according to § 17 of the Act on Car and Motorbike Tax.

Earlier, the municipalities received as State subsidies a certain percentage of the expenditure incurred in the areas of social and health care. According to the new Act on the Planning and State Subsidies of the Social and Health Care from 1 January 1993 State subsidies received by the municipalities have become subject to a formula. The formula is based on, among other things, the municipality's population and its age structure, as well as the unemployment and morbidity rates. The effect of the State subsidies system reform will be monitored and evaluated in many ways, starting from the beginning of 1994. A municipality may organize its social and health care by providing services itself, jointly with other municipalities, or by purchasing services from public or private producers.

For a long time, the Finnish system has aimed at developing a wider range of services in the community instead of the formerly prevailing institutional care. A manifestation of this policy is the new Decree on the Support to Relatives for the Care Given by Them. According to this Decree the relatives of a cared-for person are paid support for the care work they have performed on the basis of a contract between them and the municipality. The contract has also to include a plan made by the person providing the care and the person receiving the care services.

In the field of rehabilitation the cooperation between the authorities and clients is being continually monitored and developed.

A Working group set up by the Ministry of Social Affairs and Health has recently given some recommendations for the future. The primary principles of these recommendations were to secure the production of high quality services more economically than recently and to be prepared for future needs. The main purpose is to support the municipalities in the development of their service delivery structures. The recommendations also advocate savings in the costs of the administration of these structures. The main problems in the structures of the service delivery were: the emphasis on institutional care, the care of clients and patients in unsuitable places, problems in housing and emphasis on investment in institutions. People are too often cared for in institutions and some of the flats are unsuitable for the elderly and people with disabilities. The working group is suggesting a new programme towards the year 2000.

The main points in the programme are new ways of operation, service delivery and methods of care which would promote the opportunity for people to manage at home independently as far as possible. The municipalities would have an important role in creating a structure of services which function better, are more cost-effective but are still of a high quality.

Ssk = Suomen säädöskokoelma

Eräkanto, S. (1992). Apuvälinehuollon järjestelyä koskeva uusi lainsäädäntö, yhteistyö ja työnjako. STH Tiivistelmä 16.10.1992.

HE 259/1990 vp. Hallituksen esitys eduskunnalle kuntoutusta koskevan lainsäädännön uudistamiseksi.(Government proposition 259/1990)

Ministry of Social Affairs and Health (1991). Social security and health care in Finland.

Seppäläinen, R. (1989). Rehabilitation in Finland. Second revised edition. Rehabilitation International Finnish Committee RIFI ry.

Sosiaali- ja terveysministeriö. Työryhmämuistio 1992:17. Palvelurakennetyöryhmän muistio. Helsinki 1992. (The Ministry of Social Affairs and Health: PM 1992:17)

WHO (1990). Is the law fair to the disabled? European Series No. 29. Copenhagen : WHO Regional Publications.

Main legislation and regulations which frame and influence nowadays the living conditions of people with disabilities, came into being during the last 40 years. Following the 1949 Law, which replaced previous subsistence benefits and social welfare and for the first time looked at the need for economic reinsertion of people with disabilities, the 1957 Law defined rules for access to employment and the 1963 Law established a special education allowance. Yet, the comprehensive Disability Act of 30 June 1975 appears as the cornerstone of French legislation on behalf of people with disabilities.

Sometimes considered as a cultural revolution, this Act recognises people with disabilities as full citizens with specific rights. This fundamental principle is also clearly reaffirmed in the Law 90-602 of 12 July 1990 concerning the protection of people against discrimination due to their health situation or their handicap. In this context, the 1975 Disability Act asserted the right of people with disabilities to education, work and leisure and made provision for homogeneous and consistent instruments to deal with the problems of the disabled.

The Secretary of State for people with disabilities and life injured (1988-1993) also attached great importance to the development of a global disability policy. This requires legislative frameworks designed to govern different aspects of life such as access and integration into employment (Law of 10 July 1987), accessibility regulations (Law of 13 July 1991) or assistive devices (Decrees of 1981 or 1984) etc.

The purpose of this report is to make an inventory of legislation and regulations on behalf of disabled or elderly people which may have a direct or indirect impact on the rehabilitation technology market. The legislative framework for the production, distribution of assistive devices, as well as accessibility regulations will be examined for their possible impact on rehabilitation technology supply. The provisions made for daily living, education, reimbursement of assistive devices, income support or promotion of employment will be referred as they have either direct or indirect influence on the demand for rehabilitation technology.

Three main principles, i.e. responsibility, insurance and solidarity, have historically guided the successive patterns of legislation on behalf of people with disabilities. This evolution is well illustrated by the history of income compensation : from responsibility of the employer in 1898 towards the injured at work and responsibility of the nation in 1919 towards the veterans and war victims, to social insurance for people with disabilities (invalidity pensions - 1930) and solidarity introduced in the 1975 Disability Act for people not covered under other legislation.

The move from responsibility to solidarity also occurred in the legislative framework geared to promote access to employment. Mandatory employment appeared in the French legislation in the wake of first world war and applied then to war victims, giving special rights as regards vocational training and employment. The victims of industrial injury were progressively entitled to benefit from the same type of measures. It is only by Law of 23 November 1957 that these provisions were extended to all disabled workers.

The 1975 Disability Act re-defined most of the previous provisions in a general framework, including aspects such as care, school integration, access to employment, benefits and allowances, social integration, accessibility requirements etc. However, the main feature of this legislative monument was to open the path to a more comprehensive policy towards people with disabilities. In this context, the Act set out various services in cash and in kind, available for all people with disabilities irrespective of the nature and origin of their impairment.

Yet, as a result of demographic evolution, improvement of medical and reeducation techniques, desire expressed by people with disabilities themselves to stay in a home and family environment as well as move towards desinstitutionalisation, both by employment or social integration, the 1975 Disability Act was gradually enriched by implementation Laws and Decrees covering employment (Adaptation of work stations : 1984, Quota system : 1987) or accessibility (Control of accessibility rules for public buildings and houses : 1991) etc.

As a matter of fact, the existing legislative constraints related to building, housing or transport accessibility are likely to infl