Horizontal European Activities in Rehabilitation Technology
TIDE study 309
LEGAL AND ECONOMIC FACTORS
IMPACTING REHABILITATION TECHNOLOGY AVAILABILITY
CENSUS OF LEGISLATION AFFECTING
THE REHABILITATION TECHNOLOGY MARKET
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
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
Tomas Lagerwall Sweden
Leader of Line D
Centre de Réadaptation Professionnelle et B.P 34
Fonctionnelle F-77 792 Nemours Cedex
Pierre Olivier France
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
Vappu Taipale Finland
Technical Research Centre of Finland (VTT) P.O Box 316
Medical Engineering Laboratory SF-3301 Tampere
Seppo Haataja Finland
Center for Medical Technology Assessment S-581 83 Linköping
University of Linköping Sweden
Publications within Line D
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
D.2.3 (final report): Proposals for future actions on socio-economic models for studies of
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
Legal and administrative framework 7
Legislation related to rehabilitation technology 8
Future trends 13
Legal and administrative framework 20
Legislation related to rehabilitation technology 21
Future trends 24
Legal and administrative framework 26
Legislation related to rehabilitation technology 27
Future trends 34
Legal and administrative framework 39
Legislation related to rehabilitation technology 40
Future trends 45
Legal and administrative framework 52
Legislation related to rehabilitation technology 52
Future trends 57
Legal and administrative framework 61
Legislation related to rehabilitation technology 62
Future trends 65
Legal and administrative framework 69
Legislation related to rehabilitation technology 69
Future trends 73
Legal and administrative framework 75
Legislation related to rehabilitation technology 76
Future trends 79
Legal and administrative framework 82
Legislation related to rehabilitation technology 83
Future trends 89
Legal and administrative framework 92
Legislation related to rehabilitation technology 93
Future trends 99
The United Kingdom103
Legal and administrative framework 103
Legislation related to rehabilitation technology 105
Future trends 109
Purpose of the Report
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.
Structure of the 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 :
- the legal framework within each country and the statutory roles of national and local authorities where applicable
- the social, economic and historic factors which shaped the development of legislation relating to disabled and elderly people. This is essential to provide a national context for the study of relevant legislation and is important in the Netherlands, for example, where the Dutch parliament is currently debating legislative reforms which will have a considerable impact on the distribution of technical aids. It is also important in Belgium where institutional reforms are likely to influence significantly the rehabilitation technology market in the future.
- examination of legislation which has a direct or indirect impact on the rehabilitation technology market. This aspect forms the major part of each of the reports. Direct legislation comprises measures which underpin the supply of technical aids by providing regulations governing the production or the service delivery mechanisms. For such countries where this type of direct legislation plays a significant part, for example, France, it has been necessary to describe in some detail these regulations in the report. Legislation affecting the purchasing power of users such as health care, social assistance, social insurance and reimbursement schemes also have direct impact on the demand for technical aids. Indirect legislation promotes the use of rehabilitation technology in certain areas of activity : an example is buildings legislation which stipulates the need for accessibility and sometimes special facilities. In this example increased accessibility will, in turn, create a greater demand for mobility aids such as wheelchairs. Employment quota systems which seek to promote integration may also develop further need for assistive devices.
- future trends. This section was considered to be important as several countries are presently considering reforms either to legislation directly affecting disabled and elderly people or to social insurance and social security systems which will have an indirect effect on the rehabilitation technology market.
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.
Findings of the Report
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.
Belgium is currently in a phase of deep political and institutional turmoil. Since 1980, a series of matters have been transferred from the national level to the Communities (linguistic communities, i.e. the French-speaking Community, the Flemish Community and the German Community) or to the Regions (Flanders, Walloon region and Brussels). The announced purpose of the process of revision of the Belgian constitution is to transform Belgium into a federal State.
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.
Legal and administrative framework
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.
Legislation related to rehabilitation technology
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.
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.
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.
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.
Working life and vocational training
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.
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.
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.
- During a period of time that cannot exceed one year, the Community Fund can contribute towards the salary and the social insurance costs when it considers, that the output of the disabled person is diminished because of increased difficulties he may encounter to adapt to the work.
- The Community Fund may contribute towards the cost of adaptation of the working environment.
- The Community Fund contributes towards the cost of work instruments and clothes.
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.
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:
- Tax reductions on income
- Exemption from taxes on television and radio
- Exemption from taxes on cars
- Reduced telephone fee and related advantages
- Special rates for electricity and gas
- Public transportation special rates
- Special measures for disabled car-drivers
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.
Legislation related to the production, distribution and advertising of technical aids
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:
- convalescence at home rather than in a nursing-home,
- people who lack autonomy to remain at home longer (and especially elderly people),
- better security.
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.
Legal and administrative framework
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.
Legislation related to rehabilitation technology
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.
Working life and vocational rehabilitation
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.
Housing and environment
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.
Legal and administrative framework
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.
Legislation related to rehabilitation technology
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:
- The Invalid Foundation Orthopaedic Hospital, serving mainly orthopaedic clients.
- The Rehabilitation Foundation, serving the blind, the deaf, those with brain injuries, people with occupational diseases and those with multiple handicaps.
- The Hospital for Rheumatic Diseases, serving rheumatic patients. (Seppäläinen 1989).
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.
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.
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:
- Activities and therapies which activate, improve or sustain necessary physical, psychological and social functioning ability, such as physio and occupational therapy, speech therapy, neuropsychological rehabilitation and psychotherapy.
- Rehabilitation period during which there may be either outpatient or institutional activities and therapies outlined above.
- Rehabilitation evaluations which mean the assessment of the need and possibilities of rehabilitation and may include necessary testing of functioning ability and work trials.
- Technical aids which include evaluation, testing and providing the patient with the necessary technical aids and protheses as well as teaching them to use and maintain the aids.
- Adaptation training, which means supporting and improving the functioning and rehabilitation abilities of the patient by giving to him or his relatives information and encouragement which support his rehabilitation.
- Rehabilitation guidance and counselling which means information on rehabilitation possibilities to the patient and to his relatives.
- Other comparable measures.
The most extensive responsibility for rehabilitation technology lies nowadays in health care.
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,
- 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).
- Service accommodation, including both a home and any necessary services.
- Transport and the services of an assistant; the municipality, in addition to journeys to work and study, is obliged to finance at least 18 one-way journeys within its own area and that of its immediate neighbours.
- Interpreter services; as of 1 January 1994 persons who are both blind and deaf will be entitled to at least 240 hours of interpretation a year and people with severe hearing or speech impediments to at least 120 interpretation hours a year.
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.
Reform of the State subsidies system
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.
From institutional care to a wider range of services
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.
The development of services
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
Ssk 404/1948 The Military Injuries Act (Sotilasvammalaki). Entered into force on 1 January 1948.
Ssk 608/1948 The Accident Insurance Act (Tapaturmavakuutuslaki; Several Amendments). Entered into force on 1 January 1949.
Ssk 266/1959 The Building Decree (Rakennusasetus; Several amendments, especially 930/1989). Entered into force on 1 July 1959.
Ssk 279/1959 The Motor Liability Insurance Act (Liikennevakuutuslaki). Entered into force on 1 January 1960.
Ssk 482/1967 The Act on Car and Motorbike Tax (Laki auto- ja moottoripyöräverosta; Several amendments, especially 284/1969). Entered into force on 15 November 1967.
Ssk 66/1972 The Public Health Act (Kansanterveyslaki; Amendments: especially 674/1983, 605/1991). Entered into force on 1 April 1972.
Ssk 519/1977 The Act on the Special Care for the Mentally Handicapped (Laki kehitysvammaisten erityishuollosta). Entered into force on 1 January 1978.
Ssk 988/1977 The Decree on the Special Care for the Mentally Handicapped (Asetus kehitysvammaisten erityishuollosta). Entered into force on 1 January 1978.
Ssk 1026/1981 The Accident Insurance for Farming Enterprises Act (Maatalousyrittäjäin tapaturmavakuutuslaki)
Ssk 710/1982 The Social Welfare Act (Sosiaalihuoltolaki; Several amendments, especially 607/1991). Entered into force 1 January 1984.
SSk 602/1984 Unemployment Security Act (Työttömyysturvalaki). Entered into force on 1 January 1985.
Ssk 380/1987 The Services and Assistance for Disabled Act (Laki vammaisuuden perusteella järjestettävistä palveluista ja tukitoimista). Entered into force on 1 January 1988.
Ssk 487/1987 The Act on Vocational Institutions (Laki ammatillisista oppilaitoksista). Entered into force on 1 August 1987.
Ssk 759/1987 The Services and Assistance for Disabled Decree (Asetus vammaisuuden perusteella järjestettävistä palveluista ja tukitoimista). Entered into force on 1 January 1988.
Ssk 1062/1989 The Specialised Hospitals Act (Erikoissairaanhoitolaki) (Amendment 606/1991). Entered into force on 1 January 1991.
Ssk 604/1991 The Act on the Cooperation Concerning the Customer Service in Rehabilitation (Laki kuntoutuksen asiakaspalveluyhteistyöstä). Entered into force on 1 October 1991.
Ssk 610/1991 The Rehabilitation by the Social Insurance Institution Act (Laki kansaneläkelaitoksen järjestämästä kuntoutuksesta). Entered into force on 1 October 1991.
Ssk 611/1991 The Rehabilitation Allowances Act (Kuntoutusrahalaki). Entered into force on 1 October 1991.
Ssk 625/1991 The Act on Rehabilitation Organised on the Basis of the Accident Insurance Act (Laki tapaturmavakuutuslain perusteella korvattavasta kunoutuksesta). Entered into force on 1 October 1991.
Ssk 893/1991 The Rehabilitation Allowances Decree (Kuntoutusraha-asetus). Entered into force on 1 October 1991.
Ssk 1015/1991 The Decree on Medical Rehabilitation (Asetua lääkinnällisesta kuntoutuksesta). Entered into force on 1 October 1991.
Ssk 1161/1991 The Rehabilitation by the Social Insurance Institution Decree (Asetus kansaneläkelaitoksen järjestämästä kuntoutuksesta). Entered into force on 1 October 1991.
Ssk 733/1992 The Act on the Planning and State Subsidies of the Social and Health Care (Laki sosiaali-ja terveydenhuollon suunnittelusta ja valtionosuudesta). Entered into force on 1 January 1993.
Ssk 318/1993 Decree on the Support to Relatives for the Care Given by Them (Asetus omaishoidon tuesta). Entered into force on 1 July 1993.
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.
Legal and administrative framework
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 influence the rehabilitation technology supply side whereas policies towards independent living at home for disabled and elderly people may have an impact on demand for rehabilitation technology. Similarly, the legislative provisions stimulating integration into school or employment could lead to a rise in the demand for rehabilitation technology, due to a higher living standard or simply to increased activity.
Legislation related to rehabilitation technology
The 1975 Disability Act stipulates that measures should be taken to enable every person with a disability to reach the highest level of autonomy and social integration. The provision of technical aids to daily living obviously contribute to this aim.
In France, technical aids are provided under the sickness insurance benefits, whose expenses are covered by the insurance system to which the person is affiliated. For example, the total reimbursement of technical aids amounted in 1992 to more than FF. 2,6 billion (ECU 0,39 billion).
Assistive devices registered in the inter ministerial tariff of health benefits (T.I.P.S.) are the only ones which are legally reimbursed. Their Schedule describing general and technical requirements, sometimes functional and comfort characteristics, are defined by Order. Some foreign assistive devices, including wheelchairs, are also officially registered in the T.I.P.S.. It should be noted that recent schedules (1991 and 1992) refer to national French standards and existing corresponding ISO standards.
A Consultative Commission for Health Benefits was established in January 1984 in order to simplify approval procedures for equipment and technical aids required for care or for people with disabilities. This Commission includes National Insurance Funds, Ministries of Health, Agriculture, Economy, Industry and Unions of suppliers. Meeting once a month, this Commission is expected in particular to give its opinion on the possible registration of new technical aids in the T.I.P.S.. Public authorities may give their approval by Order. It should be admitted that rehabilitation technologies have not appeared so far as priorities, and are not likely to be approved in the near future given the general economic context and the trend to reduce health expenses.
According to the Decree 81-460 of 08.05.1981, the French buying procedure for a registered technical aid includes the forwarding of a medical prescription and estimated invoice of the approved retailer to the Social Security Fund for approval. For a non-registered technical aid, other benefits may be provided by Regional Funds, using their own Fund for Health and Social Action. For example, these can be made available for expenses resulting from the adaptation of a vehicle. Local, regional authorities or Retirement Funds may also subsidise the acquisition of alarm systems, excluding the few traditional models used in hospitals or medical institutions, which are registered in the T.I.P.S.
If the technical aid is to be used for a professional activity, Decree 84-380 of 17.01.1984 establishes that a written request can be made by the employer to the town council, the County Department for Health and Social Action, the Technical Commission for Adult Vocational Guidance and Professional Reclassification (COTOREP).
Finally, the Order of 5 February 1991 establishes a list of rehabilitation technologies for which VAT is reduced from 18,6% to 5,5%. These include adapted controls for environment control and communication, vocal synthesis communication equipment, electronic cards and specific communication software, special keyboards for computers, mechanical or electrical assistive devices for the movement of arms, transfer equipment, wheelchairs and special equipment facilitating driving, etc.
The right of education, whatever the disability, was officially acknowledged for children in the 1975 Disability Act. This gave rise to a number of changes in the legislative and regulatory framework as far as special education is concerned. More recent decrees dated 1988 and 1989 establish precise conditions for the integration into school of young disabled children. Specific provisions are included in a new Annex XXIV (primarily Annex XXIV to the Decree of 9 March 1956) on behalf of young people with multiple disabilities and the specialised institutions concerned.
In order to compensate partially the additional expenses incurred by the education of their disabled child, parents can obtain a family benefit entitled Special Education Allowance. All disabled children, whatever the level of income of their parents, are entitled to receive this financial aid, provided their degree of disability equals or exceeds 80% or between 50% and 80% if they attend a specialised institution. These benefits may contribute to the acquisition of specific equipment by the parents.
Working life and vocational rehabilitation
The 1975 Disability Act establishes "training and vocational guidance" as a national obligation. It also makes provision for the adoption of measures geared to promote access to employment for people with disabilities, with the opportunity to pursue individual programmes which would take into account their personal capabilities.
The Act of 30 June 1975 fixed a "minimum" professional wage which is guaranteed to disabled workers employed in a normal work environment, in protected workshops or in assistance-through-work centres. Fixed in relation to the minimum wage (SMIC) , it is provided by the State in the form of an extra payment added to the salary paid by the employer. These guaranteed resources vary from 70 to 100% of the SMIC, depending on the type of employment . Most of the beneficiaries of these guaranteed resources work in assistance-through-work centres.
There is also a general trend towards better integration of young disabled into ordinary education or vocational training schemes. For example, a Convention was signed in 1992 between the State and AFPA and between AFPA and AGEFIPH to increase the access of people with disabilities to training courses in ordinary environments. This is likely to have an influence on the need for adapted rehabilitation technologies.
In order to promote integration into normal employment, national financial support can be made available "for the adaptation of machines or equipment, for the modification of the workplace, including individual fitting out of workplaces and provision for access to such workplaces. Grants can also be made for additional instructional expenses". Financial support provided by the State cannot exceed 80% of the costs of the planned adaptation (Decree 84-380 of 17 May 1984). Requests are examined by the County Department for Labour and Employment. The decision is taken by the Prefect if it amounts to less than FF. 40.000 (ECU 6.061), otherwise by the Ministry of Labour.
This possible financial support for adaptation of the workplace is also implicit in the more recent Law of 10 July 1987 . This Law reconsiders all previous provisions concerning mandatory employment for people with disabilities. The 1987 legislation establishes an employment quota, equivalent to 6% of the work force of all companies with more than 20 employees. This also applies to public institutions with more than 20 civil servants (including those working in public hospital services). Although compulsory, the obligation can be fulfilled by companies via a range of substitutive measures to recruitment : long-term contractual agreements ; subcontracts with sheltered workshops ; financial contribution to a National Fund, the AGEFIPH . The huge amounts of money collected this way are to be dedicated to "actions required for integration and follow-up of disabled workers", including subsidies either to the employer or to the disabled employee. (Integration bonus, adaptation of work station, subsidy for training etc.).
The legal provisions governing income compensation and allowances are worth examining for their direct impact on the level of income and purchasing power of potential disabled and elderly buyers.
In that respect, the assessment of 40 years of legislation on behalf of people with disabilities will certainly show a progressive and regular improvement of their situation, especially for adults. In particular, the social welfare allowance amounted to 30% of the minimum wage in the 1950s, whereas in 1993, the Disabled Adult Allowance represents 54% of the Minimum Wage (SMIC) and 63% with the FF. 500 (ECU 76) supplement. Despite this positive evolution, the allowance is far from representing 80% of the gross SMIC, referred to by associations of people with disabilities as the minimum requested to cover their vital needs.
Due to historical evolution and a change in perception of the handicap, the French allowance system is based on the three main principles previously described, i.e. responsibility, insurance and solidarity. Some pensions can be drawn at the same time as others, some are exclusive. The allocation of a specific benefit and its rate is usually conditioned by means-tests, degree of disability, age, ability to carry out a professional activity or additional expenses incurring as a result of the disability.
The "responsibility" principle underlies the pensions payable to victims of military invalidity and industrial injury. Invalidity pensions, on the other hand, aim at compensating a reduced earning capacity and are thus to be considered as a kind of insurance. Finally, the series of new benefits introduced by the 1975 Disability Act lies within the scope of solidarity. These include allowances for the parents of disabled children, the disabled adult allowance set at a basic subsistence level and the compensation allowance. The payment of this allowance is dependent on the inability to carry out alone the essential actions of everyday life or the necessity to incur additional expenses as a result of disability. These additional expenses can be transport expenses, purchase of adapted equipment, arrangement of a vehicle, etc.
As far as elderly people are concerned, old age pension vary greatly from one person to another, depending on his or her previous professional activity.
Transport and access
Provisions related to adaptations of public transport services or gradual change in standards for the construction of public vehicles are made in Article 52 of the 1975 Disability Act and described in its application Decree of 1978 . Two Orders of 1979 respectively cover the technical requirements to respect and the establishment of a departmental commission for accessibility . A Circular of 1979 compiles the previous regulations and adds recommendations to be used essentially by constructors (obligations, dispensations, standards and technical requirements, adaptation of public highways, signals etc.).
In accordance with the Decree 78-1167 of 9 December 1978, conversion programmes for the public transport services identified were launched, aiming at the adaptation of access paths to vehicles, of vehicles themselves or at the setting up of specifically adapted services. Since then a yearly report has enabled the COLITRAH or Liaison Committee for the Transport of People with Disabilities to examine progress made by public transport services in implementing their programmes. Yet, very few transport services or local administrations have presented their programmes.
As far as vehicles with a capacity of less than 9 people and personal cars are concerned, the various adaptation requirements are described in two circulars dated 18 March 1981 and modified on 12 April 1988. Accessibility, security and comfort conditions are defined in the AFNOR standard R 18-802 of December 1984.
A major step was made in 1989 with the adoption by the Secretary of State for people with disabilities and life injured and the Ministry of Transport, of around 60 measures covering the journey from home to the person's destination.
Historically, the Decree 74-553 of 24 May 1974 stipulates accessibility of collective accommodation buildings to wheelchair-users. Yet it is the 1975 Disability Act which establishes not only buildings' accessibility but adaptability of all accommodation. The 1980 Decree modifies the Code of Construction and Housing in that direction. Following legislation distinguishes between new and existing buildings and between public/private housing.
The P 91-201 standard from AFNOR or Agence Française de Normalisation (July 1987) defines the general accessibility conditions of accommodation and other buildings as well as their equipment for people with physical disabilities. It also covers the adaptability conditions for buildings, their access and normal use by people with disabilities. It deals finally with the conception of construction and its environment. It seems that special exemption from these rules could be granted after consultation with a departmental accessibility commission, when the characteristics of the terrain or the presence of existing structures hamper their implementation.
In 1990, a Plan entitled "Open town" was launched to improve legislation relating to buildings open to the public, to reinforce requirements for collective housing buildings, to develop financial and fiscal incentives, to reinforce control procedures and develop partnerships.
However, it appeared necessary to complete the existing legal frameworks, including provisions on behalf of people with sensorial disabilities. As a matter of fact, previous legislation mainly addressed wheelchair users. As a result, the Law 91-663 of 13 July 1991 includes a concern to meet the needs of people with non-motor disabilities, by establishing some implementation conditions such as the a priori control of building licences and the initial education of architecture students. This major piece of legislation is designed to favour accessibility of people with disabilities to dwellings, workplaces and buildings geared to receive the public. In this context, the State and public authorities are requested to show the way. For example, public buildings are now to comply with accessibility rules, just as they have to comply with security rules (i.e. in case of fire). For collective buildings not financed by the State and in order to get their building licence, architects and builders have to produce a technical notice and commit themselves regarding accessibility. Financial state support is also dependent upon compliance with accessibility rules.
The Code of Construction and Housing now clearly stipulates in its Article L.111-7 that "Architectural provisions and arrangements of dwellings and buildings open to the public ... have to be such that these places and buildings are accessible to people with disabilities..." and "... is reported to be accessible to disabled people with reduced mobility, any installation allowing people, especially those circulating with a wheelchair, to enter, to move, to go out of an installation in normal functioning conditions and to benefit from all services offered to the public and for which the buildings were planned ...".
It is possible to note that French legislation regarding accessibility mainly concern newly constructed buildings. As far as new housing is concerned, the minimum accessibility requirements do not apply yet to individual accommodation. In addition, some security regulations may also be in conflict with accessibility requirements.
Legislation related to the production and provision of assistive devices
The field of assistive devices for people with disabilities has been historically controlled in France by the Secretary of State for Veterans and the Sickness Insurance authorities.
In particular, the Secretary of State for Veterans is in charge of the technical approval of assistive devices reimbursed by Social Security. A central Research and Study Centre on Technical Aids was established in May 1984 by this Secretary of State to carry out research, perform tests and compile relevant documentation. This Centre is the only one in France entitled to approve wheelchairs according to schedules defined by Ministerial Orders. The various tests carried out before approval are paid by the manufacturers.
Apart from this approval procedure with which producers of assistive devices have to comply, the production of technical aids is not governed in France by any general legislation or regulation.
As far as alarm systems are concerned, manufacturing international standards such as ISO 9000 are to be respected, in addition to security standards or technical ones established by the national telecommunication company. Another legal constraint, which specifically applies to the production of alarm systems is the confidentiality clause set up by the National Commission "Information Technology and Freedom" and which protects the consumer against the free circulation of personal files.
It should also be mentioned that assistive devices registered in the Inter ministerial Tariff of Health Benefits (T.I.P.S.) will not be reimbursed if the advertising made by the producer is not authorised by the Health Ministry or if a non-therapeutic use of the appliance is presented to the public (Decree 81-460 of 8 May 1981).
Production of assistive devices can also be affected by regulations related to test and quality controls. In that respect, the Secretary of State for Veterans appointed 20 Appliance Centres to check that the given appliance was manufactured in accordance with the requirements of the person with a disability and those from the T.I.P.S.. The service provided by those centres is considered to be a guarantee for the user and a way to control the quality of products manufactured. Due to the cost of those tests incurred by the Sickness Insurance Fund (amounting to 10% of the appliance allocated), consultation of appliance centres is no longer mandatory. However, measures should be taken by the manufacturer to ensure that any potential user of assistive device is aware of the possibility to consult such centres.
Finally, the Order of 29 February 1984 and Article R.165-18 of the Social Security Code both define the conditions and process of consultation of a "medical consultative body for appliances", which may be compulsory under certain circumstances and thus have an impact on production of assistive devices.
As far as retailers are concerned, a distinction should be made between approved retailers and others. Only approved retailers are entitled to sell technical aids registered in the T.I.P.S. and reimbursed by Social Security. The Order of 30.12.1985 establishes the conditions to fulfil to be acknowledged as an approved wheelchair retailer. These are the following : make a request to the Sickness Insurance Regional Fund, fulfil specific professional conditions, accept all controls from the Regional Fund, commit oneself to comply with the obligations specified in the Schedule and the List, prove compliance to defined premises requirements, offer an acceptable choice of wheelchair models and justify skills. The 1985 Order also states that approval of wheelchair retailers is only granted after completion of a compulsory training course at the Research and Study Centre on Technical Aids. This medico-technical course includes provision of information related to regulations, reimbursement schemes, technical requirements, recommendations to the user, etc.
Retailers selling other assistive devices than those mentioned in one of the eight items of the T.I.P.S., are not subject to any regulation. These main items, subdivided themselves into groups according to components and characteristics, should clearly have a therapeutic purpose : medical optics, audio-prostheses, pedo-orthoses, large assistive devices for upper/lower limbs or trunk, vehicles for physically disabled (i.e. wheelchairs), ocular prostheses, small appliances, equipment and care equipment. It is clear from this list that the distribution of rehabilitation technologies designed to assist communication, to adapt accommodation or work stations (ISO Classes 18, 21 and 27) are not subject to any specific regulation, apart from existing national or international technical standards applying to the products themselves.
Disability issues have always been in France under the responsibility of a number of ministries, including the Ministries of Social Affairs, Health, Labour and Education. Yet, between 1988 and 1993, a Secretary of State for people with disabilities and life injured was established to provide an impulse to the development of a policy towards people with disabilities and to carry out studies on related matters. Since March 1993, a technical counsellor to the Minister of Social Affairs and Health is in charge of both disabled and elderly people, whereas the actual handling of dossiers is still carried out by various ministries.
The 1975 Disability Act was presented as the central piece of French legislation on behalf of people with disabilities. It would certainly need to be updated, to take into account the situation of people with disabilities in 1993, which is different in various aspects from their situation in 1975. In particular, it seems that no provision was made in the 1975 Act for the compensation of extra-expenses generated by disability (except the compensation allowance geared to compensate for additional expenses resulting from the need for a personal assistant or the exercising of a professional activity) and did not include either, measures for the maintenance at home of severely disabled people (instead of staying in institutions).
Finally, this report outlined the priority given in France to medical or therapeutic assistive devices, through reimbursement schemes or income support. The example of alarm systems is particularly relevant. Although 2 to 3% of the calls require urgent medical action, 75% of the existing alarm systems are managed by emergency services. Most people calling only require somebody to talk to.
Relatively few people with disabilities currently use alarm systems compared to the vast majority used by elderly people. One reason could be a lack of information. A second reason may simply be that dependent disabled persons usually stay in institutions, where their need for alarm systems is limited. People with disabilities are also more likely to use alarm systems, especially if they include multimedia, when such rehabilitation technologies are common products to be found on the market. In the future, "medically-oriented" tele-alarm systems should expand towards tele-assistance, tele-medicine (including tele-diagnosis or tele-prescription) and tele-contact. The latter system is still considered as a "technology for comfort", using very new technologies such as environmental control interfaces and smart houses. Yet, its perspectives of evolution are important, provided measures are taken to increase the level of income of people with disabilities.
Law "Cordonnier" of 2 August 1949.
Act 75-534 of 30 june 1975, comprehensive Act on behalf of people with disabilities (O.J of 01.07.75).
Law 90-602 of 12 July 1990 concerning the protection of people against discrimination due to their health situation or their handicap.
Order of 30.06.1975 relative to prices.
Decree 78-325 of 15.09.1978 establishing a compensation allowance.
Decree 81-460 of 08.05.1981 simplifying procedures and conditions for assistive devices entitling to health benefits.
Decree N°81-461 of 08.05.1981 related to equipment costs for people in public hospitals.
Order of 12.01.1984 on composition and functioning of the consultative commission for Health Benefits.
Order of 30.12.1985 on conditions to fulfil for approval as a retailer.
Circulars 93/03 and 93/04 of 9 February 1993 establishing a lump-sum support in favour of independent living of people with disabilities.
Law of 31 July 1963 establishing a Special Education Allowance
Decree 88-423 of 22 April 1988, Decree 89-798 of 27 October 1989, Circulars 88-09 of 22 April 1988, 89-17, 89-18 and 89-19 of 30 October 1989 on special education.
Circular 76-156 of 22 April 1976, on the Commissions for Special Education.
Circular of 29 January 1982, on the setting up of a policy towards integration of disabled children and teenagers.
Circular of 29 January 1983, on the development of supportive actions and special care for integrated children.
Circular of 29 August 1986, on the introduction of transport expenses of disabled children in the budgets of special education establishments.
Act of 10 July 1989 on education.
Annexes XXIV of the Decree of 27 October 1989, on the creation of the services for special education and community care.
Law of 23 November 1957 on the Reclassification of disabled workers.
Decree N°84-380 of 17.01.1984 on State support for the adaptation of work stations.
Law 87-517 of 10 July 1987 on behalf of employment of people with disabilities (O.J of 12.08.87).
Circular 93-217 of 9 June 1993 on the adaptation of workstations for disabled civil servants.
Decree 74-553 of 24 May 1974 on accessibility
Accessibility of buildings open to the public (Art. 49, 52 of the 1975 Disability Act. Art. L.111-7, L.111-8, L.151-1, L.152-4, L.152-5, L.152-6 of the Code of Building and Housing, Art. L.131-5 of the Code of Communes, Art. A.421-8 of the Code of Urbanism).
Decree 78-109 of 1 February 1978, stipulating measures to make accessible newly constructed buildings open to the public to disabled people with reduced mobility (O.J of 02.02.78)
Decree 78-1167 of 9 December 1978, stipulating measures to make accessible to disabled people with reduced mobility existing buildings open to the public and belonging to public persons and to adapt public transport services to facilitate movement of people with disabilities (O.J of 16.12.78), Order of 18.04.80 and 19.12.80 on the follow-up of programmes planned to implement the Decree of 9 December 1978.
Law 85-729 of 18.07.85, regarding the definition and the implementation of adaptation of principles.
Accessibility of housing (Art.49, 50, 54 of the 1975 Disability Act. Art. L.111-7, L.111-8, R.111-5, R.111-18.1, R.111-18.2, R.111-18.3, R111-19 of the code of Building and Housing)
Decree 80-637 of 04.08.80 and Order of 21.12.80 on accessibility of new collective dwellings and accommodation for people with reduced mobility. Order of 21.09.82
Circular 82-81 of 04.10.82 on accessibility and adaptability of housing to people with disabilities in dwelling houses.
Accessibility to the workplace (Art. 28, 29 of the 1975 Disability Act)
Decree 88-809 of 01.10.87 (Art. R.232.2.6 Labour Code)
Decree 88-930 of 20.09.88 (Art. R.235.13 Labour Code)
Law 91-663 of 13 July 1991 making provision for various measures designed to favour accessibility to people with disabilities to dwellings, working places and buildings open to the public.
Decree 92-535 of 16.06.1992, Decree 92-332 and 92-333 of 31.03.1992 on the implementation of the Accessibility Law to dwellings, workplaces and buildings geared to receive the public.
ASH (1993). Actualités Sociales Hebdomadaires. N° 1820, 18.02.1993. N° 1836, 11.06.1993. N° 1837, 18.06.1993. Paris : ASH.
Buffet, S. (1991). L'accessibilité des lieux d'habitation. Réadaptation, N° 377, Février 1991, pp 6-9. Paris : ONISEP - CNIR.
Centre d'Etudes et de Recherche sur l'Appareillage des Handicapés (1993). Dossier d'inscription au stage de formation des revendeurs et loueurs de véhicules pour handicapés physiques. Woippy : CERAH.
COmité de LIaison pour le TRAnsport des personnes Handicapées (COLITRAH) (1992). Transport des personnes handicapées - Législation et réglementation. Paris : Conseil National des Transports.
Comité National Français de Liaison pour la Réadaptation des Handicapés (1991). Le guide des aides techniques pour le bien-être des personnes âgées ou handicapées. Paris : CNFLRH.
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.
Conte, M. (1992). De la téléalarme au télécontact. Réadaptation, N° 394, Novembre 1992, pp20-22. Paris : ONISEP - CNIR.
Cunin, J.C. (1992). Aides techniques et compensation des incapacités. Réadaptation, N° 394, Novembre 1992, pp 29-32. Paris : ONISEP - CNIR.
Employment Observatory MISEP (1992). Policies 39. Commission of the European Communities.
Falek, F. (1991). Villes accessibles à tous. Réadaptation, N° 377, Février 1991, pp 12-14. Paris: ONISEP - CNIR.
Falek, F. (1991). Pour des locaux de travail accessibles. Réadaptation, N° 377, Février 1991, p15. Paris : ONISEP - CNIR.
Fardeau, M. (1991). Le budget social du handicap. In : A. Triomphe (Ed.), Les personnes handicapées en France : Données sociales. pp. 249-281. Paris : CTNERHI.
FMP (1992). Rencontres du handicap en Ile de France : Accessibilité, facteur d'insertion sociale et professionnelle. Colloque de la Fédération des Mutualités Parisiennes, 14 novembre 1992. Paris : FMP.
HELIOS (1993). Base de données Handynet. Commission des Communautés Européennes.
Le Particulier (1991). Vos ressources. Le particulier, N° 58 Spécial, Septembre 1991, pp 49-67. Paris : Le Particulier.
Lospied, C. (1993). 40 ans de législation en faveur des personnes handicapées. De l'assistance à la citoyenneté. Réadaptation, N° 400, Mai 1993, pp 9-10. Paris : ONISEP - CNIR.
Louvigné, Y., Pialoux, B., Pichancourt, D., Le Moulec, R. (1983). Les méthodes d'évaluation appliquées en France aux fauteuils roulants. In : Evaluation of assistive devices for paralyzed persons. First European Workshop, Commission des Communautés Européennes.
Savy, J. (1991). "Ville ouverte" - Améliorer l'accessibilité de la ville et de l'habitat aux personnes handicapées. Entretien avec J. Bienvenu, P. de Saintignon, Ph. Saint-Martin. Réadaptation, N° 377, Février 1991, pp 6-9. Paris : ONISEP - CNIR.
Secrétariat d'Etat aux Handicapés et Accidentés de la Vie. (1992). Le handicap en France.
Tarif Interministériel des Prestations Sanitaires (1992). N° 4.
Turpin, P. (1992). Favoriser la mobilité et l'autonomie : modifier l'environnement urbain. Problèmes politiques et sociaux : L'intégration des personnes handicapées. N° 677, 3 avril 1992, pp 56-62. Paris : La Documentation Française.
WHO (1990). Is the Law fair to the Disabled ? European Series, N° 29, pp 79-102. Copenhagen : WHO Regional Publications.
Legal and administrative framework
The human being needs both social protection and personal freedom - this idea forms an essential part of the German model of the social market economy. A good economy provides the basis for social policy and good social policy provides the basis for a good economy by giving social peace. (Blüm 1991.)
The state has had an important role in the development of social protection, especially by passing legislation concerning social insurance. For example, sickness insurance was introduced in 1883 and unemployment insurance in 1927. (Ibid.)
The main principles of social insurance have been sustained throughout legal reforms. They are 1) the principle of insurance, which means that the insured pays contributions and has a right to appropriate payments in return, 2) combination of statute frame law and self-government and 3) the plurality of forms of insurances and their providers. In addition to social insurance, social assistance is given when needed and when the individual is not entitled to social insurance. (Ibid.)
The principle of subsidiarity is fundamental. According to it self-help and the action of non-governmental organisations are of primary importance. (Ibid.)
The administrative structure consists of three levels: national, regional (Länder) and local government. The ministries which are responsible at the national level for the administration of policies relating to people with disabilities are the Federal Ministry for Labour and Social Affairs and the Federal Ministry for Family and the Elderly. (Observatory on national policies to combat social exclusion.)
The administrative framework is complex: some benefits are provided, for example, by the sickness funds which are autonomous, others by Federal agencies, others by nationally organized but decentralized bodies. Such bodies include the sickness funds, bodies responsible for accident insurance, the Federal Job Agency, social welfare offices in Länder and voluntary welfare organisations. (Brooke-Ross 1984.)
Legislation related to rehabilitation technology
(This chapter is largely based on the information given by the Federal Ministry for Labour and Social Affairs)
In education the principle of providing as much special assistance as necessary, and as much shared learning as possible is adopted.
Attempts are being made to expand assistance to facilitate integration in schools for children with disabilities and young people and those threatened by disability and to increase interaction with non-disabled children. Many children with disabilities can receive very effective assistance in mainstream schools, if they also receive additional care as well as facilities which are tailored to the needs of the disabled and provided that there is no more than a certain number of disabled children per class.
Career advice is also available (Sections 20 et seq. of the Employment Promotion Act).
A primary task is combining educational and social policy for the integration of people with disabilities. The aim is to provide comprehensive training opportunities for people with disabilities in order to give them the greatest possible degree of equality of opportunity when competing with non-disabled persons for permanent employment.
Working life and vocational rehabilitation
The Employment Observatory of the European Communities has summarized Germany's employment policies for people with disabilities as follows:
- Grants-in-aid for employers covering up to 100% of the training allowance depending on the nature and severity of the disability.
In Germany the term "vocational rehabilitation" covers vocational training including initial training, further training and retraining aimed at preparing people for an occupation. It also covers measures required to integrate people into a suitable job (including employment in a workshop for people with disabilities).
Subject to certain conditions, participants in vocational training measures receive a training allowance or a transition allowance. The costs of measures are reimbursed. Employers who employ people with disabilities can be granted a settling-in allowance of a maximum 80% for up to two years.
- Grants-in-aid covering up to 100% of the salary for a maximum period of 3 years.
- There are about 120,000 jobs in sheltered workshops.
Financial assistance to people with disabilities starting enterprises
- There are no special measures for people with disabilities.
- 6% of jobs in firms with at least 16 employees have to be filled by people with disabilities. The same percentage applies to the public sector. (Policies 39.) If employers do not comply with this requirement, they have to pay a compensatory levy for unfilled compulsory places.
There is a lot of vocational assistance benefits for rehabilitation. Details are laid down in the benefit legislation applicable to the individual funds responsible for occupational rehabilitation (pension and accident insurance funds, war victims welfare fund, Federal Employment Office, social assistance).
Employers may receive subsidies of up to 80% of the wages paid to a person with a disability for a period of up to two years (integration assistance), and grants for equipping a workplace for people with disabilities for a probationary period of employment of limited duration (Section 54 et seq. of the Rehabilitation directive).
The Federal Employment Office is the primary body responsible for the initial integration of people with disabilities in the working environment and bears the greatest responsibility in more than 75% of cases for reintegration in the event of subsequent disabilities, although benefits paid by accident and pension insurance take precedence over benefits under the Employment Promotion Act. The reason for this is that the accident insurance and social compensation funds have a clearly defined group of persons to assist.
Special forms of assistance are also available in addition to the occupational rehabilitation benefits (Severely Disabled Persons Act). The Severely Disabled Persons Act provides for work to be adapted to accommodate the disability by, among other things,
- equipping of workplaces for people with disabilities with the requisite technical equipment and
- designing and maintaining the working environment, furnishing, machinery and appliances with the aim of enabling the highest number possible of severely disabled persons to be employed.
According to the Act there must be the necessary technical aids at the workplace (SchwbG § 14 and 31, SchwbAW § 5). A severely disabled person can get support for a motor vehicle and its equipment in order to reach the workplace (SchbG § 31, SchbAW § 6). (Jung & Cramer 1987.)
Of approximately 124,000 employers who were subject to the employment obligation in 1988, in October 23,300 (around 19 per cent) had fulfilled their obligation. In 1988 DM 4.5 million (ECU 2.3 million) from compensatory levy revenue were used for technical aids.
For people with disabilities who, because of the nature or severity of their disability and in spite of every assistance, are unable to participate in the general labour market, workshops for the disabled offer the opportunity to exercise a suitable occupation (Section 54 of the Severely Disabled Persons Act). These people with disabilities include those who need technical aids. Assistance in the working environment is one of the functions of integration assistance, in accordance with Section 40 of the Federal Social Assistance Act.
People with disabilities and people threatened by disability can claim, in the first instance, the same social assistance and other benefits available to any other citizen. In addition there are regulations which are deliberately aimed at integrating people with disabilities, and people threatened by disability, into society.
According to Section 10 of Book 1 of the Social Code, any person who is physically, mentally or psychologically disabled, or who is threatened by such a disability, has a "social right", independently of the cause of his/her disability, to the assistance which is required to:
- avert, eliminate, alleviate the disability, prevent its aggravation, and reduce its effects, in order to
- secure him/her a place within the community, in particular in working life, in accordance with his/her inclinations and abilities.
"Disabled persons" are all persons who are limited in their capacity for integration into society (handicap) because of the effects (disability) of a physical, mental or psychological condition which is contrary to the norm (impairment), and where limitation of this capacity for integration is not merely of a temporary nature. The "condition which is contrary to the norm" is defined as the loss or impairment of normally existing physical, psychological or mental structures. If the loss or impairment of a particular function resulting from this condition affects several areas of life, the handicap is to be found in the effects of disability. The same disability can lead to various degrees of handicap.
According to the Severely Disabled Persons Act, severely disabled persons are persons whose degree of disability is at least 50 %. The Act only applies to those who live either in Germany, have their usual residence there, or are employed there.
In addition to rehabilitation benefits such as those from the Federal Employment Office and statutory pension insurance funds, the benefits and assistance provided under the Severely Disabled Persons Act are intended to facilitate integration into working life. Furthermore, severely disabled persons may claim compensation for the disadvantages, for the restriction placed upon them by their disability, and, under certain conditions, also for extra expenses resulting from such a disability, normally where additional requirements are also satisfied.
The disability of persons with slight disabilities who are not recorded statistically is explicitly "recognized"; this recognition is based on the award of a pension by the accident insurance fund or in accordance with the law on social compensation or on the basis of the findings of the War Pension Office. This recognition is also a prerequisite for certain types of tax relief.
According to Section 10 of the Rehabilitation Harmonisation Act, medical services for rehabilitation should cover all areas of support necessary to prevent a threatened disability, to eliminate a disability, to alleviate it or to prevent its aggravation. In particular they cover,
- medical and dental care,
- medicines and dressings,
- therapeutic remedies including physiotherapy, kinesistherapy, speech therapy and occupational therapy,
- provision of prosthetic, orthopaedic and other appliances, including necessary modification, repair and replacement as well as training in the use of such appliances,
- tolerance level testing and work therapy, also in hospitals, sanatoria and special institutions, together with the necessary subsistence and accommodation.
Special emphasis is given to the supply of technical and other aids, considered necessary from a medical point of view, as part of medical rehabilitation in statutory health insurance according to Section 33 of Book 5 of the Social Code. Accordingly, an individual is entitled to the aids required in each individual case, e.g. a wheelchair with special fittings. Any fixed amount determined by the health insurance fund only applies if it is valid for this particular aid. Consultation between the medical service and orthopaedic supply centres (Section 275, Subsection 3 of Book 5 of the Social Code) is also intended to ensure the supply of aids according to the individual's requirements. Details on the supply of aids are regulated by the guidelines of the leading associations of insurance funds. In the area of accident insurance, it is necessary to refer to the regulation governing the supply of orthopaedic aids to people injured in accidents, and to the newly drafted Orthopaedic Regulation of 1989 in the area of social compensation.
Difficulties of definition regarding the areas of responsibility of the various funds are solved in a variety of ways, for example, in the form of agreements, by the forming of working groups or through similar methods of cooperation between funds.
In the event that it is not clear who holds responsibility in any particular case or if the immediate introduction of necessary measures for medical rehabilitation is jeopardised, the pension insurance fund responsible must provide provisional benefits (Section 6 of the Rehabilitation Harmonisation Act). Social Assistance intervenes when none of the funds is responsible.
The principle of preferring out-patient to in-patient care is based on Section 40 of Book 5 of the Social Code.
An increasingly important role in medical rehabilitation is being played by care services, organisations for the disabled and self-help groups.
Social integration of people with disabilities includes making it possible or easier for the disabled to participate in the life of the community, giving them the opportunity to exercise an occupation or other suitable activity and making them as independent as possible (section 40, Federal Social Assistance Act). (Legislation on the rehabilitation of people with disabilities in sixteen member states of the Council of Europe 1990).
The provision of technical aids and appliances in the broadest sense is designed to help people with disabilities to achieve the greatest possible degree of independence. Section 9 of the Integration Assistance Order also contains a comprehensive list of such aids, ranging from communication and mobility aids for persons with hearing, sight and speech impairments to personal articles for daily use. (Ibid.)
In addition to medical technical aids it is thus possible to get technical aids from social assistance, for example alarm systems, typewriters, additional costs for text telephone and telephones (§§ 40 Abs.1 Nr.2 BSHG, 7-10 EhVO). Technical aids are given as social assistance only if they are necessary and suitable in the individual case. (Brühl 1990.)
Under section 40 of the Federal Social Assistance Act, assistance in the sheltered workshop field is one of the functions of integration assistance; under section 100 of the same Act, the cost of this assistance is borne by the regional social assistance authorities. (Legislation on the rehabilitation of people with disabilities in sixteen member states of the Council of Europe 1990).
In order to integrate people with disabilities into society, it is essential that planning developments and the design of the environment take into account the needs of people with disabilities. In accordance with the Second Housing Act, housing for severely disabled is promoted. The Rent Subsidy Act also contains special concessions for the severely disabled. Assistance in obtaining and maintaining a home which corresponds to the particular needs of the disabled person is one of the many tasks of integration assistance (Section 40, Subsection 1 No.6 of the Federal Social Assistance Act, Section 18 of the Integration Assistance Regulation).
Participation in social life is also promoted by the elimination of mobility restrictions. The aim is to create a barrier-free, safe environment for people with disabilities, and in doing so to make it possible for people with disabilities to live their lives as independently as possible of outside help. This objective has meant that many roads, paths and squares have been designed with people with disabilities in mind and that most public buildings are now easily accessible to people with disabilities.
The interests of people with disabilities have been considered when building and modernising railway stations. Concessions to facilitate travel by public transport are constantly being developed.
There are also special transport services which are regulated locally.
Assistance given towards a motor vehicle is payable according to the Integration Assistance Regulation or the Motor Vehicle Assistance Regulation.
Travelling involves certain difficulties for people with disabilities and the elderly. The German Federal Railways have adopted guidelines for the construction of rolling stock which make it easier for people with disabilities to use the railway. These guidelines make particular reference to planning standards DIN 18024 and 18025. The needs of disabled have also been taken into account as far as possible in the construction or modification of railway stations. Railway carriages have also been modified. The severely disabled, in particular wheelchair users, should be able to travel on intercity trains. Each intercity should have one larger carriage suitable for wheelchairs. (WHO 1990.)
According to H. Mittler, Deutsche Bundesbahn, the German federal railways, faced with the competing pressures to base its business policies on economic and financial considerations and to take into account people with disabilities' demands that vehicles and premises be designed in a barrier-free manner, seeks to achieve solutions that are responsive to users' needs and at the same time economically justifiable. On account of the 19th century infrastructure legacy and a wide range of existing rolling stock in long-distance and short-distance rail travel, this can however be realised only step by step. The facilities offered to people with disabilities so far range from free use of short-distance trains to the accessibility-oriented design of coaches for the Intercity Express. It is hoped that the various services and facilities provided will encourage people with disabilities to use railways which are compatible with environmental considerations. (Mittler 1989)
Since 1977, the Association of German Civil Air Fields has been implementing the Guidelines on the construction of installations for the disabled on air fields, based on planning standards DIN 18024 and 18025 (ibid).
People with disabilities are permitted to drive vehicles provided that they are capable of handling these vehicles safely. The provision of driving licences for and the licensing of mechanically operated invalid vehicles are covered on a comprehensive basis in the Road Traffic Licensing Order. (Ibid.)
In the field of telecommunications several measures are used by the Federal Postal Service. Special public telephone booths for wheelchair users were introduced in 1976. Specially developed Vitaphon telephones for people with disabilities have been provided since 1983. Persons suffering from particular serious physical disabilities or those in low income groups are charged concessionary fees and persons who are particularly dependent on the telephone receive additional free metered units. (WHO 1990.)
It is also important to mention the waiving of radio and television fees for severely affected or financially disadvantaged people with disabilities, as set down in the regulation of the federal regions. (Länder.)
Provision of assistance and technical aids in the broadest sense serves the objectives of achieving the most comprehensive degree of self-reliance and independence. Section 9 of the Integration Assistance Regulation indicates the existing and far-reaching range of benefits available, particularly in the case of communication and mobility aids for people with hearing, sight and speech disabilities, but also for objects which are part of everyday life. These are supplemented by aids and concessions given by the German Federal Post Office with regard to postal and telecommunications service (particularly in the case of concessions on fees and the range of special communication equipment available etc.)
The main feature of future development in legislation affecting people with disabilities will be the updating of the Severely Disabled Act. The general aim is to increase the prospects of recruitment and employment of severely disabled on the labour and training markets. (WHO 1990.)
The Rehabilitation-Adaptation Act will be updated at a later stage. The goal is to form a single, lucidly arranged Act on the integration of people with disabilities. It is noted that medical, professional and social rehabilitation measures must be even better coordinated. Information and counselling on integration opportunities and cooperation between the rehabilitation institutions also need to be improved. (Ibid.)
In January 1991, the Government coalition parties agreed that the existing rehabilitation and severely disabled persons' legislation should be rearranged and integrated in the German Social Code as Book IX - Integration of people with disabilities. According to U. Gerke. and G. Schafer, this forthcoming codification is intended as an opportunity to introduce appropriate adjustments and amendments, as well as to consider the possibilities for limited material reform. The Federal Rehabilitation Council has submitted a number of proposals to the Federal government aimed at settling various intersectoral aspects of rehabilitation legislation in the forthcoming Book IX. (Gerke & Schafer 1992.)
Anordnung des Verwaltungsrates der Bundesanstalt für Arbeit über die Arbeits - und Berufsförderung Behinderter.
Bundessozialhilfegesetz (Federal Social Assistance Act).
Gesetz über die Angleichung der Leistungen zur Rehabilitation. 7 August 1974. (Rehabilitation Harmonisation Act).
Gesetz über die sozialversicherung Behinderter in geschützen Einrichtungen.
Gesetz sur Sicherung der Eingliederung Schwerbehinderter in Arbeit, Beruf und Gesellschaft (Schwerbehindertengesetz). 16 June 1953. (Severely Disabled Persons Act, also several regulations).
Eingliederungshilfe-Verordnung (Integration Assistance Order).
Sozialgestzbuch (Social Code).
Verordnung über Kraftfahrzeughilfe zur beruflichen Rehabilitation. 28 September 1987. (Motor Vehicle Assistance Regulation).
Blüm, N. (1991). Sozialstaat als Gestaltungsauftrag. In : Übersicht über die Soziale Sicherheit. Bonn : Der Bundesminister für Arbeit und Sozialordnung.
Brooke-Ross, R. (1984). The Disabled in the Federal Republic of Germany. Social Policy & Administration. Volume 18, Number 2, Summer 1984, pp. 172-178.
Brühl, A. (1990). Sozialhilfe für Betroffene von A-Z. 2. Auflage. Beck-Rechtsberater im dtv.
Committee on rehabilitation and integration of people with disabilities (1990). Legislation on the rehabilitation of disabled people in sixteen member states of the council of Europe. 4th Edition. Strasbourg: Council of Europe.
Der Bundesminister für Arbeit und Sozialordnung (1991). Übersicht über die Soziale Sicherheit.
Employment Observatory MISEP (1992). Policies 39. Commission of the European Communities.
Gerke, U. & Schafer, G. (1992). Weiterentwicklung des Rechts zur Eingliederung Behinderter - Vorschlage der Bundesarbeitsgemeinschaft fur Rehabilitation zu einem SGB IX. Rehabilitation-Stuttg. 31(4): 211-6.
Jung, K. & Cramer H. (1987). Schwerbehindertengesetz Kommentar. München: Verlag Vahlen.
Massnahmen, Deutschland (1992). Beschäftigungsobservatorium, MISEP. Komission der Europäischen Gemeinschaften.
Observatory on national policies to combat social exclusion (1992). Second Annual Report. Commission of the European Communities.
WHO (1990). Is the law fair to the disabled?. European Series, No 29. Copenhagen : WHO Regional Publications.
The Republic of Ireland has no legislation which provides statutory provision of equipment for people with disabilities and in the absence of a proactive role for national and local government, voluntary organisations and religious orders have undertaken much of the provision.
The lack of statutory provision can be attributed to a number of factors. There is no co-ordinated mechanism for collecting information about people with disabilities and thus no accurate statistics are available, either on the number of people with disabilities or their needs. Ireland has a population of only 3.5 million and the estimated number of people with disabilities, 81,2001, is very small. This, coupled with the disparate nature of the population, has meant that services and facilities have not developed in a co-ordinated way throughout the country.
However international example and internal pressures have led to the recognition that Ireland should have a more cohesive and rights-based approach to the needs of people with disabilities. The impact of the 1981 - International Year of the Disabled was crucial in this process. So was the emergence of articulate groups of congenitally disabled people demanding to be treated as equals. In 1960, a number of people with disabilities founded the Irish Wheelchair Association, a body committed to the principle of anti-discrimination legislation for people with disabilities. The association has 4,000 wheelchair users in membership. In addition, Ireland has small but increasing numbers of people who become disabled through farming and road accidents.
In 1993, the Irish Government formed a Department of Equality and Law Reform, whose remit will include equality issues for people with disabilities. It is currently considering proposals for equality legislation and is carrying out consultations with many voluntary groups and organisations of and for people with disabilities. A Commission on Disability, with people with disabilities forming 60% of the membership, is also being set up. The Department of Equality does not, at present, have a budget to provide services to people with disabilities - this is still controlled by the Department of Health. Thus the role of the new Department in service provision is still unclear.
Legal and administrative framework
The Irish Constitution of 1937 guarantees the rights of all citizens, including those with disabilities. Citizens who feel they have been discriminated against, by private or statutory bodies, may ask the Ombudsman, who is responsible for investigating complaints on a wide range of issues, not only disability questions, to intervene on their behalf. In practice, however, there is only one Ombudsman to cover the entire country and this recourse is rarely used.
The provision of services and equipment to people with disabilities in Ireland is currently carried out by the Department of Health, the National Rehabilitation Board (an executive agency of the Department of Health), regional health boards and voluntary organisations. There are eight health boards which receive their budget from their Department of Health. They can use this budget to provide services themselves or to contract voluntary organisations to provide the services. The National Rehabilitation Board was set up as a statutory body in 1967 and is the central co-ordinating authority in the field of rehabilitation. The Department of Health and the regional health boards work in close co-operation with the voluntary and non-governmental sector.
At present, most Irish law makes no specific mention of disability or reference to the need for equipment. However, new Building Regulations introduced in 1992 provide the legal basis for access to public buildings for people with disabilities, although the requirement for access only applies to new buildings and those being renovated.
People with disabilities are assumed to have the same legal rights as other citizens. Their needs are provided for under general health legislation, principally the 1947-1970 Health Acts and the 1945-1961 Mental Treatment Acts.
Vocational rehabilitation services for people with disabilities are provided by regional health boards under Section 68 of the 1970 Health Act. Equipment to enable people with disabilities to take jobs is also provided for under guidance circulars issued by the Government, although there is no statutory requirement to provide it.
In practice, many direct services for people with disabilities are provided by the voluntary sector which receives full public funding through the health boards for the task. Most services and equipment are provided subject to means tests primarily carried out by the health boards. Most provision is connected with vocational training.
Legislation related to rehabilitation technology
There is no legal basis for providing aids and equipment in the homes of people with disabilities through the public sector in Ireland. Equipment may be provided by voluntary organisations, but most people with disabilities have to use the private sector through which products may be purchased.
Advice on the availability of equipment and aids is provided through the information service of the National Rehabilitation Board (NRB). As a development of their technical aids service, the NRB opened a Disability Resource Centre in Dublin in September 1993, which includes permanent displays of equipment designed or adapted for people with disabilities.
Although the Irish Constitution guarantees that "all children will be cherished equally" there is no specific reference in education laws to the needs of children with disabilities. There is no legal basis for providing educational equipment for children with disabilities in schools.
Most children with physical disabilities attend mainstream schools, which often lack the equipment they need to make full use of their education. Cash allowances are available from the Department of Education to transport children with disabilities to school, but privatised bus services lack adaptations to make the vehicles accessible and lack operators able to lift children on to buses.
Special schools with appropriate equipment and trained teachers are available to some blind and deaf children. There are however only two schools for each category of child. Attendance therefore means living away from home for many pupils in addition to the disadvantage of being isolated from other children of the same age. There are also special schools for children with learning difficulties. These schools provide education up to secondary leaving standard, but they operate under general legislation for the education of junior school age children.
Working life and vocational rehabilitation
The NRB runs a range of free services aimed at helping people with disabilities obtain and retain jobs as part of its general remit to coordinate rehabilitation work. There is no legal obligation to provide these services and their availability is dependent upon budgetary considerations. Schemes which are currently being offered include:
- Job Clubs for people with disabilities seeking work.
- Grants to deaf people to pay for an interview interpreter and to blind people to pay for a personal reader.
- Employment Support Scheme which provides grants to employers to take on people with disabilities. It is designed to enable people with 50-80% of standard of productivity to work alongside their able-bodied colleagues. The employer pays a wage which actually reflects work performance and the State pays the remainder of the salary.
- Job Integration Grants of up to I£5.000 (ECU 6.250) for workplace equipment or adaptations to employers. These grants can cover the cost of ramps for wheelchair users, alarm systems with flashing lights to help deaf people; voice synthesizers for computer operators; modified toilets and machinery adaptations for foot rather than hand control.
- Equipment loans which can also be made where people with disabilities are already in jobs, are self-employed or on work experience programmes.
More specific responsibilities are placed on regional health boards by Section 68 of the 1970 Health Act. This requires them to provide a service for the training of people with disabilities for employment suitable to their condition of health and for making arrangements with employers to place people with disabilities in suitable employment. In practice, most training centres and community workshops for people with disabilities are run by voluntary bodies, funded by health boards with support from the European Social Fund, a European Community training fund.
In 1977, a Ministerial Order introduced a 3% quota of public sector jobs for people with disabilities, a figure to be achieved within five years. The intention was to provide an example which the private sector would follow. By the end of 1990, the overall figure in the public sector was 1.28%2. According to an unpublished report to the Monitoring Committee set up by the Irish Prime Minister in May 1992, NRB had achieved 5.44% at the end of 1991.
Various benefits are available to people with disabilities, although many are subject to means tests. These benefits are administered by the health boards. Under section 69 of the Health Act 1970 and the associated regulations, the health boards pay the Disabled Persons' Maintenance Allowance to substantially disabled adults aged between 16 and 66 years who are unable to work. Payment of the allowance may act as a passport to other benefits from the Department of Social Welfare, including free travel, free electricity, free bottled gas, free television licence, free telephone rental, free fuel and free children's footwear. In 1991, this benefit was paid to 26,397 people3.
Under section 61 of the Health Act 1970, health boards pay a mobility allowance, available to the same age group, for people unable to walk; 1,321 people received this in 19913. Health boards are also responsible for the domiciliary care allowance, paid to parents of severely disabled children aged 2 to 16; and for the infectious diseases maintenance allowance for people being treated for specified diseases. All these benefits are means tested.
Health boards also administer supplementary allowances paid to blind people receiving a Blind Pension from the Department of Social Welfare, which is also responsible for invalidity pension, disability benefit, and a carer's allowance for people caring full-time for a dependent relative.
Ireland changed its former three-tier health service as a result of the Health Amendment Act 1990. The new system is still based on a means test and about 36% of the population (35.6% in December 1992)4, including the majority of people with disabilities, now qualify for medical cards. These entitle them to free drugs, hospital and general practitioner services, to dental, ophthalmic and aural services and appliances, and to maternity and infant care services.
People earning more than the medical card income limits, which vary according to family size and are revised each January, are entitled to the same services but must pay charges, including (in 1993) I£6 (ECU 7,5) for an out-patient hospital visit and a daily I£20 (ECU 25) for public hospital accommodation, in both cases subject to upper limits. They also pay drugs charges but may qualify for rebates if the family has to pay more than I£90 (ECU 112,5) a quarter for prescribed drugs and medicines.
Some people who do not qualify for a medical card are exempt from charges, including children receiving treatment for specified mental and physical disabilities.
People who have various specified disabilities, generally because of long term illness, may also qualify for free medical services including refunds of the cost of drugs and medicines.
The Department of Health, health boards and voluntary agencies provide residential places and day care services for people with learning disabilities, as well as places for people with hearing or visual impairment or other physical disabilities. Yet in recent years, policy has moved towards care in the community, particularly for elderly people, a minority of whom have a physical impairment. There is no overall responsibility or legislation on providing them with alarm systems, although consultants have recommended that an integrated system for the elderly should be facilitated.5
A pilot study on the use of alarm systems is being monitored by one of the health boards. A new Nursing Homes Act, enacting recommendations from a 1988 report6, has been passed but not implemented because of lack of resources.
Most health legislation does not refer specifically to equipment for people with disabilities, but aids and appliances, including wheelchairs, other mobility aids and surgical appliances, are available free of charge to medical card holders. Health boards may make grants available after means tests towards the costs of wheelchairs, which usually have to be purchased by the individual disabled person if they are needed permanently. Grants meet only part of the cost, so most people insure themselves privately through health insurance schemes against the contingency of having to buy a wheelchair.
The Irish Wheelchair Association, a voluntary body, is the largest provider of wheelchairs, maintaining a supply for loan or sale to individuals and health boards. The Association sells between 300 and 400 wheelchairs a year, and loans about 40 free of charge.
Grants to convert cars or to buy an adapted new motor vehicle for use by a disabled person are available from health boards, subject to a means test. Section 43 of the Finance Act 1968 exempts from road tax vehicles adapted or constructed for use by people with disabilities, who are also exempt from value added tax on new cars under the VAT Order 1980. People with disabilities are also entitled to the refund of excise duty on petrol up to 600 gallons per person per year. Invalid carriages not exceeding 6cwt (about 300kg) unladen weight and specially constructed or adapted vehicles for people who cannot walk are exempt from parking restrictions and fees.
There is no legislation related to the accessibility of public transport for people with disabilities.
Housing and environment
1980 Housing Regulations enable a local authority to pay grants for structural alterations and extensions to houses to improve the living condition of people with disabilities. Loans are also available towards adaptation costs for low-income applicants.
Part M of the Building Regulations, which took effect in June 1992, provide guidelines for architects and others on making new public buildings and extensions to old buildings accessible for people with disabilities.
New public buildings must have: accessible paths and ramps from car park to entrance; a suitable passenger lift in larger buildings; and suitable communication aids for deaf people in theatres, places of worship, meeting and conference centres.
Signs must be available in large print and braille and buildings must have adequate safety features in case of emergency. The newly refurbished building housing the Department of Equality and Law Reform has fire proof "respite" areas on each floor to ensure that people with disabilities can be rescued by firefighters without having to evacuate the building.
The regulations also require hotels and guest houses to ensure that at least one in 20 bedrooms is wheelchair accessible.
No legislation exists in Ireland governing the provision of information technology or multi-media systems to help people with disabilities. However, the local IT industry is developing advanced multi-media systems, including a "talking" Windows operating system to make it available to the visually impaired. The Handynet system has both DOS and Windows versions, but DOS is text orientated.
The Irish Government is planning to draw up Equal Status legislation which will prohibit discrimination on a wide range of grounds, including gender, age and handicap. A Bill is expected to be presented to the Irish Parliament by the end of 1993.
It is expected that the Bill will cover employment; education; the provision of goods, facilities and services; and the disposal of property. The services to be covered include recreational facilities, entertainment, housing, transport and professional services.
A new law would set the basic principle of equal status for people with disabilities and would be backed by several other initiatives. Together, they would represent a fundamental shift in official philosophy. People with disabilities would be treated as citizens, not as sick people.
A Commission on Disability is being set up and is expected to lead to a permanent Council on Disability to advise Government, monitor developments and make recommendations.
Other Government aims include: a Bill of Rights for people with learning disabilities; a major development programme to make streets and buildings accessible; a capital expenditure programme to make public transport accessible; and examination of a scheme to provide an allowance to enable people with a disability to employ a personal assistant where they need help at home to maintain independence.
The Government is also committed to ensuring that the public sector complies with the 3 per cent jobs quota and encouraging the private sector to follow suit voluntarily. If the private sector resists, a law to make the quota mandatory on all employers is being considered. The model is likely to be the French system which includes a levy on defaulting employers to finance the equipment and other facilities needed to make employment available to people with disabilities. A Government Committee has been set up to examine this issue, as well as looking at ways in which sheltered workshops for people with disabilities could be set up.
1 EUROSTAT (1992). Disabled Persons: Statistical Data. Volume II. Luxembourg Office for Official Publications of the European Communities.
2 Forum of People with Disabilities (1992). 3% Public Service Quota. Dublin.
3 Department of Health (1991). 1991 Health Statistics. Dublin : Government Publications.
4 Department of Health (1993). An Information Guide to Our Health Service. Dublin : Government Publications.
5 O' Connor, J. et al. (1986). Communications Networks and the Elderly. A report to the Department of Health. Dublin : Social Research Centre.
6 1988 The Years Ahead ..... A Policy for the Elderly. Report of the Working Party on Services for the Elderly. Dublin : The Stationery Office.
Finance Act 1968. Exempts adapted vehicles from road tax.
Health Act 1970. Established vocational rehabilitation services and benefits for people with disabilities through regional health boards.
Ministerial Order 1977. Introduced 3% quota of public sector jobs for people with disabilities.
Housing Regulations 1980. Enabled local authorities to pay grants for alterations and extensions for people with disabilities.
VAT Order 1980. Exempts new adapted cars from Value Added Tax.
Nursing Homes Act 1988. (Not yet implemented.)
Health Amendment Act 1990. Changed Ireland's health system from a three-tier to two-tier system.
Building Regulations 1992. Provided for access to new public buildings for people with disabilities.
Directorate-General for Employment, Industrial Relations and Social Affairs (1993). European Year of Older People and Solidarity between Generations. In : Social Europe. Luxembourg: Commission of the European Communities.
Fianna Fail (1993). Fianna Fail and Labour Programme for a Partnership Government 1993-1997. Dublin.
National Social Service Board (1990). Entitlements for Disabled People. Dublin : NSSB.
WHO (1990). Is the law fair to the disabled? European Series, No 29. Copenhagen : WHO Regional Publications.
Legal and administrative framework
According to the Italian Constitution, Italy is a republic based on the principle of work. Moreover, again according to the Constitution, Italy protects the family as a "natural society". Furthermore, it protects the right of workers to live according to their previous standard of living when becoming old or disabled, while it grants to non-workers the minimum income necessary for survival. (Observatory on national policies to combat social exclusion.)
There are two levels of legislation: national laws and regional laws. In such fields as health services and social assistance, the general framework of law is defined at the national level, whilst regional administrative bodies are responsible for enacting detailed rules.
There is thus a distinction to be made between ministries and institutions at the national level (with their laws and regulations) and local Government, which can be further divided into regions, provinces and municipalities, each with different competencies. In general, education and social security, including pensions for people with disabilities, are state regulated and administered, while social assistance is delegated, by law, to the appropriate level of local Government.
Apart from trade unions, there is a number of institutions and organisations which have been in existence for a considerable time which organise volunteer activities and advocacy initiatives in the area of social marginalisation. Non-profit (religious or lay in inspiration) associations, volunteer groups and self-help groups are particularly active in the areas of mental and physical handicap, of drug addiction and of Third World immigration. (Observatory on national policies to combat social exclusion)
Legislation related to rehabilitation technology
The integration of disabled children into state schools is covered by Acts which deal with schools. Although problems and controversies still abound in this area, educational integration may be said to have become a reality in Italian schools. (Legislation on the rehabilitation of disabled people in sixteen member states of the Council of Europe 1990.)
Special education is covered by separate Acts. Profoundly deaf children are taught in appropriate special schools or else in the ordinary classes of state schools equipped with support services. (Ibid.)
The compulsory schools, through their administrative bodies, receive public contributions to give technical aids to students.
According to the new framework law of 1992, schools have to be supplied with technical equipment to facilitate learning and communication for blind, partially blind, deaf and partially deaf pupils (Torbidoni, Fratello & Taddei 1992).
Working life and vocational rehabilitation
According to the Employment Observatory MISEP (Mutual Information System on Employment Policies) Italy has the following employment policies for people with disabilities:
- There are no national programmes specifically for people with disabilities. There are, however, specific programmes on a regional level to train people with disabilities.
- There are no national programmes specifically for people with disabilities. There are, however, specific recruitment incentive programmes on a regional level.
- In order to integrate disadvantaged people into the labour market, social cooperatives have been created. These cooperatives should include at least 30 % disadvantaged workers and are exempt from the payment of social contributions. The authorities can draw up agreements with cooperatives for the supply of goods and services aimed at creating job opportunities for these disadvantaged groups.
Financial assistance to people with disabilities starting enterprises
- Some regions have specific programmes for people with disabilities starting enterprises.
- Employers in the private sector who have more than 35 employees have to employ a quota of disabled workers equivalent to 15% (including widows, orphans and refugees) of their workforce. The same percentage applies in the public sector.
On 30 June 1991, the number of disabled workers in public administrations and private companies who have benefitted from the provisions regarding compulsory recruitment was 317,407 (MISEP 1992).
Social cooperatives also have the aim of promoting the access of disadvantaged individuals to employment. The disadvantaged people for whom these cooperatives are intended are physically, psychologically or sensory disabled people. These people form at least 30 % of the workers in these cooperatives, of which they are associates, in as much as their condition permits this. The Regions provide the method of liaison between the social cooperatives and the socio-medical services, and the services for vocational training and employment promotion. Social cooperatives are exempt from payment of compulsory insurance contributions for social security and assistance based on the remunerations of the disadvantaged people they employ. (Ibid.)
Adaptation of the workplace is subject to regional legislation. Communes are compelled, under national law, to cover costs for the adaptation of the workplace for blind telephonists.
If the disability is due to an acknowledged accident at the workplace, provision of technical aids is ensured through the National Institute for Labour Accidents Insurance (INAIL) upon medical description by an INAIL physician and administrative authorization of the provincial director (Andrich 1990).
The national Italian legislation providing economic support to war wounded, civilian disabled, civilian blind and deaf-blind people, is composed of a multitude of norms, which have been established over time. The norms are complex and not always very easy to interpret because of the number of norms itself and also because of the constant need to refer to other norms and precedents. It is also necessary sometimes to refer to medical norms, which may not be clearly expressed in the relevant Acts. (Ministero dell'interno 1991.)
In Italy, a new Framework Law was approved in January 1992 , unifying all previously existing laws concerning the rights of people with disabilities and the obligations of the public authorities towards them. Regions must now establish their own implementing laws and regulations. The Framework Law defines the rights of people with disabilities in relation to health care from birth; social integration (by home helps, elimination of architectural barriers, transport); schooling; vocational training and job insertion; sport and leisure; and housing (a quota of public housing). It also provides support to those caring for people with disabilities: supplement to any social pension which the carer is receiving (but therefore benefiting only carers with low incomes); rights of job security if employment is suspended in order to undertake caring; and credits towards pensions for such absent periods. But these latter rights apply only to those in permanent full-time work i.e. the privileged "core" workers. (Observatory on national policies to combat social exclusion 1992; Leggequadro per l'assistenza, l'integrazione sociale e i diritti delle persone handicappate 1992.)
According to article 1 of the Act, the Republic:
- guarantees the full respect for human dignity and the rights to freedom and independence of people with disabilities, and promotes their full integration in the family, the school, the labour market as well as in society.
- foresees and removes the disabling conditions which prevent the development of the human person, the achievement of the maximum possible autonomy, and the participation of people with disabilities in society, as well as the realisation of civil, political and inherited rights.
- enables the functional and social recuperation of the physically, mentally, or sensory impaired person, and guarantees the services and the actions needed for the prevention, the treatment and the rehabilitation of the impaired persons, as well as the provision of advice in judicial and economic matters relevant to people with disabilities.
- prepares regular intervention measures in order to overcome marginalisation and exclusion of the disabled person.
According to this new law "the disabled person is one who shows a physical, mental or sensory impairment, stable or progressive, which causes difficulties in learning, in relationships and in job integration, and thus is subject to social disadvantage" (Torbidoni, Fratello & Taddei 1992).
People with disabilities, rehabilitation and health care professionals, teachers, architects, health authorities and manufacturers can get counselling services from SIVA (Servizio Informazioni e Valutazione Ausili), the Technical Aids Evaluation and Information Centre. It has a data bank, related paper files, counselling service and the permanent exhibition of technical aids. (Andrich 1990.)
There is also the network of Technical Aids Counselling Centres (TACC). They belong to the SIVA network and provide qualified support to people with disabilities or to the professionals. (Ibid.)
Several tax deductions related to medical aids are possible.
According to the Health Reform Act of 1978 "All citizens shall, irrespective of circumstances, be guaranteed health care". It removes thus any distinction between the various categories of people with disabilities. In the Act there are also specific sections on rehabilitation. (Legislation on the rehabilitation of disabled people in sixteen member states of the Council of Europe 1990.)
Public health services are delivered to any citizen by the National Health Service (Servizio Sanitario Nazionale, SSN) through its 700 local Health Authorities (Unita` Sanitarie Locali, USL).
Prostheses, appliances and general technical aids which can be considered as medical devices fall clearly under the heading of health services and are free of charge like any other kind of health service (Andrich 1990).
The border line between technical aids which can be considered as medical devices and those which should be considered a matter of social assistance is sometimes unclear. But at least "Prosthetic Assistance" falls under the heading of health service. This is established by the "Nomenclatore Tariffario" (National Register of rehabilitation devices and relevant permitted prices) published by the Ministry every two years. Devices whose characteristics correspond to the Nomenclatore Tariffario but exceed the permitted price may also be eligible for prescription in accordance with a special procedure at the regional level. (Ibid.)
In revising and defining the Tariff Nomenclature of Prostheses the new law states that electronic equipment and other technical aids have to be included (Torbidoni, Fratello & Taddei 1992).
The VAT rate of 4% instead of 19% applies to all medical technical aids.
The National Health Service (SSN:Servizio Sanitario Nazionale) was established by the Health Reform Act in 1979. It is based upon Local health Authorities (USL: Unita Sanitarie Locali) which are responsible for providing health services to any citizen or person within their territory, according to the principles established at the national level. Funding of the SSN is provided by an annual tax paid by all citizens. (Andrich 1990.)
Social assistance should provide technical aids other than medical devices. These are not in principle free of charge, depending on the locally available budget. (Andrich 1990.)
Social assistance is the responsibility of the regional authorities through municipalities, and various regional laws, ordinances and benefits are in force. Very often these provisions concern the school or the work environment, specific categories of people with disabilities or specific technical aids. (Ibid.)
Despite the variety of benefits there is still a high number of people who are unable to obtain public funding and therefore the technical aid must be paid for out of the person's pocket. In this case it is possible to pay a reduced V.A.T. rate and to obtain a tax deduction for "medical" expenses. (Ibid.)
In the field of housing there are residential centres, collective housing units and group accommodation. Other services include day-centres and home-help services. Integrated co-operatives are work co-operatives whose members include people with disabilities. Alongside these integrated co-operatives there are ordinary co-operatives (often agricultural) which take in people with disabilities. (Legislation on the rehabilitation of disabled people in sixteen member states of the Council of Europe 1990.)
In addition, there are some organisations, which are able to offer a variety of services, such as rehabilitation, group accommodation, sheltered workshops or co-operatives, vocational training, and information and guidance (ibid).
Elimination of architectural barriers has become an element of social integration. Presidential Decree No. 384 of 27 April 1978 provides for the elimination of physical barriers which may prevent the social integration of people with disabilities. These measures are compulsory both during the construction of new buildings and during the restoration of existing buildings. (Legislation on the rehabilitation of disabled people in sixteen member states of the Council of Europe 1990.)
A financial contribution for the removal of architectural barriers in private buildings is provided by a variety of regional laws and, since 1989, by a national law.
Accessibility is also one of the objectives of the new framework legislation passed in 1992. According to article 24 of this legislation, all building activities concerning public or private buildings that are open to the general public, and are likely to be difficult to access or visit, should be subject to the specific provisions in the acts and decrees. Some of the obligations for the removal of the barriers can be made on a temporary basis. Before building starts, a declaration and a graphical description have to be presented showing how the barriers will be removed or accessibility secured. The mayor has to check that accessibility is considered before granting the building licence.
According to the same article, buildings open to the public, which are not fulfilling the accessibility requirement, will be considered inaccessible and a fine will have to be paid. A part of the public building budget will be used to remove barriers.
There are also rules concerning access to communications and information. According to article 25 of the same Act, the Post and Telecommunications ministry will contribute to increasing people with disabilities' access to radio and telephonic information by installing decoders (like subtexting) and complementary devices, as well as by modifying telephone booths. When radio or telephone company concessions are renewed or modified, initiatives are required for providing people with disabilities with information, culture, leisure programs as well as diffusion of decoders. Equal rights for people with disabilities to use public transport are provided for in article 26 of the Framework Act.
Contributions for partial reimbursement of costs incurred by a person with a disability in possession of a special driving licence for the adaptation of the car are provided in various regions. According to this new law the State contributes up to 20% of the cost for personal car adaptation expenses. It also provides the basis for the installation of a special network for the adaptation of telephones and TV-sets by the Telecommunication Board. (Torbidoni, Fratello & Taddei 1992).
According to the new Framework Law regions must establish their own implementing laws and regulations. It will be important to see what effects this reform has on the demand for services and assistive devices as well as the effects which different implementation mechanisms in the various regions will have on the development of services.
Legge-quadro per l'assistenza, l'integratione sociale ei diritti delle persone handicappate. Legge 5 febbraio 1992, n. 104.
Disciplina delle cooperative sociali. Legge 1 novembre 1991, n. 381.
Norme integrative in materia di assistenza economica agli invalidi civili, ai ciechi civili ed ai sordomuti. Legge 21 novembre 1988, n. 508.
Legge disciplina generale delle assunzioni obbligatorie presso le pubbliche amministrazioni e le aziende private. Legge 2 aprile 1968, n. 482.
Andrich, R. (1990). The provision of technical aids in Italy: present situation and new models. In : The second workshop on rehabilitation engineering. REHAB-II, Fagernes, Norway, May 12-15, 1991. United Nations Economic Commission for Europe in cooperation with the International Federation for Medical and Biological Engineering.
Committee on the rehabilitation and integration of people with disabilities (1990). Legislation on the rehabilitation of disabled people in sixteen member states of the Council of Europe (1990). 4th edition. Strasbourg : Council of Europe.
Employment Observatory MISEP (1992). Policies 39. Commission of the European Communities.
König, A. & Schalock, R.L.(1991). Supported employment: Equal opportunities for severely disabled men and women. International labour review. Volume 130, Number 1. 1991/1.
Ministero dell'interno direzione generale dei servizi civili (1991). Providenze Legislative a Favore dei Mutilati ed Invalidi Civili, Ciechi Civilie Sordomuti.
Mutual Information System on Employment policies (MISEP)(1992). Basic Information Report Italy. Commission of the European Communities.
Observatory on national policies to combat social exclusion (1992). Second annual report. Commission of the European Communities.
Torbidoni, L., Fratello, F. & Taddei, S. (1992). The Italian Framework for the Provision of Technical Aids. Third UN/ECE Workshop on Rehabilitation Engineering REHAB-3. Trebon (Czechoslovakia), 24-27 May 1992.
Care systems for disabled and elderly people in the Netherlands developed mainly from the work of pluralistic religious bodies and local authorities, which provided help to the poor before the introduction of the Dutch Welfare State not long after the last War.
The Dutch system places broad responsibility for welfare on the State with the right to provision determined mainly by the individual's work and insurance records. However people who are disabled from birth or in childhood, are entitled to services, including an income from the state.
A complex system of public, private and voluntary bodies provide pensions, equipment and services. A key principle is that the technical aids and equipment necessary for the individual to live as full a life as possible should be made available to people below retirement age. At present, no upper financial limits are set on the cost of providing rehabilitation technology for people under the age of 65.
The rising cost of services, plus the exclusion of the elderly from provision of equipment, has led to a new and controversial proposal to extend cover to retired people but within the same budget as before. The new system is expected to be implemented in April 1994.
Legal and administrative framework
Article I, paragraph 1 of the Dutch Constitution guarantees equal treatment for all people living in the Netherlands. The Constitution prohibits discrimination on grounds of religion, belief, political opinion, race or sex, but does not specifically mention disability. Anti-discrimination legislation, which took effect in 1993, also covers religion, gender, age and race but not disability. However, local authorities were asked to guard against discrimination when setting up small-scale living accommodation for people with learning difficulties in a 1985 Circular from the Ministry of Housing, Planning and Environment.
Official policy in the Netherlands starts from the idea that people with disabilities are part of the community and aims "to ensure that the disabled can take as active a part as possible in all contexts and in every sphere of life, according to their age and in relation to their social and cultural setting, and can achieve full development within their potential."
This policy means that people with disabilities receive help under general legislation, supplemented by specific laws aimed at meeting their extra needs for facilities and technical aids. Most of their support is provided under health legislation, with the Ministry of Welfare, Health and Cultural Affairs coordinating policy. It is the lead ministry in the Interministerial Steering Group on Policy for the Disabled (ISG), established in 1968 as an advisory body to Government. Membership of the ISG includes representatives from the Ministries of Social Affairs and Employment; of Transport, Public Works and Water Management; Housing, Planning and Environment; Education and Science, with the Ministry of Finance represented by an observer.
In addition to general legislation, people with disabilities receive services and equipment under two key Acts - the Exceptional Medical Expenses Act 1967 (AWBZ), which covers all age groups, and the General Disability Benefits Act 1976 (AAW) which covers people below retirement age.
The basic principle is that people with disabilities can be loaned any equipment that is available in the Netherlands provided it is the cheapest, adequate solution to their need. More expensive equipment, for example wheelchairs of more modern design, may be provided if the individual disabled person can persuade his or her adviser that there are good reasons for it. However, legal entitlement depends on age, insurance records and income. While central Government determines the law, private non-profit making organisations are responsible for providing services.2
Because a variety of organisations provide aids and equipment to people with disabilities, it is not always clear where they should go for information. For example, the General Disability Benefits Act is implemented by industrial insurance boards who are advised by the Joint Medical Service (GMD).3 For many people, the first contact is likely to be with their doctor.
Legislation related to rehabilitation technology
Aids and equipment for daily living are provided to people of working age, including students and housewives, under the General Disability Benefits Act (AAW). Facilities provided under this Act are not limited, but the supply of equipment is sometimes subject to a means test. Article 57.1 of the Act refers specifically to provisions that will maintain, restore or facilitate the individual disabled person's capacity to work. Article 57.2 refers to provisions to improve daily living, including transport inside and outside the home; communications equipment; household equipment, leisure and education facilities. Wheelchairs for people under the age of 65 are generally provided under this Act.
Other technical aids, including prostheses, hearing aids and walking aids can be provided under the Exceptional Medical Expenses Act (AWBZ), which has become the main source of help for elderly people excluded from help under the AAW. The kinds of technical aids that can be provided under this Act are limited, and there is a defined budget governing supply. Much of the equipment supplied under this Act is provided by health insurers, but home care organisations supply technical aids, too.
People over the age of 65 may also claim essential facilities, including wheelchairs and communication aids, under the National Assistance Act 1963. A means test is applied.
The Interim Act on Special Education and Secondary Special Education 1985 (ISOVSO) provides for a 10-year programme in which the 15 different types of schools providing special education are being comprehensively reviewed and redeveloped. During the period the Interim Act is in force, facilities are being developed for cooperation between schools giving secondary special education and colleges for elementary vocational training. The eventual aim is to integrate most disabled children into ordinary schools. This involves creating regional units each responsible for the education of approximately 2,000 students. Each unit would include several ordinary schools and a school for children with varying degrees of learning disabilities. This transitional phase will be followed by a permanent new law to be introduced later in the 1990s.
Children attending special schools have their transport costs met directly by the Ministry of Education, under a scheme administered by local authorities. Transport costs for children attending mainstream schools are paid for under the AAW.
Working life and vocational rehabilitation
Special vocational training and adaptations of the workplace are provided under the General Disablement Benefits Act (AAW). The State meets the cost of workplace adaptations. Any item that is not part of "normal" household equipment and which is specifically required because of an individual's handicap and which cannot be obtained under other statutory schemes may be provided under this Act.
Local authorities are required under the Sheltered Employment Act, 1969, to create and maintain suitable sheltered employment for all people with disabilities who need it. The costs are met by central Government, which pays 100 per cent of the wage costs and 80 per cent of other subsidies due under the Financial Proportions Act, 19604. The Act covers the costs of specially adapted transport to and from work, of workplace modifications and of special technical aids necessary for the performance of the work. These steps can include reserving specific jobs for people with disabilities, setting up joint training centres to help them find work, and redefining jobs.
The Handicapped Workers Employment Act 1986 placed an obligation on employers, employers' organisations and workers' organisation to take steps to facilitate the employment of people with disabilities.
The Act applies to both public and private sectors. It introduced a 5 per cent quota on firms which employers were expected to achieve within three years. A flexible quota of between 3 and 7 per cent, which could be imposed on employers who failed to meet the earlier target, was introduced under the Act in 1989. This legislation did not succeed in enforcing employers to meet the quota. Employers subject to the quota who fail to meet their obligation have to pay a levy into the General Disability Fund, from which employers who exceed their quota can claim compensation.
People with physical or mental disabilities in the Netherlands are more likely than other people to rely on social security for their incomes, but their benefits depend mainly on their work record, previous income and degree of disability.
The Sickness Benefits Act 1964 (ZW) insures employed people under the age of 65 against loss of wages due to sickness or infirmity for a maximum of a year. The Disability Insurance Act 1967 (WAO) entitles them to benefits if they are still unfit for work after 52 weeks of disability. The amount depends on the degree of incapacity for work and the last-earned wage. Reductions to entitlement under the Disablement Insurance Act will be made under the new law.
The General Disablement Benefits Act (AAW) provides benefits for people aged 18 to 65 who are disabled and do not qualify under work related schemes. For people not covered by these Acts, a basic income can be provided under the National Assistance Act. A state retirement pension is payable to every Dutch national at age 65 under the General Old Age Pensions Act.
Health care and social services in the Netherlands are provided by non-profit institutions or agencies which originated through private initiatives rooted in Christian, Socialist and Liberal movements. The State is responsible for ensuring the availability and quality of services.
Employees and others insured under the Health Insurance Act, 1966 are entitled to drugs, treatment and nursing in a hospital, rehabilitation centre or other medical institution for a period of up to 52 weeks. Their cover also includes physiotherapy; speech and hearing therapy; prosthetics; doctor and ambulance services, ophthalmologists, dentists and other specialists.
Where longer periods of treatment are necessary, the Exceptional Medical Expenses Act (AWBZ) covers all residents, irrespective of age or status. The Act provides for treatment in hospitals, rehabilitation centres, psychiatric hospitals and hostels for people with disabilities and for elderly people not covered by other Acts.
Previous policy has led to large numbers of disabled and elderly people being housed in long stay institutions, and has now changed to aim at keeping them in their own homes for as long as possible. Equipment is available to help them do so under the various health and disability Acts, but elderly people in general have to pay for their own technical aids, including alarm systems. They may also receive home help services under the Exceptional Medical Expenses Act, for which they pay progressive contributions after a means test.
An Order introduced in 1978 under the General Disablement Benefits Act (AAW) provided for insured people needing home help for more than three months to be compensated for the cost of private help.
Under the General Disability Benefits Act (AAW), grants can be made to adapt cars for disabled drivers. People unable to drive can be granted other help with their transport costs, including allowances for taxi fares or car loans, particularly in connection with helping a disabled person to travel to work. The National Assistance Act also provides a transport allowance for retired people. The Health Insurance Act provides for the refund of travel costs, including taxis and public transport, in connection with medical treatment.
The Sheltered Employment Act provides for transport costs for workers in sheltered workshops. The Exceptional Medical Expenses Act (AWBZ) covers transport costs for day treatment in nursing homes, and to day care centres for children and adults.
Disabled drivers and passengers are exempt from parking restrictions under Article 83a of the Road Traffic Act, 1983 supplemented by various subsequent decrees. Those unable to walk more than 100 metres are entitled to an invalid's parking card. People escorting people with disabilities can travel free of charge on all public transport.
There is no legislation covering public transport for people with disabilities but the Ministry of Transport has sent guidelines to all local authorities on traffic and road provisions for people with disabilities.
However, several access experiments are being conducted in 1993. They include a pilot scheme funded by the Ministry of Transportation and Civil Works in the city of Nieuwegein. This scheme will involve 11 low floor buses with kneeling mechanisms and a ramp operated by the driver to allow wheelchair access. The buses will be equipped with sight and sound information systems. Nieuwegein has a wheelchair accessible light rail line connecting it with the main railway station in Utrecht.
A train equipped with a lift for wheelchair users is expected to go into service in November 1993 in a one-year pilot to be evaluated for possible extension to all trains. However, toilets on the first train are not accessible to larger wheelchairs. Also in 1993, the TreinTaxi service which links railway stations in 80 cities, is to be expanded to include an accessible minivan for disabled passengers.
Housing and environment
The costs of converting a house for a disabled person, plus removal expenses, up to a defined limit can be met under the 1978 Decree on Financial Aid for Housing for the Disabled now renamed Regulation on Financial Aid for Housing for the Disabled. The decree also covers adaptations to the existing home of a disabled person, with grants on a sliding scale relating to cost and income, administered by local authorities. The individual disabled person is expected to meet a quarter of the costs.
About seven per cent of all housing in the Netherlands has been adapted for people with disabilities. Because of the rising costs of adaptations, Dutch policy has changed to require a greater contribution from the disabled individual, and now exhorts builders to ensure that new housing carries features that will avoid expensive conversions at a later stage.
Local authorities are required under article 3 of the Housing Act 1962 to issue model building regulations on access to new buildings for people with disabilities and wheel chair users. The regulations, which are expected to cover private housing as well as public buildings, work like statutory regulations although they are not binding in law. Article 4 of the same Act makes similar provisions about existing buildings.
The open ended system of providing technical aids and equipment which at present operates in the Netherlands has led to dramatic increases in expenditure in recent years, while sources of help with disability are complicated and unclear. This has led to the new Services for Disabled Persons Act, now being debated in the Dutch parliament. Because of its controversial nature, passage of the Act has been delayed and it is now expected to take effect on April 1, 1994.
The new Act will devolve responsibility to local councils and insurers, who will be given cash limited budgets equal to the amount spent on providing equipment and services under the existing system. However, the new Act will cover people over the age of 65 who have no right to help with technical aids and equipment under the AAW but may be able to get some help through the National Assistance Act. Their inclusion under the new Act is expected to double the numbers covered and local councils will have discretion about who they will help. These factors have given rise to concern that the new system will mean that the provision of equipment is rationed as budgets run out and that richer councils will supply more expensive wheelchairs than others.
The new Act will simplify a system that is acknowledged to be unnecessarily complicated, but there will still be three parallel systems in place. Transportation and accommodation is to be transferred from central government responsibility under the General Disability Benefits Act to local councils. Some technical aids to daily living will continue to be available from the State under the Exceptional Medical Expenses Act. Facilities connected with helping people with disabilities at work will remain under the General Disability Benefits Act.
1 Council of Europe (1988). Legislation on the rehabilitation of disabled people in thirteen member states of the Council of Europe. Page 17, Strasbourg : Council of Europe Publications and Documents Division.
2 Ministry of Welfare, Health and Cultural Affairs (1992). Policy on Disabled People - Fact Sheet W-Z-E. Netherlands.
3 Rietdijk, S. Paper on research on technical aids in the Netherlands.
4 See footnote 1.
5 Ministry of Social Affairs and Employment. Working with a Handicap. (Information Leaflet), The Hague.
Sickness Benefits Act 1964.
National Assistance Act, 1963. Implemented in 1965.
Health Insurance Act, 1966.
Exceptional Medical Expenses Act, 1967. Implemented in 1968.
Disability Insurance Act, 1967.
Sheltered Employment Act 1969
General Disability Benefits Act, 1976.
Decree on Financial Aid for Housing for the Disabled, 1978.
Road Traffic Act, 1983.
Interim Act Special Education and Secondary Education, 1985.
Handicapped Workers Employment Act, 1986.
Services for Disabled Persons Act (yet to be passed).
Source: (for part) Social Security in the Netherlands, (1990) Ministry of Social Affairs and Employment, Kluwer Law and Taxation Publishers
Commission of the European Communities (1993). 1993 European Year of Older People and Solidarity between Generations. Social Europe. Luxembourg : Commission of the European Communities.
Council of Europe (1988). Legislation on the rehabilitation of disabled people in thirteen member states of the Council of Europe. Strasbourg : Council of Europe Publications and Documents Division.
van Gelder, C. P. and Gorfen, K. A. (1993). Atlas of the Social Position of Disabled People. Netherlands Institute of Social Research.
WHO (1990). Is the law fair to the disabled? European Series No 29. Copenhagen : WHO Regional Publications.
Legal and administrative framework
An important principle of the welfare state is equality of opportunity, rights and obligations. Welfare state ideals were an important reason why people with disabilities came to be regarded as normal members of society, and why the idea of integration took hold. (Plan of action.)
People with disabilities have the same needs as others. In addition many need practical assistance, personal support, adjustment of their physical environments, and/or technical aids with which to manage everyday tasks. The need for various kinds of assistance is determined by the nature and degree of the disability and by the design of their surroundings. (Plan of action.)
The general policy in Norway is to ensure normalization of everyday life, and organisational and social integration of people with disabilities. This means that the normal service agencies in society retain full responsibility for all people with disabilities. (Lorentsen 1990.) In Report no. 88 (1966-67) to the Norwegian Parliament (Storting) it is stated that in this new way of thinking, an important principle is normalisation, which means not drawing unnecessary dividing lines between people with disabilities and others with regard to medical or social treatment, upbringing, education, employment or welfare. In Report no. 23 (1977-78) to the Parliament the concept of organisational and social integration was established. It means that:
- society's normal service agencies retain full responsibility for all people with disabilities, with each agency building up the necessary specialised measures.
- each disabled person can live the life he or she would have lived without his or her disability, i.e. live, work and reside in his natural environment, side by side with other people. (Plan of action.)
The ministries which are responsible for administering policies related to rehabilitation are: the Ministry of Education, Research and Church Affairs; the Ministry of Labour and Administration; the Ministry of Social Affairs, under which there are the National Board of Health, the National Insurance Administration, the Social Security Offices (local and regional); the Ministry of Child and Family Affairs.
The Norwegian Council for Technical Aids, Health and Social Affairs was established in 1975 with a secretariat placed at the Department of Biomedical Engineering at the Centre for Industrial Research. (Lorentsen 1990.)
Social benefits by way of cash benefits in the event of unemployment, ill health and maternity, invalidity, old age and loss of guardian are mainly regulated by the National Insurance Act. Social security measures are almost all administered by the National Insurance Administration and the local and regional social security branches, all under the auspices of the State. Benefits in the event of unemployment as well as employers' schemes are likewise administered by the Directorate of Labour under the Ministry of Labour and Administration as well as local and regional labour offices, also under the auspices of the State. (Social security 1993.)
The county authorities, of which there are 19, are responsible for general and psychiatric hospitals as well as special health care services outside institutions. The statutory basis is first and foremost the Hospitals Act 1969 and the Act on Mental Care 1961. (Social security 1993.)
The 454 municipalities are responsible for the general health and social services outside institutions as well as for social cash assistance. The statutory basis is first and foremost the Act on Municipal Health Services 1982, and the 1992 Acts on Social Services and Social Assistance, Protection of Children and Young Persons and Measures for the Prevention of Alcoholism. In Norway it is the regional authorities which run the hospitals. In addition to the treatment offered by the general hospitals and specialist hospitals, the hospitals also offer clinical psychological treatment, laboratory services, etc. Furthermore, special nursing homes and special housing for people with disabilities form part of the hospital sector. (Social security 1993.)
Block grants from the State are given to the health and social sectors in the counties and municipalities. These grants are not for specific services. In addition, the municipalities receive State subsidies in the form of refunds of charges for treatment in out-patient clinics, repayment of the county authorities' approved expenses and repayment of treatment by specialists as well as psychological assistance and dental treatment. Furthermore reimbursements are given towards trips abroad for treatment purposes, treatment abroad and partial payment of treatment in certain health institutes. The purpose of the block grant is first and foremost to decentralize the decision-making process so that financial responsibility lies with the relevant administration. (Social security 1993.)
As in other Nordic countries, Norway also has non-governmental organisations for people with disabilities which are involved in the implementation of services for people with disabilities.
Legislation related to rehabilitation technology
According to the Act Concerning Primary and Lower Secondary Education 1992, all pupils are entitled to instruction according to their abilities and qualifications. The integration of disabled children into the state schools has developed successfully, and may in many respects serve as an example to other sectors. According to the Act Concerning Upper Secondary School, applicants for places in upper secondary schools in the 16 to 20 age group have priority if, in the judgement of experts, they are in exceptional need of special instruction. This marks an important extension to the principle of integration which has been practised in the basic school for a long time. (Plan of action) However, in Norway there are special schools for the deaf and blind, special schools for disabled and for children who are slightly retarded as well as for children with reading and writing difficulties. There are schools for children with speech impairments, special schools for children suffering from cerebral palsy, and special schools for epileptic children. Disabled children of pre-school age are given priority as regards places in kindergartens. Almost all disabled children, children with sight or hearing impairments, attend municipal day care institutions. They are integrated with children without an impairment, either individually or in groups. Approximately 75 % of the mentally retarded are integrated into ordinary institutions. In addition, there are special schools for the blind, those with visual impairments, persons with reduced hearing or for the deaf, those who are mentally retarded or have emotional disturbances, and there are special schools for people with speech impairments. (Social security 1993).
Working life and vocational rehabilitation
In Norway many different cash benefits may be paid in the event of unemployment. They may include: wage subsidies to employers who recruit unemployed people, support in connection with unemployed persons' participation in vocational rehabilitation courses, subsidies to wage costs and operational costs in connection with in-house training at companies, special subsidies in connection with apprenticeships/training places, wage costs in connection with the scheme "work for social assistance" and reimbursement of wage costs in connection with extra apprentices in the State sector. (Social security 1993.)
In Norway the State grants a wage subsidy to enterprises which initiate vocational rehabilitation measures for their own employees. Furthermore, the municipal and State authorities cooperate in connection with measures for young people with disabilities and grant wage subsidies for job training. Furthermore, wage subsidies may be granted to groups with more serious behaviourial problems. Wage subsidies may also be granted to special labour market enterprises engaged in vocational rehabilitation. A special integration subsidy of NOK 17.000 (ECU 2.054) per year may be granted in connection with the establishment of permanent job offers to mentally retarded persons and other groups with special problems. (Social security 1993.)
A special enterprise grant of a maximum amount of NOK 200.000 (ECU 24.163) may be given to people who want to set up their own business. The unemployed are a priority group in connection with the award of this grant (Social security 1993).
Mobility promoting measures are granted with a view to reducing the travel costs for the purpose of obtaining a new job and support for moving to a new place
(Social security 1993).
The public employment service may assist with external guidance, and if it is considered appropriate, a work suitability test and/or psychological assistance may be offered. Reference may be made to the rehabilitation authorities which will examine the unemployed person's basis for undertaking different training/ rehabilitation programmes. The public employment service may also grant special support or refer to appropriate specialised organisations those people with disabilities who are not able to find employment on the open labour market. (Social security 1993.)
Labour market courses cover a broad range of labour market needs. Training in fields with the greatest need for manpower is given the highest priority. The training takes place partly under the auspices of the Labour Market Authority and partly it is bought from private and public organizers of training. (Social security 1993.)
A number of work introduction measures are given within the framework of sheltered employment which offer job training and training with a view to choosing an occupation and employment on the ordinary labour market. During the first half of 1991 about 4500 persons participated in such measures, and about 4150 persons in other measures. (Social security 1993.)
In Norway - as in other Nordic countries - there are three types of pension:
1) A statutory basic pension.
2) A statutory supplementary pension.
3) Additional pensions either statutory or agreed between employer and employee. In Norway all pensions are subject to taxation. In addition, the pensioners also have other advantages in connection with taxation (Social security 1993.)
In Norway all old age pensioners are entitled to both the basic and the supplementary pension under the National Insurance scheme from the age of 67. Until the age of 67 the pension level is fixed on the basis of previous and present income. After the age of 70 old age pension is payable to everyone without a means-test. The old age pension is payable under the National Insurance scheme and consists of a basic pension, a supplementary pension and possibly other supplementary allowances due. (Social security 1993.)
In Norway invalidity pensions are granted in the form of a basic pension and a supplementary allowance. The rules for entitlement to supplementary pension are the same as those applying to the basic pension. It is normal to defray a disability benefit before early retirement/invalidity pension is payable. Persons aged 16-66 are entitled to early retirement pension (invalidity pension) if their working capacity is permanently reduced by at least 50 % owing to ill health, injury or if the person is disabled. Early retirement pension consists of a basic pension, supplementary pension, minimum supplementary allowance (special allowance) and maintenance allowance for spouse and children. The pension is by and large organized in the same way as the old age pension scheme. Persons who are born disabled or who have lost at least 50% of their working capacity before the age of 21 are guaranteed a supplementary pension which is higher than the minimum pension level. Those who face expenses on account of permanent ill health injury or handicap also qualify for a basic allowance and/or an extra cash benefit. The basic benefit and/or the extra cash benefit are payable irrespective of whether the individual is receiving a pension or not. The same supplementary allowances are payable to invalidity pensioners under the National Insurance scheme as to old age pensioners. (Social security 1993.)
A pension in the event of industrial injury is payable under the Act on National Insurance 1966. In the event of industrial injuries the pension is calculated on the basis of more favourable rules than those for invalidity pensions. (Social security 1993.)
In Norway a war pension is payable to both military and civilians who sustained an accident in connection with war accidents in Norway, on a ship flying the Norwegian flag, or in enemy or political captivity. (Social security 1993.)
The National Insurance Scheme provides for special benefits to disabled and mentally disabled persons. Extra holidays may be given to elderly employed persons. The National Insurance Scheme also provides for financial support to cover the additional expenses incurred as a consequence of disability. The National Insurance Scheme also covers expenses on technical aids, etc. (Social security 1993.)
Norway has no general law to protect the rights of people with disabilities. The various provisions concerning people with disabilities are contained in many different Acts. In Norway aid for people with disabilities is given according to the National Insurance Act. § 5.3 concerns aid for working life and § 5.8 concerns aids for promoting general functioning level. In Norway many municipalities integrate the provision of a home help and home nursing into a common service. There is no special legislation on measures for people with disabilities. Social and health responsibilities vis-à-vis people with disabilities are defined in the Act on Social Services 1992. (Nilsson 1992; Social security 1993.)
National Insurance legislation provides for:
- Financial support towards technical aids and the like which are necessary to facilitate general functions.
- Basic benefits to those who because of long-term illness, injury or impairments incur significant additional expenses, for instance for transport, extra wear and tear of clothes, or the like.
- Supplementary benefits to those who because of long-term illness, injury, or impairments need special care or help at home. (Plan of action.)
The Norwegian old people's homes are considered as social institutions. As from 1988 the responsibility for homes for those in need of care has been transferred from the county authorities to the municipal authorities. In most municipalities homes for the ill are thus administered together with old people's homes, other service flats, home help and home nursing scheme, as common care and nursing services. (Social security 1993.)
People with disabilities receive basic training and vocational training in the ordinary school system. As a supplement there are sheltered workshops by way of workplaces with special vocational training for people with disabilities. These schemes are financed or subsidized by central government. The National Insurance scheme gives financial assistance towards the additional charges resulting from disability, covers expenses on technical aids and provides help towards the purchase of a special vehicle for people with disabilities. (Social security 1993.)
Sickness benefits under the statutory schemes in Norway, in principle, cover the whole population. Sickness benefits are administered by the national insurance offices. The benefits are subject to tax. The employers pay sickness benefits during the first two weeks of illness. After that period, sickness benefits are paid by the social insurance system for up to 50 weeks. The self-employed will also receive sickness benefits from this system after two weeks of illness. There is no waiting period. Self-employed persons may take out supplementary insurance within the national insurance system covering the first two weeks of illness. Furthermore, cash benefits are paid in connection with medical and vocational rehabilitation. The rehabilitation benefit is paid for medical treatment exceeding 50 weeks (the sickness benefit period) irrespective of whether sickness benefits have been paid or not. There is no limit for payment of the rehabilitation benefit. Furthermore, the benefit is paid for vocational rehabilitation in an institution, school, training course, taking-up of a new job, moving to another place, etc. and also during the waiting period until the rehabilitation can be introduced and invalidity pension granted. Furthermore, a supplement is granted for the acquisition of technical equipment which may improve their functional abilities. (Social security 1993.)
Cash benefits are paid in connection with industrial injuries and work-related illness by the general illness and National Insurance scheme. In certain cases the National Insurance Scheme pays out higher benefits due to less strict conditions in connection with industrial injuries than with other accidents. In the case of invalidity or death as a result of an industrial injury, the benefits are, as a rule, paid in accordance with rules which correspond to invalidity pension and survivors' pension. (Social security 1993.)
Unemployment insurance is compulsory in Norway. The membership contributions to the National Social Insurance also cover unemployment insurance. (Social security 1993.)
In Norway general medical treatment is provided both by health care centres run by municipal authorities and by private general practitioners. In addition to general medical services the centres are also in charge of nursing ill patients and health and home care and - to varying extents - also of school health services and physiotherapy. Preventive measures are also undertaken by the primary health care sector. Some of the private clinics are run by private organisations, but the main rule is that they are subject to public planning and financing. The regional authorities are responsible for specialist medical services, services offered by clinical psychologists, X-ray clinics and laboratories outside the hospitals. (Social security 1993.)
Technical Aids Centres (TAC) have been established in 13 out of the 19 counties. The goal is that all 19 counties shall have such centres by 1995. The two main roles of the TACs are to ensure a professional provision process, and to maximize the use of technical aids. A professional provision process can only be achieved through proper knowledge and by establishing a collaboration network across departments and service agencies. The TAC is an autonomous institution, providing specialized services to institutions, local professionals and the end-users. The main task is to take care of the difficult cases, while the simpler ones should be taken care of locally. In the field of mobility this is possible since locally there is generally some knowledge about technical aids for those with mobility problems. In the fields of hearing, sight, speech and cognitive impairments, the local knowledge of technical aids is poor. This is due to the fact that the municipalities lack professionals with proper knowledge in the field, i.e. special teachers, opticians, engineers etc. Also most of the municipalities lack occupational therapists. Medical doctors, nurses, social workers do not receive education in this area. The TAC purchases products directly from the dealers, and they keep the most common aids in stock, according to agreements with the National Insurance Administration. In addition to providing technical aids, the TACs are asked to take the leading role in connection with adaptation of cars for people with disabilities. They are also becoming more and more involved in the planning of adaptation of homes/buildings to meet the needs of different users. The national authorities finance 75% of the running costs, while the county finances the remaining 25%. The national authorities finance 100% of the administrative computer system. (Lorentsen 1990.)
The National Insurance System finances 100% of the cost of technical aids to individual users:
- if the handicap is long-lasting,
- if it can be verified that a technical aid is necessary to improve function and/or break social isolation.
The National Insurance System thus finances technical aids to be used in daily life. Also, the National Insurance System finances aids/expenses in connection with adaptation of workplaces. In these instances, the National Insurance System may finance 100% of the cost, but may also only finance part of the cost depending upon the situation and the role of the employer. However, of the total expenses in 1989 only 1.7% of the total expenditure was used for adaptation of workplaces. The National Insurance System does not in general finance technical aids for sports activities. Municipalities are responsible for financing technical aids for short term use, for pupils with disabilities in primary schools, and for cultural activities. The county is responsible for financing technical aids for students in secondary school/high school. The National Insurance System has regulated the role of the TACs concerning provision and purchasing procedures. It has, thus, issued certain general rules for purchasing, and specific rules for those technical aids which have to be tested. (Lorentsen 1990.)
Provision of prosthetic devices and hearing aids is not included in the system for providing technical aids to individual users. Prosthetic devices are provided by specialized shops, all of which are private except for one. Prostheses and orthoses are provided free of charge for the individual user. The cost is regulated through price regulations between the National Insurance Administration and the shops. Hearing aids are provided by the Ear, Nose and Throat wards of regional and county hospitals. These aids are also financed by the National Insurance System. (Lorentsen 1990.)
Provision of technical aids to individual users should, as far as possible, be done with due regard to the environment of the user. The reason for this is that:
- Technical aids are meant to solve problems in this environment.
- They should fit with this environment.
- The use is dependent upon local attitudes.
- The use is dependent on local follow-up. (Lorentsen 1990.)
In Norway there are central treatment institutions for the mentally retarded. The big institutions for the treatment of persons with mental handicaps were being discontinued from 1990. As of 1 January 1991 the municipal authorities took over the responsibility for these from the county authorities. In terms of other institutions which exist in Norway there are day places in approved schools or day care institutions, private care or family care and sheltered housing and accommodation with a certain degree of supervision and help. (Social security 1993.)
In Norway social assistance is granted in accordance with a new Act on Social Services which entered into force in 1993 and which superseded the previous Act passed in 1964. The purposes of the Act are according to § 1-1:
- to promote economic and social security, to make the living conditions better for the socially deprived, to promote the growth of equality and to solve social problems.
- To promote the principle that an individual shall have the opportunity to live independently and to lead a meaningful life among other individuals.
According to § 3-1 subsection 3, social administration shall promote welfare and activity possibilities for children, elderly people and people with disabilities and others who have similar needs.
The municipalities are responsible for providing important services like health services, home help, personal support, respite care, constant attendance, etc. according to the Act on Social Services 1992 and the Act on Municipal Health Services 1982. Support measures and leisure time activities:
- telephone links
- visiting friends
- physio- and occupational therapy
- hair dressers and pedicure
- snow clearing
- laundry and repair services.
Home help is granted to old people and people with disabilities and it is provided by the municipal authorities and is carried out by municipal authority home helps. (Plan of action; Social security 1993.)
In Report No 23 (1977-78) to the Parliament it is stated that a person is disabled, if, owing to a permanent illness, injury or impairment or because of social problems such as drug abuse, is significantly restricted in the practical conduct of his life compared to the society around him. This may apply for instance to education and work and to physical or cultural activity. There are two important aspects to this definition:
- Disability is viewed in relation to its social context.
- Disability is of a permanent nature.
Earlier terms which have now been abandoned include crippled and invalid. The most frequently used term today is disabled, or in some cases handicapped. The National Insurance Act defines the term disability as: A state of long-lasting and serious reduction of the ability to function, owing to illness, injury or congenital deformity. (Plan of action.)
A frequently used definition of disability emphasises that disability relates among other things to the environment: A disability is a discrepancy between the capabilities of the individual and the functions demanded of him by society in areas which are essential to the establishment of independence and a social life. (Plan of action.)
Almost all municipal authorities have established special transport facilities for people with disabilities. It is often up to the social welfare departments to decide whether a person qualifies for special transport. Depending on the municipality in which a person resides, an amount is due to be paid which is equal to the amount payable for the use of public means of transport. The county authorities receive a subsidy from the central government to finance the service. The municipalities make an agreement with the county authorities on the extent and type of transport. In addition to the county's financial support, the municipal authorities may also themselves contribute financially. The scheme is voluntary without statutory basis. (Social security 1993.)
Access to public transport and better door-to-door transportation facilities will give people with disabilities better opportunities to participate actively in society. For example, bus stops with raised platforms and "wheelchair ramps" resulted in an increase in the numbers of passengers in the municipality of Nesodden, including many elderly and people with disabilities who had previously been prevented from using public transport. With effect from 1 January 1988 municipalities have been responsible for transport services for people with disabilities. (Plan of action.)
Norwegian Telecom is responsible for the provision and operation of visual telephones for persons with impaired hearing or speech. When the Parliament was dealing with Proposition no. 92 (1986-87) it was stated that Norwegian Telecom's monopoly service should be instructed to provide equipment for clients with special needs owing to disability. One member of Norwegian Telecom's research staff is employed full time on developing measures on behalf of people with disabilities. (Plan of action.)
In order to achieve full participation and equality for people with disabilities, special emphasis will be given to the following areas:
- The development of a non-disabling society.
- Ensuring treatment of illness or injury.
- The prevention of injuries and illnesses which cause disability.
- Participation in decision-making/user participation. (Plan of action.)
In Target 3 of the WHO programme Health for All in Norway by the year 2000 it is stated that by the year 2000, people with disabilities shall have the physical, social and economic opportunities to allow them to live socially and economically satisfactory lives. (Plan of action.)
Report No 23 (1977-78) to the Parliament stated that certain practical measures currently implemented by voluntary organisations ought to be transferred to the statutory authorities. In principle, the organisations of the disabled should operate as pressure groups in the realm of social policy and receive grants for such work. (Plan of action.)
1953 17 July Nr. 14 The Act on the Protection of Children and Young Persons (Lov om barnevern). Entered into force on 1 July 1954.
1961 28 April Nr. 2 The Act on Mental Care (Lov om psykisk helsevern). Entered into force on 1 July 1961.
1966 19 June Nr. 12 The National Insurance Act (Lov om folketrygd; several amendments). Entered into force on 1 January 1967.
1969 13 June Nr. 24 The Act Concerning Primary and Lower Secondary Education (Lov om grunnskolen). Entered into force on 1 July 1971.
1969 19 June Nr. 57 The Hospitals Act (Lov om sykehus m.v.). Entered into force on 1 January 1970.
1974 21 June Nr. 55 The Act Concerning Upper Secondary School (Lov om vidergående opplaering). Entered into force on 1 January 1976.
1982 19 November Nr. 66 The Act on Municipal Health Services (Lov om helsetjenesten i kommunene). Entered into force on 1 January 1984.
1982 19 November Nr. 68 The Act on the Planning of the Social and Health Care in the Municipalities (Lov om planleggning av og forsoksvirksomhet i sosialtjenesten og helsetjenesten i kommunene). Entered into force on 1 January 1984.
1989 2 June Nr. 27 The Act on Measures for the Prevention of Alcoholism (Lov om omsetning av alkoholholdig drink m.v.). Entered into force on 1 January 1990.
1991 13 December Nr. 81 The Act on Social Services (Lov om sosiale tjenester
m.v.). Entered into force on 1 January 1992.
The Government's plan of action for the disabled 1990-1993. Norway
Lorentsen, O. (1990). Provision of technical aids and other rehabilitation engineering services in Norway. Proceedings, First workshop on rehabilitation engineering: REHAB-1, Washington D.c. 14-16 June 1990. United Nations Economic Commission for Europe.
Nilsson, B. (1992). Rapport från Norge. Nordisk konferens om handikapplagstiftning Stockholm, 30-31 januari 1992. Nordiska nämnden för handikappfrågor NNH 4/92.
The Nordic Social-Statistical Committee (1993). Social Security in the Nordic Countries : Scope, expenditure and financing 1990. Statistical reports of the Nordic Countries 59. Copenhagen : NOSOSCO.
Legal and administrative framework
The need in Sweden for government-sponsored social welfare policies grew with the full emergence of industrialisation towards the end of the nineteenth century. It may be said that the history of Swedish social welfare began at the start of the 1880s with industrial and social reforms aimed at improving conditions for working people. Two early examples are the Industrial Safety Act of 1889 and an act in 1913 establishing a national pension scheme. The 1930s saw the dawn of a second era with higher social security benefits and housing assistance for families with children. However, it was not until the end of the second world war and the introduction of a national Social Insurance Scheme that the social welfare system began to assume its present-day character. (The social services 1992.)
Throughout the present century the aim in Sweden - as in the other Nordic countries - has been to build up a welfare state with a maximum of equality between different groups of the population. A system of social security has been created to this end. The Swedish welfare model makes provision for allowances for young families, people in low income brackets (housing benefits), the sick and injured, pensioners and the disabled, among others. In addition childminding services, education at all levels, social support and assistance and health and medical care are, as far as possible, offered on equal terms to all members of the society at very little, if any, cost to the individual. The corner-stones of present-day social welfare policy are:
- national social insurance,
- family welfare,
- social services, and
- health and medical care. (The social services 1992.)
Swedish social welfare policy may be defined as measures taken by central and local government to secure an acceptable living standard for everyone in society and progressively reduce inequalities in living conditions not only associated with different social classes or groups but also with the different periods and changing circumstances of a normal lifetime. Thus social welfare policy is not just directed towards the less affluent sections of society but to society as a whole. (The social services 1992.)
Sweden has a strong central government to administer its law, as well as an extensive system of local government, both at the county and municipal levels. There are 23 county councils and 286 municipalities. They have a right to collect taxes, they have their own elected decision-making bodies, and they are responsible for a large number of public activities and services. Traditionally these public agencies and commissions at all levels are responsible for almost all public services within important sectors such as employment, medical care and social welfare. (WHO 1990.)
The Ministries which are responsible for administering policies relating to rehabilitation are: the Ministry of Education; the Ministry of Labour; the Ministry of Health and Social Affairs, under which the National Social Insurance Board, the National Institute of Public Health and other welfare and health bodies operate.
Public administration in Sweden consists of both national and regional bodies. The municipality of the lowest regional level is the smallest unit. At an intermediary level there is both the regional state administration and the county council which to a major degree have the same boundaries but different areas of responsibility.
In Sweden local self-government has a long tradition. The municipal authorities enjoy a considerable degree of autonomy. The main source of revenue for the municipalities is the direct local income tax, which residents have to pay. (The social services 1992.)
In Sweden there are 24 regional State administrative boards, which amongst other responsibilities, exercise a supervisory function with respect to the social services run by the municipalities. (The social services 1992.)
In Sweden county councils are responsible for tasks for which a large percentage of the population has need, for instance medical care. The county councils' principal concern is the provision of health and medical care. Other responsibilities are the national dental service, certain types of care for the disabled and mentally retarded persons and, in certain cases, local public transport. Revenue from taxation is raised in the same way as in the municipalities. (The social services 1992.)
During recent decades the distribution of tasks and responsibilities among the State, the county councils and municipalities has gone through considerable change. There has been a strong effort from the government to give municipalities and county councils additional independence. The action at each level taken must result from a comprehensive analysis of the individual's need. (The social services 1992.)
An important factor in Sweden is the tradition of popular movements. The labour movement, the revivalist movement and the temperance movement all have deep popular roots and have meant participation in society's decision-making process. This tradition is also reflected in a strong movement involving and on behalf of the disabled. In the municipalities and counties there are about 1200 associations of people with disabilities with about 350 000 members. At the national level there are about 30 associations representing different disability groups. In spite of that, charitable organisations - often working on behalf of people with disabilities - have a smaller role to play than they do in many other countries. (WHO 1990.)
Legislation related to rehabilitation technology
The vast majority of pupils with educational difficulties and handicaps now attend ordinary schools and are taught together with other able-bodied pupils. Integration and coordinated remedial teaching form the basis for teaching of pupils with educational difficulties and handicaps. The integration of pupils with handicaps and the coordination of special supportive measures with ordinary teaching have gone so far that it is very difficult today to draw dividing lines between the various sorts of pupils, with one exception: it has not been found possible to integrate deaf children into ordinary classes. Individualization within the framework of the class, and access to special teaching, are important aspects of the attempt to create the right conditions for a course of study suitable to the circumstances and needs of handicapped pupils. (WHO 1990.)
For the more severely handicapped categories of pupils, extraordinary resources must be available if they are to enjoy an education equivalent to that offered to ordinary pupils. Under the new system of government subsidy to the comprehensive school, which was introduced on 1 July 1978, the special allocation of resources to remedial teaching has disappeared. The local authorities and the schools now decide for themselves how to make use of their State subsidy. (WHO 1990).
Working life and vocational rehabilitation
The aim of labour market policy measures for people with disabilities is to enable a person with disabilities to obtain employment on the open labour market, within sheltered employment or as self-employed person. In order to make it easier for people with disabilities to obtain employment, wage subsidies may be paid to the employer. There is no quota for the employer of people with disabilities in Sweden. In the sphere of working life, extensive legislative work was carried out in the 1970s to strengthen the position of older and disabled individuals on the labour market. (WHO 1990; Legislation 1990.)
According to the Security of Employment Act any dismissals of employees must be "on reasonable grounds". If any employee or his or her trade union believes that a dismissal is not on reasonable grounds, they can take the matter to court. The Act does not contain any detailed description of what are to be regarded as reasonable grounds. As a general rule, illness and reduced work capacity are not regarded as sufficient grounds for dismissal. In 1974 two laws came into force with the aim of strengthening the situation of employees on the labour market, and in particular that of the older and the disabled worker. The Security of Employment Act is intended to give all employees increased job security. Older and disabled employees are given special protection by the rules which stipulate the circumstances in which employees are to be dismissed or laid off. The Act Concerning Certain Employment-promoting Measures contains rules which aim at increasing the opportunities of older workers and the disabled to obtain employment on the open market. It gives the labour market authorities an opportunity to negotiate with employers and trade unions, demand information and as a last resort, to employ the staff which the employment service office indicates. (WHO 1990; Legislation 1990.)
In Sweden the labour market authorities have at their disposal a number of labour market policy measures:
- Work testing, work training and indepth vocational guidance which take place at employment assessment centres.
- Vocational training which takes place at labour market training centres.
- Training on the open labour market. Subsidies are payable to the employer. The trainee is employed and receives wages and employment benefits in accordance with collective agreements.
- Provided that there is a trade agreement on appointment on probation, this may be combined with the training of the older workers and the disabled within the company, if the parties are in agreement.(Legislation 1990.)
The employment service can give subsidies for the individual adaptation of work places and employment. Special mention may be made for:
- Grants for motor vehicles for the disabled.
- Special arrangements at the workplace (e.g. alterations to an individual workplace, work premises, entrances or communications)
- Special technical aids.
- Grants for a work assistant. (Legislation 1990.)
The Promotion of Employment Act deals, among other things, with measures to promote the employment of older employees and employees with reduced work capacity. Adjustment groups are supposed to exist at all workplaces with at least 50 employees. There is a three-way collaboration in each adjustment group between management, the trade union and the employment service. Their most important task is to help arrange employment for older people and people with disabilities. (WHO 1990.)
Money to finance measures designed to make it easier for people with disabilities to obtain or retain employment is allocated by the Government and Parliament within the framework of labour market policy. Wage subsidies are paid to employers hiring persons with reduced work capacity who would be unable to find employment in the open labour market without such subsidies. According to the Decree on Grants for the Working Aids, grants are obtainable towards the cost of working aids needed by a disabled person in order to do a job, or towards the cost of adaptations and other workplace adjustments. Grants are also payable towards the cost of a work assistant or a vehicle for travelling to and from work. (WHO 1990.)
There is an extensive social insurance system in Sweden. The disability pension is intended to provide basic economic security to those aged 16 or over, who have not reached the general retirement age of 65, and who, for medical reasons, such as illness or other reduction in physical or mental performance, cannot support themselves by employment. A disability pension may be granted if work capacity is permanently reduced by at least one half. A full, two thirds or half pension may be paid depending on the extent to which work capacity is reduced. Disability pensions take the form of a basic pension and a supplementary pension, and are taxable income. Decisions regarding disability pensions are made by the social insurance office. (WHO 1990.)
The temporary disability pension is subject to the same rules as the disability pension. It is granted for a limited period and is payable if the reduction in work capacity is not considered to be permanent, but is expected to continue for a considerable period, as a rule a minimum of one year. (WHO 1990.)
The aim of the disability allowance is to give the disabled person financial compensation for the need for help and the extra costs that the disability involves. A person aged 16 or over, who has become disabled before the age of 65, is entitled to a disability allowance. Physical or mental functional capacity should be reduced for a considerable period, as a rule a minimum of one year. The size of the disability allowance depends on how much help is needed and the additional costs incurred. Disability allowances are always paid to the blind, the deaf and those with severely impaired hearing. The disability allowance is not taxable. Decisions regarding the disability allowance are made by the social insurance office. (WHO 1990.)
The Social Services Act 1980 and the Health and Medical Care Act 1982 apply to all inhabitants. Government policy seeks to give the physically disabled every opportunity to take part in community activities and live normal lives as far as possible. The local authorities are responsible for ensuring that people with disabilities receive the help and support they need to do this. The social services offer advice and assistance with personal and practical problems and provide home help and escort services, transportation facilities etc. (The social services 1992.)
The municipality must also assist in providing specially adapted housing. Only in exceptional circumstances should a disabled person have to live in an institution. The larger residential institutions are being closed down and gradually replaced by small group homes and other alternative forms. The social services also have a special responsibility to help to arrange meaningful employment for the severely disabled. (The social services 1992.)
With regard to legislation concerning people with disabilities, there have been many amendments recently. The new Act on Support and Services for Certain Functionally Impaired was passed in spring 1993 and has not yet entered into force. Also other legislation was amended.
The 1989 Disability Commission (Committee report of the State 1991:46 p. 27-28) states that everybody is entitled to enjoy the same human rights and the right to be respected. This should be irrespective of the lack of a particular ability or an impairment.
Disability policy in Sweden is based on two concepts:
- Integration, and
Persons with disabilities are entitled to live like others and with others. One important means of achieving these goals is the provision of assistive devices and technical aids. (Fagerberg & Lundberg 1990.)
Sweden has no general law to protect the rights of people with disabilities. In accordance with moves to integrate the various matters relating to people with disabilities into the areas where they belong, special paragraphs concerning people with disabilities have been included in certain Acts, such as the Building Act 1987 and the Social Services Act 1980. In the case of other legislation (the Education Act and the Work Environment Act) it is considered self-evident, or is stated in the legislative measures, that people with disabilities are also covered. (WHO 1990; Legislation 1990.) One exception to this rule is still, however, the Care of the Mentally Retarded Act (SFS 1985:568), which has been replaced by the new Act on Support and Services for Certain Functionally Impaired.
The overall goal of the Health and Medical Care Act is the provision of good medical services and good health care on an equal basis for the whole population. This concept includes preventive measures, which were not a part of the previous Act. The new Act also deals directly with the individual patient's circumstances: care and treatment must as far as possible be designed and implemented in consultation with the patient. (WHO 1990.)
In 1992 responsibility for nursing homes, parts of home medical care and certain types of hospital care was transferred from the county councils to the municipalities. In the future, treatment and care for elderly and people with disabilities must offer a greater variety of services in order to let the individual have a choice. The reform implies that the area of responsibility between the authorities within the social services and the health and medical care will become more flexible. The action taken must result from a comprehensive analysis of the individual's need. (The social services 1992.)
In addition to the Health and Medical Care Act Services 1982 it has been made clear that the municipalities have an obligation to provide aids which people with disabilities need in their everyday life and to ensure that the aids needed for an individual's care and treatment are available for those who need them. As part of their responsibility for the health and medical service, municipalities have a duty to ensure that individual needs for special aids are met. (Prop. 1992/93:159.)
The municipalities are only responsible for aids which are needed for daily living. The county council is responsible for the more advanced aids, the supply of which requires specialized qualifications to try out, adjust and prescribe. The financial responsibility for the aids support is divided between the municipalities and the county councils.
Technical aids for daily-living are the ones most frequently demanded as they enable the individual to live independently or with the help of someone else to be able to:
- Meet the basic personal needs (to dress, to eat, to wash and so on).
- Communicate with others in the world around him.
- Function in the home and in the surrounding areas.
- Take care of the daily chores in the home.
- Go to school.
- Take part in normal spare-time and recreation activities. (Prop. 1992/93:159.)
Sweden has several programmes for providing assistive devices and other rehabilitation engineering services free of charge to persons with disabilities, depending on the type of need or use, as follows:
- Devices for daily living, primary and secondary education.
- "Cost-free supplies" for persons with osteotomy, diabetes etc.
- Vocational devices.
- Home adaptations.
- Telecommunication devices for the deaf (TDDs) (Fagerberg & Lundberg 1990.)
In order to provide a direct service, all county councils have specialized centres for assistive devices. There are five types of centres:
- The 39 technical aids centres are responsible for provision, administration and service functions regarding devices for mobility impairments, communication and cognitive impairments and certain medical technology products used in out-patient health care.
- The hearing centres (about 100) are all affiliated to an ear clinic or audiology clinic.
- The 35 vision centres are organisationally part of the eye clinics and are responsible for the vision rehabilitation within the health care system. Their activities include optical rehabilitation and vision training as well as fitting of optical and other vision devices and Activities of Daily Living devices for visually impaired persons.
- Orthopaedic workshops (about 30) are run by contractors to the county councils. They are responsible for the manufacture and provision, following prescription or referral from a physician, of prostheses, orthoses and orthopaedic footwear.
- Interpretation centres provide sign language and text interpretation services for persons with deafness, hearing impairment, deaf-blindness and speech impairment. (Fagerberg & Lundberg 1990.)
According to the Social Services Act 1980 each municipality is responsible for the social services within its boundaries. It is up to the municipality to familiarize itself with local conditions and, through direct contact, to determine who is in need and what measures are to be taken to promote satisfactory living conditions. Every municipality must have a Social Welfare Board, which should:
- Try to ensure that persons who, for physical, mental or other reasons, encounter difficulties in their everyday lives, are able to participate in the life of the community and to live under the same conditions as others.
- Help to ensure that the individual has a meaningful occupation and that he or she is provided with accommodation appropriate to the special support needed.
- Provide domestic help and publicly subsidized transport to facilitate the individual's integration into society. (WHO 1990.)
According to § 21 clause 1 of the Social Services Act, the Social Welfare Board has to take action when necessary so that people who meet considerable difficulties in their daily life because of physical, mental or other reasons, can take part in the life of their community and live like everybody else. According to § 21 clause 2 of the Social Services Act, the Social Welfare Board has to assist the individual to obtain a meaningful occupation. According to § 21 clause 3 in the Social Services Act, houses for people with disabilities should be set up by the municipalities for the people who have the kind of difficulties which are mentioned in the first clause and who need this kind of living arrangement.
According to the Care of the Mentally Retarded Act the special care arrangements comprise:
- Personal care, counselling, other personal support and support by a special liaison officer.
- Daily activities at day centres or other occupation for persons above school age who are not gainfully employed and are not undergoing training or education.
- Short-term stays away from home, mainly in order to relieve relatives of the tasks of care and supervision, and short-term supervision away from home of school pupils over 12 years old.
- Accommodation in family homes or boarding-houses for children and young persons needing to live away from their parental homes.
- Group housing accommodation for adults unable to live independently.
- Recreational and cultural activities for those in boarding-houses and group housing. (WHO 1990.)
Some mentally retarded people still live in homes or specialized hospitals. As with old-age care, the authorities have for some time felt the need to move away from earlier, institutional care models towards smaller, more flexible units which are simpler to manage and which permit more direct contact with the community. Changes have been set in motion and will continue as rapidly as staff, financial and other factors permit. Those who cannot live at home will be entitled to special care in foster homes (for children), student hostels or group homes. (The social services 1992.)
An easily accessible work environment is a necessary condition for people with disabilities to obtain work. In addition to the provisions of the Building Act 1987, which also cover work premises, The Work Environment Act now prescribes that the employer is obliged to adapt working conditions (physical environment, work organisations, etc.) to individuals' physical and mental requirements. This means demands for adaptation to meet the needs of individuals with various disabilities as well. Regulations concerning the state of the work environment, general obligations for employers and employees, the organisation of working hours, and cooperation between employers and employees are contained in the Work Environment Act. One statutory provision with a particularly important bearing on employment prospects for people with disabilities is that the employer must give consideration to the particular aptitudes of each employee for the work in hand. In the planning and arrangement of work, due regard must be taken of the fact that individual persons differ in their aptitudes to perform tasks. (WHO 1990; Legislation 1990.)
The objective of Swedish housing policy is to provide the whole population with sound, well planned and practical dwellings of a high standard and at a reasonable cost. In the planning of housing, special regard should be paid to the needs of the elderly and the disabled. (WHO 1990.)
The Building Act 1987 incorporates regulations concerning the accessibility and utility of buildings for individuals with disabilities. The principal rule is that permanent housing, public rooms and working quarters should be designed so that they are accessible to, and can be used by, persons with impaired locomotor function or sense of locality. (Certain exceptions are nevertheless permitted.) Conversions, too, are regulated by the Building Act.
Those parts of buildings which are affected by the alterations must meet reasonable requirements for adaptation to the needs of people with disabilities. According to the Building Act Chapter 2 § 4 subsection 1, building environments should be constructed so that people with lower mobility or orientation abilities could use that area. Opportunities for independent, integrated housing for the disabled do not depend only on the dwellings' technical designs. It is important that the environment, including the communications systems, functions well. (WHO 1990.)
The Act Governing the Adaptation of Public Transport Services for Disabled People 1979 prescribes that the authority responsible for supervising public transport and the agencies operating such traffic shall ensure that the transport is adapted to meet the needs of the disabled. The direct responsibility for executing adaptations for the benefit of disabled passengers lies with the various traffic officers and carriers. Therefore the following must be observed:
- When public transport is planned and implemented the special needs of people with disabilities have to be taken into consideration as far as possible.
- The means of transportation which are used have to be as suitable as possible for the travellers who are disabled.
A traffic authority, the Transport Council, was established in 1979, to co-ordinate the adjustment of the public transport system to the needs of the disabled, and to issue the necessary detailed regulations. The Board of Transport issues advice and recommen-dations on appropriate ways of modifying and adapting different forms of transport such as buses, airplanes, invalid vehicles, etc. to the special needs of people with disabilities. The Act Governing the Adaptation of Public Transport Services for Disabled People 1979 states that all public transport vehicles in Sweden must be suitably adapted to their needs. (WHO 1990; Legislation 1990.)
According to § 4 in the Decree Governing the Adaptation of Public Transport Services for Disabled People the Board of Transport must take the initiative, plan, check and coordinate the adjustments. Furthermore the Board must inform the relevant authorities about the adjustments which are needed. The Boards for rail, air, and sea transportation have to be informed about the instructions which are needed in the construction of equipment for, and running of, the means of transportation and terminals. Before the Board informs about the instructions, they have to co-operate with the authorities, with the representatives for people with disabilities and with those who manage transportation.
According to paragraph 2 clause 2 in The Road Traffic Decree a wheelchair which is electrically operated, driven by the disabled and built for a speed of 15 km/h at the most is considered a bicycle. According to paragraph 4 clause 3 a disabled person who independently handles his own wheelchair is considered a pedestrian if he travels at walking speed. According to paragraph 81, a driver is required to show special consideration for children, the elderly, school groups, persons who appear to be blind, be sight- or hearing impaired, persons who are disabled or ill and those who are likely to cause harm to other motorists. The exceptions concerning disabled drivers in the areas of, for example, parking are to be found in other Road Traffic legislation.
Framework legislation has a number of advantages - flexibility, improvements in administration, and ease of coordination - that make it possible to pay due regard to local needs and circumstances and desires of the individual. Framework legislation, however, entails certain risks, for example, the risk of an unmanageable number of regulations emanating at the lower levels, the problems of interpretation, the problem of legal rights, questions of constitutionality, uncertainty as to lines of authority and fiscal responsibility, and failure to consider the needs of minority groups such as people with disabilities. To ensure that the intentions of framework legislation are fulfilled at the local level, evaluations are undertaken at intervals. (WHO 1990.)
In Sweden in the field of social welfare and health, privatisation of service production has been one important new trend. Also decentralization of services to municipalities have taken place in accordance with new legislation.
SFS = Svensk författningssamling (The Swedish Code of Statutes)
SFS 1972:603 The Road Traffic Decree (Vägtrafikförordningen)
SFS 1974: 13 The Act Concerning Certain Employment - promoting Measures (Lag om vissa anställningsfrämjande åtgärder)
SFS 1977:1160 The Work Environment Act (Arbetsmiljölagen). Entered into force on 1 July 1978.
SFS 1979:558 The Act Governing the Adaptation of Public Transport Services for Disabled People (Lag om handikappanpassad kollektivtrafik (Amendments: 1987:159, 1988:268)
SFS 1980:398 The Decree Governing the Adaptation of Public Transport Services for Disabled People (Förordning om handikappanpassad kollektivtrafik (Amendments: 1985:815, 1991:1722)
SFS 1980:620 The Social Services Act (Socialtjänstlagen); (Amendments: 1990:1403,1993:390). Entered into force on 1 January 1982.
SFS 1982:80 Security of Employment Act (Lagen om anstallningsskydd). Entered into force on 1 April 1982.
SFS 1982:763 The Health and Medical Care Act (Hälso-och sjukvårdslag) (Amendment 1993:391). Will enter into force on 1 January 1994.
SFS 1985:568 Care of the Mentally Retarded Act (Lag om särskilda om psykiskt utvecklingsstörda m.fl.) is in force until 31 December 1993.
SFS 1984:1100 Education Act (Skollagen)
SFS 1987:10 The Building Act (Plan - och bygglag). Entered into force on 1 July 1987.
SFS 1987:409 The Decree on Grants for the Working Aids (Förordning om bidrag till arbetshjälpmedel).
SFS 1993 The Act on Support and Services for Certain Functionally Impaired (lag om stöd och service till vissa funktionshindrade) Will enter into force on 1 January 1994.
Regeringens proposition 1992/93:159 om stöd och service till vissa funktionshindrade.
SOU 1989:39 Hjälpmedelsutredningens betänkande. Hjälpmedelverksamhetens utveckling - kartläggning och bedömning.
SOU 1991:46 Betänkande av 1989 års handikapputredning. Handikapp - Välfärd - Rättvisa
SOU 1991:97 Handikapputredningens betänkande
Committee on rehabilitation and integration of people with disabilities (1990). Legislation on the rehabilitation of disabled people in sixteen member states of the Council of Europe. Strasbourg : Council of Europe.
Fagerberg, G. & Lundberg, B. (1990). System for providing assistive devices and other rehabilitation engineering solutions to individual users in Sweden. In: Proceedings, First workshop on rehabilitation engineering: REHAB-1, Washington D.C. 14-16 June. United Nations Economic Commission for Europe.
National Board of Health and Welfare (1992). The social services in Sweden. A part of the social welfare system.
WHO (1990). Is the law fair to the disabled? European Series No 29. Copenhagen : WHO Regional Publications.
Social and public health legislation in the latter part of the nineteenth century, and policy development in the early part of the present century created the context for extensive legislative action in the immediate postwar period. Yet, the specific needs of people with disabilities, whether physical, sensory or mental, have been recognised only partially and comparatively recently in British law.
There is an assumption that all citizens are covered by general legislation. Yet, the lack of explicit reference to people with disabilities has often led to their exclusion from services and facilities apparently available to all.
Recognition that people with physical disabilities may have specific needs, for equipment, facilities and financial support, to enable them to have independent lifestyles gained acceptance in Britain largely in the twentieth century. The first and second Great Wars in Europe produced large numbers of "innocent" casualties, both from the armed forces and the civilian population which supported them. These conflicts led to the development of new perceptions of people with disabilities, and a collective responsibility for their support.
The casualties of the 19th century industrial revolution in Britain were not recognised in the same way as being the responsibility of the community. The relatives of people killed or permanently disabled in the new factories that brought rural communities to the cities had to manage as best they could.
While the wars brought recognition of the need for specific measures to assist the integration of people with disabilities, no consolidated piece of legislation has been introduced to achieve this objective. Individual pieces of legislation addressing specific needs have been passed over a period of time.
Legal and administrative framework
Any discussion of British law has to start by recognising that it differs between the four countries that make up the UK. Scotland has a separate legal system, while much of the legislation that applies to England and Wales only extends to Northern Ireland if the province is specifically included in the legislation or accompanying regulations. In some cases, separate Acts specifically for Northern Ireland are passed at a later stage.
This report refers to primary legislation in the form of Acts of Parliament and secondary legislation in the form of Statutory Instruments or regulations. Statutory Instruments and regulations are a mechanism for amplifying the general provisions of an Act. Private Member's Bills are bills introduced into Parliament by Members of Parliament, rather than the Government. Once adopted, these bills also become Acts of Parliament.
Since 1974, successive Governments have included a minister to take special responsibility for people with disabilities.
A report (1) said in 1988 that "aids and equipment supply is the single most confused area of service provision for disabled people". This was because some equipment was available from a range of different sources, while other equipment was not available at all. In addition, policy varied between different geographical areas, producing confusion among professionals, people with disabilities and their carers and inhibiting the ability of professionals to gain a comprehensive knowledge of the system.
The basis for providing equipment for people with physical and sensory disabilities is found in general welfare legislation.
Technical aids for daily living are provided under the Chronically Sick and Disabled Persons Act, 1970 (CSDPA), amended by the Disabled Persons Act 1986. Both measures were introduced to the British Parliament as Private Member's Bills rather than as primary legislation by the Government of the day.
Housing legislation also refers explicitly to home adaptations. The Local Government and Housing Act of 1989 introduced disabled facilities grants, renovation and minor work grants and includes a detailed list of access criteria for mandatory disabled facilities grants.
Education in Britain is in principle available to all children and citizens on an equal basis. Yet equipment to enable children or adults with specific handicaps to receive education on an equal basis is not provided for in primary legislation. Regulations do refer; so does primary legislation on the assessment of children with special educational needs.
Employment legislation allows for necessary facilities to be made available, particularly post 2nd world war laws designed to help war wounded adults to find employment. With the exception of the Disabled Persons (Employment) Act 1944, which introduced quotas for the private sector, most legislation is permissive.
Legislation related to rehabilitation technology
The CSDPA sought to make mandatory and to extend the services previously provided by local authorities under permissive welfare legislation, notably the National Assistance Act, 1948.
Such laws gave local authorities discretion about which local residents would receive services, and which services would be provided. Some local authorities were more willing to accept communal responsibility for people with disabilities than others and all had competing demands on limited resources.
The 1970 Act attempted to introduce uniformity in provision by requiring local authorities to identify their disabled residents by undertaking surveys, inform them of the services available to them and to provide those services once a need had been established. It specified which services must be provided.
These services included the provision of technical aids and adaptations to the home, and of facilities to help people with disabilities maintain contact with the outside world, including telephones and technical aids to enable disabled to use them. The Act covers England, Wales and Scotland and was extended to Northern Ireland in a separate Act in 1978.
Although Government circulars have said that local authorities may determine criteria of need in the light of resources, the legislation itself suggests that once a need is recognised it must be met irrespective of a lack of resources. The latter view has been upheld when refusal to provide services, for which a need has been defined, has been challenged in the courts.
Local education authorities have a general duty to provide education for all children under the Education Act, 1944, the Education and Libraries (Northern Ireland) Order 1986 and the Education (Scotland) Act 1980. The 1944 Act refers to "...equipment to afford for all pupils opportunities for education...".
Equipment needed for education can include access, adaptations to school premises, computers, special furniture, reading and speech aids. Such equipment may be provided by schools or education authorities; by health or social services where it is not specifically an educational need; or by voluntary bodies, including charities and parents groups. In some areas, education, health and social services combine to provide an equipment pool for disabled children to use in schools.
However, most children with severe physical and specifically multiple disabilities are educated in special schools. The 1981 Education Act incorporated proposals to integrate these children into mainstream schools, and also introduced assessments and statements (records in Scotland) of special educational need (SEN).
SEN children are those with learning difficulties. Education authorities are responsible for ensuring that the SEN, including equipment needs, of children are met. But detailed legislation on this applies only to statements or records of needs which only a minority of SEN children have.
Regulations provide for allowances to pay for "major items of specialist equipment" for disabled students following higher education courses, and for general allowances for the extra expenses they may incur. The special equipment allowance must be paid where the student receives a mandatory student grant and can cover the cost of word processors with braille printers, induction loops in the lecture theatre, and closed circuit televisions to enlarge book print.
Working life and vocational rehabilitation
The Disabled Persons (Employment) Act 1944, and a similar Act covering Northern Ireland in 1945, required any private employer with 20 or more employees to reserve three per cent of jobs for people registered as disabled. This quota did not apply to public authorities, but they were expected to comply with it voluntarily. Few employers - public or private - fulfil the quota. It is the only British law that positively discriminates in favour of people with disabilities. But applications by employers to be exempted from the quota are readily granted.
The Acts give powers to Government departments to provide equipment to meet employment needs of registered people with disabilities. The equipment that can be provided includes adapted telephone switchboards, adapted computers, ramps, stairlifts, talking calculators, wheelchairs, page turners, closed circuit television systems, amplifiers, telephone aids and adapted toilets.
Equipment is generally provided under the "special aids to employment" scheme to cover items which would not normally be provided by employers and which meet individual employment needs. At present, there is no financial limit and equipment is loaned free of charge for as long as it is needed. Equipment is repaired and maintained by the Government service. However current Government proposals announced in June this year and due to be implemented in April 1994, will substantially change the way in which this scheme operates. Under the proposals, employers will be expected to pay 50% of the cost of equipment and support needed by a disabled employee after a period of six months. There will be a financial limit (as yet unspecified) on the maximum cost to an employer over five years and a financial limit on the amount a disabled person can receive over a five year period. In addition an employer will be expected to pay the entire cost of an item of equipment costing less than £100 (ECU 133). The new scheme, if it is implemented in its present form, would provide for communication support for deaf people for the first time.
Loans or grants to adapt premises are available to employers under the Employment and Training Act 1973 in England, Wales and Scotland, and in Northern Ireland under the Employment Subsidies Act. Both Acts aim at helping people with disabilities find, train for and obtain jobs and to help employers find suitable employees. Adaptation grants are subject to upper cost limits, but can include wheelchair lifts, ramps, alarm systems with flashing lights and machinery modified from hand to foot control.
The Disabled Persons (Employment) Act 1944 and the Disabled Persons (Employment) (Northern Ireland) Act 1945 also provide for sheltered employment schemes and for the Personal Reader Service (PRS), administered by the Royal National Institute for the Blind. The PRS gives two year renewable grants to people needing reading aid at work, when starting a new job or when in danger of losing a job, where they are returning to a different job or where their career development is being restricted.
Sheltered employment schemes help people with disabilities to work by offering employers subsidies to make up for lost production. Funds from central government for places on these schemes were increased substantially in the mid 1980s and as a result the numbers of places increased from 16.000 in 1986 to 20.000 in 1992.
Severely disabled people can also receive grants to help them set up businesses at home, although these are seldom used. The Employment and Training Act 1973, as amended by the Employment Act 1988 provides for capital costs of equipment and alterations to their own homes. This scheme, used by about 350 people, provides grants to set up their own businesses at home and a subsidy to bring their incomes up to a guaranteed level. The scheme does not cover Northern Ireland. These schemes are currently under review.
Employment training programmes included extra funds for people with disabilities until 1989 when Training and Enterprise Councils (TECs), private-sector led organisations, normally involving local authorities on a partnership basis, replaced a central agency. Private employers have set up a Forum on Disability to improve job prospects for people with disabilities and central Government has produced a voluntary Code of Practice for them to follow. Employers who accept this code may award themselves a "two ticks" symbol indicating that they are making efforts to employ more people with disabilities.
Social security benefits are the main source of income for most people with disabilities in Britain. Those who have never been able to earn a living rely principally on Income Support, a means-tested benefit set at a basic subsistence level. Others depend on retirement pensions, invalidity pensions, industrial injury or war pensions. The cause of disability, rather than the need it creates, determines which benefit is paid and rates vary widely.
In the 1970s, a series of new benefits specifically for people with disabilities was introduced, including a mobility allowance to help with travel costs and an attendance allowance to help pay for care assistance.
Long-term benefits for people with disabilities were linked in the 1970s to rises in wages or prices, whichever rose higher. That link was dropped early in the 1980s. A review published in 1990 (2) identified 22 different benefits available to people with disabilities and proposed changes. The main changes, implemented in 1992, replaced attendance and mobility allowances with a combined Disability Living Allowance to help more people with the extra costs of disability. The allowance has mobility and care components. A new means-tested benefit, the Disability Working Allowance, was also introduced to help people with low wages.
Changes to the general social security system in the 1980s resulted in reduced levels of income for thousands of people with disabilities. The Government estimated that 80.000 had been adversely affected by the change and responded by introducing the Independent Living Fund, initially intended to help up to 1.000 severely disabled people by providing much higher weekly allowances. These allowances were to enable the recipients to pay for the wide range of services and facilities needed by them to lead independent lives. This fund was replaced in 1993 by the Independent Living (Extension) Fund.
Disability organisations in the UK have argued for more than 30 years that a comprehensive income system is needed to meet the demonstrable extra costs of disability. Such a system should meet three principles: that all people with physical and mental disabilities should be covered; that there should be no discrimination on the cause of disability; and that there should be recognition of the greater financial needs of the most severely disabled people. The Government's own Social Security Advisory Committee, came to similar conclusions in its 1988 annual report (3).
Policy in the UK has concentrated on care in the community rather than in institutions for more than 20 years, but successive investigations have shown that progress has been patchy. The NHS and Community Care Act 1990 introduced major changes, including new rules on assessing the needs of elderly people, and those with mental or physical disabilities. The Act is intended to help more people with disabilities live in the community, including by making available the equipment they need to do so.
Health legislation provides for free medical care for all citizens, paid for out of general taxation. There are charges for prescribed drugs, but pensioners and people on low incomes are generally exempt.
Medical equipment, including wheelchairs, can be prescribed by general practitioners (GPs) who also refer patients needing more specialised equipment to hospital consultants. Wheelchairs can also be prescribed by consultants, therapists and nurses.
Most health legislation does not refer specifically to wheelchairs, although they are mentioned in Welsh regulations governing the Welsh Health Common Services Authority (WCHSA) set up in 1990. The legal basis for providing them is contained in general legislation referring to duties to provide facilities or services necessary to meet "all reasonable requirements".
Where wheelchairs are needed for a temporary period, for example, after an accident and generally up to a period of three months, they can be loaned by hospitals, community health professionals, social services (social work departments in Scotland), or voluntary bodies like the Red Cross. Usually, the loans are free of charge.
Wheelchairs for permanent use are also normally provided on loan through the wheelchair service which provides a standard range of chairs, free of charge. More specialised chairs can be provided for individuals assessed as needing them. These include commercial models, adapted wheelchairs and, in exceptional cases, customised models. However outdoor, powered models are not generally available except to people able to purchase them privately.
Transport and access
Local authorities can operate concessionary bus fare schemes for people with disabilities under the Transport Act 1968 and the London Regional Transport Act 1968. However, many buses need adaptations to make them accessible to people with disabilities, as the Department of Transport's Disabled People Transport Access Committee (DPTAC) recognised in 1985. Most new buses will have oral signs, colour coding and lower steps to help people with disabilities, as recommended by DPTAC, and there is pressure to make them standard on all buses.
Specialised transport for people with more severe disabilities was introduced in London in the 1980s on the initiative of local authorities, including the now abolished Greater London Council. The Dial-a-Ride service allows people with disabilities to book a door-to-door bus trip a few days ahead. There is also a Taxicard scheme which gives members subsidised fares when they use taxis and is widely used to travel to work.
Disabled drivers and car passengers including visually impaired people can park free at meters and in other restricted parking areas under the Orange Badge Scheme introduced under the CSDPA. The same Act also allows them to use invalid carriages on the public footway, subject to certain minimal conditions.
Young people with disabilities who receive the mobility component of the disability living allowance can apply for a provisional driving licence at 16, a year earlier than non-disabled people, under the Motor Vehicles (Driving Licences) Regulations 1981. People with disabilities who receive the higher rate mobility component are able to use this benefit to buy or hire a car. The scheme is administered by Motability, a voluntary organisation set up on the initiative of the Government. Parents of children in receipt of this higher rate of benefit and those in receipt of the war pensioners' mobility supplement can also use the scheme. Under the hire purchase option it is also possible to buy an electric wheelchair or a good used car instead of a new car.
As well as access to transport, people with disabilities are often excluded from normal life by difficulties in entering buildings.
The Building (Disabled People) Regulations 1987 (which added a new Part M to the main 1985 Building Regulations) require that all new buildings which are open to the public and their toilets must be accessible to people with disabilities.
The CSDPA gave local authorities responsibility to consider the special housing needs of people with disabilities and led to an increase in the number of wheelchair accessible homes. The Act also provided for adaptations to the home to be made from social services budgets.
Grants for house adaptations can also be made to the occupiers under housing legislation. Disabled facilities grants were introduced under the Local Government and Housing Act 1989; these are means tested but if the adaptation is to allow people with disabilities basic access to parts of their homes, housing authorities must make the grant available. Housing Associations which are voluntary organisations funded by the Housing Corporation, a statutory body, play a very important role in the provision of adapted housing for people with disabilities. There are 3.500 Housing Associations throughout the country and Local Authorities are increasingly looking to them to meet the housing needs of disabled residents. The Housing Associations Act 1988 permitted the Housing Corporation to give grants to housing associations for the adaptation of houses to meet the needs of people with disabilities. Housing provision which uses local authorities to identify the needs of people with disabilities, a housing association to provide appropriate accommodation and housing benefits to pay for the accommodation is an example of a well-integrated system of support for the disabled.
The British CSDPA pioneered disability legislation that has since been copied in many other countries. There was, however, dissatisfaction with the way it was implemented and with the continued exclusion from the labour force and public facilities of many people with disabilities. In 1979 a Committee on Restrictions Against Disabled People (CORAD) was set up by the then Minister for Disabled People.
CORAD took evidence from a wide range of individuals and organisations and concluded that people with disabilities suffered widespread and unfair discrimination. Britain already had Sex Discrimination and Race Relations laws. The committee recommen-ded that a similar measure should be introduced to give people with disabilities legal redress when their right to equal treatment was infringed.
There have been several attempts to introduce an anti-discrimination law for people with disabilities in Britain but all have failed because the Government of the day has declined support. Despite Government opposition, there are individual politicians within all the main political parties in Britain who support the proposal for anti-discrimination legislation. The main disability organisations drew up their own "disability manifesto" in 1991 (4) which demands that "All people should have equal rights, equality of income and participation and be afforded equal respect and opportunities."
1 Beardshaw, V. (1988). Last on the List; community services for people with physical disabilities. London : King's Fund Institute
2 Department of Health (1990). The Way Ahead. Benefits for Disabled People. London : HMSO
3 Social Security Advisory Committee (1988). Benefits for Disabled People; a strategy for change.
4 An Agenda for the 1990s - Disability Manifesto 1991 published jointly by Action for Blind People; Deaf Accord; Disability Alliance; Greater London Association of Disabled People; MENCAP; MIND; Muscular Dystrophy Group; National Federation of the Blind (UK); RADAR, Royal National Institute for the Blind; Royal National Institute for the Deaf; Spastics Society, and Spinal Injuries Association.
Disabled Persons (Employment) Act 1944. Introduced quota and provided for vocational training, rehabilitation and sheltered employment. Disabled Persons (Employment) (Northern Ireland) Act 1945 extended the law to Northern Ireland.
Education Act, 1944. Introduced universal education for all children.
National Assistance Act 1948. Introduced the National Health Service (NHS) and provided for residential accommodation for the elderly and infirm and the welfare of people with physical or mental disabilities.
Transport Act 1968 and London Regional Transport Act 1968. Gave local authorities powers to operate concessionary bus fares.
Chronically Sick and Disabled Persons Act, 1970 (Northern Ireland Act 1978). Gave local authorities mandatory duties to identify severely disabled residents, inform them of services available to them, and make certain services available, including aids and adaptations to the home. Also covered housing, access to public buildings, free parking for disabled drivers and passengers.
Employment and Training Act, 1973, amended by Employment Act 1988; Employment Subsidies Act, 1978. Provided for special aids to employment and adaptations to workplace premises and equipment.
Education Act 1981. Introduced proposals to integrate severely disabled children into mainstream schools and introduced assessments and statements (records in Scotland) of special educational need. Education and Libraries (Northern Ireland) Order 1986; Education (Scotland) Act 1980.
Disabled Persons Act 1986. Amended Chronically Sick and Disabled Persons Act 1970.
Motor Vehicles (Driving Licences) Regulations 1981. Enabled people with disabilities to apply for a provisional driving licence at 16, one year earlier than others.
Building (Disabled Persons) Regulations 1987. Required new buildings which were open to the public and toilets to be accessible to people with disabilities.
Local Government and Housing Act 1989. Introduced disabled facilities grants for house adaptations.
Housing Associations Act 1988. Permitted the Housing Corporation to make grants to registered housing associations to adapt houses for people with disabilities.
NHS and Community Care Act 1990. Introduced new rules on assessing the needs of elderly people and those with mental and physical disabilities.
An Agenda for the 1990s - Disability Manifesto 1991published jointly by Action for Blind People; Deaf Accord; Disability Alliance; Greater London Association of Disabled People; MENCAP; MIND; Muscular Dystrophy Group; National Federation of the Blind (UK); RADAR, Royal National Institute for the Blind; Royal National Institute for the Deaf; Spastics Society, and Spinal Injuries Association.
Beardshaw, V. (1988). Last on the List; community services for people with physical disabilities. London : King's Fund Institute
Darnbrough, A. and Kinrade, D. (1991). Directory for Disabled People. Cambridge : Woodhead-Faulkner (Publishers) Limited.
Department of Health (1990). The Way Ahead. Benefits for Disabled People (1990). London: HMSO
Healy, P. (1992). Disability in London: the last 13 years. London: Disability Resource Team.
Mandelstam, M. (1992). How to get Equipment for Disability. London: Jessica Kingsley Publishers Ltd.
Robertson, S. (1993). Disability Rights Handbook. London : Disability Alliance Educational and Research Association.
Social Security Advisory Committee (1988). Benefits for Disabled People; a strategy for change.
WHO (1990). Is the law fair to the Disabled? European Series No 29. Copenhagen : WHO Regional Publications.