With 15 percent of the world's population living with some form of disability, this Technical Learning Sessions discussed how MSH's Universal Health Coverage (UHC) priorities cannot be realized without inclusion and specifically how the LMG Project has engaged in this space. Topics explored: the need for inclusive development, how to consider inclusion throughout the project cycle, and practical resources to use in your current work, regardless of the health area or building block you focus on.

1. 11
HOW INCLUSIVE DESIGN AND
PROGRAMMING ADVANCES
UNIVERSAL HEALTH
COVERAGE
LMG Project Technical Learning
Session
Photo:MSHStaff

2. 2
Seminar Objectives
• Raise awareness of inclusive development and its connection
to universal health coverage
• Discuss how to design inclusive programs, and how adapt
existing programs to be more inclusive
• Provide recommendations for practical actions and
resources that MSH can use with governments, service
providers, civil society, and development partners to ensure
inclusion of persons with disabilities

3. LMG Project Experience in Inclusion
3

4. 4
Seminar Outline
1. Setting the stage: UHC as an anchor of MSH’s work
2. State of health for persons with disabilities
3. Designing inclusive health programs – example using inclusive
health checklist
4. Questions and discussion

5. • Consensus goal in Global Health
• Key principle: people should receive the healthcare they need
without having to suffer financial hardship
5
Universal Health Coverage

6. 6
What does disability inclusion have to do
with UHC?

7. 7
Disability is a Global
Health Issue
• More than 1 billion people with
disabilities globally = about 15%
of world’s population or 1 in 7
people
• 93 million children – or 1 in 20 of
those under 15 years of age – live
with a moderate or severe
disability
• Disproportionately affects women,
older people, poor people,
LGBTQ, and minorities

8. State of Health for Persons with Disabilities
• Greater unmet needs around health and
rehabilitation than general population
• Seldom targeted by health promotion
and prevention activities
• Women with disabilities receive less
breast and cervical cancer
screenings
• People with intellectual disabilities
are less likely to have their weight
checked
• Adolescents and adults with
disabilities more likely to be
excluded from SRH programs 8

9. 9
• Lack of awareness, knowledge, and
understanding
• Prejudice and stigma
• Inadequate policies and standards
• Physical, financial, and attitudinal
barriers to services
• Inadequately trained providers
• Exclusion of persons with
disabilities from decision-making
• Lack of data and evidence
Why Health Systems Fail
Persons with Disabilities:

10. 10
Left Behind?
Afghanistan Case
Widely held up as a HSS success story, yet…
• Afghans with disabilities report health care
coverage and positive experiences did not improve
between 2005 and 2013
• Services less available to address their needs
despite decade of international investment
• Persons with disabilities commonly not included in
design of health system reconstruction,
mainstream health workers were not trained, and
NGOs did not deliberately plan for inclusion
Source: Trani J-F, Kumar P, Chandola T. Assessment of the progress toward
universal health coverage for disabled people in Afghanistan: a multi-level analysis.
Lancet Global Health 2017;5:e828-38

11. What is Needed to Move Inclusive Health Forward?
Purposefully seek out persons
with disabilities – apparent and
non-apparent – and obtain their
input for program design
Establish partnerships with
disabled people’s organizations
(DPOs)
Ensure persons with disabilities
are aware of their rights and the
mechanisms for complaints
 Budget for inclusion
 Address misconceptions, stigma,
and lack of knowledge of
disability among health providers
and community
 M&E to inform policy and guide
future programming efforts
 Ensure representation in
decision-making/governance
bodies
11

12. 12
A Checklist for Inclusive Programming
LMG Project
adapted tool:
Inclusive
Health
Checklist

13. 13
Inclusive Programming Through the Project Cycle
SITUATIONAL
ANALYSIS
PLANNING AND
DESIGN
HUMAN RIGHTS
PRINCIPLES
MONITORING AND
EVALUATION
IMPLEMENTATION
Reproduced from: UNFPA, Harvard School of Public Health Program of
International Health and Human Rights (2010) A human rights-based
approach to programming. United Nations Population Fund, New York;
Page 377
Inclusive Health Checklist
• Human rights-based
approach
• Spark thinking about
inclusion throughout the
phases of the project cycle
• Identify rights-holders and
duty-bearers
• Consider empowerment and
accountability capacities

14. 14
Using the Checklist to Design & Deliver More
Inclusive Programs (Example)
Imagine that MSH recently won a $10 million award to support
UHC reform in Kenya. The main objectives are to:
1. Improve service timeliness and quality through scale up of
basic package of health services
2. Pilot and adapt decentralized financing mechanisms
3. Enhance institutional capacity of national health insurance
agency and district level health management teams
What are some steps we can take to ensure the project is inclusive
of persons with disabilities?

15. 15
Step 1: Situational Analysis (Example)
 Who are the key rights-holders
and duty-bearers?
Right holders: Persons with disabilities (all types), Kenyan
National Council for Persons with Disabilities, Association for the
Physically Disabled of Kenya, United Disabled Persons
Duty bearers: Health providers, MOPHS, National Health
Insurance Fund of Kenya, Ministry of East African Community
Labor and Social Protection (MEACLSP)
 What are the capacity gaps of
persons with disabilities and
gaps of duty-bearers?
 What are the relevant power
relationships, discriminatory
practices, stigma, inequities?
 Is the right to health for persons
with disabilities protected in
domestic laws/policies? Has the
UNCRPD has been ratified?
Ratified CRPD in May 2008, but not Optional Protocol. Disability
rights added to constitution in 2010. There are disparities between
health laws/reforms and practice, many legal provisions lack
enforcement modalities. Financing remains a challenge. There is
no law that expressly provides for free and informed consent to
treatment, it is implied.
Persons with disabilities are often shunned away in society, and
lack opportunities to work or go to school. They do not have
access to mainstream health services, particularly in rural areas.
Stigma is especially high for mental health related disabilities.
Persons with disabilities are not empowered to speak up against
HS injustices. Many providers are not trained on disability. Weak
MOPHS and MEACLSP coordination, especially at district level.

16. Step 2: Design and Planning (Example)
 Have you identified interventions
to close gaps in empowerment
capacities of persons with
disabilities?
 Have you involved persons with
disabilities in the planning of project
activities? And established
partnerships with DPOs?
Stakeholder meetings are planned with GoK representatives,
DPO representatives, health workers, and community members
(with and without disabilities) to receive input on project design.
Project staff pursue partnership with district level groups of
United Disabled People of Kenya.
Possible interventions: strengthening leadership of DPOs,
developing advocacy skills, building networks and alliances,
raising awareness of health rights and services available for
persons with disabilities.
 Have you identified interventions
to close gaps in accountability
capacities of the duty-bearers?
Possible interventions: training of health workers on rights and
needs of persons with disabilities, addressing barriers to
accessibility of services, establishing cross-ministry oversight to
ensure health-related policies are inclusive and enforced,
building HMIS capacity to collect disability data.
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 Have we ensured that project
information, materials, and curricula
will be available in accessible
formats?
Materials are made in large print, sign language interpreters are
provided during meetings, reasonable accommodations will be
factored into district budgets for service delivery, transportation
costs are taken care of for people with mobility needs.

17. 17
Step 3: Implementation (Example)
 Are persons with particular types of
disabilities not utilizing the project’s
services? Have measures been taken
to investigate these situations and
target potentially excluded groups?
 Have you established routine ways
for persons with disabilities to be
engaged in activity implementation and
in the review of progress/results?
 Have you established mechanisms
and reviewed procedures to ensure
that persons with disabilities are in fact
benefiting from project implementation?
Review of service statistics in 3 districts indicated
that all service users with disabilities in the first
quarter had physical disabilities. The project then
established relationships with Kenya National
Association of the Deaf and the Kenya Society for
the Blind to identify possible barriers to accessing
existing services.
DPO partners participate in quarterly project
review and planning meetings. Persons with
disabilities are represented on district level UHC
governance committees.
Partners from United Disabled People of Kenya
participate in monthly audits of services and
conduct annual surveys of users and potential
clients.

18. 18
Step 4: Monitoring & Evaluation (Example)
 Have persons with
disabilities been involved in
defining success for the
project and establishing the
M&E plan?
DPOs have participated in the initial stakeholder meeting
to establish the vision of the overall project as well as
launch meetings in each target district where M&E plans
were finalized.
 Did persons with disabilities
and duty-bearers participate in
deciding how the results will
be disseminated?
 Is data routinely
disaggregated by disability?
Data is disaggregated by type of disability in accordance
with Kenyan law by visual, hearing, learning or physical
incapability.
DPOs and GoK, along with other stakeholders, were
consulted to design project results meetings within each
district, resulting in the addition of sessions for dialogue
between all parties to plan rollout of effective practices
from insurance pilots to new regions.

19. 19
Questions & Discussion

20. 20
THANK YOU!
For more information please contact:
Kate Wilson – kwilson@msh.org
Maggie Lamiell – mlamiell@msh.org
Meredith Schlussel – mschlussel@msg.org

21. 21
INCLUSIVE HEALTH
RESOURCES

22. Suggested Resources
• World Report on Disability by World Health Organization & World Bank,(2011)
• First ever world report on disability with comprehensive coverage of health issues.
http://whqlibdoc.who.int/publications/2011/9789240685215_eng.pdf
• Promoting sexual and reproductive health for persons with disabilities by WHO & UNFPA
• This guidance note addresses issues of sexual and reproductive health (SRH) programming for persons with disabilities.
http://whqlibdoc.who.int/publications/2009/9789241598682_eng.pdf
• A Health Handbook for Women with Disabilities by Hesperian Health Guides
Developed with the participation of women with disabilities in 42 countries, this guide helps women with disabilities to overcome the
barriers of social stigma and inadequate care to improve their general health, self-esteem, and independence.
http://hesperian.org/books-and-resources/
• WHO Action Plan 2014-2021 “Better Health for Persons with Disabilities”
• The Disability Action Plan outlines measures to assist Member States to align their national health and rehabilitation policies and plans
with the CRPD. http://www.who.int/disabilities/policies/actionplan/disability_action_plan_en.pdf
• QualityRights Tool Kit by World Health Organization
• Provides countries with practical information and tools for assessing and improving quality and human rights standards in mental health
and social care facilities. The Toolkit is based on the United Nations Convention on the Rights of Persons with Disabilities.
http://www.who.int/mental_health/publications/QualityRights_toolkit/en/
• Make a Change!: A Call to Action from Women Leaders with Disabilities by MIUSA
This video calls attention to the need for a new strategy for working toward disability inclusion in development and humanitarian
programs. We are calling it the practice of "infiltration", in which people with disabilities are proactively participating in the services and
programs which, as members of their communities, are rightfully theirs.
http://www.youtube.com/watch?v=ojx2-IcA6oo
22

23. Connecting with Disabled People’s Organizations
The LMG Project has started a list of contact info for DPOs:
https://docs.google.com/a/msh.org/document/d/1FgQTMVPClA
Y5Cg0un-a3Ha5MimTi0-m5bitFYJdUS1M/edit?usp=sharing
23

24. Text from UN Convention on the Rights of Persons with Disabilities,
Article 25 – Right to Health
States Parties recognize that persons with disabilities have the right to the enjoyment of the highest
attainable standard of health without discrimination on the basis of disability.
States Parties shall take all appropriate measures to ensure access for persons with disabilities to health
services that are gender-sensitive, including health-related rehabilitation.
In particular, States Parties shall:
a) Provide persons with disabilities with the same range, quality and standard of free or affordable health
care and programmes as provided to other persons, including in the area of sexual and reproductive
health and population-based public health programmes;
b) Provide those health services needed by persons with disabilities specifically because of their
disabilities, including early identification and intervention as appropriate, and services designed to
minimize and prevent further disabilities, including among children and older persons;
c) Provide these health services as close as possible to people's own communities, including in rural
areas;
d) Require health professionals to provide care of the same quality to persons with disabilities as to others,
including on the basis of free and informed consent by, inter alia, raising awareness of the human rights,
dignity, autonomy and needs of persons with disabilities through training and the promulgation of ethical
standards for public and private health care;
e) Prohibit discrimination against persons with disabilities in the provision of health insurance, and life
insurance where such insurance is permitted by national law, which shall be provided in a fair and
reasonable manner; 24

25. AAAQ Framework
•Availability: Health facilities, goods, and services must be available in adequate numbers
through a State, including adequate numbers of health care providers trained to provide
disability-specific support and mental health-related services.
•Accessibility: Includes four overlapping dimensions:
• Non-discrimination
• Physical accessibility
• Economic accessibility
• Information accessibility
•Acceptability: Health care facilities, goods, and services provided to persons with disabilities
must be culturally acceptable and respectful of medical ethics.
•Quality: Health care facilities, goods, and services provided to persons with disabilities must
be of good quality, as well as scientifically and medically appropriate.
25

26. SNAPSHOTS OF THE LMG
PROJECT’s INCLUSION PROGRAMS
26

27. 27
• Teams of senior decision makers
from civil society and government
• Work on sector-level challenge
throughout program
• Training includes:
– Disability rights and
UNCRPD
– Good governance practices
– Leading in teams
– Strategic problem solving
• 3 regional programs involving 15
countries and 103 participants
SENIOR LEADERSHIP PROGRAM
on Physical Rehabilitation and Disability
Rights

28. PROGRAMS
• East Africa: 23
participants from Sudan,
Ethiopia, Tanzania,
Zambia
• Southeast Asia: 38
participants from
Cambodia, Laos PDR,
Myanmar, Philippines,
Vietnam
• Francophone Africa: 42
participants from Togo,
DRC, Burundi, Chad,
Madagascar, Niger
SAMPLE
ACHIEVEMENTS:
28
EXAMPLES OF TEAM
PROBLEMS:
• Lack of materials and
supplies for services
• Under-utilized services
at facilities
• Insufficient human
resources
• Poor quality of
services or low client
satisfaction
• Lack of services in
particular regions
• Lack of data on needs
LMG/ICRC REGIONAL SENIOR LEADERSHIP
PROGRAMS
SAMPLE ACHIEVEMENTS:
• Developed & piloted
national data collection
tool
• Established national
advisory groups
• Increase national
budget for PR
• Held stakeholder
meetings
• Advocated for inclusion
in health insurance
• Drafted policy

29. 29
• Part of WHO Wheelchair Service
Training Package
• Helps stakeholders:
– understand need for and benefit of
an appropriate wheelchair
– understand their role in developing
appropriate wheelchair provision
and barrier-free environments;
– increase quality of service delivery
– gain more commitment to
seek/provide appropriate budgetary
support
• 20 meetings in 18 countries
WHEELCHAIR SERVICE STAKEHOLDER
MEETINGS

30. 30
• LMG supported Mobility International USA
(MIUSA) to scale up their WILD program
–Action-planning so women identify
how to use what they learn in the
program
–M&E and follow up coaching
–Facilitator Guide so alumni can
replicate WILD
• Alumni return to their communities to lead
change and advocate for their rights
• Women from over 50 countries attended
WILD in Eugene, Oregon
–20 trained as WILD trainers
WOMEN’S INSTITUTE ON LEADERSHIP AND DISABILITY (WILD)

31. RECOMMENDATIONS FOR ACTIONS
TO OVERCOME PERSISTING
BARRIERS AND REALIZE
INCLUSIVE HEALTH
(resulting from the roundtable
discussions at the PMAC conference
2017)
31

32. 32
RECOMMENDATIONS FOR ACTION
1. “Nothing about us without us.” Support persons with disabilities to “infiltrate”
the health system and become advocates, policy makers, and program
implementers WITHIN the health system themselves.
– Many persons with disabilities have been systematically excluded from
education and isolated from society. They need education, capacity
building, peer support and coaching to be prepared to advocate for their
rights and engage in policy. Investments should be made to build this
capacity at the community level.
– Advocating is like advertising, you don’t know something is on sale
until you see the ad. So for someone with a disability to be an
effective advocate, they must be aware of their rights and understand
the policy process.

33. 33
RECOMMENDATIONS FOR ACTION (continued)
2. Civil society advocates and technical experts should:
– Strategically consider their audience and target messaging and approach
accordingly
– Identify key champions to influence change, looking for catalysts with influence
who can get the ball rolling
– Start where they can and demonstrate benefits to advocate for expansion
– Aim to influence multiple levels of the system; consider what the Philippines
calls a “bibingka approach”—working at both national level through high-level
champions and grassroots level with community action.
– National level action can be slow, but at lower levels local authorities may
have resources at their immediate disposal.
– Provide input to government on what data to collect and help make sure that the
data collection process is accessible to all individuals , regardless of their type
of disability. (e.g., including sign-language interpreters for house-hold surveys).

34. 34
RECOMMENDATIONS FOR ACTION (continued)
3. Government (ministry of health and health officials) should:
• Establish some form of permanent counsel for persons with disabilities
to support program and reform continuity, despite turnover of elected
officials. This counsel should have the authority to work across
government agencies and coordinate action.
• Foster more partnerships for joint action with civil society.
• Make sure the following are in place in the health system to ensure
persons with disabilities are included in all health programs: supportive
legislation, implementing regulations and responsible body within
government with appropriate authority; standards and guidelines;
measures and indicators for collecting data on inclusion.
• Reach out to other ministries and agencies that affect health and health
programming ,such as the planning and finance ministries.

35. 35
RECOMMENDATIONS FOR ACTION (continued)
4. Development partners should:
• Support the development of tools which can help determine costs and
budgetary requirements to ensure all health programs are inclusive of
persons with disabilities
• Support evidence-generation on the needs and the benefits of inclusive
health
• Support organizational capacity building for Disabled People’s
Organizations (DPOs)
• Advise governments and service providers on how to monitor and
improve the quality of the implementation of inclusive health programs