Global Disability Context and Wheelchair Mobility
Original Editor - Naomi O'Reilly as part of the Wheelchair Service Provision Content Development Project
Top Contributors - Naomi O'Reilly
Over a billion people in the world today are estimated to live with some form of disability, which corresponds to about 15% of the world's population or one in seven people. Between 110 million (2.2%) and 190 million (3.8%) people 15 years and older have significant difficulties in functioning, while some 93 million children, or one in 20 of those under 15 years of age live with moderate or severe disability. Furthermore, the rates of disability are increasing in part due to ageing populations and an increase in chronic health conditions, while national patterns of disability are influenced by trends in health conditions and environmental and other factors, such as road traffic crashes, falls, violence, humanitarian emergencies including natural disasters and conflict, unhealthy diet and substance abuse. Women, older people, and poor people are disproportionately affected by disability with children from poorer households, indigenous populations and those in ethnic minority groups also at significantly higher risk of experiencing disability. The prevalence of disability is also greater in lower-income countries than higher-income countries with an estimated 80% of people with disability living in developing or low-resource countries. Disability is extremely diverse. While some health conditions associated with disability result in poor health and extensive health care needs, others do not. 
Disability has been highlighted as a human rights issue in a wide range of international documents including the World Programme of Action Concerning Disabled People (1982), the Convention on the Rights of the Child (1989), and the Standard Rules on the Equalisation of Opportunities for People with Disabilities (1993) and more recently the United Nations Convention on the Rights of Persons with Disabilities (2006) which to date is the most extensive recognition of the human rights of persons with disabilities outlining the civil, cultural, political, social, and economic rights of persons with disabilities. 
United Nations Convention on the Rights of Persons with Disabilities
On 13 December 2006 the United Nations Convention on the Rights of Person with Disabilities (UNCRPD) and its Optional Protocol (A/RES/61/106) was adopted at the United Nations Headquarters in New York, opening for signature on 30 March 2007 and finally entering into force on 3 May 2008, becoming international law. While there are basic human rights that apply to everybody, the UNCRPD focuses on ensuring that everybody recognises that these rights also apply to people with disabilities. Intended as a human rights instrument with an explicit, social development dimension, the UNCRPD "adopts a broad categorization of persons with disabilities and reaffirms that all persons with all types of disabilities must enjoy all human rights and fundamental freedoms, clarifying how all categories of rights apply to persons with disabilities and identifies areas where adaptations have to be made for persons with disabilities to effectively exercise their rights and areas where their rights have been violated, and where protection of rights must be reinforced". Its overall purpose is to “promote, protect, and ensure the full and equal enjoyment of all human rights and fundamental freedoms by people with disabilities and to promote respect for their inherent dignity”.
Disability has increasingly been recognised as both a human rights and development issue following the entry into force of the UNCRPD, with an increasing body of evidence highlighting that people with a disability experience worse socioeconomic outcomes and poverty than persons without disabilities. The UNCRPD advances disability reform legally through direct involvement of people with disabilities through use of a human rights framework. Its core message is that people with disabilities should not be considered “objects” to be managed, but “subjects” deserving of equal respect and enjoyment of human rights.
Despite this recognition scientific information and global awareness of disability continued to be limited, with no agreement on definitions of disability and little internationally comparable information on the incidence, distribution and trends of disability albeit a few documents outlining how individual countries have responded to and developed policies in relation to people with a disability. In response to this situation, the World Health Assembly (resolution 58.23 on “Disability, including Prevention, Management and Rehabilitation”) requested the production of a World Report on Disability based on the best available scientific evidence, which was then produced by the World Health Organization (WHO) in partnership with the World Bank, as previous experience has shown the benefit of collaboration between agencies for increasing awareness, political will and action across sectors.
To find out more detail about the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) click here or to access the United Nations Convention on the Rights of Persons with Disability in it's entirety, click here.
World Report on DisabilityThe World Report on Disability, directed at policy-makers, practitioners, researchers, academics, development agencies, and civil society, published in 2011 by the World Health Organization and the World Bank, amassed a wide range of evidence that, across the globe, people with disabilities have poorer access to health care and poorer health outcomes than nondisabled people, with these disparities more prevalent in low-income contexts, within which most people in the world find themselves. The disparities relate to almost every aspect of health and health care and highlighted that disability may lead to a lower standard of living and poverty through lack of access to education and employment, and through increased expenditure related to disability, which is largely due to the barriers they face in their everyday lives, rather than their disability. 
The International Classification of Functioning, Disability and Health (ICF) adopted as the conceptual framework for this World Report on Disability, understands functioning and disability as a dynamic interaction between health conditions and contextual factors, both personal and environmental (see Box 1.1) and provides a common language and framework for describing the level of function of a person within their unique environment. Promoted as a bio-psycho-social model of disability was it represents a compromise between medical and social models. Disability is the used as the umbrella term for impairments, activity limitations and participation restrictions, referring to the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors). 
The overall aims of the Report were;
- To provide governments and civil society with a comprehensive description of the importance of disability and an analysis of the responses provided, based on the best available scientific information.
- Based on this analysis, to make recommendations for action at national and international levels.
The Report focused on measures to improve accessibility, equality of opportunity; promoting participation and inclusion; and increasing respect for the autonomy and dignity of persons with disabilities. 
Widespread barriers in accessing services, such as those for healthcare (including medical care, therapy and assistive technologies), education, employment, and social services, including housing and transport exist for many people with a disability. In many cases the origin of these barriers relates to inadequate legislation, policies and strategies; the lack of service provision; problems with the delivery of services; a lack of awareness and understanding about disability; negative attitudes and discrimination; lack of accessibility; inadequate funding; and lack of participation in decisions that directly affect their lives. 
Specific barriers also exist in relation to persons with disabilities being able to express their opinions and seek, receive and impart information and ideas on an equal basis with others and through their chosen means of communication , which overall contribute to the disadvantages experienced by people with disability. But many of the barriers they face are avoidable and the disadvantage associated with disability can be overcome. The World Report on Disability outlines the following cross-cutting recommendations linked to detailed implementation actions suggesting steps for all stakeholders, including governments, civil society organizations and disabled people’s organizations, to create enabling environments, develop rehabilitation and support services, ensure adequate social protection, create inclusive policies and programmes, and enforce new and existing standards and legislation, to the benefit of people with disabilities and the wider community with people with disabilities as central actors to these endeavors. 
- Enable access to all mainstream systems and services
- Invest in specific programmes and services for people with disabilities
- Adopt a national disability strategy and plan of action
- Involve people with disabilities
- Improve human resource capacity
- Provide adequate funding and improve affordability
- Increase public awareness and understanding
- Improve disability data collection
- Strengthen and support research on disability 
To read more detail about the International Classification of Functioning, Disability and Health click here or to access the International Classification of Functioning, Disability and Health in it's entirety, click here.
Global Disability Action Plan 2014 - 2021
It called for Member States to remove barriers and improve access to health services and programmes; strengthen and extend rehabilitation, assistive devices and support services, and community-based rehabilitation; and enhance collection of relevant and internationally comparable data on disability, and research on disability and related services, which if achieved better enables all people with a disabilitiy, from birth to old age, to fulfil their aspirations in all aspects of life. 
The vision of the action plan is a world in which all persons with disabilities and their families live in dignity, with equal rights and opportunities, and are able to achieve their full potential with the overall goal being to contribute to achieving optimal health, functioning, well-being and human rights for all persons with disabilities. 
The action plan has the following three objectives:
- to remove barriers and improve access to health services and programmes;
- to strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation; and
- to strengthen collection of relevant and internationally comparable data on disability and support research on disability and related services. 
Rights to a Wheelchair
It is estimated that there are 65 million people globally who would benefit from a wheelchair but currently up to 20 million of these people do not have access to them. The prevalence of wheelchair use is rising, in part due to the aging of the population. Of the wheelchairs in use in highly developed parts of the world, about 70% are manual wheelchairs, with the remainder divided about equally between powered wheelchairs and scooters. Both the United Nations and the World Health Organisation recognizes and acknowledges that poor access to assistive technology including wheelchairs is a critical problem that needs to be addressed.
Article 20 of the UNCRPD provides for the right to personal mobility, which is means the means and ability to move in a manner, at a time of one’s own choice. It affirms that "States Parties shall take effective measures to ensure personal mobility with the greatest possible independence for persons with disabilities", which is a commitment to provide mobility aids, such as wheelchairs, that make personal mobility possible. This key international declarations create rights to wheelchairs because it is universally recognized that an appropriate wheelchair is a precondition to enjoying equal opportunities and rights, and for securing inclusion and participation. 
Article 20 - Personal Mobility 
|States Parties shall take effective measures to ensure personal mobility with the greatest possible independence for persons with disabilities, including by:
Wheelchairs and wheelchair services are critical to ensure people with mobility impairments have personal mobility. Wheelchair Service Personnel can help to implement Article 20 of the UNCRPD by: 
- Provision of an appropriate wheelchair for wheelchair users who access their service;
- Development of adequate training for wheelchair users to learn how to use their wheelchair effectively including transfers, propulsion, and maintenance enabling them to be as independent as possible for the individual;
- Educate family members to support wheelchair users to be as independent as they can be.
- Action 2.2 provide adequate financial resources to ensure the provision of appropriate assistive technology
- Action 2.3 develop and maintain a sustainable workforce for rehabilitation and habilitation as part of a broader health strategy
- Action 2.5 make available appropriate assistive technologies that are safe, of good quality and affordable
- Action 2.5 promote access to a range of assistance and support services and support independent living and full inclusion in the community
Independent mobility and access to assistive technology makes it possible for people to study, work, participate in cultural life and access health care. Without wheelchairs, people may be confined to their homes and unable to live a full and inclusive life. It is a vicious circle: lacking personal mobility aids, people with disabilities cannot leave the poverty trap. They are more likely to develop secondary complications and become more disabled, and poorer still. If they are children they will be unable to access the educational opportunities available to them, and without an education they will be unable to find employment when they grow up and will be driven even more deeply into poverty.
Personal mobility and access to assistive technology are an essential requirement to participating in many areas of social life, and wheelchairs are for many the best means of guaranteeing personal mobility. With an appropriate wheelchair, people with mobility impairments can more easily access and enjoy many of the other human rights outlined in the UNCRPD including; 
- Living independently and being included in the community (Article 19) ;
- Right to education (Article 24);
- Right to the enjoyment of the highest attainable standard of health (Article 25);
- Right to work and employment (Article 27);
- Right to participate in political and public life (Article 29);
- Right to participate in cultural life, recreation, leisure and sport (Article 30).
Disability is not only a public health issue, but also a human rights and development issue. WHO’s efforts to support Member States to address disability are guided by the overarching principles and approaches reflected in the WHO Global Disability Action Plan 2014-2021, the World Report on Disability, and the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). While many countries have started taking action to improve the lives of people with disabilities, much remains to be done. The evidence in the World Report on Disability suggests that many of the barriers people with disabilities face are avoidable and that disadvantages associated with disability can be overcome. The report calls on governments to review and revise existing legislation and policies for consistency with the United Nations Convention on the Rights of Persons with Disabilities (CRPD) and to develop national disability strategies and action plans.
Access to good quality and affordable assistive products has been mandated by the Convention on the Rights of Persons with Disabilities (CRPD) for ten years but still only 10% of people in need of assistive products have access to them. If this urgent need is not addressed, the percentage of people with access will decrease, as demand increases and access to services remains stagnant. The need is acute everywhere, especially in low-and middle-income countries.
- World Health Organization. WHO Global Disability Action Plan 2014-2021: Better Health for all People with Disability. World Health Organization; 2015. Available at: http://apps.who.int/iris/bitstream/handle/10665/199544/9789241509619_eng.pdf?sequence=1 (accessed 12 June 2018)
- World Health Organisation. World Report on Disability 2011. World Health Organisation. Geneva. 2011. Available at; http://www.who.int/disabilities/world_report/2011/en/ (accessed 2 June 2018)
- Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle. Wheelchair Service Training Package - Reference Manual for Participants - Basic Level. Section A. Core Knowledge.World Health Organization, Geneva. 2012
- United Nations. Convention on the Rights of Persons with Disabilities – Articles. Available at;https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities/convention-on-the-rights-of-persons-with-disabilities-2.html (accessed 2 May 2018)
- The International Classification of Functioning. Disability and Health. Geneva, World Health Organization, 2001.
- Sykes C. Health Classifications 1 - An introduction to the ICF. WCPT Keynotes. World Confederation for Physical Therapy. 2006.
- The ICF: AN Overview Available at https://www.wcpt.org/sites/wcpt.org/files/files/GH-ICF_overview_FINAL_for_WHO.pdf (accessed 17 June 2018)
- The International Classification of Functioning. Disability and Health. Geneva, World Health Organization, 2001.
- Bickenbach J. The World Report on Disability. Disability & Society. 2011 Aug 1;26(5):655-8.
- World Health Organisation. Better Health for People with Disabilities: Infographic. http://www.who.int/disabilities/infographic/en/ (accessed 2 June 2018).
- William Armstrong, Johan Borg, Marc Krizack, Alida Lindsley, Kylie Mines, Jon Pearlman, Kim Reisinger, Sarah Sheldon. Guidelines on the Provision of Manual Wheelchairs in Less Resourced Settings. World Health Organization; Geneva: 2008.
- Tebbutt E, Brodmann R, Borg J, MacLachlan M, Khasnabis C, Horvath R. Assistive Products and the Sustainable Development Goals (SDGs). Globalization and Health. 2016 Dec;12(1):79.