Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries.

The one billion people living with disabilities globally already face a heightened risk of poverty, which will likely be exacerbated by the COVID-19 pandemic unless interventions to address its economic impacts are disability-inclusive. This paper draws on the literature on disability, poverty and social protection in low- and middle-income countries to explore the pathways through which the current pandemic may increase the risk of poverty amongst people with disabilities, such as loss of income from disruptions to work, particularly in the informal sector, and higher future spending and productivity losses from disruptions to healthcare and other key services (e.g. rehabilitation, assistive devices). It also explores how social protection and other initiatives to mitigate the economic impacts of the pandemic should consider the needs of people with disabilities, with recommendations for disability-inclusive actions in the design and implementation of eligibility criteria and application procedures, as well as the delivery and content of benefits. Across recommendations, meaningful consultations with people with disabilities, leadership at the program and policy level, appropriate budgeting and monitoring of progress through routine collection of data on disability are key for improving access to and impact of economic responses amongst people with disabilities.

The COVID-19 pandemic and strategies essential for its containment are resulting in severe strains on economies, particularly in low- and middle-income countries (LMICs) (IMF, 2020b). These impacts will be felt most by groups already in or at risk of poverty, including the estimated one billion people with disabilities globally (Kuper et al., 2020). Interventions to address the short- and long-term economic effects of the pandemic are urgently needed. However, people with disabilities, defined by the United Nations’ Convention on the Rights of Persons with Disabilities (UNCRPD) as “those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others” (United Nations, 2006), are likely to be excluded if these responses are not disability-inclusive in design and implementation (Kuper et al., 2020).

This paper draws on research on disability, poverty and social protection in LMICs. It highlights the pathways through which the current pandemic may increase the risk of poverty amongst people with disabilities, and suggests how social protection and other economic responses should consider the needs of people with disabilities.

How the COVID-19 pandemic may increase the risk of poverty amongst people with disabilities

The COVID-19 pandemic has led to economic pressures for many households, which may disproportionately affect people with disabilities and their households.

Notably, the pandemic has resulted in massive disruptions to the labor market. A rapid survey of over 5,000 households in Bangladesh found 63% of people had been rendered economically inactive and weekly income had dropped by almost 80% amongst poor households since the start of the pandemic (Rahman & Matin, 2020). Households with members with disabilities tend to have fewer working members to offset income losses if one or more members lose work, as people with disabilities are more likely to be un- or underemployed and other household members may forgo work to provide caregiving support (WHO & World Bank, 2011). For example, a survey of people with physical impairments in Jordan found that 58% lived in a household with a single income earner pre-pandemic, of which 78% had lost their jobs due to COVID-19 restrictions (Humanity & Inclusion, 2020). Further, people with disabilities – particularly women with disabilities – are more likely work in the informal sector (Mizunoya & Mitra, 2013), which lacks job security and financial protections such as unemployment insurance or paid sick and carer leave. People with disabilities may also take longer to re-enter the workforce after restrictions are eased, as factors such as stigma of disability, inaccessible environments and poor access to education and training limit job opportunities (WHO & World Bank, 2011).

Additionally, many of the health and social services that people with disabilities require (e.g. rehabilitation, assistive devices, care for chronic conditions, psychiatry, medications, personal assistance) have been disrupted due to COVID-19. For example, there is concern that restrictions in China led to poor access to mental healthcare, particularly for older adults and people unable to access telehealth services (Yang et al., 2020). Disruptions to needed services can results in deteriorating health, which may lead to higher future healthcare spending and immediate and long-term losses to functioning and productivity (Shakespeare et al., 2018).

Finally, people with disabilities and their households often have fewer coping mechanisms for managing economic stressors, as many are already living in poverty. Numerous studies conducted pre-pandemic found people with disabilities have lower incomes and savings, weaker social networks, fewer assets and a heightened risk of food insecurity compared to people without disabilities (Banks et al., 2017, WHO & World Bank, 2011). People with disabilities also incur disability-related extra costs – such as for assistive devices, health services, accessible transportation and personal assistance – that lower their disposable income (Mitra et al., 2017).

Considerations to promote disability-inclusion in responses to the economic toll of COVID-19

Some countries have begun implementing interventions addressing the economic impacts of COVID-19, such as food assistance, emergency cash transfers, unemployment assistance or expansions to existing social protection programs (IMF, 2020a). As these programs are developed, it is important to ensure their design and delivery is inclusive of people with disabilities.

Eligibility criteria

Programs must consider whether their targeting strategies are disability-inclusive. For example, many interventions target people living in poverty using means-testing (income thresholds to determine poverty) or proxy-means-testing (household or individual characteristics to predict poverty). However, means-testing often underestimates poverty among people with disabilities by not accounting for extra costs of disability (Banks et al., 2016, Gooding and Marriot, 2009): incorporating even conservative estimates of disability-related extra costs increased the proportion of people with disabilities who were considered poor by 3.7 percentage points (pp) in Vietnam (Braithwaite & Mont, 2009), 9.7 pp in Bosnia and Herzegovina (Braithwaite & Mont, 2009), and 18.4 pp in Cambodia (Palmer et al., 2019). Similarly, proxy means-testing often has exclusion errors that are particularly biased against people with disabilities and older adults (Kidd, 2017).

Some programs explicitly target people with disabilities. For example, Georgia, Mexico, Mongolia, Lesotho, Tunisia and São Tomé and Principe plan to implement new or expand existing disability-targeted social assistance schemes in their COVID-19 response (IMF, 2020a). However, determining who is disabled is methodologically and logistically challenging (Mactaggart et al., 2016, Mont et al., 2019). Many disability assessments require clinical documentation of impairments, which is not in line with the conceptualization of disability espoused by the UNCRPD (Mont et al., 2019, Walsham et al., 2019) and, particularly during COVID-19, may be difficult to conduct when health services are limited. Further, some schemes only include people with very severe disabilities, such as people requiring full-time caregiving or deemed unable to work - excluding the much larger group of people with more moderate disabilities, who often have a high need for social protection (Banks et al., 2016, Gooding and Marriot, 2009). Functioning-based assessments of disability, involving trained community informants, may be an effective and rapid method for identifying people with disabilities for social protection and other assistance, particularly during the COVID-19 pandemic.

Finally, COVID-19 programs that are not coordinated with other social protection schemes risk the exclusion of people with disabilities. For example, some countries do not allow the receipt of multiple forms of social protection (Banks, 2019), which could limit access for recipients of other schemes (e.g. disability-targeted cash transfers or Old Age Pensions) who require additional support to cope with the economic effects of COVID-19.

Application procedures

Previous studies have found many people with disabilities are not enrolled in schemes they are eligible for. For example, coverage of disability-targeted programs was 40% in Cam Le, Vietnam (Banks, Walsham, Minh, et al., 2019), 25% in the Maldives (Hameed et al., 2020), and 13% in Tanahun, Nepal (Banks, Walsham, Neupane, et al., 2019). Similarly, studies of non-disability targeted program in Peru and Tanzania found low levels of enrolment amongst eligible people with disabilities despite high levels of poverty (Bernabe-Ortiz et al., 2016, Kuper et al., 2016).

Common barriers to enrolling in social protection schemes should be considered when developing COVID-19 interventions. Frequent challenges include: poor awareness of available program, lack of accessible information and communication (e.g. Braille, screen-reader compatible, sign language), misconceptions and stigma of disability amongst staff, urban-based and physically inaccessible application points, and financial and administrative difficulties gathering necessary documentation, particularly for medical assessments of disability (Banks et al., 2016, Banks, Walsham, Minh et al., 2019, Banks, Walsham, Neupane et al., 2019, Mitra, 2005).

Adaptations to enrolment procedures may help support the inclusion of people with disabilities. For example, in some districts of Nepal, Disabled Peoples’ Organizations were credited with improving enrolment in disability-targeted programs, as they provided their members with accessible information about available schemes, helped with applications, and worked with assessment panels to improve their understanding of disability (Banks, Walsham, Neupane, et al., 2019). Further, decentralization and streamlining of application processes was credited with increasing enrolment in disability-targeted programs in Vietnam (Banks, Walsham, Minh, et al., 2019).

Delivery of benefits

Previous studies highlight that people with disabilities can face challenges receiving social protection benefits once enrolled, due to difficulties reaching delivery points or unpredictable delivery schedules (Gooding & Marriot, 2009). COVID-19 is altering delivery mechanisms in some countries, such as in the Gambia, Morocco and Togo, where cash transfers are being distributed through mobile applications (IMF, 2020a). These strategies may improve access to benefits for some recipients, particularly those who would struggle to travel to delivery points. However, it is important that delivery methods – and information on how to use them – are accessible to people with sensory impairments and that alternatives are available for people without access to mobile technology.

Additionally, many people with disabilities have limited control over their entitlements, which may limit their impact. For example, approximately a third of adult recipients of disability-targeted cash transfers in Vietnam, Nepal, and the Maldives reported that their allotment was controlled fully by others in their household (Banks, 2019, Hameed et al., 2020).

Adequacy and relevance

COVID-19 economic responses must be relevant to people with disabilities. For example, temporary employment schemes often focus on unskilled manual labor, which is not suitable for many people with physical impairments. Similarly, unemployment insurance is typically limited to the formal sector, which would exclude many people in LMICs, particularly people with disabilities given their overrepresentation in this sector. Encouragingly, several countries such as Brazil, Cabo Verde, the Dominican Republic, Georgia, Honduras, Indonesia, Lesotho, Mauritius, Sudan, and Togo have announced plans for expanding financial assistance to cover unemployed informal sector workers (IMF, 2020a).

Although evidence is limited, existing social protection programs have often shown only limited impact in protecting people with disabilities from poverty (Banks et al., 2016). For example, impact evaluations of regular cash transfer schemes in the Maldives and Lesotho found that recipients with disabilities experienced modest benefits, particularly in health; however, a large proportion of recipients were still living in poverty and were much poorer compared to people without disabilities (de Groot et al., 2020, Hameed et al., 2020). Impact may be even less for one-off emergency payments.

To improve the adequacy of COVID-19 economic responses, people with disabilities may require adjusted benefit packages. For example, the amount provided should consider the effect of high levels of poverty and extra costs of disability combined with low availability of alternative coping strategies on people with disabilities’ ability to meet basic needs. Further, interventions may be required to address the specific concerns of people with disabilities during the COVID-19 pandemic, such as access to disability-related health and social services during restrictions.

Responses must also consider both the financial and non-financial barriers people with disabilities face in meeting their basic needs and improving their livelihoods. While cash transfers are important, people with disabilities often face additional non-financial barriers – what Sen & Nussbaum call “conversion handicaps” under the capability approach (Nussbaum & Sen, 1993) – that impede the translation of economic resources into needed goods and services. For example, people with physical impairments who receive cash transfers may not be able to purchase food if shops that are open during COVID-19 restrictions are inaccessible or far away with no accessible transport, they rely on personal assistance or delivery services that are no longer available, they face stigma from shopworkers or other customers, or they have underlying health conditions that require stricter adherence to social distancing. Complementary activities targeting these and other non-financial barriers are essential for improving the effectiveness of COVID-19 responses.

Conclusion and recommendations

People with disabilities will be disproportionately affected by the economic implications of the ongoing COVID-19 pandemic unless responses are disability-inclusive. Key challenges and recommendations for their resolution are described in Table 1 . To support these recommendations, meaningful consultations with people with disabilities, leadership at the program and policy level, appropriate budgeting and monitoring of progress through routine collection of data on disability is required throughout . Many recommendations will be beneficial to people without disabilities (e.g. reforming complex application procedures, benefit packages). Consequently, creating disability-inclusive responses may not just reduce inequalities, but also improve programs for all recipients.

Table 1

Summary of key challenges hindering disability-inclusive economic responses and recommendations for their resolution.

	Challenge	Recommendations
Eligibility criteria	Means-testing and proxy-means testing underestimates poverty amongst people with disabilities	• Raise poverty thresholds for applicants with disabilities to account for disability-related extra costs and/or address disability-related costs through separate programs
	Disability assessments for disability-targeted programs are resource intensive and exclude many people with disabilities	• Ensure definition of disability and assessment procedures are UNCRPD compliant (e.g. functioning-based rather than impairment-based) • Train community informants to conduct assessments rather than relying on medical personnel
	People with disabilities may be ineligible to receive COVID-19 related interventions if they are already recipients of another social protection program	• Coordinate new COVID-19 related programs with existing social protection programs
Application procedures	Application process is not accessible	• Ensure information about the program and application materials are available in accessible formats (e.g. Braille, screen-reader compatible digital materials, simplified texts and recordings) • Adapt application facilities so they are physically accessible • Involve DPOs in the dissemination of information about programs and in reviewing the accessibility of application procedures
	Application process is time-consuming and expensive, particularly for people with disabilities	• Decentralize and streamline the application process to limit long and frequent travel (e.g. community-based registration drives) • Provide accommodations to reduce difficulties reaching application points (e.g. home-based assessments for people with mobility limitations unable to travel to application points with available public transportation)
	Misconceptions and stigma of disability lead to the exclusion of people with disabilities	• Train program staff on disability and provide needed supports (e.g. sign language interpretation, accessible informational materials) for effective consultations
Delivery of benefits	Delivery methods are not accessible	• Ensure mobile platforms are accessible for people with visual impairments (e.g. phone-based applications are screen-reader compatible) and alternatives are available for people who lack required technology • Ensure delivery points are physically accessible and nearby; offer accommodations (e.g. pick-up by a nominated individual)
	People with disabilities have little control over the benefits they receive	• Transfer benefits directly to the recipient except in clearly defined circumstances (e.g. children, people with severe intellectual/cognitive impairments, where requested by the recipient)
Adequacy & relevance	Programs are not relevant to many people with disabilities	• Consider the needs and situation of people with disabilities when designing benefit packages and offer adaptations (e.g. temporary employment schemes with alternatives to manual labor, unemployment insurance covering the informal sector)
	Benefit packages are insufficient to meet intended aims, particularly for recipients with disabilities	• Adjust benefit packages for people with disabilities (e.g. higher benefit levels to cover both extra costs and high levels of poverty; disability-specific benefits such as access to disability-related health and social services) • Consider the financial and non-financial barriers people with disabilities face to meeting basic needs and coordinate with other sectors/actors to develop complementary or adapted interventions (e.g. food delivery where purchasing food is challenging)

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.