**4.2 National health insurance scheme**

The National Health Insurance Scheme (NHIS) was established from the National Health Insurance in 2003 under Act 650. Act 852 replaced Act 650 in 2012 to strengthen the management and effective administration of the NHIS. The principal aim of the NHIS is to guarantee access to healthcare for all Ghanaian residents. Persons exempted from paying premium include "pregnant women, indigents, categories of differently-abled persons determined by the Minister responsible for Social Welfare, persons with mental disorder, Social Security and National Insurance Trust (SSNIT) contributors and SSNIT pensioners, persons above 70 years of age (older adults) and other categories prescribed by the Minister" ([31], p. 20). Everyone that qualifies for LEAP enrolls on NHIS. For persons with disabilities to enroll free to the scheme, they must qualify as "indigent." Regulation 58 (Section 1) of the legislative instrument (LI 1809) that operationalises the NHIS defines an *indigent* as a persons who is (a) is unemployed and has no visible source of income; (b) does not have a fixed place of residence according to standards determined by the scheme; (c) does not live with a person who is employed and who has a fixed place of residence; and (d) does not have any identifiable consistent support from another person.

The term *indigent* as stated in the NHIS policy is also vague thus, given frontline workers liberty to use their discretion to enroll who they believe is *indigent*. For example, what does it mean not to have a fixed place of residence because in Ghana many people live in their family houses or with family members? And how can PWDs who are more likely to be poor afford to pay the premium of GH 72-approximately US\$11.64?

## **4.3 District Assembly Common Fund (DACF)**

The District Assembly Common Fund (DCAF) for Persons with Disabilities is the only intervention that specifically targets PWDs. The DCAF seeks to minimise poverty among PWDs in the informal sector [32]. The government of Ghana in 2005 gave a directive instructing all district assemblies to allocate up to 5% of their shares of the District Assembly Common Fund for PWDs. In 2007, the government in its quest to support development of PWDs, added a *ring-fencing* clause to the guidelines for the utilisation of the District Assembly Common Fund. Part I, guideline #6 of the DACF states that, "two percent (2%) shall be utilized to support initiatives by the physically challenged in the district." The government increased the required DCAF percentage to 3% in 2018. An effort hailed by everyone, especially persons with disabilities, their families and their organisation.

Ghana's initial report to the United Nations Convention on the Rights of Persons with Disabilities (CRPD) in 2018, indicates that approximately GH 85.5 million Ghana cedis was disbursed to MMDAs to support persons with disabilities between 2013 and 2017 [26]. This is commendable. But the multimillion question is, how many persons with disabilities enjoyed this support and how does the DCAF for persons with disabilities meaningfully impact their lives? There is evidence that not every person with a disability who needed the DCAF support benefits, and the amount of money that beneficiaries received is inadequate and does not guarantee meaningful and sustainable impact on their lives [33]. Attitidinal and environmental barriers were identified as hindrances to accessing DCAF for PWDs.

#### **4.4 Community based rehabilitation (CBR) programme**

The CBR programme was introduced to improve the quality of life of PWDs. CBR aims at integration and equalisation of opportunities for PWDs in the community by establishing community-based programmes and rehabilitation services. CBR emphasis on community involvement, PWD should live in their own communities and get the resources required for full participation in the community [34, 35]. The programme was initially funded by the Norwegian Association of the Disabled (NAD) and the Swedish Handicap Organization from 1992 to 1999. After 1999, the United Nations Development Programme (UNDP) expanded the projected national coverage of CBR from 1999 to 2002 [36]. The CBR programme provides home-based rehabilitation services delivered by family members of PWDs, with the support of trained volunteer local supervisors. After the funding of the programme from its external donors ceased, each community was required to mobilize local community resources to support and sustain the activities of CBR programme, which has become a challenge for the continuation of CBR in Ghana.

### **4.5 Educational/training institutions**

There are educational institutions that provide specialized services to PWDs to promote successful integration and inclusion in mainstream society. There are two specialized schools for persons with visual impairment, ten basic schools and a secondary school for persons with hearing impairment and three assessment centres [37]. For people with mental disabilities, there are seven regional mobile centres for children with learning difficulties and other development problems and nine schools for persons with mental disabilities. Boarding schools for persons with mental disabilities in Echoing Hills and the Autism Awareness Care and Training Centre provides training for autistic children. There are 38 National Vocational Training (rehabilitation) centres across the country that serves the populace but only 10 focuses mainly PWDs.

It is noteworthy that, although these institutions do not require payment of school fees, there is anecdotal evidence that students provide most of the necessities including, toiletries, school uniforms and some food items. The assessment centres also require payment for services provided. Social workers can play diverse roles to ensure that persons with disabilities receive better services.

#### **4.6 Social work leadership in the field of disability**

Social workers can undertake different leadership roles, especially at messo and macro levels, to promote disability rights in Ghana. At the messo-level, social workers could take up leadership roles in rehabilitation teams in hospitals and communitybased rehabilitation team-where they exist, community planning teams, boards of nongovernment organisations and civil society organisations working for and with persons with disabilities. At the messo level, social workers could occupy leadership positions in departments where decision making happen. Disabilities issues cut across several sectors of the society, including education, transport, healthcare, social welfare, and employment. Social workers could advice on disability inclusion and advocate for services for persons with disabilities.

At the macro level, Ghanaian social workers could engage policy decision-making, lobbying and advocacy [38]. They could lobby for effective and efficient implementation of existing policies, advocate for policies and programmes that could promote disability rights and/or for the representation of persons with disabilities in decisionmaking, especially on interventions and issues relating to them. Currently, there is little representation of person with disabilities on boards/committees making decisions about their lives [39].
