Disability inclusion in African health systems’ responses during COVID-19: A scoping review

Background People with disabilities often experience poorer access to healthcare because of multiple barriers even in non-crisis times, especially more so in low- and middle-income countries. The coronavirus disease 2019 (COVID-19) pandemic significantly constrained health systems, thus exacerbating access barriers. African health system responses to, and considerations made for people with disabilities during the pandemic have not been adequately examined to inform future inclusive practices during emergent and non-emergent periods. Objectives This review aimed to explore disability considerations and accommodations included by African governments in their health systems’ responses during the COVID-19 pandemic. Method A scoping review was carried out of peer-reviewed published articles on the Web of Science, Academic Search Premier, MEDLINE, Africa-Wide Info, and CINAHL databases. A desktop search of African government websites for COVID-19 country plans and reports was also conducted. Deductive thematic analysis of included texts was performed to identify disability inclusiveness in the health responses. Results Ten peer-reviewed articles and three COVID-19 country plans or reports were included in the review. Data reflected a general finding that included countries that failed to effectively consider and include the healthcare needs of persons with disabilities during the pandemic. Conclusion Poor inclusion of persons with disabilities was effected in healthcare systems’ responses during COVID-19 in Africa. Contribution This article contributed insights about gaps in healthcare systems’ responses and highlighted development foci that could improve systems towards greater inclusivity of persons with disabilities’ health needs in low- and middle-income countries.


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Introduction
People with disability are often excluded from policy actions during emergency responses to crises situations (McKinney, McKinney & Swartz 2020;Ned et al. 2020;Toquero 2020).Prior to the coronavirus disease 2019 (COVID-19) pandemic, studies of disaster risk frameworks showed that people with disabilities are not explicitly considered in such frameworks, despite the adoption of the Sendai Framework Disaster Risk Reduction 2015-2030 that guides inclusive disaster risk responses (Bennett 2020).For example, a study of Indonesian disaster regulation laws found that people with disabilities were not mentioned in higher laws, and were often referred to as 'vulnerable groups' or mentioned with other vulnerable groups (Pertiwi, Llewellyn & Villeneuve 2020:3).With climate change, social instability, and new and emerging infectious diseases likely to cause more global health emergencies as observed during COVID-19, there is a need to continuously examine disaster responses to realise inclusion and rights of people with disabilities.Both the pandemic and its measures for containment, if not inclusive, pose threats to people with disabilities.Thus, more research is needed to explore the inclusiveness of health systems during the COVID-19 pandemic, more so in LMICs (low-and middle income countries) as 80% of the 16% global population with disabilities live in LMICs (World Health Organization [WHO] 2022).
The COVID-19 pandemic caused major disruptions in global health systems and challenged governments and health systems to make quick policy decisions to reduce the virus spread and curb morbidity and mortality associated with the virus (Haldane et al. 2021).Health systems had to ensure availability of hospital beds and staff to deal with the COVID-19 patient loads while Background: People with disabilities often experience poorer access to healthcare because of multiple barriers even in non-crisis times, especially more so in low-and middle-income countries.The coronavirus disease 2019 (COVID-19) pandemic significantly constrained health systems, thus exacerbating access barriers.African health system responses to, and considerations made for people with disabilities during the pandemic have not been adequately examined to inform future inclusive practices during emergent and non-emergent periods.preventing complete health system collapse (Haldane et al. 2021).For example, many countries around the world restricted the use of hospital services by cancelling and rescheduling elective and non-urgent procedures (Desborough et al. 2020;Kendzerska et al. 2021) as well as through diverting other health services and facilities to respond to the pandemic.School closures similarly impacted the health and function of people who received such health services through schools.People with disability were particularly affected by these changes in routine services because many people with disabilities have higher health needs including rehabilitation, medications, and other specialist services (Ned et al. 2020(Ned et al. , 2021)).In addition, some hospitals transitioned to remote services through telemedicine and closed certain wards and units to establish and allocate resources for COVID-19 patients (Desborough et al. 2020;Haldane et al. 2021).Although telemedicine plays a significant role in decreasing extra costs for some, such as travel costs, while also enhancing access for others, its limited availability within public health settings, poor connectivity, as well as an existing digital divide means that it may not be appropriate for a huge section of society in remote settings and for specific impairments.Triage systems were used to prioritise patients for healthcare through considering travel history, severity of COVID-19 symptoms, and patients' risk profile (Kendzerska et al. 2021).Although these systems were effective for optimising human and material resources for COVID-19 patients' care, certain groups of patients such as those who required chronic care were excluded (Kendzerska et al. 2021;Sabatello et al. 2020).People with disabilities constitute one group, which was vulnerable to such exclusionary COVID-19 policies.As such, some people with disabilities faced barriers while attempting to access vaccines including booking appointments, travelling to vaccination sites for vaccines and inaccessibility of such sites (Rotenberg & Nagesh 2021).Sabatello et al. (2020) highlighted three thematic areas of exclusion that mostly affected people with disabilities during the pandemic, namely communication and medical information, reasonable accommodation, and rationing of medical goods and services.In the first place, studies show that many people with disability had challenges accessing health information from governments and health organisations, such as the WHO, because of the lack of accommodations like sign language interpreters and subtitles (Croft & Fraser 2022;Fernández-Díaz, Iglesias-Sánchez & Jambrino-Maldonado 2020).Secondly, many hospitals imposed restrictions that limited the number of visitors, preventing people with disabilities from receiving support from caregivers and/or personal assistants in the absence of reasonable accommodations of their visitor needs (Sabatello et al. 2020).Many hospitals constructed new buildings and/or rearranged existing structures to accommodate the high demand of COVID-19 patients and care.The emergency context under which alternative care structures were developed resulted in a disregard of physical accessibility needs although it was not necessarily regarded as a violation of anti-discrimination laws under emergency circumstances (Sabatello et al. 2020).Insufficient planning in relation to reasonable accommodations led to the exclusion of persons with hearing impairment when transparent face masks for lip-reading were not available during the pandemic (Sabatello et al. 2020).
Thirdly, aspect of exclusion was through rationing of health services and equipment.Triage policies of health systems in many countries specifically excluded people with certain disabilities; for example, one North American state originally excluded people with 'severe or profound mental retardation', moderate to severe dementia, and traumatic brain injury from ventilator treatment during the pandemic (Mello, Persad & White 2020:1).In addition, the reduction of health services to prioritise space and human resources for COVID-19 also severely impacted people with disabilities as they struggled to access routine health rehabilitation services (Agbelie 2023;Lund & Ayers 2022;Tetali et al. 2022).
Disability is not routinely considered when planning for health services (Hunt 2020;Ned et al. 2020).Sabatello et al. (2020) call for improved disability inclusive policies to ensure that people with disabilities who already experience discrimination in accessing services are not further excluded by COVID-19 health policies.Even health systems that responded relatively well to the COVID-19 pandemic had severe shortcomings in relation to disability inclusion.For example, an Australian study found that laws that addressed people who experience multiple exclusion were applicable to people with disabilities, but not specifically for people with disabilities, and thus failed to address the specific needs of people with disabilities (Colon-Cabrera et al. 2021).These laws failed to address the lack of access to healthcare, employment and social care, and unfair discrimination in medical rationing (Colon-Cabrera et al. 2021).A South American analysis found good practices in the articulation of disability specific policies; however, the implementation of these practices was not always adequate (Sakellariou, Malfitano & Rotarou 2020).Challenges identified with the implementation of such policies include discrepancies between national and local government policies, and the benefits not reaching all people with disabilities because of structural barriers (Sakellariou et al. 2020).These findings highlight the importance of not only articulating disability inclusive policies but also ensuring implementation and equity within communities of people with disabilities (Sakellariou et al. 2020).A study conducted in four West African countries also found that the governments' efforts did not adequately address the needs of people with disabilities in the pandemic even though some efforts from these governments were recorded (Aboagye et al. 2022).Similar to the South American study, people with disabilities experienced structural barriers such as being unregistered with government disability agencies (Aboagye et al. 2022).
Disability inclusive policies are even more crucial for people with disabilities in LMIC countries, particularly in Africa, where health systems are strained and under-resourced.Studies pertaining to other systems or ministries than health were also excluded from the review.Where no full text was available of original research, reviews, meta-analyses, and conference abstracts or posters, studies were excluded from this review, as well as studies published before or after March 2020 and December 2022.Studies published in languages other than English were excluded as the review team had limited ability to undertake analysis in other languages.

Study screening, selection, and extraction
All search results were uploaded onto Rayyan.ai, a software package used to organise and conduct reviews.Duplicates were removed before first screening of titles and abstracts, which was performed on Rayyan.ai by three reviewers (L.M., Y.N., L.N.) independently and conflicts were resolved by the third reviewer (L.N.).Excel was further used for bibliographic management, screening, coding, and data synthesis.The reasons for exclusion of articles were recorded.This was followed by a full text screening of all included titles, which was also performed by all three reviewers.Further articles were excluded after full text screening and all reviewers agreed.Reference lists of articles identified by the search were also examined for eligible publications.
A data extraction sheet was developed to record information from reviewed articles, including year of publication, type of literature, target population, scope, and location.The authors further mined for information relevant to the key questions of the review as well as the predetermined themes.Three reviewers performed data extraction.A short summary of each article was produced containing information about the responses, which are reported on.

Analysis
A deductive thematic analysis was performed to provide an overview of different types of healthcare responses, and of how persons with disabilities were prioritised or considered in responses.A thematic framework (see Table 1) was derived from the WHO brief on disability considerations during the COVID-19 outbreak (2020) as well as from the UN brief on disability inclusive responses to COVID-19 (2020), and the documents were analysed according to nine themes.Descriptive analysis explored common themes across the different bodies of evidence to determine similarities, differences, and gaps in the inclusion of persons with disabilities in actions across different healthcare contexts and governments, as well as perceptions of disability inclusive responses during the COVID-19 pandemic across countries.

Ethical considerations
Primary data collection and informed consent procedures were not applicable in this review, but ethics approval for the broad study was obtained from Stellenbosch University Social, Behavioural and Education Research Ethics Committee (REC: SBE), project number 15244.Institutional documents that are part of grey literature are publicly available.

Findings
The results of the search and screening processes for both bodies of literature are presented in the PRISMA flow chart (see Figure 1).The first search produced 2903 peer reviewed articles and 18 country reports for screening.After titles and abstracts were screened, 2882 articles as well as 15 non-English language country reports were excluded.The full text of the remaining 24 articles was assessed, and 16 of these were excluded because of not being health-related or not having a disability focus.The reference lists of full text     • Minister of Social Development stipulated that caregivers had to be available to provide care in residential facilities and for required home-based care services during the lockdown period, including psychosocial support services, which had to be provided to all those infected with or affected by COVID-19.
• The same minister stated that people with disabilities requiring psychosocial interventions had to have access to all prescribed medications and counselling as a minimum requirement for crisis interventions.
• Minister of Justice and Correctional Services stipulated that support should be available to persons with disabilities in all courts, court precincts and justice service points Furthermore, the South African Minister of Communications and Digital Technologies classified services related to digital and broadcasting technologies as essential services in combatting the spread of COVID-19 (Wickenden et al. 2022).
The ministry directed that electronic communications and broadcast licensees support the health sector by, for example, zero-rating Department of Health COVID-19 sites as well as calls to the department's national helpline (Wickenden et al. 2022).The same ministry enabled pharmacies to deliver medical products at home during various levels of lockdown, which included but were not specific to persons with disabilities (Wickenden et al. 2022).
Some evidence suggested that the South African Government engaged disability organisations in working groups and committees who were tasked with developing healthcare responses to the pandemic.(McKinney et al. 2021).No evidence was available about the implementation of recommendations from disability stakeholders.
The pandemic brought a global sense of panic and heightened anxiety and even in the early days of the crisis the emergence of mental health concerns was noticed by health authorities.
Only two countries in this review appeared to have included persons with disabilities to some degree in their healthcare responses in mental health interventions during the pandemic.The South African Minister of Social Development instructed that support from caregivers in residential facilities and/or homes during lockdown periods should include psychosocial assistance to those infected with or affected by COVID-19 during lockdown periods (Wickenden et al. 2022).The same ministry also stipulated that persons with disabilities who required psychosocial intervention should have access to prescribed medication and counselling as a minimum requirement during the crisis intervention period (Wickenden et al. 2022).It is noticed that these directives were not set by the government department who is primarily responsible for mental healthcare services, and as such, these were issued to the Department of Health rather than to service providers directly.Cape Verde's country report stipulated the provision of counselling services to persons with disabilities as a response during the pandemic, including assessing this group's 'mental wellness' (Aboagye et al. 2022:7).
Five reviewed countries showed evidence of efforts to ensure continuity of support services to persons with disabilities during the pandemic.In these countries, caregivers were allowed to continue with service provision to people with disabilities under lockdown restrictions (Aboagye et al. 2022;Wickenden et al. 2022).Additionally, in Senegal, networks were formed in communities to identify persons with disabilities, monitor their well-being, and offer support (Aboagye et al. 2022), and South Africa issued regulations about access to personal assistance for persons with disabilities at various facilities, such as service points and supermarkets (Wickenden et al. 2022).
None of the included countries reported measures to reasonably accommodate persons with disabilities in relation to public health services and restrictions on movement in public spaces.Furthermore, documents included did not address how countries protected people with disabilities from discriminatory decisions around medical resource allocation, apart from Zambia's inclusion of persons with disabilities in vulnerable groups while setting priority plans during the pandemic (Kapiriri et al. 2022).No further information was found in the Zambian document, however, of how this inclusion realised for persons with disabilities.South Africa was the only country that mentioned measures to protect people with disabilities from increased social exclusion through issuing regulations for continued availability of caregivers in residential facilities and home-based environments during lockdown restrictions (Wickenden et al. 2022).Continued psychosocial support services and access to prescribed medications and counselling were also mentioned in regulations to mitigate social exclusion risk for this group.Unrelated to healthcare services, the South African Minister of Justice and Correctional Services issued regulations that permitted support persons to be available in courts, court precincts and justice service points to assist persons with disabilities (Wickenden et al. 2022).In addition, this ministry stated that inmates (including people with disabilities) could be referred to external health facilities only if medical emergencies occurred, circumstances under which access to healthcare may have been denied to inmates with long-term physical and/or mental health disabilities (Wickenden et al. 2022).
Only South African evidence included the protection of people in residential settings in the documents reviewed.The Minister of Social Development stated that a satisfactory assessment from a social worker should be a prerequisite for releasing persons with disabilities from Department of Social Development-operated facilities into different places of accommodation (Wickenden et al. 2022).This review did not find evidence of policy considerations or implementation pertaining to persons with disabilities' access to healthcare systems and services in remote areas during the pandemic.

Discussion
The health and lives of persons with disabilities have been disproportionately affected by the outbreak of the novel coronavirus 2019 and the ensuant pandemic (United Nations 2020).Adversity created by this global crisis had even more severe marginalisation and disadvantageous effects for people with disabilities from low-and middle-income countries (McKinney et al. 2021).This review considered how countries on the African continent included persons with disabilities in the responses of their healthcare systems during the pandemic.
The most consistent evidence found in this review was in the sampled countries' promotion of access to public health information through the provision of sign language interpretation during visual broadcasts of COVID-19-related information and precautions.Although not all countries reported such inclusion measures, the ones who did may have http://www.ajod.orgOpen Access mitigated the isolating effect of the pandemic for sign language users through their attention to alternative and/or augmented means of communication.The availability of and existing infrastructure to support sign language interpretation may have been seamlessly applied for the use of pandemic informationsharing because of these services having been operational before the crisis.Promoting access through other means, however, that accommodated the entire range of communication impairments, was not stipulated and may have resulted in exclusion of persons with disabilities, and also where broadcasting and digital accessibility were limited or unavailable.The omission or under serving of persons with disabilities in healthcare extended to their exclusion from targeted mental health interventions during the pandemic and in its wake.
Mental health concerns during COVID-19 related not only to care and intervention for persons with existing mental health conditions but also to health system planning to handle a 'second pandemic' of mental health crises as a result of the COVID-19 pandemic (Choi et al. 2020:340;Kola et al. 2021).
Countries included in the review, furthermore, generally failed to plan for the protection of people with disabilities in residential settings, and the healthcare needs of persons with disabilities living in rural areas.Rurality, in African countries that form part of the Global South, is known to create an intersection with disability that intensifies the disadvantages and exclusion of this group in healthcare systems (Ned et al. 2020).Overall, evidence from this review confirms that sampled African states failed to effectively include the needs of persons with disabilities in health system responses to the emergency of COVID-19.Where inclusions were specified, the implementation of these fell short and left persons with disabilities more exposed, vulnerable, and excluded from healthcare than non-disabled counterparts.

Limitations of this review
Grey literature from African countries, that may have been relevant to this scoping review, was not included when only available in languages other than English.This may have limited the reflection of evidence to report on from non-English speaking African countries.The inclusion of grey literature, however, served only to expand on and supplement the peer review articles that were eligible for inclusion because of the limited number of articles found.

Implications and recommendations
Sakellariou and colleagues make the important point that legislation and policy afford legal recognition and protection of the rights of people with disabilities, even if they do not always prevent discrimination against this group (2020).As such, the significance of inclusive laws, policy frameworks, and regulations to direct health system responses during emergencies should not be underestimated, and gaps in such laws need to be addressed.Regulations that are promulgated in the context of emergencies or disasters must be interpreted in order to be applied by those who implement them (Wickenden et al. 2022).It would follow that service providers' knowledge and understanding of disability inclusion are crucial to the effective implementation of inclusive healthcare policies in practice.
This review has shown that, although governments in some instances heeded the principles of including and collaborating with organisations of people with disabilities to address and plan appropriately inclusive emergency responses, these occasions were insufficient and took place too late for effective implementation to run its course.Moreover, no evidence of outcomes or monitoring and evaluation reporting is available to ascertain what impact these deliberations had on healthcare inclusion, if any.Government and policymakers should therefore strengthen and incorporate collaborative relationships with organisations that represent people with disabilities to consistently influence planning forums at regional, local, and national government levels during and beyond emergency contexts.
Access to public health information should now move beyond governments' standard response to communication impairments (such as sign language interpretation during visual broadcasts) and incorporate universal design principles to bolster sophisticated communication means in all 'sensory channels' (Wickenden et al. 2022:13).As such, attention should be paid to creating access to information for, for example, persons who do not read, or who require texts or messages to be shortened or simplified for comprehension.

Conclusion
From this review of a sample of African countries' health system responses to the inclusion needs of persons with disabilities during the COVID-19 pandemic, it is concluded that an overall poor inclusion response was stipulated.
Countries appear to have been most responsive in terms of creating access to health information, and most neglectful in stipulating reasonable accommodation measures to equalise health system access and services to persons with disabilities.
This review shows areas of concern and priorities where governments should develop health inclusive efforts in existing and future health systems that could address the needs of persons with disabilities as equal citizens during and beyond health emergencies.

•
Minister of Social Development agreed that when a person with disability was to be released from department of social development (DSD)-operated facilities, such as high care facilities in old age person (OAP) homes, as well as drug and alcohol rehabilitation centres, a social worker should have been satisfied with regard to the state of readiness of the place that will So far research that examines African governments' health system responses in a holistic way is scarce.Aside from the study performed by Aboagye and colleagues of four West African countries (2022), there are no published holistic examinations of broader health system and policy responses from this context.The majority of available studies focus on specific aspects and experiences of people with disabilities, country plans that described any type of government healthcare responses or other measures regarding COVID-19 for persons with disabilities (e.g., accessible public health information and communication) that were published or promulgated between March 2020 and December 2022 in the different African countries.This included any considerations or accommodation in relation to healthcare targeted at people with disabilities by governments across all African countries.Coronavirus disease 2019 legislation, policy documents, and reports from the non-governmental sector (NGOs) were excluded but addressed in a separate study. http://www.ajod.orgOpenAccess

TABLE 1 :
(Badu, Agyei-Baffour & Peprah Opoku 2016)bility-inclusive response to COVID-19.Mohamed et al. 2022).While not directly from the Ministry of Health, the South African Department of Basic Education published health-related guidelines for the prevention of the spread of the virus during the phased return to school for learners with different types of impairments(Wickenden et al. 2022).Only South Africa appeared to have issued safety precautions related to persons with specific impairments, namely visual impairments(Lugo-Agudelo et al. 2022).Although access to healthcare is a human right, barriers to equitable healthcare remain one of the major challenges to people with disabilities(Badu, Agyei-Baffour & Peprah Opoku 2016).The COVID-19 pandemic intensified the nature of challenges that people with disabilities experienced in accessing healthcare services.Five countries in this review responded in varying degrees to this principle, while other countries did not reflect any specific responses to ensuring healthcare access for persons with disabilities.Zambia and Nigeria grouped citizens with disabilities together with other vulnerable groups, giving them access to social and humanitarian means in these countries (Presidential Task Force 2021; Republic of Zambia 2020).No further information was available, however, about the operationalisation priority measures for people with disabilities.
Source: Adapted from World Health Organization, 2020, Disability considerations during the viewed23 January 2023, from https://iris.who.int/bitstream/handle/10665/332015/WHO-2019-nCov-Disability-2020.1-eng.pdf?sequence=1;United Nations, 2020, Policy brief: A disability-inclusive response to COVID-19, United Nations, from https://www.un.org/sites/un2.un.org/files/2020/05/sg_policy_ brief_on_persons_with_ disabilities_final.pdf;Sakellariou, D., Malfitano, A.P.S. & Rotarou, E.S., 2020, 'Disability inclusiveness of government responses to COVID-19 in South America: A framework analysis study', International Journal for Equity in Health 19, 1-10.https://doi.org/10.1186/s12939-020-01244-xorg/10.1186/s12939-020-01244-xCOVID-19, coronavirus disease 2019; PWD, people with disabilities; WASH, Water, Sanitation, and Hygiene.http://www.ajod.orgOpen Access Findings were primarily reported in descriptive form and reflected analyses of how disability-inclusive African government responses were to the COVID-19 pandemic.It was interesting to see that the included articles were pointing out gaps and challenges and offered suggestions and recommendations, rather than documenting what the governments are doing in response to shortfalls.Table 2 presents the government responses in each country.(PPE).Nigeria, Tanzania, Ghana, and Cape Verde included the provision of PPE to people with disabilities in their documented responses to the pandemic (Aboagye et al. 2022; Mohamed et al. 2022).Researchers reported, however, that not all Tanzanians with disabilities received face masks and sanitiser (Allowance, was made available from June 2020 to October 2020 to caregivers of children, but not to those who cared for persons with disabilities (Wickenden et al. 2022).Reviewed documents did not report regulations pertaining new disability grant applicants and how such applications were processed during lockdown restriction periods and thereafter.http://www.ajod.orgOpen Access
Comprehensively inclusive guidelines exist in the global arena to direct disability-related policy and implementation efforts, for example, the UN Policy Brief for a disability-inclusive response to COVID-19 (United Nations 2020), UNESCO's reference report on policy responsiveness during COVID-19 and best practice guidelines (UNESCO 2021a; 2021b), and the United Nations' guidance brief on protecting the rights of persons with disabilities during COVID-19 (UN Office of the High Commissioner for Human Rights 2020).The WHO (2022) suggests governance as one of the strategic entry points for disability inclusion in health systems.Further and renewed efforts to incorporate such guidelines by African Union and United Nations member states should be launched and sustained in preparation for greater and targeted policy inclusiveness of the health needs of persons with disabilities under non-emergent and emergent circumstances.