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Assistive technology and people: a position paper from the first global research, innovation and education on assistive technology (GREAT) summit

DESMOND, Deirdre
LAYTON, Natasha
BENTLEY, Jacob
BOOT, Fleur Heleen
BORG, Johan
DHUNGANA, Bishnu Maya
GALLAGHER, Pamela
GITLOW, Lynn
GOWRAN, Rosemary Joan
GROCE, Nora
MAVROU, Katerina
MACKEOGH, Trish
MCDONALD, Rachael
PETTERSSON, Cecilia
SCHERER, Marcia J
2018

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Assistive technology (AT) is a powerful enabler of participation. The World Health Organization’s Global Collaboration on Assistive Technology (GATE) programme is actively working towards access to assistive technology for all. Developed through collaborative work as a part of the Global Research, Innovation and Education on Assistive Technology (GREAT) Summit, this position paper provides a “state of the science” view of AT users, conceptualized as “People” within the set of GATE strategic “P”s. People are at the core of policy, products, personnel and provision. AT is an interface between the person and the life they would like to lead. People’s preferences, perspectives and goals are fundamental to defining and determining the success of AT. Maximizing the impact of AT in enabling participation requires an individualized and holistic understanding of the value and meaning of AT for the individual, taking a universal model perspective, focusing on the person, in context, and then considering the condition and/or the technology. This paper aims to situate and emphasize people at the centre of AT systems: we highlight personal meanings and perspectives on AT use and consider the role of advocacy, empowerment and co-design in developing and driving AT processes.

Tensions and unity in the struggle for citizenship: Swedish disability rights activists claim ‘Full Participation! Now!’

SÉPULCHRE, Marie
2018

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This article analyses the claims of contemporary disability rights activists mobilising in a context where de facto second- class citizenship co-exists with legal and political declarations about the rights of disabled people. As an empirical case, it focuses on the blog ‘Full Participation.Now’, which was initiated by disability rights activists in Sweden. Drawing upon citizenship research, the article points to the tensions and dilemmas featuring the bloggers’ demand for participation and equality, as well as the challenges relative to their struggle. Although the bloggers formulate contrasting arguments, the article highlights that the activists share a common aspiration for ‘full citizenship’.

Disability inclusive elections in Africa: a systematic review of published and unpublished literature

VIRENDRAKUMAR, Bhavisha
JOLLEY, Emma
BADU, Eric
SCHMIDT, Elena
2018

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The United Nations Convention on the Rights of Persons with Disabilities underscores the equal right of persons with disabilities to participate in political life. However, in Africa they are often unable to exercise their right to vote. This study sought to systematically review available evidence on inclusive elections in Africa. Findings showed that although most African countries ratified disability-focused legislation and proclaimed equal opportunities, the implementation of the legislation varies across the continent. Barriers to political participation can occur at any electoral stage and can be broadly categorised into three groups: lack of education and financial resources; stigma and negative social attitudes; and inaccessible physical infrastructure.

Cross-sectional Survey to Assess Prevalence of Disability and Access to Services in Albay Province, The Philippines

HODGE, Marcus
BOLINAS, Amable
JAUCIAN, Erlynn
BONEO, Rebecca
SCHAPIRA, Allan
VILLANUEVA, Mary Mediatrix V
2017

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Aim:  A cluster randomized cross-sectional survey to assess the prevalence of disability and access to support services was conducted in Albay Province, the Philippines in April 2016.

 

Method:  The population-based survey methodologies developed by the Washington Group of the United Nations Statistical Commission and UNICEF were utilized.  A sample of 70 barangays (the 3rd level administrative division in the Philippines) was selected as clusters, with probability proportional to size, and 30 households were selected randomly in each barangay to be surveyed.

 

Results:  The estimated prevalence of disability using the standard criteria of the Washington Group and UNICEF among children (2-17 years old) was 2.0% and for adults (≥18 years old) it was 6.5%.  The estimated prevalence of disability was higher in rural than in urban areas.  Deficiencies in the performance of existing services were identified; access by children with disabilities to support services was lowest in rural highland and rural plain barangays.

 

Conclusions: There was a large unmet demand for support services addressing the needs of persons with disabilities in Albay Province, especially in rural highland areas.  Persons with disabilities were disadvantaged in access to education and employment; many had not been educated in their basic rights.

 

Implications:  To identify, educate and fully support persons with disabilities, community-based rehabilitation (CBR), health and other rehabilitation services must communicate effectively with each other, their current work should be mapped and analysed, their comparative strengths identified, and their future work coordinated.  It is a priority to educate persons with disabilities and their families about their rights, and facilitate their access to support services; this requires increased investment in communication targeting persons with disabilities and the communities, especially rural.  Providers caring for persons with disabilities need to work in partnership to identify unreached persons with disabilities.  Prevalence surveys, with stronger focus on the profiles and performance of CBR and related services, would add to the evidence-base to improve the quality and coverage of services for persons with disabilities.

Disability Inclusive Development Good Practices: Level of Commitment to Core Concepts of Human Rights

HENDERSON, Cheryl
MANNAN, Hasheem
POWER, Jessica
2017

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Aim: Good practices have been documented by International Non-Governmental Organisations (INGOs) to promote disability inclusive development and encourage the replication or scaling up of good practices that use rights based approaches. This study aimed to investigate the extent to which Core Concepts of human rights are illustrated in disability inclusive development good practices related to health.

 

Methods: This study analysed case studies of disability inclusive development good practices focusing on health that are available in the public domain using EquiFrame, an established content analysis framework in benchmarking health and social policies.

 

Results: A total of 42 health related good practices were identified from 3 different INGOs working in the field of disability inclusive development. The highest occurring human rights Core Concepts were; access 55%, individualised services 48%, capacity building 45% and participation 38%. The Core Concepts with the lowest levels of commitment were; autonomy 3%, cultural responsiveness 3%, accountability 3%, and efficiency 3%. Privacy and autonomy were not mentioned at all. The quality of reporting of the core concepts of human rights was low as they did not state specific programme actions or intentions to monitor Core Concepts.

 

Conclusion: Level of commitment to Core Concept coverage and quality of reporting was low. EquiFrame was successfully extended to analyse disability inclusive development good practices focusing on health. Its use in further analysis of inclusive good practice is advised.

 

Implications: These results can be used for advocacy in disability inclusive development and to guide programme staff training and documentation of disability inclusive development good practices.

Challenges faced by parents of children with learning disabilities in Opuwo, Namibia

TADERERA, Clever
HALL, Herna
2017

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Background: Parenting children with learning disabilities requires a high level of knowledge and access to resources, information and services. In developing countries, however, these resources and services are not always available. Parents in Namibia, a developing country, therefore face challenges addressing children’s learning and other developmental disabilities, including challenges related to preventative and supportive interventions.


Objective: This research focuses on challenges faced by parents as they parent children with learning disabilities in Opuwo, Namibia.


Method: In-depth interviews were conducted with eight parents regarding the challenges they face in parenting their children with learning disabilities. Thematic analysis enabled the researchers to identify, analyse and report on themes that emerged from the qualitative interview data.


Results: Analysis of the interviews indicated that some participants had only a vague understanding of learning disabilities, as they did not have access to essential knowledge about this phenomenon. They also lacked an awareness of the availability of programmes, services and policies meant to benefit their children with learning disabilities. Participants voiced that they, their children with learning disabilities and community members have stereotypes and prejudices regarding learning disabilities. In this study, most of the children with learning disabilities were raised by single, unemployed parents who seemed to have access to less support from external sources than married couples parenting children with learning disabilities. These single parents are usually not married and because of lack of financial support from the other parent, the majority of them indicated that they struggle to meet the financial and material needs of their children.


Conclusion: The researchers concluded that the participants in this study experience a range of challenges in parenting their children with learning disabilities. The main challenges emanate from financial instability, as well as lack of knowledge regarding services and programmes for children with learning disabilities. This lack of knowledge on the part of participants could indicate poor policy education by policy implementers at grass-roots level.

Community Action Research in Disability (CARD): An inclusive research programme in Uganda

HARTLEY, Sally D
YOUSAFZAI, AK
KAAHWA, MG
FINKENFLÜGEL, H
WADE, A
BAZIRAKE, G
DRACHLER, ML
SEELEY, J
ALAVI, Y
MATAZE, W
MUCURNGUZI, E
2017

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The ideology of Emancipatory Disability Research (EDR) reflected in the phrase ‘Nothing about us without us’, was first put forward in the 1990s. Although it aimed to place research control in the hands of the ‘researched’, i.e., people with disability, this rarely happens even today, 25 years later.

 

The Community Action Research on Disability (CARD) programme in Uganda embraced and modified the EDR approach, recognising the need for including people with disability in the research process from concept to outcome, and nurturing participation and collaboration between all the stakeholders in achieving action-based research. The research teams always included people with disability and staff from Disability People’s Organisations (DPOs) as well as academics and service providers. It endeavoured to generate and carry out research around issues that mattered to people with disability and their families. Leadership roles were assigned by team members. The objectives of the CARD programme were: (1) to fund teams to carry out action-based research on disability in Uganda; (2) to develop research and administrative capacity to manage the initiative within the academic registrar’s office at Kyambogo University; (3) to incorporate new knowledge generated from the studies into the ongoing local community-based rehabilitation and special education courses; and, (4) to ensure wide dissemination of research findings to all stakeholder groups.

 

CARD ran for 5 years, commissioning 21 action research studies in the field of disability and community-based services. This paper describes the process, presents the 12 completed studies, examines the extent to which the objectives were achieved and evaluates the experiences of the participating research teams, particularly in relation to the inclusion of its members with disability. It concludes with recommendations for future initiatives designed to promote validity, good value and inclusive approaches in disability research.

The Impact of Community-Based Rehabilitation in a Post-Conflict Environment of Sri Lanka

HIGASHIDA, Masateru
2017

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Purpose: Conflict and disability are closely associated; it is therefore significant to examine strategies at the grassroots-level for restoring the human rights of people with disabilities living in post-conflict societies. The aim of this study is to reveal the impact of and issues with community-based rehabilitation (CBR) in the Northern Province of Sri Lanka that was ravaged by civil war from 1983 to 2009.

 

Methods: The research was implemented in October 2016, in collaboration with a local NGO in the Mullaitivu district. A mixed-methods approach was followed, which included quantitative analysis of the NGO’s registration database of people with disabilities in the area (n=964), group interviews with 9 community rehabilitation committees (CRCs) of people with disabilities and their family members (n=118), and semi-structured interviews with clients of the CBR programme (n=5). Thematic analysis was applied to the narrative data.

 

Results: The quantitative analysis on clients of the NGO revealed that 60.9% of disabilities were related to war. Livelihood assistance was the most common type of self-reported need (44.6%). The qualitative analysis revealed that in communities with inadequate local resources, CRCs that had access to livelihood assistance made a positive impact on the socioeconomic conditions of people with disabilities and their family members. Potential issues were observed, such as the expectation of and dependence on the financial aid without self-help. Some people with disabilities would not attend CRCs if there were no financial benefits. As most of the participants had war-related disabilities, it is also possible that participation of people with intellectual and psychiatric disabilities unrelated to war may not have been promoted in some CRCs.

 

Conclusions: The CBR programme has had positive impacts on the living conditions of participants, albeit with some potential issues such as financial expectations and aid dependency. The authors argue that empowerment of people with disabilities and addressing socioeconomic inequality should be considered simultaneously.

“Our children have the right to an education too”: Strategies employed by Orange Farm Caregivers of Children with Disabilities in Pursuit of the Right to a Basic Education

Elphick, Jean
De SasKropiwnicki, Zosa
Elphick, Rosalind
2016

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Purpose: This paper aims to understand the agency that caregivers who participated in a CBR empowerment component programme exercised, in order to promote the rights of their children with disabilities to a basic education.

 

Methods: An interdisciplinary theoretical framework and qualitative methodology were used to examine the agency and the opportunity structures within which the caregivers operate. Focus group discussions, case study interviews and secondary Programme data were analysed using manual thematic analysis.

 

Results: Thousands of children with disabilities in South Africa are effectively denied the right to a basic education as a result of discriminatory norms, stigmatising discourses and unjust power relations. Yet, a group of caregivers have successfully advocated for their children with disabilities in the township of Orange Farm, Gauteng. Their lobbying has contributed to the establishment, by the State, of a new school.

 

Conclusion and Implications: The findings suggest that human rights advocacy movements, as well as disability organisations, would do well to recognise and encourage the power and agency possessed by caregivers of children with disabilities. Catalysing civic action and providing opportunities for active citizenry and self-help seem to nurture increased efficacy and competence at navigating systems and accessing rights. While advocacy organisations may act as proxy agents, direct and collective agentic strategies should be nurtured. 

 

In implementing inclusive education, policy makers and the Department of Education should recognise the role that caregivers of children with disabilities can play, and the potential contribution that their motivation, resourcefulness, and disability-related knowledge can make.

China’s Mental Health Law: Analysis of Core Concepts of Human Rights and Inclusion of Vulnerable Groups

Hussey, Meghan Marie
Mannan, Hasheem
2016

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Purpose: The aim of this research is to assess China’s first Mental Health Law in terms of Core Concepts of Human Rights and equitable coverage of Vulnerable Groups.

 

Methods: The EquiFrame analytical tool provided the framework for evaluation of the inclusion of Core Concepts of Human Rights as well as Vulnerable Groups in the Law.

 

Results: China’s Mental Health Law scored 83% for Core Concept coverage, with a Core Concept Quality score of 76%. The Law had a 42% score for Vulnerable Groups coverage. This gave the Law an overall score of “Moderate” in terms of Human Rights coverage.

 

Conclusions: China’s Mental Health Law is a landmark document providing the country’s first ever legal framework for mental health. While the Law scores high on level commitment in Core Concepts of Human Rights, the potential for equitable protection would be enhanced by increased inclusion of Vulnerable Groups.

 

Limitations: Further analyses of health and social policies in the People’s Republic of China from a Human Rights perspective would provide a deeper understanding of the Law in context.

Inclusive education: A transformation and human rights agenda under spotlight in South Africa

MAGUVHE, Mbulaheni
2015

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This study investigated the progress made in the implementation of inclusive education as a transformation and human rights tool since its inception in 2001. The study was conducted upon realising that most people underestimate the transformation and human rights value that inclusive education strives to maintain. The total number of participants interviewed was 84. Data was collected using semi-structured interview schedules for the teachers and community members, whereafter it was presented in thematic sections and qualitatively examined for meaning. The results showed that participants comprising teachers and community members do not know or understand the transformational and human rights value of inclusive education. The participants seemed to be equally aware of inclusive education, but they rated its success and value differently. The participants concurred that the philosophy of inclusive education was noble, but they differed regarding the extent to which it had transformed, added value or played an advocacy role in the lives of learners and the community at large over the years.

Is any wheelchair better than no wheelchair? A Zimbabwean perspective

VISAGIE, Surona
MLAMBO, Tecla
VAN DER VEEN, Judith
NHUNZVI, Clement
TIGERE, Deborah
SCHEFFLER, Elsje
2015

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Background: Within a rights-based paradigm, wheelchairs are essential in the promotion of user autonomy, dignity, freedom, inclusion and participation.

 

Objectives: This paper aimed to describe a group of Zimbabwean wheelchair users’ satisfaction with wheelchairs, wheelchair services and wheelchair function.

 

Method: A mixed method, descriptive study was done. Quantitative data was collected from 94 consecutively sampled wheelchair users, who accessed wheelchair services at 16 clinics in five Zimbabwean provinces between October 2013 and February 2014, using the Quebec User Evaluation of Satisfaction with Assistive Technology for adults and children and Functioning Every day with a Wheelchair questionnaire. Qualitative data were collected through two focus group discussions (22 participants) and two case studies with participants purposively sampled from those who participated in the quantitative phase.

 

Results: More than 60% of participants were dissatisfied with the following wheelchair features: durability (78.6%), weight (75.6%), ease of adjustment (69.1%), effectiveness (69.0%), safety (66.7%), reliability (66.7%), and meeting user needs (60.6%). Similarly, more than 66% of participants were dissatisfied with various services aspects: professional services (69.0%), follow-up (67.0%), and service delivery (68.3%). Although 60% of participants agreed that the wheelchair contributed to specific functions, more than 50% of participants indicated that the features of the wheelchair did not allow in- (53.2%) and outdoor (52.7%) mobility.

 

Conclusion: Findings indicate high levels of dissatisfaction with wheelchair features and services, as well as mobility. It is recommended that policy and minimum service standards which incorporate evidence and good practice guidelines for wheelchair services and management of wheelchair donations are developed for Zimbabwe.

A Transect Walk to Establish Opportunities and Challenges for Youth with Disabilities in Winterveldt, South Africa

LORENZO, T
MOTAU, J
2014

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Winterveldt was one of the 9 sites included in a national study to determine the livelihood strategies of youth with disabilities, undertaken by the Occupational Therapy Departments of 6 Universities in South Africa. Community-based rehabilitation (CBR) programmes were initiated in Winterveldt in the 1990s by non-governmental organisations and the Occupational Therapy Department at the University of Limpopo - Medical University of South Africa (MEDUNSA).

 

Purpose: This paper describes the use of a Transect Walk to identify aspects of context that contribute to the vulnerability of youth with disabilities with regard to their livelihood strategies.

 

Method: Transect Walk was employed as a participatory rapid-appraisal tool to gather data. Convenience sampling was used to identify 11 participants, including three youth with disabilities. Field notes and observations were analysed deductively for themes related to the 5 categories of livelihood assets.

 

Results: The findings describe the natural and built environment, the access to health, educational and financial services, and the social attitudes of people in this community towards youth with disabilities. The discussion uses the 5 CBR components as a framework to explore strategies for enhancing the assets of youth with disabilities, namely, empowerment, social, health, education, and livelihood.

 

Conclusions: There is significant development that could be maximised if youth with disabilities were aware of their rights and were able to access services and resources. The implication for local government is to create an inclusive environment in which youth with disabilities are able to participate in mainstream youth development opportunities.

Breaking the Barriers: Ghanaians’ Perspectives about the Social Model

NAAMI, A
2014

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Purpose: The social model of disability emphasises the identification and removal of barriers to the inclusion of persons with disabilities in mainstream society. The study examines issues associated with the exclusion of women with physical disabilities in Tamale, Ghana, and makes recommendations for the effective participation and inclusion of persons with disabilities, especially the women, in society.

 

Method: Data were gathered through in-depth individual interviews and focus group discussions. Purposive and snowball sampling were used to recruit 10 women with physical disabilities for the in-depth interviews. Purposive sampling was also used to recruit 14 representatives from government and civil society organisations for 2 multi-organisational focus groups. Using open coding and line-by-line analysis, themes and categories were identified. Themes that emerged from the focus groups and from the individual interviews were compared and contrasted to arrive at conclusions about the participation of women with physical disabilities in mainstream society.

 

Results: Study participants identified barriers (attitudinal, institutional, architectural, transportation, and information) and suggested methods to eradicate them and foster inclusion. At the same time they felt that it was equally important to change certain attitudes of persons with disabilities (ignorance about available resources, opportunities and potential, low levels of self-confidence, and negative reactions to societal attitudes) which contribute to their exclusion from society.

 

Conclusion: Advocacy interventions are recommended, which include public education, building relationships and mobilising the public for advocacy campaigns. Decision-makers need to be persuaded to make additional policies and/or enforce existing ones, to promote the inclusion and effective participation of persons with disabilities in society.

India’s Disability Policy – Analysis of Core Concepts of Human Rights

O'DOWD, J
MANNAN, H
MCVEIGH, J
2014

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Purpose: To analyse India’s National Policy for Persons with Disabilities (2006), using a Human Rights approach.

 

Method: A framework analysis was carried out using EquiFrame, which analyses policies for inclusion and quality of Core Concepts of Human Rights and inclusion of Vulnerable Groups.

 

Results: India’s National Policy for Persons with Disabilities scored 67% for Core Concept Coverage, 24% for Core Concept Quality and 42% for Vulnerable Group Coverage. This gave the policy an overall ranking of Low quality.

 

Conclusions: The current policy for persons living with disabilities in India would benefit from being updated to encompass the Core Concepts of Human Rights.

Policy implementation in wheelchair service delivery in a rural South African setting

VISAGIE, Surona
SCHEFFLER, Elsje
SCHNEIDER, Marguerite
2013

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Background: Wheelchairs allow users to realise basic human rights and improved quality of life. South African and international documents guide rehabilitation service delivery and thus the provision of wheelchairs. Evidence indicates that rehabilitation policy implementation gaps exist in rural South Africa.

 

Objectives: The aim of this article was to explore the extent to which wheelchair service delivery in a rural, remote area of South Africa was aligned with the South African National Guidelines on Provision of Assistive Devices, The United Nations Convention on the Rights of Persons with Disabilities and The World Health Organization Guidelines on Provision of Wheelchairs in Less-Resourced Settings.

 

Method: Qualitative methods were used. Data were collected through semi-structured interviews with 22 participants who were identified through purposive sampling. Content analysis of data was preformed around the construct of wheelchair service delivery.

 

Results: Study findings identified gaps between the guiding documents and wheelchair service delivery. Areas where gaps were identified included service aspects such as referral, assessment, prescription, user and provider training, follow up, maintenance and repair as well as management aspects such as staff support, budget and monitoring. Positive findings related to individual assessments, enthusiastic and caring staff and the provision of wheelchairs at no cost.

 

Conclusion: The gaps in policy implementation can have a negative impact on users and the service provider. Inappropriate or no wheelchairs limit user function, participation and quality of life. In addition, an inappropriate wheelchair will have a shorter lifespan, requiring frequent repairs and replacements with cost implications for the service provider.

Political liberalism and the justice claims of the disabled: a reconciliation

BADANO, Gabriele
2013

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Unlike his theory of justice as fairness, John Rawls’s political liberalism has generally been spared from critiques regarding what is due to the disabled. This paper demonstrates that, due to the account of the basic ideas of society and persons provided by Rawls, political liberalism requires that the interests of numerous individuals with disabilities should be put aside when the most fundamental issues of justice are settled. The aim is to accommodate within public reason the due concern for the disabled while upholding political liberalism. To achieve this aim, a revision of the basic ideas of persons and society is proposed. The idea of persons should be regarded as more fundamental than that of social cooperation, and persons should be defined in terms of minimal moral powers.

Human Rights, Social Inclusion and Health Equity in International Donors' Policies

Eide, A H
Amin, M
MacLachlan, M
Mannan, H
Schneider, M
2013

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Background: Health policies have the potential to be important instruments in achieving equity in health. A framework – EquiFrame - for assessing the extent to which health policies promote equity was used to perform an equity audit of the health policies of three international aid organizations.

 

Objective: To assess the extent to which social inclusion and human rights feature in the health policies of DFID (UK), Irish Aid, and NORAD (Norway).

 

Method: EquiFrame provides a tool for analyzing equity and quality of health policies with regards to social inclusion and human rights. Each health policy was analyzed with regards to the frequency and content of a predefined set ofVulnerable Groups and Core Concepts.

 

Results: The three policies vary but are all relatively weak with regards to social inclusion and human rights issues as defined in EquiFrame. The needs and rights of vulnerable groups for adequate health services are largely not addressed.

 

Conclusion: In order to enhance a social inclusion and human rights perspective that will promote equity in health through more equitable health policies, it is suggested that EquiFrame can be used to guide the revision and development of the health policies of international organizations, aid agencies and bilateral donors in the future.

 

Limitations: Analyses are limited to “policy on the books” and does not measure how effectively vulnerable groups are included in mainstream health policy work.

Core Concepts of Human Rights and Inclusion of Vulnerable Groups in the Namibian Policy on Orthopaedic Technical Services

VANROOY, G
AMADHILA, E
MANNAN, H
MCVEIGH, J
MACLACHLAN, M
AMIN, M
2012

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Purpose: Despite a highly progressive legislation and clear governmental commitment, living conditions among persons with disabilities in Namibia are systematically lower than among persons without disabilities. This implies that persons with disabilities are denied equal opportunities to participate and contribute to society, and consequently are denied their human rights.

 

Methods: EquiFrame, an innovative policy analysis framework, was used to analyse Namibian Policy on Orthopaedic Technical Services. EquiFrame evaluates the degree of stated commitment of an existing health policy to 21 Core Concepts of human rights and to 12 Vulnerable Groups, guided by the ethos of universal, equitable and accessible health services.

 

Results: A number of Core Concepts of human rights and Vulnerable Groups were found to be absent in the Namibian Policy on Orthopaedic Technical Services, and its Overall Summary Ranking was assessed as Moderate.

 

Conclusion and Implications: The Namibian health sector faces significant challenges in addressing inequities with respect to its policy on Orthopaedic Technical Services. If policy content, or policy ‘on the books’, is not inclusive of vulnerable groups and observant of core concepts of human rights, then health practices are also unlikely to do so. This paper illustrates that EquiFrame can provide the strategic guidance for the reform of Namibian Orthopaedic Technical Services policy, leading to universal and equitable access to healthcare.

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