Investigating disability-inclusion in social protection programmes in low- and middle-income countries, with case studies from Vietnam and Nepal

Background: Social protection is increasingly used by governments in low- and middle-income countries (LMICs) as a strategy for alleviating poverty “in all its forms”. People with disabilities are frequently targeted as key beneficiaries due to high levels of poverty and marginalisation. Little is known, however, on whether people with disabilities are accessing existing programmes, and whether these programmes adequately meet their needs. Aim: To explore the need for, access to and adequacy of social protection amongst people with disabilities in LMICs. Methods: Systematic reviews were used to compile and evaluate evidence from across LMICs on 1) the link between monetary poverty and disability, and 2) access to and impact of social protection amongst people with disabilities. Case studies were then undertaken in the districts of Cam Le, Vietnam and Tanahun, Nepal in 2016 to explore in-depth the need for, access to and adequacy of social protection amongst people with disabilities in these areas. Data was collected through population-based surveys (n=12,397, across both settings), with nested case-control studies of people with and without disabilities (n=359, each) matched by age, sex and location. Further, qualitative research was conducted with people with disabilities recruited from the surveys and key informants involved in the design or implementation of social protection. Need for social protection was assessed using monetary and multidimensional indicators of poverty amongst people with disabilities ages 15+. Access to social protection was measured through participation in disability-targeted and non-targeted programmes. Adequacy of social assistance was then evaluated by measuring levels of monetary and multidimensional poverty amongst social assistance recipients. All analyses compared indicators between people with and without disabilities, and amongst people without disabilities (e.g. recipients versus non-recipients). Key findings: Evidence from the systematic review and research in Nepal and Vietnam indicate a high need for social protection among people with disabilities. In the systematic review, 80% of the 150 included studies found a link between disability and economic poverty. In both Vietnam and Nepal, people with disabilities were more likely to be living in both monetary and multidimensional poverty compared to people without disabilities, and faced high disability-related extra costs. People with disabilities in Vietnam and Nepal were more likely to access social assistance compared to people without disabilities (Vietnam: aOR 9.6, 5.6-16.5; Nepal: aOR 3.0, 1.6-5.3). However, evidence from the case studies and from the systematic review indicate that many people with disabilities are not accessing social protection benefits for which they are eligible. Factors affecting access included the accessibility of the application process, complexity of disability assessment procedures, awareness of programmes and their eligibility requirements and the perceived utility of benefits. Further, the systematic review and research in Vietnam and Nepal indicated that social protection is often inadequate to protect many recipients with disabilities from poverty. For example, a quarter to a third of social assistance recipients with disabilities were living in monetary poverty and half were multidimensionally poor in Vietnam and Nepal. Social protection was particularly insufficient at promoting social inclusion amongst people with disabilities, as well as ensuring sustainable livelihoods. Conclusion: People with disabilities face a substantial need for social protection, given high levels of monetary and multidimensional poverty, in both absolute terms and relative to people without disabilities. However, many people with disabilities were not accessing programmes for which they were eligible, indicating a need to increase awareness of programmes and address barriers encountered during the application process. Further, evidence from this research indicates that more transformational approaches to social protection design and delivery are necessary, such as providing meaningful coverage for disability-related extra costs and addressing drivers of social exclusion