**4. Organisation of services for persons with disabilities**

Persons with disabilities need both mainstream and specific services to promote their well-being [20]. The Persons with Disability Act (Act, 715) is the legal framework that promotes the rights of PWDs, providing the blueprint to respond to their challenges. Act 715 provides for the basic rights of PWDs, including the right to education, health care, employment, transportation, housing, medical rehabilitation services, access services, buildings and sporting events, festivals, and cultural activities. Section 41 of the Act establishes the National Council for Persons with Disabilities to advise the government on disability centered policies and programmes as well as to oversee the implementation of same.

Ghana has put in place programmes and services to promote the rights of the vulnerable including PWDs. These include Livelihood Empowerment Against Poverty (LEAP), District Assembly Common Fund (DACF), Community Based Rehabilitation programmes, specialized schools, and training centres [21] to promote PWDs inclusion in society.

#### **4.1 Livelihood empowerment against poverty (LEAP)**

The Livelihood Empowerment Against Poverty (LEAP) programme is a social protection programme that started in 2008. LEAP seeks to promote access to services and to increase consumption among the extremely poor and vulnerable populations with the ultimate goal of reducing poverty [22, 23]. The beneficiaries receive cash transfers bi-monthly ranging from GHS 64.00 for an eligible person, GHS 72.00 for households with two eligible members, GHS 88.00 for households with three eligible persons, and GHS 106.00 for households with four or more eligible persons per payment cycle. Payments are made via E-zwich inter-bank payment platform.

Enrollment in this programme is subjected to means-testing and demonstrated eligibility [24–26]. The LEAP outlines eligibility as:

*"The programme covers extremely poor and vulnerable households, including orphans and vulnerable children, persons with a severe disability with no productive capacity and elderly persons 65 years and above" [27].*

But the question is, who is a *person with a severe disability with no productive capacity?* Which PWDs fall under this category? Not all those who require this service. What happens to those who are unemployed, given that most persons with disabilities in Ghana are more likely to be unemployed and/or work in menial, seasons, and marginal jobs? [10–12].

Also, LEAP is said to be one of the successful social protection schemes that aim at eradicating household poverty [26, 28]. For example, de Groot [29] in his review of Ghana's LEAP programme reported that the LEAP programme had a strong impact on fighting household poverty, particularly on certain subgroups such as PWDs. Also, the UNICEF report on the impact of the LEAP on its target population, indicates that as of December 2017, LEAP was reaching more than 213,000 poor families, including PWDs in all 216 districts of Ghana. LEAP has improved school enrollment, access to health, consumption and wellbeing among LEAP recipients. However, how many PWDs have received these services thus far? We do not know because only aggregated data is reported, which makes it difficult to know how many PWDs benefit from such programmes. Also, it would be difficult to conclude that meagre LEAP benefits could improve the well-being of PWDs who must also cater for disability-related expenses, noted to be very expensive [30].

#### **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?
