Why Ramps Alone Won’t Fix Disability Exclusion in African Health Care

When policymakers in sub-Saharan Africa talk about making health care accessible for persons with disabilities, the conversation too often stops at the front door: build a ramp, widen a doorway, install accessible signage. A new commentary published in the International Journal for Equity in Health argues that this narrow framing is precisely why exclusion persists. Led by Mohamed Daud Mohamed of Somali National University, the analysis contends that disability inclusion in primary health care is not a peripheral concern or a specialist add-on, but a fundamental test of whether health systems in the region are genuinely advancing health equity and universal health coverage. According to the authors, the barriers facing persons with disabilities are layered, systemic, and embedded in the everyday design, financing, and governance of health services—meaning that physical access improvements, while necessary, address only a small fraction of the problem.

The commentary draws on the World Health Organization’s Global Report on Health Equity for Persons with Disabilities, which frames disability-related health inequities as avoidable differences produced by unfair social, economic, and health-system conditions rather than by impairment alone. The evidence it synthesizes is stark. Persons with disabilities experience higher mortality and morbidity, greater limitations in functioning, unmet health needs, poorer quality of care, stigma and discrimination, unaffordable services, inaccessible facilities, health information provided only in unusable formats, poor communication with providers, and weak referral systems. In sub-Saharan Africa, these disadvantages are intensified by chronically under-resourced primary health care systems, heavy reliance on out-of-pocket payments, limited and poorly equipped rehabilitation services, and fragile referral pathways, particularly in low-spending settings.

A central contribution of the analysis is its detailed mapping of how barriers accumulate along the entire care pathway, beginning long before a patient reaches a clinic. Evidence shows that difficulties in recognizing health needs and deciding to seek care are often compounded by limited health information, low health literacy, and dependence on caregivers for decision-making, especially among children and people with cognitive or sensory impairments. Once a person attempts to access services, direct and indirect financial obstacles pile up: consultation fees, diagnostic costs, medicines, rehabilitation expenses, assistive technologies, transport, caregiver time, and the burden of repeated visits. These economic constraints are especially acute for women and children with disabilities living in poverty or in rural areas, where the intersection of disability with gender inequality, rural residence, age, and chronic conditions compounds exclusion and amplifies vulnerability to unmet needs and catastrophic health expenditure.

Communication failures represent another layer that physical accessibility upgrades cannot touch. The absence of sign-language interpretation, the lack of materials in Braille or alternative formats, and poor provider communication skills limit informed consent and erode trust between patients and health workers. Stigma, discrimination, negative provider attitudes, lack of privacy, and low disability competence discourage care-seeking and worsen patient experiences across every domain of primary health care, including sexual and reproductive health, maternal health, child health, non-communicable disease management, mental health care, rehabilitation referrals, assistive technology access, and emergency response. Weak referral systems and limited rehabilitation capacity then entrench exclusion even after a successful initial contact with the health system. In short, the commentary argues, a person with a disability may navigate an accessible entrance only to encounter a facility that cannot communicate with them, cannot afford to treat them, and cannot refer them onward.

At the heart of the paper’s argument is a powerful conceptual critique: many health systems in the region are designed around an implicit ‘standard patient’—one who can see, hear, move independently, communicate without support, read written information unaided, travel easily to facilities, pay out-of-pocket costs without hardship, and advocate for themselves. This default model systematically excludes persons with diverse mobility, sensory, communication, cognitive, psychosocial, and support needs. Addressing only physical access, the authors warn, risks perpetuating inequity. Instead, disability inclusion must be treated as a core design principle for primary health care and universal health coverage, not an optional enhancement reserved for donor-funded pilot projects or charitable services.

The commentary makes a strong case that primary health care is the most appropriate and equity-oriented platform for disability-inclusive care in sub-Saharan Africa, because it is the level at which universal health coverage becomes meaningful for households and communities. Persons with disabilities have greater health needs and face systematically higher risks of exclusion from coverage, quality care, and affordability, making their inclusion essential to realizing universal health coverage. Integrated primary care can support early identification of disability-related needs, inclusive health promotion, accessible communication, respectful care, immunization, maternal and child health, and sexual and reproductive health and rights. It also serves as a critical entry point for non-communicable disease and mental health care, areas where persons with disabilities often experience unmet needs and poorer service quality.

Concrete examples from across the continent illustrate both progress and persistent gaps. Community health workers and rural providers report that persons with disabilities face geographic, financial, attitudinal, and communication barriers, underscoring the need for disability-sensitive outreach and health education. Evidence from Ghana shows that improving primary care for persons with disabilities requires more affordable services, greater provider availability, better system navigation support, and disability-friendly infrastructure and equipment. In South Africa, efforts to embed rehabilitation referral recommendations into national primary care treatment guidelines demonstrate how standardized pathways from first contact to rehabilitation can strengthen service delivery and increase referrals, although gaps in referral pathways, assistive device availability, and provider capacity persist in rural districts. These experiences suggest that inclusion succeeds when it is woven into routine service functions rather than bolted on as a parallel program.

The paper’s most consequential reframing, however, moves the conversation from access barriers to system accountability. What is not measured, funded, supervised, and monitored, the authors argue, remains invisible to planners, facility managers, and universal health coverage reforms. Interventions to date have often been fragmented and insufficiently integrated into routine performance systems. Genuine accountability requires disability-disaggregated data in routine health information systems, service readiness assessments, facility accessibility audits, inclusive quality-of-care indicators, health worker training, supportive supervision, referral tracking and follow-up, accessible complaints mechanisms, reasonable accommodation, and accessible communication. Financing must explicitly cover rehabilitation services and assistive technologies, because services that are not budgeted are unlikely to be sustained. Without these elements, persons with disabilities remain uncounted in monitoring frameworks and unaccounted for in resource allocation decisions.

Crucially, the commentary insists that accountability cannot be achieved without the meaningful participation of persons with disabilities and their representative organizations in health planning, facility assessment, monitoring, evaluation, service redesign, and policy development. Participation must not be reduced to symbolic consultation. Persons with disabilities are best placed to identify hidden barriers within services, test usability in real-world contexts, and hold systems accountable for change, ensuring that reforms are grounded in lived experience rather than assumptions or external perspectives. The authors also call for disability inclusion to be embedded in emergency preparedness, outbreak response, conflict and displacement responses, and climate-related disaster planning, noting evidence that persons with disabilities were largely overlooked in African COVID-19 responses and experienced exacerbated access barriers during the pandemic.

The policy agenda that emerges from the analysis is practical and specific. Ministries and districts should integrate disability-disaggregated indicators into primary care information systems and universal health coverage monitoring so that gaps in coverage, quality, and financial protection become visible and actionable. Facility managers can use these data to prioritize progressive accessibility upgrades—ramps, pathways, toilets, signage, and adapted examination spaces—guided by structured audits that quantify gaps and identify low- and medium-cost improvements. Communication accessibility and reasonable accommodation should be addressed alongside the built environment, supported by practical tools that help staff identify and address communication barriers. Rights-based disability training should be institutionalized for all cadres of health workers, tackling negative attitudes while building concrete skills in accommodation, informed consent, and referral. Rehabilitation and assistive technology should be planned and financed as integral primary care functions, and financial protection reforms must explicitly include rehabilitation, assistive products, and transport, given consistent evidence that direct and indirect costs are major barriers to needed care. Disability-inclusive primary health care, the authors conclude, is not a niche agenda. It is a practical and ethical benchmark for whether health systems across sub-Saharan Africa are becoming more just, more responsive, and more truly universal—and a clear measure of whether universal health coverage reforms are being implemented in meaningful rather than rhetorical ways.

Subject of Research: Disability-inclusive primary health care and health equity in sub-Saharan Africa

Article Title: Beyond physical access: disability-inclusive primary health care as a test of health equity in Sub-Saharan Africa

Article References: Mohamed, M. D., Abdullahi, Y. B., Hassan, A. A., Ibrahim, I. O., Sudi, L. A., & Rashid, N. A. S. (2026). Beyond physical access: disability-inclusive primary health care as a test of health equity in Sub-Saharan Africa. International Journal for Equity in Health, 25(1), Article 217. https://doi.org/10.1186/s12939-026-03000-z

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03000-z

Keywords: disability inclusion, primary health care, health equity, universal health coverage, sub-Saharan Africa, health systems, assistive technology, rehabilitation, health financing, disability-disaggregated data, health workforce training, patient participation