R e s e a r c h a r t i c l e E q u it y a n d t h e D i s t r i b u t i o n o f R e h a b il it a t io n P e r s o n n e l in o n e H e a l t h D is t r ic t in t h e W e s t e r n C a p e A B S T R A C T : This paper describes a situation analysis o f the rehabilitation personnel, employed by the state and non-governmental organisations, and the services available f o r people with disabilities in one health district in Cape Town. The recurrent cost o f employing the rehabilitation personnel is analysed to determine how funding is allocated within the district. The results indicate that most expenditure on personnel is at two state institutions in the district, with 76% o f the expenditure at the regional psychiatric hospital and its residential fa cility f o r people with a profound intellectual disability. The balance - 24% o f expenditure - is the cost o f em ploying rehabilitation personnel who provide a district level service. Seventy percent o f this district level expenditure is at one special school that accepts 6% o f children with disabilities in the district. A high percentage o f intellectually disabled children and adults, with or without physical disabilities, do not have access to rehabilitation. There is m inim al expenditure on employing rehabilitation personnel at the com m unity heath centre. The only expenditure on com m unity based reha­ bilitation is provided by the non-governmental organisation. The study demonstrates the inequitable distribution o f fu n d in g f o r rehabilitation services within one relatively well-resourced health district and makes recom mendations to facilitate change. K EYW O RD S: EQUITY; REHABILITATION; PERSONNEL COSTS; RESO URCE ALLOCATION; D ISABILITY STRUTHERS P; B.Sc (Physiotherapy), M.PHIL (Public Health)1 1 Departm ent o f Physiotherapy, U niversity of the W estern C a p e . INTRODUCTION In any co u n try th e state has a re sp o n si­ b ility to e n s u re eq u ity in th e p ro v isio n o f h ealth services, in clu d in g reh a b ilitatio n . A s reso u rces are alw ay s scarce, ch o ices m u st be m ade and eco n o m ic issues need to be ex p lo red (N o rm an d , 1991). M a jo r ch a n g es have taken p la ce in th e South A frican health system w ith the m ove to o n e in teg rated h ealth system and the d e v e lo p m e n t o f a d istric t h ealth system . T his study explores an aspect o f equity in o n e h ealth d istric t in C ap e Town. It d escrib es a situ atio n a n a ly sis o f the reh ab ilitatio n personnel and the facilities av ailab le fo r p eo p le w ith d isab ilities. An an aly ses o f th e co s t o f e m p lo y in g the reh a b ilita tio n p erso n n el is d o n e to deter- C O R R E S P O N D E N C E TO: P S tru th ers D ep a rtm en t o f P h y sio th erap y U n iv ersity o f the W estern C ap e P riv ate B ag X 17 B e llv ille 7375 Tel: (021) 9 5 9 -2 5 4 2 (w) m ine how funding is allo cated w ithin the d istrict. It d escrib es the m e th o d o lo g y u sed to m easu re th e co st o f the services, an d d isc u sse s the in e q u ita b le fu n d in g o f reh a b ilita tio n serv ices w ith in this re la ­ tively w ell-reso u rced health district. T his ty p e o f study can p ro v id e useful in fo r­ m ation to health service planners to assist w ith p rio ritisin g the b u d g et allo catio n . BACKGROUND S in ce 1994 th ere has been a re o rie n ­ ta tio n o f th e h e a lth sy ste m in S o u th A f r ic a to a p r im a ry h e a lth c a re ap p ro ach , w h ich has b ee n im p lem en ted th ro u g h th e d e v e lo p m e n t o f th e d istric t health system . T h e p rim ary health care a p p ro a c h in c lu d e s h e a lth p ro m o tio n , p rev en tio n , cu rativ e ca re an d re h a b ili­ tatio n (W H O 1978). ‘R eh a b ilita tio n is the w o rd u se d to d es crib e w ays o f h elp in g p e o p le with d isa b ilities to b ec o m e fu ll y p a rticip a tin g m em b ers o f society, with a cc ess to a ll the b en efits a n d o p p o rtu n itie s o f th a t so c iety.’ (W h ite P ap er on an In teg rated N a tio n a l D is a b ility S tra te g y , S o u th A frica, 1997) R e h ab ilita tio n can red u c e the extent o f p erm a n en t d isa b ility w hen th erap y is p ro v id ed early in the h isto ry o f the d isability. In S o u th A frica, reh ab ilitatio n is p ro v id ed in a n u m b er o f co n tex ts in c lu d in g h o sp itals, co m m u n ity health c e n tres, sch o o ls, p riv ate p ractices and a t h o m e by p h y sio th erap ists, o c c u p a ­ tional th e ra p ists and sp eech and hearing th e ra p is ts , a s s is ta n ts an d c o m m u n ity reh a b ilita tio n w orkers. A n aly sis o f the co st o f reh ab ilitatio n can m ak e an im p o rta n t co n trib u tio n to p la n n in g h ea lth c a re se rv ic es (W H O 1994). It gives an in d ic atio n o f the p ro p o rtio n o f th e total b u d g et th at is sp en t on reh a b ilita tio n services, w h ere this sp e n d in g takes place in th e d istrict, and w ho has access to th e service. In ad d itio n , it en a b le s p lan n ers to co n s id er a ltern ativ e uses o f av ailab le funding. T h ey may, fo r ex am p le, c h o o s e to use a g re a te r o r le sser p ro p o rtio n fo r a c o m m u n ity b ased reh a b ilita tio n service. T h e c o s ts o f an y h e a lth s e rv ic e in c lu d e both cap ital an d rec u rren t costs. T h e cap ital co sts in c lu d e fixed costs such as the b uildings. T h e recu rren t costs 4 SA J o u r n a l o f P hysiothera py 2001 V o l 57 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Ta ble 1: R eha bilitation personne l in M itchell's Plain Facility for people with disabilities Therapists Assistants Rehab workers Lentegeur Hospital & Care and Rehabilitation Centre 27 46 Agape Cerebral Palsy School 11 Lentegeur State Training Centre 1 UW C Rehabilitation Project 2.2 4 Community Health Centre 2 Private practitioners 3 Beacon Training Centre 0 Joy Day Care Centre 0 Mitchell's Plain Special Care Centre 0 are th e costs o f ru n n in g the service. T h e m ain recu rren t co sts in the p ro v isio n o f a reh ab ilitatio n serv ice are firstly the rec u rren t co st o f the h u m an reso u rces - the co st o f em p lo y in g the perso n n el - and secondly, assistiv e dev ices. T h is study o n ly rep o rts on th e rec u rren t co st o f the h u m an resources. OBJECTIVES T h e o b jectiv es o f this stu d y w ere firstly to d escrib e a situ atio n an aly sis o f re h a ­ b ilitatio n serv ices an d facilities in the M itc h e ll’s P la in H e a lth D is tric t an d seco n d ly to d eterm in e th e rec u rren t co st o f the hum an reso u rce c o m p o n e n t o f the reh a b ilita tio n services. METHODOLOGY T h e m e th o d s o f d a ta co llec tio n and the ca lc u latio n o f costs are d escribed. Research setting M itc h e ll’s P lain w as se lec ted as the rese arch setting, b ec au se th e urban area fo rm s a sin g le d istin c t h ealth d istric t and the d istric t level h ea lth fac ilities are m ain ly u tilised by th e local com m unity. It w as o n e o f the ea rliest h ea lth d istricts to b e e stab lish ed in C a p e Tow n. M itc h e ll’s Plain lies 2 7 k m fro m c e n ­ tral C a p e Tow n. It w as d ev e lo p e d in th e 1 9 7 0 ’s as a d o rm ito ry tow n for ‘c o lo u re d ’ p eo p le w ho w ere m o v ed o u t o f C a p e T ow n u n d er th e G ro u p A reas Act. It has a good infrastructure including tarred roads, electricity, safe w ate r and te lep h o n e s (L allo o , 1994). A t the tim e o f th e study, the p o p u latio n size w as estim a ted to b e 28 0 7 10 (C ity o f C ap e T ow n, 1994/5). T h e co n firm e d p re v a ­ len ce o f d isab ility w as 4.4% w ith 12.9% o f the p o p u latio n h av in g im p airm en ts (K atzen ellen b o g en et al, 1995). In actual num bers, this am ounted to approxim ately 12 351 p eo p le w ith d isab ilities o f w hom 3087 w ere ch ild ren b etw een the ages o f 6-15 years. T h e d is tric t h a s w e ll e s ta b lis h e d h ea lth an d ed u c a tio n fa c ilitie s in c lu d ­ in g th e reg io n al p sy c h iatric ho sp ital, a c o m m u n ity h e a lth c e n tre , a p riv a te h o sp ital, a sp ecial school an d a n u m b er o f ce n tres su p p o rted by n o n -g o v em - m ental o rg an isa tio n s (N G O s). T h e situ atio n an aly sis d escrib ed all state d ep a rtm en ts and N G O s th at p ro ­ vide physiotherapy, o ccu p atio n al therapy and speech therapy. Secondly it described all the fac ilities av a ila b le fo r p eo p le w ith a disability. Research design T h e stu d y u tilise d q u an tita tiv e m eth o d s to g ath er the data. T h e p relim in ary d ata w e re o b ta in e d fro m an in d e p e n d e n t s u rv ey th a t h ad b een d is trib u te d by D isco -C h ip , an u m b rella o rg an isatio n fo r o rg an isa tio n s of, o r w o rk in g w ith p e o p le w ith d is a b ilitie s in M itc h e ll’s P la in . T h is q u e s tio n n a ir e p r o v id e d in fo rm atio n o n th e n u m b ers o f p eo p le w ith d isa b ilities in v o lv ed in th e o rg an i­ sation; w h eth e r they w ere ch ild ren o r adults; and th e ty p e o f serv ice offered b y the o rg an isatio n . In this study on th e co sts o f reh a b ili­ tatio n , fu rth e r d a ta w ere o b tain ed , using a sn o w b allin g m eth o d , to id en tify o th e r o rg an isatio n s in M itc h e ll’s P lain that h ad lin k s w ith p eo p le w ith d isab ilities. P h o n e calls w ere m ad e to all the o rg a­ n isatio n s, in c lu d in g all h ea lth facilities, sp ecial sch o o ls, w o rk sh o p s fo r p eo p le w ith d isab ilities, day care ce n tres and d is a b ility r e la te d o rg a n is a tio n s . K ey p erso n n el, u su ally th e p erso n -in -ch a rg e o r the h ea d -o f-d ep a rtm en t, w ere in te r­ view ed using a se m i-stru ctu red interview to clarify a n d /o r co n firm q u es tio n n a ire in fo rm atio n on th e n u m b ers o f p eo p le w ith d isab ilities. In fo rm atio n w as also o b ta in ed on the n u m b e rs o f th erap ists em p lo y ed and w h o w as fu n d in g th eir salaries. In total, 18 serv ice p ro v id ers w ere co n tac ted an d in terv iew ed . Calculation of costs T h e rec u rren t co st o f the reh a b ilita tio n perso n n el is th e co st o f th e ir salaries. T h is w as c a lc u la te d u sin g th e 1996 state P erso n n el A d m in istra tio n S tan d ard (PAS) salary scale, p lu s 40% fo r s u p p le ­ m en tary b en efits. T h e low e s tim a te o f the co st w as ca lc u lated u sing th e low est en d o f th e scale and the h ig h e stim a te o f the c o s t w as the h ig h e st en d o f the scale (W H O , 1994). RESULTS Table 1: R e h a b ilita tio n p e r s o n n e l in M itc h e ll’s P lain Cost o f rehabilitation personnel - Regional and district level rehabilitation services S ev en ty six p e rc e n t (76% ) o f th e total ex p e n d itu re o n e m p lo y in g reh a b ilita tio n p erso n n el w as a t the reg io n al p sy c h iatric ho sp ital, L en te g e u r H ospital, in clu d in g th e C are an d R e h ab ilita tio n C e n tre for p rofoundly in tellectually disabled people. T h is is the m a jo r p sy c h iatric h o sp ital fo r the C a p e M e tro p o lita n region, w ith m o st o f its p atien ts fro m o u tsid e th e district. T h is c a n n o t th e re fo re be co n s id ered a d istric t level facility, b u t is a reg io n al facility. T h e rem a in in g 24% o f the total ex p e n d itu re w as d ed icated tow ards re h a ­ b ilitatio n serv ices on d istric t level for th e en tire p o p u la tio n in th e d istrict. Graph 1: Expenditure on human resources p r o v id in g re h a b ilita tio n (reg io n a l a n d d is tr ic t f a c ilitie s ) S A J o u r n a l o f Physiotherapy 2001 V o l 57 No 4 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) G rap h 1: Expenditure on human resources providing rehabilitation 4500000 4000000 3500000 3000000 2500000 2000000 1500000 1000000 500000 0 low estimate I high estimate ■I ■ ■ n■tW _______ — Lentegeur Hospital & Care & Rehabilitation Centre Agape School Lentegeur State Training Centre Mitchells Plain CHC UWC Community Rehabilitation Project Regional and District Services C o s t o f r e h a b ilita tio n p e r s o n n e l - D istr ict level reh a b ilita tio n services F urther analysis w as d o n e on the balance (the rem ain in g 24% o f total expenditure) th a t e x c lu d e d th e e x p e n d itu re at th e reg io n al p sy ch iatric hospital. T h e g reatest p o rtio n o f ex p en d itu re C h a rt 1: E x p e n d itu re on reh a b ilita tio n C h a rt 2 : D is tr ic t level: E x p en d itu re on d is a b le d ch ild ren S eventy p erc en t (70% ) o f this d istrict ex p en d itu re on reh ab ilitatio n w as at the o n e special school fo r ch ild ren w ith cerebral palsy, w h ere 11 th erap ists w ere e m p lo y ed (79% o f d istric t b ased th e ra­ pists) w o rk in g w ith 190 ch ild ren (6% o f the ch ild ren w ith d isab ilities in th e dis- c o n stitu ted th e em p lo y m en t o f therapists w o rk in g w ith child ren . A total o f 506 c h ild re n ag e d 6-15 a tte n d e d sp e cia l schools or day care centres in the district. T his w as on ly 16% o f the total estim ated p o p u latio n o f ch ild ren w ith disab ilities ag ed 6-15 years in the d istrict (see above total o f 3087). Chart 2: Expenditure on disabled children trict). A s a p art o f the ad m issio n criteria, the school on ly accep ted ch ild ren w ith cereb ral palsy w ith m ild o r no in te lle c­ tual disability. T h e only fu n d in g for sp eech therapy service in th e d istrict w as for ch ild ren at this special school and this serv ice w as n o t av ailab le to the rest o f the com m unity. M o st o th e r c e n ­ tres pro v id in g a service to children w ith m ore sev ere in tellectu al d isab ilities did not em p lo y therapists. Table 2: R eh a b ilita tio n p e r s o n n e l f o r ch ild ren a t sch o o ls a n d ca re cen tres A t the d istrict level, 17% o f the co st o f the reh ab ilitatio n p erso n n el w as fun d ed by th e N G O , w h ich p ro v id ed co m m u ­ nity based reh ab ilitatio n for adults and ch ild ren . F ifteen p erc en t o f the cost o f reh ab ilitatio n p erso n n el w as at the co m m u n ity h ealth centre, p ro v id in g a service m ain ly fo r adults. A t th e tim e o f th e study all th e state ex p en d itu re in the M itc h e ll’s P lain H ealth D istrict w as on in stitu tio n al b ased reh ab ilitatio n for adults and child ren . DISCUSSION T h e d istrib u tio n o f reh ab ilitatio n p e r­ sonnel in the M itc h e ll’s P lain h ealth d istric t reflec te d a co n tin u atio n o f the h isto ry o f state fin an cial su p p o rt to the e m p lo y m e n t o f p erso n n el at in stitutional level and not at p rim ary level facilities w ith in th e co m m u n ity o r co m m u n ity b ased reh ab ilitatio n . (N o n e o f th e fac i­ lities referre d to are tertiary institu tio n s.) T h e situation analysis in d icated the co n cen tratio n o f reh ab ilitatio n perso n n el a t tw o sta te in s titu tio n s , L e n te g e u r H o s p ita l an d A g a p e C e re b ra l P alsy S chool. O nly th e clien ts o f these in sti­ tutio n s h ad access to therap ists. P eo p le w ith d isab ilities at th e o th e r facilities, o r th o se b eing cared fo r at hom e, could n o t g et therapy fro m them . A n an aly sis o f th e co st o f em p lo y in g the rehabilitation personnel indicated that th ere w ere in eq u alities in the d istrib u ­ tion o f fu n d in g in th e M itc h e ll’s Plain h ea lth d istrict. A p art fro m th e regional p s y c h ia tric h o s p ita l, w h ich ac c e p te d p eo p le fro m th ro u g h o u t the reg io n , c h il­ dren w h o h ad an in tellectu al d isab ility in ad d itio n to p o ssib ly hav in g a ph y sical d isab ility h ad far less access to reh a b ili­ tation services than th o se w ith on ly a physical disability. A t o n e cen tre fo r 160 ch ild re n w ith in te lle c tu a l d isa b ilitie s th ere w as on ly one therap ist, and at th ree o th e r cen tres th at p ro v id ed a day care service for 156 ch ild ren w ith intellectual disab ilities th ere w as no state fun d in g fo r reh ab ilitatio n perso n n el. F u n d in g fo r sta te th e ra p is ts w as fro m th e p ro v in cial h ealth departm ent. T h e com m unity based organisation had external d o n o r fun d in g . A n ev alu atio n is Chart 1: Expenditure on rehabilitation District expenditure 76% 6 SA J o u r n a l o f Ph ysioth era p y 2001 V o l 57 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 2: Rehabilitation personnel for children at schools and care centres Centre Children Therapists Agape Cerebral Palsy School 190 11 Lentegeur State Training Centre 160 1 Beacon Training Centre 104 0 Joy Day Care Centre 20 0 Mitchell's Plain Special Care Centre 32 0 n eed ed to d eterm in e w h at p ro p o rtio n o f th e p ro v in c e ’s b u d g et g o es on reh a b ili­ tation an d w h eth er it co u ld be allo cated m o re appropriately. C u rren tly the th e ra­ pists h av e no in p u t in d eterm in in g the b u d g et allo catio n . T h ere is a need fo r im p ro v e d lin k s b e tw e e n th e D e p a rt­ m ents o f H ealth, E d u catio n an d Social D e v e lo p m e n t to jo in tly d e te rm in e w h ere th erap y p o sts are needed. T h e n eed fo r im p ro v ed access to reh a b ilita ­ tion fo r ad u lts an d ch ild ren has b een d em o n strated . T h is p ro v isio n n eed s to b e ch a lle n g ed by p eo p le w ith d isab ilities and th eir carers as w ell as by the re h a ­ b ilitatio n p erso n n el p ro v id in g the ser­ vice. Is it ac ce p ta b le to p ro v id e in ten siv e th erap y to a few in in stitu tio n s, w hile m an y h av e none? T h e d e v e lo p m e n t o f an in c lu s iv e e d u c atio n system also ch allen g es the su p p o rt p ro v id ed by reh a b ilita tio n p e r­ sonnel w o rk in g in the ed u catio n sector. T h e D e p a rtm e n t o f E d u c a tio n has e m p h asised the n eed fo r a p aram o u n t sh ift in the su p p o rt cu rren tly p ro v id ed to ch ild ren in sch o o ls fro m “a narrow v isio n o f a hig h ly sp ecialised , in dividu- ally -fo c u sed serv ice p ro v isio n ” (D e p art­ m ent o f E d u catio n , 1997: 23). T h e 2001 E d u ca tio n W hite P a p er 6: S p ecia l N eed s E d u ca tio n , B u ild in g a n in c lu siv e e d u ­ c a tio n a n d tra in in g sy stem em p h asises th e n eed fo r rem o v al o f ‘b arriers to le a rn in g ’ w ithin the ed u catio n system (D e p artm e n t o f E d u catio n , 2 0 01). A n accessib le, in teg rated an d h ealth p ro ­ m o tiv e ap p ro ach is n eed ed (D ep artm en t o f E ducation, 1997). T his approach w ould fa c ilita te th e d e v e lo p m e n t o f a m o re equitable way for rehabilitation personnel to p ro v id e a su p p o rt service. E q u ity is n o t the sam e as equality. It is ab o u t b ein g fa ir an d ju st. It is about the d istrib u tio n o f m aterial reso u rce s as w ell as pow er. R e alistic goals can help red u c e in eq u ities (N aid o o , 2000). W hile few w ill arg u e w ith th e n ee d fo r equity, it w ill only b e p o ssib le at a price. W ith scarce reso u rce s ch o ices w ill h av e to b e m ade. W hat lev el o f reh ab ilitatio n w o rk e r w ill w e c h o o se to em p lo y ? W h at b en e fits w ill b e lost b y m ak in g a d iffe r­ en t c h o ice ? E v ery o n e w ants a reh a b ili­ tation sp ecialist on th e ir d o o rstep b u t this can resu lt in the sp ecialist being u n d er-u tilised w h ile th e p atien ts co u ld be tre a te d e ls e w h e re a t lo w e r c o s t (D ru m m o n d e t al, 1987). In p la n n in g reh a b ilita tio n services, altern ativ e uses o f fu n d in g n eed to be ex p lo red . T his m ay in v o lv e em p lo y in g assistan ts o r reh ab ilitatio n w orkers rath er than th erap ists, if it is m ore co st effec­ tive b u t still w ith ap p ro p riate b en efits. T h e D ep a rtm en t o f E d u ca tio n m ay fo r e x a m p le c o n s id e r e m p lo y in g this level o f w o rk e r to p ro v id e sup p o rt fo r c hildren with special needs in m ainstream schools. C o llab o ratio n b etw e en the D e p a rt­ m ents o f H ealth an d E d u catio n is needed to p lan effectiv ely an d appropriately. W ithin each h ealth d istric t a D istrict H ealth A u th o rity has b ein g estab lish ed w hich has the p o ten tial to play a sig n i­ fican t ro le in p lan n in g an d ev alu atin g th e h ea lth se rv ic es a t a lo c al level. In tersecto ral lin k s are n eed ed w ith the E d u catio n M a n a g e m e n t an d D ev e lo p ­ m e n t C e n tre s in th e n e w e d u c a tio n d istric ts in the W estern C a p e to p lan the p ro v isio n o f reh a b ilita tio n services. CONCLUSION T h e an aly sis o f the co st o f reh ab ilitatio n serv ices is a u sefu l in d ic ato r fo r d e te r­ m in in g w h e th e r fu n d in g is allo ca te d eq u itab ly w ith in a d istrict. M itc h e ll’s P lain is a re la tiv e ly w ell o ff h ea lth d istric t in term s o f the n u m b e r o f reh a­ b ilitatio n perso n n el. H ow ever, a h igh p erc en ta g e o f c h ild ren and ad u lts w ith d isab ilities, p articu larly p eo p le w ith an in tellectu al disability, d o n o t h av e access to th e r e h a b ilita tio n se rv ic e s in th e d istric t. E x c lu d in g th e re g io n a l p s y ­ ch iatric h o sp ital, m o st fu n d in g is at o n e s p e c ia l s c h o o l, w h ic h h a s th e o n ly fu n d in g fo r sp eech th erap y in th e d is­ trict. M o st o f th e reso u rce s go tow ards the th erap ists p ro v id in g the se rv ic e fo r children w ith a physical disability w ithout an asso cia te d in te lle ctu al disability. A very sm all p erc en ta g e o f the C o m m u n ity H e a lth C e n tre b u d g e t g o e s to w a rd s e m p lo y in g reh a b ilita tio n perso n n el. W ith o u t a c c e ss to r e h a b ilita tio n , p eo p le w ith d isa b ilities m ay b e u n ab le to reach their full p otential, denying them the ch a n ce o f in te g ratio n in to society. In ad e q u ate o r in ap p ro p ria te fu n d in g o f reh a b ilita tio n serv ices w ill co n tin u e to lead to the m arg in alisatio n an d im p o v e r­ ish m en t o f p eo p le w ith d isab ilities. H e a lth se rv ic e p la n n e rs , p la n n in g rehabilitation services, need to fam iliarise th em selv es an d an aly se the co st o f all the reh a b ilita tio n serv ices p ro v id ed by state an d N G O s at the d istric t lev el to en su re eq u ity w ith in a d istrict. T h is an a ly sis c o u ld then b e u sed to co m p are d iffe ren t d istric ts to en a b le th e p ro v in cial lev el p la n n e rs to set p rio rities fo r p lan n in g serv ices and seco n d ly to en a b le p eo p le w ith d isa b ilities to h av e access to a p p ro ­ p riate an d affo rd ab le reh ab ilitatio n . RECOMMENDATIONS FROM THE STUDY • T h a t ea ch d is tric t h e a lth au th o rity d e v e lo p s a d ire c to ry o f fa c ilitie s , reh a b ilita tio n p erso n n el an d nu m b ers o f clien ts w ith d isa b ilities to facilitate p lanning. • T h at th ere is jo in t p lan n in g betw een the D ep a rtm en ts o f H ealth , E d u catio n an d W elfare to p lan fo r the p ro v isio n o f e d u c a tio n s u p p o rt se rv ic e s fo r children. • T h at th ere is in c re ase d fu n d in g for e m p lo y in g re h a b ilita tio n p erso n n e l to w o rk w ith c h ild re n w h o h a v e a m o d e ra te o r se v e re in te lle c tu a l disability. • T h at th ere is a g rea ter p ro p o rtio n o f fu n d in g fo r adults w ith d isab ilities in the district. • T h at th ere are fu rth e r stu d ies in oth er d istric ts o f the C ap e M e tro p o le to c o m p are d istric ts an d in fo rm p lan n ers in th e P ro v in c ia l A d m in istratio n o f the W estern C ape. SA J o u r n a l o f P hysiothera py 2001 V o l 57 No 4 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) REFERENCES C ity o f C ape Town 1994/5 A n nual R eport o f the M edical O fficer o f H ealth D e p a rtm e n t o f E d u c a tio n 1997 N a tio n a l C o m m issio n on Special E d u cation N eeds i a E d u cation and T raining/N ational C o m m ission on E d u cation S u p p o rt S ervices (N C S N E T / N C E S S ). Q u a lity E d u c a tio n fo r A ll: O v e rco m in g b arriers to learning and dev elo p ­ m ent. D e p artm en t o f E du ca tio n , P retoria D e p a rtm e n t o f E d u c a tio n 2001 E d u ca tio n W hite P aper 6 - S pecial needs education: B u ilding an inclusive e d u cation and training system . D ep artm en t o f E d ucation, P retoria D ru m m o n d M , S to d d a rt G , L a b e lle R, C u sh m a n R 1987 H e alth E c o n o m ic s: An In tro d u ctio n fo r C linicians. 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C o st a n alysis in P rim ary H ealth C are - A training m anual for pro g ram m e m anagers. C reese A, P arker D (editors). G eneva: 33-35 ACKNOWLEDGEMENT A d v ice fro m P rof. D M c In ty re , H ealth E co n o m ics U nit, U niversity o f C a p e Town 8 SA J o u r n a l o f P hysiotherapy 2001 V o l 57 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )