Throughout the DDR process, special arrangements will be necessary to meet the health needs of specific needs groups. The World Health Organization (WHO) recommends planning for children, the elderly, chronically ill and persons living with disabilities, as well as for women and girls who are pregnant or lactating and anyone who has survived sexual violence.
Children and Adolescents:
Boy and girl children and adolescents associated with armed forces and groups can range in age from 6-18. It is very likely that they have been exposed to a variety of physical and psychological traumas, including mental and sexual abuse, and that they have had very limited access to clinical and public health services. Children and adolescents, who are often brutally recruited from very poor communities, or orphaned, are already in a poor state of health before they face the additional hardship of life with an armed force or group. Their vulnerability remains high during the DDR process, and health services should therefore deal with their specific needs as a priority. Special attention should be given to problems that may cause the child fear, embarrassment or stigmatization, e.g.:
Child and adolescent care and support services should offer a special focus on trauma-related stress disorders, depression and anxiety;
Treatment should be provided for drug and alcohol addiction;
There should be services for the prevention, early detection and clinical management of sexually transmitted infections (STIs) and HIV/AIDS;
Special assistance should be offered to girls and boys for the treatment and clinical management of the consequences of sexual abuse, and every effort should be made to prevent sexual abuse from taking place, with due respect to confidentiality.
To reduce the risk of stigma, these services should be provided as part of general medical care. Ideally, all health care providers should have training in basic counselling, with some having the capacity to deal with the most serious cases.
Disabled and chronically ill people:
According to the UN Convention on the Rights of Persons with Disabilities, “Persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others” (Article 1).
“‘Discrimination on the basis of disability’ means any distinction, exclusion or restriction on the basis of disability which has the purpose or effect of impairing or nullifying the recognition, enjoyment or exercise, on an equal basis with others, of all human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field” (Article 2).
Non-discrimination and fair and equitable treatment are core principles in both the design and implementation of DDR. Throughout planning and implementation, special measures must be taken to cater to the specific needs of disabled and chronically ill combatants so that they may take equal advantage of all DDR benefits and opportunities. Ex-combatants with disabilities should be treated as victims of armed conflict; they have special needs and require special care. To assist this group, DDR health practitioners and national authorities should agree on a system to respond to war disabilities in order for disabled people to gain entitlement to disability pensions and/or to join the social security system. An approach can be designed that measures an individual’s physical impairment and how much the impairment limits his/her capacity to benefit from socio-economic reintegration.
In the context of DDR, the overall goal of health action is to reduce avoidable illness and death. However, ex-combatants with disabilities may find it more difficult to achieve this goal as a result of numerous barriers. These barriers could be encountered throughout any stage of the DDR process and could occur directly in the cantonment site or in the community and within the larger existing health systems. For example, in demobilization, ex-combatants with traumatic brain injuries may not understand public health information campaign posters, or after reintegration into the community, an ex-combatant with lower limb amputations would need additional assistance to allow for socio-economic reintegration.
Barriers that ex-combatants with disabilities may face are very similar to the barriers that people with disabilities face when accessing health-care services as outlined in the Community based rehabilitation (CBR) guidelines (WHO, 2010) and may include:
Absent or inappropriate policies and legislation – where policy and legislation do exist such as the Convention on the Rights of Persons with Disabilities (CRPD) being ratified by a country, they may not be implemented or enforced;
Economic barriers – following reintegration into the community, ex-combatants with disabilities will often be required to pay out-of-pocket for health interventions such as assessments, treatments and medications, which presents difficulties, as ex-combatants are likely to have limited income or coverage for health care;
Physical and geographical barriers – lack of accessible transport and inaccessible buildings and medical equipment are examples of common barriers, as well as the limited health-care resources of rural areas and the long distances to reach services in big cities;
Communication and information barriers – communicating with health workers may be difficult, e.g. an ex-combatants who is deaf might find it difficult to communicate his/her symptoms to a doctor, and health information is often not available in accessible formats, e.g. picture formats for ex-combatants with cognitive impairments;
Poor attitudes and knowledge of health workers about ex-combatants with disabilities – health personnel may have inappropriate attitudes, or lack the knowledge, understanding and skills to manage health issues for ex-combatants with disabilities;
Poor knowledge and attitudes of ex-combatants with disabilities about general health care and services – ex-combatants with disabilities may be reluctant to use health services; many also have limited knowledge about their rights and health issues, and about what health services are available.
Some ex-combatants with disabilities may be more vulnerable to discrimination and face greater barriers than others, particularly the following groups: women, ex-combatants with multiple impairments (e.g. are both deaf and blind) those with intellectual impairments, HIV/AIDS or mental health problems. These groups of people may suffer double or multiple disadvantages, due to the type of disability they have (UN Enable, 2003–04), and therefore may find it more difficult to access healthcare services.
The right to health for ex-combatants with disabilities is not only about access to health services; it is also about access to the underlying determinants of health such as safe drinking water, adequate sanitation and housing and other health initiatives implemented in the DDR process. The right to health for ex-combatants with disabilities also contains freedoms and entitlements. These freedoms include the right to be free from non-consensual medical treatment such as experiments and research and the right to be free from torture or other cruel, inhuman or degrading treatments. The health-related entitlements include the right to a system of health protection; the right to prevention, treatment and control of diseases; access to essential medicines; and participation in health-related decision-making (OHCHR & WHO, 2008).
To ensure that ex-combatants with disabilities achieve good levels of health it is important to remember that:
Ex-combatants with disabilities have general health care needs (e.g. promotion and prevention services and medical care) like the rest of ex-combatants;
While not all ex-combatants with disabilities have problems related to their primary health condition, many will require specific healthcare services for their disability, including rehabilitation, on a regular or occasional basis and for limited or lifelong periods.
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