THE IMPLEMENTATION OF THE INTERNATIONAL CLASSIFICATION AND FUNCTIONING (ICF) IN TAIWAN: Opportunities and problems

by Professor Wang Kuo-yu (Lisa Wang), Department of Social Welfare, National Chung Cheng University, Chai-yi, Taiwan.

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As a latecomer to the status of welfare state, Taiwan in the last two decades has been using other countries’ solutions to solve its social problem. Disability policy is no exception. In this short article, I briefly review Taiwan’s disability policy, explain why and how the ICF (International Classification of Functioning) was introduced in Taiwan, and discuss the future challenges Taiwan faces with regard to the ICF.

In 2007, the Legislative Yuan passed Taiwan’s latest disability statute, the Rights Protection Act for People with Disability. The passage of this legislation was the result of the efforts of advocacy groups in Taiwan during the past two decades. This new legislation adopted the ICF system as a way to assess the needs of, and the services available to, the disabled population in Taiwan.

The development of disability legislation in Taiwan

It was not until the beginning of 1980’s that Taiwan began to establish a welfare system for its disabled population. The first disability legislation, called the Welfare Law for People with Disabilities, was introduced by the KMT (Kuomindom.the old Chiang Kei Sheik Regime) government in 1980- The legislation restricted the definition of the disabled population to people with intellectual disabilities, vision and hearing impairment, mobility problems, or multiple disabilities; to qualify, a disability had to be certified as such by the central government. The content of the legislation was adopted from the laws of other countries.

Examples are Japan’s issuance of identification cards to persons who qualify under the government’s definition of disabled, and Germany’s mandatory employment quota system. However, the most important provision of the 1980 law was the restriction of eligibility to people who fit within the government’s six original categories of disability; those who did not fit into these categories were not qualified to receive services, even if their conditions required help or assistance from society.

This initial legislation laid the foundation for Taiwan’s disability policy: the disabled person first had to present themselves to local government officials to obtain his/her disability card, and only then could he /she gain access to all the services in the welfare system — no card, no services. This administrative requirement created many problems for providers as well as for disabled people.

In 1990, under pressure from the opposition party and the results of competition among different parties in general election, the KMT government began to reform its welfare policy. The Welfare Law for People with Disabilities was one of the many items on its welfare policy agenda. In the 1990’s, there were two revisions of the Law. The first revision, in 1991, introduced a mandatory employment quota system under which public-sector and organizations with 50 or more employees were required to reserve 2% of their job opportunity for the disabled person. For private-sector companies with 100 or more employees, this figure was 1%. This 1991 revision also expanded the number of disability categories from six to 11. The new categories included, for example, dementia and facial disfigurement. This expansion of add on new categories of disability into the system, matched by the government increasing its budget for services to disabled people, also increased the number of people who were registered as disabled. However, implementation of the 1991 revision was hindered, primarily by the adoption of the mandatory employment quota system. The problem was that most of the administrative authority was assigned to the welfare service bureau; thus, other relevant governmental officials were not required to take an active and pro-active role in implementing the legislation. This lack of employment opportunities and insufficient coordination among the various government administrative offices led the advocacy groups to formally demand that the government revise the 1991 law.

Driven by dissatisfaction with implementation of the 1991 law and the progress of democratic development, the government began in 1994 the second and more sweeping revision of the law. When this process was completed in 1997, both the name and the substance of the 1991 law were totally changed. The new legislation, which was named the Rights Protection Act for People with Disabilities, specified that different agencies were to assume the major role in delivering services to people with disabilities. These services included education, employment counseling, medical care, welfare service and in cash assistance. The new law also mandated that the rights of people with disabilities must be protected; if the government failed to do so, the disabled person could appear to the court to sue the government. The law also guaranteed disabled person opportunity to participate in the government’s decision-making processes.

The 1997 legislation required that each government office deliver services to people with disabilities in such a way as to enforce equal protection of these citizens under the law. All levels of government, from local to central, had to establish a Rights Appeal Committee for People with Disabilities. The law stipulated that at least one third of the membership of these committees must be people with disabilities.

As progressive as this expansion may seem on the surface, it should be noted that all the category expansions were politically motivated and without any logic of taxonomy; that is, the categories of disability were not guided by any proper classification system. Thus, politicians were free to propose any new category they wished without the consent of relevant professionals. This circumstance provided the backdrop for yet another revision of the law that began in 2003 and ended in 2007.
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Introduction of the ICF in the 2007 Legislation

The 2007 Rights Protection Act for People with Disabilities made critical changes to the disability system in Taiwan. The adoption of the WHO’s new ICF classification system was the major breakthrough. The new law also required that who has a disability must be determined by the ICF scheme. Also, under the old legislation, medical doctors played the critical role in determining whether someone qualified as disabled and thus could be issued a Disability ID card. Adoption of the ICF system created the opportunity for other professionals to participate in the decision-making process, especially rehabilitation physicians, but also physical therapists, occupational therapists, social workers, and special-education teachers. The disposition of each case depended on the applicant’s needs, environmental support, family, and even living conditions. The problem is that most local rehabilitation professionals are not familiar with all these elements, which are required by the ICF evaluation process.

In the previous system, the ID cards were the province of the Ministry of Health. The new system requires cooperation between government officials from multiple agencies. Thus, ever since the legislation passed in 2007, bureaucrats have been arguing among themselves about whether physicians should take sole responsibility for the decision making and exclude other professionals from participation in the process.

The other challenge to implementing the ICF in Taiwan has come from the local level; there are not enough professional workers with different kinds of expertise to establish a proper evaluation team. This fundamental limitation illustrates the problem of the uneven distribution of resources between urban and rural areas in Taiwan. Few city governments have the capacity to mobilize and motivate the required professionals to participate in the evaluation process. Even though the legislation established a five-year preparation period, this has not been enough time to complete the establishment of local evaluation teams in some areas.

Despite these two major barriers to the implementation of the ICF, its introduction in Taiwan has had a positive impact. First of all, the ICF is a good tool for assessing the conditions of the disabled person at both the clinical and social levels. It is to be hoped that the introduction of ICF will encourage health professionals to adopt a societal rather than an individual perspective for their clinical services. This wider perspective on disability assessment would make a vital contribution to the current system.

The second contribution of the ICF system is that for the first time in Taiwan, government officials and local bureaucracies across the health, welfare, education, and labor sectors have begun to seriously raise questions about how the needs of people with disabilities should be assessed. Previously, such determinations were made mostly by social workers, and other professionals did not participate in the process. After the introduction of the ICF, the professionals and governmental officials have come to recognize that the disabled person has multiple needs and they need services that satisfy these needs. From the provider and administrative perspective, the ICF means that they must do more and take more responsibility than before. Thus, the implementation of the ICF in Taiwan has been critical in changing how we provide services and assess the needs of people with disabilities.

The main strength of the ICF is that it requires clinical or direct-care workers to take environmental factors into account when planning or providing services for people with disabilities. Another strength of the ICF pertains to research, in that it provides an excellent tool for collecting data that can be used to document the changes that the disabled person have undergone during a certain period of time and compare these changes across individuals. In fact, the ICF already has such a comparative scheme built into its coding system. Finally but not least, the ICF is based on a philosophy of universalism with regard to the experience of being disabled. This means that the ICF is useful as a tool for assessing the needs not only of the disabled population, but also of the elderly population, whose members experience a decline in their daily living skills.

Taiwan is the first Asian country to write the ICF into legislation, not just use it casually for clinical assessment in the absence of standardized procedures or implementation by professionals. Therefore, in the short term, Taiwan may experience some chaos in the processes of negotiation, coordination, and cooperation between the central and local governments. But this transition period is necessary for the future development of the ICF in Taiwan. In the long term, when the implementation system has matured, professionals representing diverse disciplines, as well as governmental officials at different levels, will benefit from the implementation of this interactive, multi-dimensional tool.

As mentioned above, Taiwan is a latecomer to the establishment of a welfare state. Given this background, it may be necessary in the short term for Taiwan to borrow or adapt solutions from other societies. In the long term, Taiwan must create a welfare system that reflects the needs of its own people. At the same time, one must remember that the ICF is a tool that is applied in a broad context and thus requires members of different professions to work together. Most of all, as the ICF system matures, people will begin to realize that everyone is affected by disabilities, not just that proportion of population who fit into the legal categories referred to earlier. By recognizing this fact, we can reduce and eventually eliminate discrimination toward people with disabilities. Finally, we must remember that Taiwan has just recently joined the international community in using the ICF and employing evaluation procedures that allow data on its disabled population to be compared with data from other countries.

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