Recently there have been a lot of research about building age-friendly hospitals as some researchers relate old age to disability, but hospitals must be friendly to persons with disabilities not only at old age but at all ages.

This study is a cross sectional that focused on persons with disabilities on the streets of Accra the capital city of Ghana. The study employed mixed method approach (quantitative and qualitative), sample size of 140 persons with disabilities begging on the streets of Accra filled the questionnaires. Respondents were made up of 119 cripples, 12 amputees and 9 blind persons. One Focused Group Discussion (FGD) was conducted using seven persons with disabilities in the group. Again one In-Depth Interview (IDI) was conducted with expert on social welfare issues. SPSS was used to analyse the quantitative data. Qualitative finding were used to support quantitative discussions to help provide better understanding and in-depth knowledge from the respondents.

The study revealed how persons with disabilities were denied the needed social support and challenges they faced when seeking healthcare at the hospitals.

Though persons without disability have the possibility to become disabled, persons in authorities have refused to create the environment needed to match the existence of persons with disability.  According to WHO (1980) mode1, disability is “any restriction or lack of ability to perform an activity in the way or within the range considered normal for a human being”.

It was estimated that about 978 million, hence about 15.3% of the world’s population had moderate to severe forms of disability according to 2004 Global Burden of Diseases. In the same report it was also estimated that Africa has slightly higher number of persons with disabilities as compared to other regions of the world. Most writers have linked the growing number of persons with disabilities to reduction in fertility rate and increasing in aging population, but in Africa road accidents and other Neglected Tropical Disease such as Buruli ulcer may be the major factors influencing the growth in the number of disabilities as our fertility rate kept growing yet that of other regions kept reducing (Research Triangle International (RIT) 2012).

According to Population and Housing Census conducted in 2010 by Ghana Statistical Service, three percent of Ghanaian are said to be with various form of disabilities, nonetheless the 2% of District Assembly Common Fund reserved to be spend on persons with disabilities, one can say that most disabled are not getting this and other benefits they deserved, most persons with disability live in poverty and result to begging on the streets and other places to earn a belligerent living.

Disability and health have been written about by many researchers, but painfully most writers limited their scope to disabilities as the result of old age, a lot of emphasis have been laid on aged friendly hospitals excluding disability before old age. This study focused on persons with disability who mostly use the streets of Accra as a place of work and sleep there at night, faced when seeking healthcare at the hospital. Since persons without disabilities are also susceptible to disability, there is the need to create the needed environment for very person’s existence. Persons with disability do not need mercy from the abled persons, what they need is the abled persons being fair to them and gives them what belong to them. Creating environment that match their disabilities will help reduce their dependency rate in every environment they are.

Demographic characteristics of the respondents Majority of 37.6% were aged between 26 and 37, total of 36.5% were between the ages 36 and 47, while 16.5% of respondents were aged between 18 and 25 years, only 9.3% were aged above 50 years. The respondents were made up 61.2% males and 38.8% females, with religion the majority of respondents 52.9% were Muslim, 38.8% Christians and the rest 8.3% are either non-religious or belongs to other minor religious bodies. Majority of respondents 49.9% have no forms of formal education, 20.0% had secondary education while 30.1% had only basic education.

Most of the respondent (43.3%) claimed they are single, 38.8% are cohabiting and 17.9% said they are married. With regards to employment, 82% of respondents said that begging is their means of survival and for that matter only job they have, 12.9% said they are self-employed and do begging in additional while only 5.1% said they are employed by other people and do begging to support their income. Three forms of disability were captured by the study, these includes 85% cripples, 8.6 % amputees and 6.4 % blind Social Support from Government and the Society for the Disabled.

The majority of respondents74.1% said they do not benefit from any government social intervention, while 25.9% said they have benefited from the district assembly common fund.  In case of Health insurance for the disables, only 52.9% hold the National Health Insurance Card and 47.1% said they do not have the National Health Insurance Card and have to pay cash anytime they attend hospital for healthcare. Majority of respondents 63.5% said they sleep in uninhabitable places such as under trees, corridors of buildings, kiosks and market places whereas 46.5% of respondents said they sleep in houses with relatives.  Majority of respondents 62.4% claimed they need someone to accompany them to the hospital and 47.6% said they can attend the hospital with or without the support of others. With regards to financing of healthcare, majority of respondents 83.3% said they find it difficult getting money to pay for their hospital bills, 16.7% said relatives always foot their hospital bills no matter the amount involved. 

Disability and Healthcare Delivery When asked about their first point of call when they are sick and needed help, 56.5% claimed they called on their family members, 28.2% said they called on the disabled friends while 15.3% said they called on opinion leaders in their communities. Getting transport to the hospital is very difficult as claimed by 87.8% of the respondents and 21.2% said they get support from family and friends. When asked if they find it difficult to access the hospital environment 85.3% said yes it is difficult due to the nature of disability, nonetheless 14.7% said they have no difficulty accessing the hospitals. Majority of respondents 87.1% said health workers delay in attending to them at the hospital while 12.9% said the delay in the hospital was normal to everyone, 60% said their complains to health workers about their challenges in the hospitals due to the difficulties in accessing the hospital facilities were ignored but 40% of the respondents claimed that hospital workers listen to their complaints. However, 85.9% of the respondents said that they find it difficult to access facilities within the hospital such as washrooms and hospital beds whenever they are admitted, 14.1% said accessibility is not their challenge in the hospital.

With regards to education on medication prior to discharged, majority of respondents 89.4% claimed that hospital worker spend much time to explain the usage of medicine to their understanding, but 10.6% said they do not explain the usage to them. With regards to behaviour of the health workers towards them, only 35.5% of respondents claimed hospital workers were rude to them but the majority of respondents 64.5% said they were not rude to them.

While 88.2% of the respondents said no special support is offered them by hospital workers to reduce their struggle due to facility unfriendliness, 11.8% stated that they were given some support by hospital workers in areas of wheelchair for easy movement within the hospital premises. With regards to discrimination, the Majority of respondents 82.4% said they do not felt that they were being discriminated against at the hospital and 17.6% claimed they were discriminated against at the hospital.

Qualitative Data
Focused Group Discussion (FGD)

The above table indicate the composition of the Focused Group which was made up of five cripples who have being on the street for three to five years, one amputee who has being on the street for more than two years and a blind man who has also spend over three years on the streets of Accra.

In-Depth Interview (IDI)

The table above shows that, In-Depth Interview was conducted using a specialised social worker who have worked on issues with disability for the past eight years.

Demographic Characteristics of the Respondents This cross sectional study was conducted in the streets of Accra the capital city of Ghana to explore social supports that are being offered to persons with disabilities begging on the major streets within Accra and the difficulties they faced when seeking health at the hospitals.

The age of majority of respondents is less than fifty years. this is because the population of Ghana is youthful one, we need to emphasise that the research was conducted on the streets of Accra where most of the persons with disability are youths with the energy to move within the busy vehicular traffic to beg, same reason depicts where we have 61.2% males when the Ghanaian population has high number of female than males.

 The World Bank and World Health Organization pinpoint the fact that persons with disability are victims of lack of education, deprived employment and mostly live in poverty (WHO & World Bank 2011) though Ghana claimed to have achieved the Millennium Development Goal on education and has being implementing inclusive education, our education institutions have little or no disability friendly facilities, even Special School which are built for children with disability hardly seen any infrastructural or service improvement (Reindal, 2009). The study revealed that only 38.8 respondents had some form basic of education. Federal Register (2006) said that the assistance needed to enable the disabled to be educated is lacking in most developing countries and Ghana is not different.

FG the distance from our house to the school is far, even my friends who tried going to the school have to stop because they were burden to others in the school since they have to support them to use school facilities everyday […] I stop school at class four because I realised that my parents were not interested in my education as compared to my abled brothers, they hardly buy book for me or pay my fees.

IDI, though the government is not doing enough to support education of persons with disabilities, sometimes they also do not put in much effort, they are quick to run to big cities to beg. 

The coming of the United Nations Convention on the Rights of Persons with Disabilities in the year 2008 (CRPD) was seen as a liberator of people with disability, but the situation of people with disability in the streets of Accra have not seen any significant improvement as begging has remained the sole profession of 64% of the respondents while the rest 36% claimed to be doing other works aside begging, a study by Appiagyei (2006) brought situation to light, till date we pay lip service to the situation while disabled begging on the streets of Accra have increased (Kassah, 2008).

FGD, we beg because there is no one to help us, some of us can work but we have no one to employ us [...]. With my condition I can only beg, look at my condition what work do you think I can do? [… ] Now we have increased in numbers we have a lot of disabled foreigners on the other streets.

The study captured three forms of disability namely Cripples, Blinds and Amputees, with the majority being cripples making (47%). Though most of the disables on the street sleep in inhuman conditions they engaged in intimate relationship with cohabiting being the most common form of the relationship (38.8%). FGD. I have girlfriends, they are not disabled persons they come for me at night […] I am dating my friend disabled person we are not married but we stay together in a kiosk […] hmm I tried to marry one lady, I even made her pregnant but her family refused our marriage saying I am disabled person.

IDI, many families will not allow their members to marry a person with disability, as disables are not economically sound, some family feared if they allow them to marry they will give birth to disabled children, it is only possible if the person with disability stands out economically, well-educated or professionally. Lack of Social Support for Disabled People Social supports are the basic help that are legally mandated to be given to persons with disability by the state or compassion from family and other people.

The constitution of Ghana through the District Assembly Common Fund Act 1993 (DACF, Act 455) stipulated that two percent of the District Assembly Common Fund (currently increased to 3%) must be allocated to persons with disability but majority of 74.1% of the respondents do not get the above benefits, other social interventions such as the Livelihood Empowerment Against Poverty (LEAP) run by the Ministry of Gender and Social Protection does not really focused on the disabled community (Ahiabor, 2013 & Ghana Statistical Service, 2013). The disturbing issue is the refusal of the authorities to give them their share of the national cake, persons with disabilities do not need our mercy, but it is the matter of the abled authorities not being fair to the disabled.

FGD, some of us have never benefited anything from the governments our authorities keep everything to themselves, even when churches give them items to be given to us, then they pretend the items were coming from them.

ID, many persons with disabilities do not benefit from some interventions because they live on the streets, we do not know which district they belong to, since the benefits are distributed according to districts, again they do not even apply for their share of interventions [….]

The National Health Insurance Card which is the license to affordable health is giving freely to abled pregnant women but the disabled people who are mostly begging on the street have to pay for it as only 52.7% of the respondents hold such card.

Accommodation is a problem for Ghanaians as whole, especially in Accra, Yirenkyi (2014) made it clear that it is difficult for the citizens to find the needed sleeping places. The sleeping place of persons with disability who beg on the street of Accra is not a place fit for human, as 63% of persons with disability sleep in such uninhabitable places where they are exposed to any weather conditions, mosquitoes and others.

FGD, I sleep in a kiosk, while my friends sleep on peoples corridor, even some sleep under this tree, when it rains is only God who see us through [… ] authorities pass here and they see us here no one care about us.

IDI, we cannot accommodate them the government is putting a programme called get them of the street we wish they will go back to their hometown and stay with their families while we support them with the needed intervention [. ..]  Begging is a crime and it is disgraceful to see them there.

 Movement for most of persons with disability without the company of others was found to be challenging as over 62% of the respondents acknowledged the fact that, they need someone to accompany them when they are going to places such as the hospital, this come as the result of unfriendly disability environmental structures both the on roads, hospital and facilities (Rechel, Doyle, Grundy and McKee, 2009). Though the disabled themselves lack the right movement equipment such as wheel chair, white sticks and others, undocumented evidence suggested that other road users hardly respect their rights.

 FGD, going to the hospital alone is not good, when someone go with us they move our document from one point to the other […] hospital workers talk about me when I go to the hospital alone, they say I make their work difficult. Some of the hospital workers frequently asked who brought you […].

Disability and Health Delivery This section of the study focused on challenges persons with disability encounter when they visit the hospital for treatment. Issues range from how they managed to get to the hospital and how they are treated. First Help at the Time of Sickness The persons with disability claimed they take care of themselves when they are sick but said that when the sickness is beyond them, they called on family members and disabled friends (agreed by over 70% of respondents) with few calling on opinion leaders. Undocumented evidence has it that persons with disability on the streets are well organised with leaders among them and rely on themselves more than any organization and over 90% claimed they frequently contact their family.

FGD, when I am sick paa, I called my siblings, they sometime send someone to take me to the hospitals [… ] sometime I called on our disability leader or some disabled friends and they respond well.

Transport to Hospital by Disabled Getting vehicle to the hospital is a major issue as 78.8% of disabled people find it difficult to board public transports which are not disability friendly. Some drivers’ find it difficult to take disabled people as they peruse taking them as time wasting and not having enough space for their wheel chair and walking sticks as this indicates some Ghanaian attitudes towards the disables (Slikker, 2009). Ambulance service could have save the situation but the Ghana ambulance service has little number of ambulances to serve the nation. The severity of disability comes into play when society turned blind eye to what they can do to make them and their environment compatible (Bury, 2000 and Allotey, Reidpath, Kouamé, & Cummins, 2003).

FGD, hmmm when going to hospital or another place it will be good for us to hire taxi but that one too we cannot afford it, as for the trotro (passenger car) though we can afford it, most of them refused to pick us because, the drivers say we waste their times [….. ]

Hospital Unfriendliness to Persons with Disability Building disability friendly social facilities is the sure way of encouraging the disables to use such social facilities. Hospitals in the country have no or little disability friendly facilities, from hospital beds, washrooms, hospital floors and others. The study revealed that it was difficult for the disabled to access hospital facilities as reported by 78.8% of the respondents, according Palmer & Harley (2012) there is the need to review health policy to enable healthcare delivery pay attention to the disabled society.

FGD. It is difficult for some of us to move from one place to the other at the hospital, I do not feel ok walking with my hands on the hospital floor and the toilet and bed are too tall for us to climb when we were admitted

Again 88.2% of respondent said the extra support they needed to reduce their struggle due to unfriendly hospital environment is difficult to get if they do not go to the hospital with a friend or family members. The ways we understand disability determine the way we associate with them (Thomas, 2004) if hospital workers blame the unfriendly health facilities for the difficulties the disabled faced they may be in place to give them the extra support. These limitations of disability friendly facilities have force the disabled people to request for extra support from hospital staff to do basic tasks which  they could have performed themselves if there  were disability enabling environment. The most valuable gift the society can give to persons with disability is to create environment which is compatible with their conditions, this will enable them to do things for themselves instead of relying on others who sometimes view them as burden (Madans, Loeb & Altman, 2011) FGD, I asked the hospital worker to help me to see the doctor without joining the queue, since I cannot be moving from one seat to the other she just look at me inhumanly, I think she did not understand me.

Delay in Getting Treatment at the Hospital by the Disabled Another issue truncating the treatment of the disabled people in the hospital is the time they wasted at the hospital before receiving treatment, delay in hospital may not be the problem of only persons with disability, most Ghanaians complained about the effect of delay in the hospitals on their economic activities. This is because the number of hospital workers working at most of our public hospitals are less than expected, coupled with the huge numbers of Outpatient Attendance (Ahoto, 2017). The complaint of delay was made by 87.1% of respondents as this may lead to a lot of them seeking treatment from other alternative sources.

FGD, sometime you can sit in the hospital for hours, it is not me alone other patients also spend hours [… ] we wait for long time and no one was telling us anything [….]

Paying for Hospital Bills According to Trani, Browne, Kett, Bah, Morlai, Bailey & Groce, (2011) access to health care for persons with disability is always herculean task, apart from unfriendly health environments financing is another problem, but in Ghana the national health insurance has come to reduce the burden of hospital bill on the society, but only 52.9% of disabled on the streets of Accra registered with the National Health Insurance Authority. Again the national health insurance does not cover all kind of sickness, making it difficult for the disabled to pay additional fees which are not captured by the national health insurance, these was revealed by 88.3% of  respondents who agreed they find it difficult to pay their hospital bills. Acton (1983) stated that disability and poverty are related, poverty can result in disability while disability mostly result in poverty, asking the disabled to pay for hospital bills are mostly difficult as the proceeds they make in begging may not be enough to pay their bills.

FGD, Hmmm last week I went to hospital without NHIS card, they gave me some few medicine, that’s what my money can pay for […] I went with the NHIS card but they say it cannot pay for some of the medicines the doctor say they should give me ID, when the common funds are released by government we pay their hospital bills, that is if they apply for support. 

Understanding of Medication Critical approach must be taken to meet the health needs of persons with disability, both time and resources should be spend on them, while health workers develop strategy to meet their health needs (Wiman, Helander, & Westland, 2002).  Understanding of how to apply medication is a vital issue in treatment 80% of the respondents agreed that health officers spend much time to explain how to apply medication to their understanding. This may encourage them to go the hospital for treatment and also speed up their healing process as they may rightly apply medications due to the better explanations given them by hospital workers.

FGD, the doctor talked to me very politely, the man who gave me the medicine educated me on how to take the medicine […..] Discrimination against Disabled by Hospital Workers Nonetheless discrimination is a major issues facing the disabled in society, 82.4% agreed they do not feel that they were being discriminated against at the hospital, this finding indicated that hospital workers have distinguished themselves from several Ghanaian societies as there are major issues of discrimination against persons with disability (Avoke, 2002 & Agbenyega, 2003). Though few (35.5%) of the respondents claimed hospital workers were rude to them.

FGD, some hospital workers argue with patients, many patients talk among themselves about the actions of some hospital workers […] though the hospital workers were sometimes rude is not to us persons with disability alone.

Disability is not new to any society, it is difficult to see persons with disability living under the same old age condition of begging and social exclusion in Ghana. Nevertheless developing countries in Africa are quick to sign international policy documents which are designed to better the lives of persons with disability such policies are not put into practice. Many persons with disability are still facing challenges due to the refusal of authorities to create the environment needed for their existent, basic facilities such as wheel chairs, white sick and others are hard for the disabled to afford.

Many researchers have written about disability and health, but the researchers mostly focused on issues that have to do with old age disability and not disability before old age. Most researches are directed at how to design and manage hospitals to meet the demand of the aging population and not disability in general, researches about aged care at the hospitals have led to the development of aged friendly hospitals while care for persons with disability have really seen any meaningful improvement in developing countries.

This research focused on the challenges disabled faced when seeking health care, much emphasis were laid on persons with disability who are mainly begging on the streets of Accra the capital city of Ghana. The study revealed that most persons with disability find it difficult to get to the hospital when they are sick, person with disability lack of money to pay for hospital bills while most of them beg on the street and they sleep on the streets and other uninhabitable places. The study also revealed that most of persons who are disabled do not benefit from the social benefits which the law have assigned for them. It was too uncovered that most hospital facilities are not disability friendly making persons with disability to struggle when they visit the hospital for treatment. The greatest need for persons with disability is to create the environment which is compatible with their conditions to enable them live their lives without the help or with little help from others.

Recommendations
Persons with disability who spend the live negotiating through moving vehicle on the streets of Accra must be given their share of the national resources. These persons do not enjoy most of social benefits being channel by the government to them, though persons with disabilities are provided for by the constitution (allocation of 2% of district assembly common fund) most disabled beggars never have their share of such benefits. Based on the findings of the study the following recommendation are made. There should be free National Health Insurance Cards for persons with severe disability, the insurance must be for their life time and should also cover all kind of sickness and this will help cater for their hospital bills.

There must be disability-friendly wards in hospitals such that facilities can be convert to suit the conditions of persons with disabilities. Disability friendly nurses must be trained to be part of health workers in the hospitals as such nurses will understand the need of persons with disabilities better and will be ready to assist them when they face difficulties at the hospitals and persons with disabilities must be given preferential treatment at the hospital (they should not join queues before seeing medical doctors). Interventions must be design to take persons with disabilities of the streets of Accra, while authorities work with their families so they can go home and register with the various districts to access the District Assembly Common Fund allocated to the districts and other benefits since they are mostly not captured by district data.

Finally the National Ambulance Service must make it a point to quickly respond to persons with disabilities to help transport them to hospitals, since they find it difficult to get vehicles which will transport them to hospitals. More research need to be done to develop disability friendly hospitals not only in the hospital structures but also in service delivery.